Genital Autonomy: Protecting Personal Choice

Transcription

Genital Autonomy
George C. Denniston · Frederick M. Hodges ·
Marilyn Fayre Milos
Editors
Genital Autonomy
Protecting Personal Choice
123
Editors
George C. Denniston
University of Washington
Robbins Road 45
98358 Norland
USA
Frederick M. Hodges
University of Berkeley
Post Office Box 5815
94705-0815 Berkeley
USA
Marilyn Fayre Milos
National Organization of Circumcision
Information Resource Centers
San Anselmo
California
USA
[email protected]
ISBN 978-90-481-9445-2
e-ISBN 978-90-481-9446-9
DOI 10.1007/978-90-481-9446-9
Springer Dordrecht Heidelberg London New York
Library of Congress Control Number: 2010933645
© Springer Science+Business Media B.V. 2010
No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by
any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written
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Printed on acid-free paper
Springer is part of Springer Science+Business Media (www.springer.com)
Preface
Why would anyone object to circumcision? For that matter, why would anyone hold
an international symposium on this subject?
In those countries and cultures where circumcision is ubiquitous, most people
would probably ask these questions when confronted with this book. Indeed, most
people from circumcising cultures accept circumcision as normal, necessary, and
good. These peoples cannot imagine that circumcision is a violation of human
rights or that it is harmful to any degree. One might as well try to convince them
that dentistry is a harmful violation of human rights. Fundamentally, most people
in circumcising cultures condone circumcision not because they are evil, malicious, sadistic, or insane, but because they have been conditioned to believe that
circumcision is good, desirable, and honorable.
In cultures where circumcision is not the norm, however, an entirely different
perspective emerges. People in (for want of a better word) “genitally intact” cultures
are horrified at the idea that someone would cut off part of the genitals of another
person—especially a baby. The act is seen as misguided at best and demented at
worst.
Where, then, does the truth lie? Can science provide objective answers? Most
people—including most scientists—imagine that “science” can be likened to an
impartial and omniscient calculating machine that emits absolute truths when questions are fed into it. Indeed, the mythos of “science” has come to replace the oracles
of the ancients. The majority of intelligent and educated people in ancient Greece
probably had as much faith in the oracle at Delphi as modern Westerners have in
“science” today. Medical journals now occupy the space once reserved only for
holy scriptures and are revered as sources of objective and inviolable truth.
Instead of soothsayers and sacred texts, we have scientists and science journals
that proclaim the newly discovered truths. The high level of credulity and absolute
faith in the statements published in science journals does not appear to be threatened
even when whistle blowers reveal evidence of fraud, data manipulation, scientific
misconduct, cover-ups, and corruption (Vastag, 2006). Even though respected medical and science journals have made headline news for having published studies that
used falsified data, the people’s trust and faith in these journals never wavers. The
journals Science, The New England Journal of Medicine, the Journal of Clinical
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Preface
Oncology, Immunity, the Journal of Experimental Medicine, and The Annals of
Internal Medicine are among the top journals to have published fraudulent studies
in recent years (Black, 2006). How many published studies based on fraudulent data
go undetected? One meta-analysis found that a pooled weighted average of 1.97%
(N = 7, 95% CI: 0.86–4.45) of scientists admitted to having fabricated, falsified, or
modified data or results at least oncea serious form of misconduct by any standardand up to 33.7% admitted other questionable research practices. In surveys asking
about the behavior of colleagues, admission rates were 14.12% (N = 12, 95% CI:
9.91–19.72) for falsification, and up to 72% for other questionable research practices
(Fanelli, 2009).
We trust the praiseworthy scientific method and have faith that self-styled scientists adhere to the scientific method when producing their scientific studies, but
should we? Most people do not feel qualified to judge whether a published paper in a
science journal has adhered to the scientific method. Instead, we spare ourselves the
difficult task of critical thinking and instead have faith that the paper was produced
honestly.
This faith, however, is at the crux of the circumcision debate. It is interesting to
note that circumcision is usually ubiquitous in countries where science education in
the public schools is weakest. In third-world Muslim countries, where circumcision
is endemic and in the United States, where mass circumcision was forced on the
populace starting after World War II, the teaching of science in the public schools
is far less adequate than it is in European public school systems. As predicted, in
Europe, circumcision is practically unheard of among native Europeans. Could this
be because the Europeans are better educated in science and therefore better able to
judge the merits of a claim made by a medical doctor? Is this because Americans
have blind faith in doctors and Europeans are more skeptical?
When doctors claim that the results of their research prove that circumcision can
prevent AIDS, most Americans blindly accept the veracity of this claim. Obviously,
without an adequate education in science, they do not feel themselves qualified to
question either the methodology or the results. Moreover, not only are the claims
unchallenged, but the doctor himself remains unchallenged. Few laymen question
his motivations. After all, since circumcision is a good thing, any doctor claiming
that circumcision is beneficial must be a good doctor. It would not occur to the
average layman that a doctor could deliberately be perpetrating a hoax or conspiring
to commit scientific fraud. We like to imagine that the scientific method has the
power to strip away any and all personal biases, motivations, or dark and disturbing
psychosexual impulses from the researchers. Unfortunately, it does not have this
power. Human psychology, especially when disturbed, unbalanced, and determined,
can have a corrosive and corrupting effect on any endeavor, including science and
religion.
The papers presented in this volume address these topics from a variety of angles.
They are each infused with a healthy skepticism that questions and dissects the true
motivations of the doctors, witch doctors, and “holy men” who promote and profit
from circumcision. With the greatest compassion, many of our authors also examine
the blind faith that the victims have in the perpetrators. It is difficult to convince
Preface
vii
someone that everything he has been told about circumcision is a lie. It is equally
difficult to convince a man that the body parts taken from him and destroyed might
have been of value. Nevertheless, our authors do not shy away from the challenge
of gently awakening the world to the fact that much of the world’s people have
been deceived and abused at the hands of a small group of perpetrators who have
alternately used science and religion as a smokescreen to hide the truth in order to
trick their victims into compliance.
It is our hope that readers of this volume will have their eyes opened a bit wider
and begin to have faith in their own abilities to think for themselves and question
extravagant claims—especially those that result in the permanent loss of a body part
or result in a child being injured to any degree.
Seattle, Washington
Berkeley, California
San Anselmo, California
George C. Denniston
Frederick M. Hodges
Marilyn Fayre Milos
References
Black A. (2006) Fraud in medical research: A frightening, all-too-common trend on the rise.
NaturalNews.com. April 18, 2006. http://www.naturalnews.com/019353.html
Fanelli D. (2009) How many scientists fabricate and falsify research? A systematic review and
meta-analysis of survey data. PLoS ONE. 4(5):e5738, doi: 10.1371/journal.pone.0005738.
Vastag B. (2006) Cancer fraud case stuns research community, prompts reflection on peer review
process. JNCI. 98(6):374–376, doi: 10.1093/jnci/djj118.
Acknowledgments
The work of putting on the symposium from which the papers in this book were
drawn is the product of many hands. We would like to thank David Smith, Margaret
Green, and the many members of NORM-UK who worked so diligently to make the
symposium at Keele University a success.
We are also honored to acknowledge Marie Fox and Michael Thomson, professors at Keele University School of Law, who co-sponsored our symposium,
presented papers, and contributed significantly to this book.
Special thanks are due to Gaye Blake-Roberts, Director of the Wedgwood
Museum and renowned speaker and author on British ceramics, for the lovely
Wedgwood plates with the International Child for Genital Autonomy that she had
commissioned as a gift for each of the symposium presenters, and for hosting the
reception of our gala dinner in the beautiful university rooms, where a fine collection
of ceramics was made available for the enjoyment of symposium attendees.
We thank Ken Brierley and Sheila Curran for their tireless efforts in helping to
make the symposium a successful event.
Of course, we would like to thank our contributors, whose papers have added to
our body of information about a crucially important human rights issue.
And, finally, we acknowledge those who have survived the pain and trauma of
genital cutting, those who have the courage to speak out against harmful traditional
practices, and everyone who works to protect the genital integrity rights of those
who are too little to defend or protect themselves. Together, we are making a safer
world for the children.
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Contents
1 “Three-Fourths Were Abnormal”—Misha’s Case, Sick
Societies, and the Law . . . . . . . . . . . . . . . . . . . . . . . . .
J. Steven Svoboda
1
2 Older Minors and Circumcision: Questioning the Limits
of Religious Actions . . . . . . . . . . . . . . . . . . . . . . . . . . .
Marie Fox and Michael Thomson
15
3 These Goalposts Don’t Move: Non-Medical Circumcision
of Boys in the Tasmanian and Australian Context . . . . . . . . . .
Paul Mason
39
4 Mass Campaigns of Male Circumcision for HIV Control in
Africa: Clinical Efficacy, Population Effectiveness, Political Issues .
Michel Garenne
49
5 AIDS XVII, Mexico City: Reason for Hope or Panic? . . . . . . . .
John Geisheker
61
6 Circumcision Psychopathology . . . . . . . . . . . . . . . . . . . .
George C. Denniston
67
7 Physical Effects of Circumcision . . . . . . . . . . . . . . . . . . .
John Warren
75
8 Complications of Circumcision: A Urologist’s Viewpoint . . . . . .
James L. Snyder
81
9 NOCIRC of Italy: Scientific Activities 2006–2009 . . . . . . . . . .
Franco Viviani, S. Bobbo, S. Malaguti, and D. Paolini
85
10
A Project About Male Circumcision in the Veneto . . . . . . . . . .
M. Gloria de Bernardo
95
11
The First Survey on Genital Stretching in Italy . . . . . . . . . . .
Pia Grassivaro Gallo, Annalisa Bertoletti, Ilenia Zanotti,
and Lucrezia Catania
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12
13
14
15
16
Contents
Knowledge and Opinions of North Italian Health Operators
About Female Genital Mutilation . . . . . . . . . . . . . . . . . . .
Pia Grassivaro Gallo, Ilenia Zanotti, Annalisa Bertoletti,
Lucrezia Catania, and Miriam Manganoni
103
Stretching of the Labia Minora and Other Expansive
Interventions of Female Genitals in the Democratic
Republic of the Congo (DRC) . . . . . . . . . . . . . . . . . . . . .
Pia Grassivaro Gallo, Nancy Tshiala Mbuyi, and
Annalisa Bertoletti
111
Preventing Infibulation: Mana Sultan Abdurahman Isse
at Merka, Somalia . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pia Grassivaro Gallo and Sandra Busatta
125
Writing Rites Gone Wrong: Autobiography, Testimonials,
and Their Relevance to the Debate Around Genital Alterations . .
Chantal Zabus
137
The Impact of Neonatal Circumcision: Implications for
Doctors of Men’s Experiences in Regressive Therapy . . . . . . . .
Robert Clover Johnson
149
17
Circumcision Memory . . . . . . . . . . . . . . . . . . . . . . . . .
Thomas W. Hennen
167
18
Foreskin Restoration 1980–2008 . . . . . . . . . . . . . . . . . . . .
R. Wayne Griffiths, J. David Bigelow, and James Loewen
189
19
Restoration: The Foreskin and the American Dream . . . . . . . .
Ron Low
199
20
Genital Autonomy: The Way Forward . . . . . . . . . . . . . . . .
David Smith
211
21
Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
George Wald
217
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
241
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
247
Contributors
Annalisa Bertoletti Working Group of FGM, University of Padua, Padua, Italy
J. David Bigelow National Organization of Restoring Men, Concord, CA, USA
S. Bobbo Faculty of Psychology, University of Padua, Italy
Sandra Busatta Working Group on FGM, University of Padua, Padua, Italy
Lucrezia Catania Resource Center for Preventing and Curing FGM and Its
Complications, University of Florence, Florence, Italy
M. Gloria de Bernardo University of Verona, Verona, Italy; University of Padua,
Padua, Italy, [email protected]
George C. Denniston Doctors Opposing Circumcision (D.O.C.), Seattle, WA,
USA
Marie Fox School of Law, University of Keele, Staffordshire, UK
Michel Garenne IRD (French Institute for Research and Development) and
Institut Pasteur, Paris, France, [email protected]
John Geisheker Doctors Opposing Circumcision, Seattle, WA, USA,
[email protected]
Pia Grassivaro Gallo Working Group of FGM, University of Padua, Padua, Italy,
[email protected]
R. Wayne Griffiths National Organization of Restoring Men, Concord, CA, USA,
[email protected]
Thomas W. Hennen Washington and California Bar Associations, Attorney
Before the US Patent & Trademark Office, Des Moines, WA, USA,
[email protected]
Robert Clover Johnson Gallaudet University Press, Washington, DC, USA,
[email protected]
James Loewen National Organization of Restoring Men, Concord, CA, USA
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Contributors
Ron Low Northwestern University, Kellogg Graduate School of Management,
Chicago, IL, USA, [email protected]
S. Malaguti Faculty of Psychology, University of Padua, Italy
Miriam Manganoni Working Group on FGM, University of Padua, Padua, Italy
Paul Mason Commissioner for Children, Tasmania, Australia,
[email protected]
D. Paolini Faculty of Psychology, University of Padua, Italy
David Smith NORM-UK, Staffordshire, UK, [email protected]
James L. Snyder American Board of Urology, American College of Surgeons,
Virginia Urological Society, Clifton Forge, VA, USA, [email protected]
J. Steven Svoboda Attorneys for the Rights of the Child, Berkeley, CA, USA,
[email protected]
Michael Thomson School of Law, University of Keele, Staffordshire, UK,
[email protected]
Nancy Tshiala Mbuyi Working Group on FGM, University of Padua, Padua, Italy
Franco Viviani Faculty of Psychology, University of Padua, Padua, Italy,
[email protected]
George Wald Professor of Biology, Harvard University, Cambridge, MA, USA,
[email protected]
John Warren Royal College of Physicians, London, UK; NORM-UK,
Staffordshire, UK, [email protected]
Chantal Zabus Universities of Paris XIII & III-Sorbonne Nouvelle, Paris, France;
Institut Universitaire de France, Paris, France, [email protected]
Ilenia Zanotti Working Group of FGM, University of Padua, Padua, Italy
About the Authors
Peter Ball MA MB, BChir DA, is a retired family practitioner, Vice Chairman of
NORM-UK, and the producer and director of a non-surgical foreskin restoration
video. Tunbridge Wells, Kent, UK.
Annalisa Bertoletti PhD, graduated in Psychology, University of Padua, and is a
member of the Padua Working Group on FGM. Padua, Italy.
J. David Bigelow PhD, earned his doctorate in psychology at Claremont Graduate
School, is a retired college professor (Whittier College), therapist, clergyman, and
author of The Joy of Uncircumcising% Exploring Circumcision: History, Myths,
Psychology, Restoration, Sexual Pleasure and Human Rights. Pacific Grove, CA,
USA.
Sandra Bussata PhD, is Professor of Social Anthropology, University of Padua,
and a member of the Padua Working Group on FGM, Padua, Italy.
Lucrezia Catania is a member of the Padua Working Group on FGM. Padua, Italy.
Georganne Chapin JD, is President and CEO of Hudson Health Plan, a non-profit
Medicaid managed care company in New York’s Hudson Valley. She is also founder
and President of the Hudson Center for Health Equity & Quality (Hcheq), an organization whose purpose is to contribute to policy and technology efforts toward
healthcare reform. Georganne is the CEO of Intact America, an organization dedicated to keeping babies whole. She has taught Bioethics as well as Medicaid and
Disability Law at Pace University School of Law, from which she received her
law degree. She also holds an undergraduate degree in Anthropology from Barnard
College and a Masters in Sociomedical Science from Columbia University. She
serves on a number of non-profit Boards, including that of Attorneys for the Rights
of the Child (ARC). Tarrytown, NY, USA.
M. Gloria de Bernardo PhD, teaches Ethno-Anthropology and Social
Anthropology, Surgery and Medicine Faculty, University of Verona and University
of Padua. She is President of the Ethic Committee in “Clinical Practice, Hospital
Institute of Verona, and has been a member of the Experimentation Committee, as an
“Expert in Bioethic Science,” following her experience at the San Raffaele in Milan
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About the Authors
and at Lana Foundation in Padua. She is a member of the Medical Anthropology
Italian Society (SIAM). She has written many articles for Etnoginecology
Magazine, as a result of her personal research and her research with the Padua
Working Group on FGM. She is the author of The Respect of Pain and Death in the
Main Confessions. Padua, Italy.
George C. Denniston MD (University of Pennsylvania School of Medicine),
MPH (Harvard School of Public Health), founder and President of Doctors
Opposing Circumcision (D.O.C.), co-author, Doctors Re-examine Circumcision,
co-editor of the proceedings of the International Symposia on Circumcision,
Human Rights, and Genital Integrity, Sexual Mutilations: A Human Tragedy,
Male and Female Circumcision: Medical, Legal and Ethical Considerations in
Pediatric Practice, Understanding Circumcision: A Multi-Disciplinary Approach
to a Multi-Dimensional Problem, Flesh and Blood: Perspectives on the Problem
of Circumcision in Contemporary Society, Bodily Integrity and the Politics of
Circumcision, Culture, Controversy and Change, and Circumcision and Human
Rights. He is also the former Associate Medical Director of the Planned Parenthood
Federation of America. Olympic Peninsula, WA, USA.
Marie Fox is Professor of Law at the University of Keele. Her main research interests are in the fields of Health Care Law, Animal Law and Feminist Legal Theory.
Selected recent publications include: (with Jean McHale), 2nd edition of Health
Care Law: Text, Cases and Materials (Sweet & Maxwell) 2006 (1204, xxxvi pages);
“The Regulation of Xenotransplantation in the United Kingdom After UKXIRA:
Legal and Ethical Issues” (with L. Williamson and S. McLean) (2007) 34(4) Journal
of Law & Society 441–464; “Rethinking the Animal/Human Boundary: The Impact
of Xeno Technologies” (2005) 26 Liverpool Law Review 149–167; (with Michael
Thomson) “Cutting It: Surgical Interventions and the Sexing of Children” (2005) 12
Cardozo Journal of Law & Gender 82–97; (with Michael Thomson) “A Covenant
with the Status Quo?: Male Circumcision and the New BMA Guidance to Doctors,”
(2005) 31 Journal of Medical Ethics 463–469; (with Michael Thomson) “Short
Changed? The Law and Ethics of Male Circumcision,” (2005) 13 International
Journal of Children’s Rights 161–181; republished in M. Freeman (ed.) Children’s
Health and Children’s Rights Leiden/Boston: Martinus Nijhoff Publishers, 2006.
Staffordshire, UK.
Michel Garenne PhD (demography), is Director of Research at the French Institute
for Research and Development and is currently working at the Pasteur Institute,
Emerging Diseases Unit, in Paris. He is also honorary Associate Professor at the
University of Witwatersrand, Johannesburg. He directed the Niakhar Demographic
Surveillance System in Senegal in the 1980 s and has collaborated with the
Agincourt Health and Demographic Surveillance System in South Africa since
1992. He is the author of numerous publications on population and health
issues in Africa, and has taught demography at several universities in Europe
(Paris, Clermont-Ferrand, Heidelberg, Antwerp), and in the United States (Harvard).
Paris, France.
About the Authors
xvii
John Geisheker JD, LLM, is the General Counsel and Executive Director of
Doctors Opposing Circumcision. Seattle, WA, USA.
Pia Grassivaro Gallo PhD, Associate Professor of Anthropology, University of
Padua’s Psychology Faculty, and former teacher of Applied Biology, Human
Genetics, and Anthropogenetics. Her research on the biology of current human populations has taken place in several developing countries, particularly Somalia (from
1972 to 1985). At the invitation of the Somali Ministry of Public Health (1981),
she was invited to take part in a scientific mission to Somaliland. From 1988, she
has been responsible for the Padua Working Group on FGM, dealing with African
immigrants in Italy. From 2000, she studied the expansive forms of the traditional
interventions on female genitalia, carrying out field researchers in Central Africa
(Uganda, Malawi, and Congo RDC). She was co-coordinator of the 8th International
Symposium on Circumcision and Human Rights, Padua, Italy.
R. Wayne Griffiths MS, MEd, a sociologist and educator, received his MS from
BYU and his MEd from Oregon State University and did post graduate work at the
University of Southern California in Los Angeles. He was an assistant professor of
sociology and criminology at Armstrong State College in Savannah, Georgia. He
is the co-founder and Executive Director of the National Organization of Restoring
Men (NORM), which was founded in 1989. He has written and published a number
of articles on foreskin restoration. Concord, CA, USA.
Thomas W. Hennen JD, received a BS degree in Mechanical Engineering from
Washington State University (1969) and a Juris Doctor in Law from the University
of Maine School of Law (1973). He is a member of both the Washington and
California Bar Associations and is admitted as an attorney before the US Patent
& Trademark Office. He has spent 33 years of his professional career working as
an Intellectual Property Attorney for government and corporate employers. Des
Moines, WA, USA.
Frederick M. Hodges Dphil (Oxon), is a medical historian, the co-author of What
Your Doctor May Not Tell You About Circumcision: Untold Facts on America’s
Most Widely Performed—and Most Unnecessary—Surgery (Warner Books 2002),
and co-editor of the proceedings of the International Symposia on Circumcision,
Human Rights, and Genital Integrity, Sexual Mutilations: A Human Tragedy,
Male and Female Circumcision: Medical, Legal and Ethical Considerations in
Pediatric Practice, Understanding Circumcision: A Multi-Disciplinary Approach
to a Multi-Dimensional Problem, Flesh and Blood: Perspectives on the Problem
Rights. Berkeley, CA, USA.
Robert C. Johnson recently retired from a 24-year career as a writer and editor at
Gallaudet University in Washington, DC, USA, where he wrote extensively about
deafness-related research. He is co-editor of Testing Deaf Students in an Age of
Accountability, published by Gallaudet University Press. In 2005, at the age of 60,
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About the Authors
determined to understand and overcome the root cause of difficulties with intimacy
he had experienced all his adolescent and adult life, he decided to pursue an eclectic
form of regressive therapy for a second time. Much to his surprise, during one session of this therapy, he began to re-experience his neonatal circumcision, an event
he believes originally occurred within hours or minutes after birth, without parental
consent (a frequent occurrence in 1945), many hours before he met his parents. His
paper describes his journey from that shocking discovery to his current status as an
anti-circumcision activist. Alexandria, VA, USA.
James Loewen Photographer, discovered his circumcised status at age seven,
which sparked his outrage. Artistic abilitiesas a child led him to a career as a
photographer and many fascinating assignments, including a three-month project
in1975, photographing the activities at the sex-change clinic of the notorious Dr.
John Brown. In 1993, Loewen happened upon Jim Bigelow’s book, The Joy of
Uncircumcising, and began connecting with others opposed to infant and childhood
genital surgeries. His lifetime of questioning gender, sexual roles, and orientation
has informed his artistic and intactivist activities. Currently he is making videos
related to intactivism and hosting a YouTube channel, “intactivist1,” with many
collected video clips related to the issue. Vancouver, British Columbia, Canada.
Ron Low BS, MS, markets TLC Tugger foreskin restoration devices (http://
TLCTugger.com), hosts the Circumspect iTunes podcast series, and moderates the Foreskin-Restoration/Intactivist Network Internet forum (http://ForeskinRestoration.net/forum). Ron was circumcised at birth and has been a foreskin
restorer since 2001. He was cited in the book Everything you know about Sex is
Wrong, featured in the BBC documentary Circumcise Me?, and interviewed by
major newspapers and Time magazine. He appears in the 2007 intactivist film Cut,
and he presented the topic of foreskin restoration to a Mensa convention and to
the Everyday Edisons reality show. In August of 2008, Ron demonstrated foreskin
restoration to Howard Stern and his radio/TV audience of millions. Ron earned a
Bachelors degree in Industrial Engineering from University of Illinois and a Masters
degree in Services Marketing and Entrepreneurship from Northwestern University’s
Kellogg Graduate School of Management. Chicago, IL, USA.
Miriam Maganoni is a member of the Padua Working Group on FGM. Padua,
Italy.
Paul Mason is the Commissioner for Children [CfC] for Tasmania. The CfC is an
officer of Executive Government, independent of the elected government of the day,
appointed to advise the Government and to increase public awareness of matters
relating to the health, welfare, care, protection, and development of children. Paul is
a family lawyer with 30 years experience.
Nancy Tshiala Mbuyi graduated in Nursing Sciences, University of Padua, and is
a member of the Padua Working Group on FGM. Padua, Italy.
Marilyn Fayre Milos RN, is the founder and Executive Director of the National
Organization of Circumcision Information Resource Centers (NOCIRC), the
About the Authors
xix
coordinator of the International Symposia on Circumcision, Genital Integrity,
and Human Rights, the editor of the NOCIRC Annual Report, and the coeditor of the proceedings of the International Symposia on Circumcision, Human
Rights, and Genital Integrity, Sexual Mutilations: A Human Tragedy, Male and
Female Circumcision: Medical, Legal and Ethical Considerations in Pediatric
Practice, Understanding Circumcision: A Multi-Disciplinary Approach to a
Multi-Dimensional Problem, Flesh and Blood: Perspectives on the Problem
Rights. San Anselmo, CA, USA.
David Smith was educated at St Joseph’s College, Market Drayton, and he qualified in business studies at Underwood College. He worked for Re-Solv, the solvent
abuse charity, but he currently works full-time as General Manager of NORMUK,
and is the organization’s only paid staff member. David created and is now the editor
of NORM NEWS, the organization’s magazine for members. Staffordshire, UK.
James L. Snyder MD, FACS, is a Diplomate of American Board of Urology,
a Fellow of the American College of Surgeons, Past President of the Virginia
Urological Society, Retired Commander, Medical Corps, United States Naval
Reserve, who retired from medical practice in 2000. He has served as expert witness
in several circumcision lawsuits. Clifton Forge, VA, USA.
J. Steven Svoboda JD, focuses on civil litigation and human rights, and is the
founder and Executive Director of Attorneys for the Rights of the Child (ARC),
a non-profit organization addressing the illegality of involuntary genital surgery.
Berkeley, CA, USA.
Michael Thomson is Professor of Law, Culture & Society at the University of
Keele. His research interests include Health Care Law, Law and Gender, and Law
and Literature. His particular focus has been the regulation of reproduction and
the relationship between law and gender. The focus of his most recent work is
masculinity and the legal regulation of the male sexed body. He is the author of
Reproducing Narrative: Gender, Reproduction and Law (Dartmouth, 1998) and
Endowed: Regulating the Male Sexed Body (Routledge, 2007). Staffordshire, UK.
Franco Viviani is Professor of Anthropology Applied to Psychology, Department
of Psychology of Work and Socialization, Faculty of Psychology, University of
Padua. His academic work has focused primarily on sport anthropology and then
on the health-related issues that arise in the context of physical activity, fitness and
health. He is President of the International Council of Physical Activity and Fitness
Research and an active member of several scientific health-related associations,
including the Presidium of NFH Shanghai, which organizes annual international
congresses on nutrition, fitness and health. After developing an interest on female
circumcision, he published books, research papers, and directed audio-visuals on the
topic. He has published several papers and articles both on male and female circumcision and co-organized congresses, workshops and participated in debates on the
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About the Authors
topic. As he is the NOCIRC representative for Italy, informing the media whenever
facts or public debates focus on male and female circumcision.
John Warren MB BChir DCH FRCP, qualified in medicine at Cambridge
University, England (1966). He obtained the Diploma of Child Health (1968),
Membership of the Royal College of Physicians of London (1970), and was made
a Fellow of the Royal College of Physicians (1987). After junior training posts, he
was appointed a consultant physician in Harlow, Essex (1975), specialising in general internal medicine and respiratory disease. He became interested in problems
surrounding infant circumcision when studying child health (1968), and followed up
this interest in the early 1990 s, leading to the establishment of NORM-UK (1995),
of which he has been chairman since its foundation. He retired from medical practice
in 2006. Harlow, Essex, UK.
Chantal Zabus is Professor of Postcolonial Literature and Gender Studies at the
University Paris 13, a Researcher at the University of Paris 3-Sorbonne Nouvelle,
and a Senior Scholar at the Institut Universitaire de France, Paris. She is the
author of Between Rites and Rights: Excision in Women’s Experiential Texts and
Human Contexts, Stanford UP, 2007); The African Palimpsest (Rodopi, 1991;
rpt 2007); Tempests after Shakespeare (Palgrave, 2002). She has also edited Le
Secret (with J. Derrida, Louvain, 1999), Changements au féminin en Afrique noire
(L’Harmattan, 2000), Fearful Symmetries: Essays and Testimonies Around Excision
and Circumcision (Rodopi, 2009), and she is currently editing Perennial Empires
(with Silvia Nagy-Zekmi). Paris, France.
Ilenia Zanotti PhD, received her degree in Psychology at the University of Padua.
She is a member of the Padua Working Group on FGM. Padua, Italy.
Chapter 1
“Three-Fourths Were Abnormal”—Misha’s
Case, Sick Societies, and the Law
J. Steven Svoboda
Abstract Law, human rights, medical ethics, and social mandates reflect, transmit, and reinforce social norms. Well over a century ago, normality was redefined,
and suddenly, “three-fourths of all male babies [had] abnormal prepuces.” Genital
cutting presents a cluster of interwoven discriminations that violate law, human
rights, and ethics. Differential terminology—MGC and FGC—facilitates differential treatment and unequal protection. Oregon’s Boldt v. Boldt case ended in the
boy’s wishes being honored, but perhaps only due to the inexcusable 5-year delay
in resolving the case and the conflation of custody and circumcision issues. This
case eloquently demonstrates the law’s inability to effectively address male circumcision. Numerous authors from a variety of disciplines have forcefully contested
the reigning paradigm whereby FGC is outlawed and MGC is legally tolerated.
Some observers also note the further irony that cosmetic FGC by wealthy westerners is permitted while traditional FGC by developing world peoples is vilified.
Activists against FGC are acknowledging their support of the movement for male
intact rights. HIV/AIDS is the latest attempted justification for male genital amputation but utterly fails scrutiny, as even the Centers for Disease Control and Prevention
(CDC) is finding itself compelled to concede in the face of growing protests in favor
of children’s rights. Not only do most of the reasons for FGC parallel the rationales
for MGC, but a surprising number of similarities link cultures around the world that
practice MGC. Parents (as in Boldt v. Boldt), doctors, and society seek treatment,
not the infant. Thus, the problem cannot be solved by a medical procedure, which
circumcision never was anyway. Only human compassion can end the nightmare.
Keywords Law · Human rights · Medical ethics · Religion · Male circumcision
Law, human rights, and medical ethics reflect, transmit, and reinforce social norms.
These official mandates are ultimately enforced by a country’s police power. Social
mandates including culture, mythology, and religion enforce social norms through
J.S. Svoboda (B)
Attorneys for the Rights of the Child, Berkeley, CA, USA
e-mail: [email protected]
G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9_1,
C Springer Science+Business Media B.V. 2010
1
2
J.S. Svoboda
less official channels but can operate at least as potently, often complementing and
enabling (and indeed, often helping give rise to) official mandates. Such social mandates have powerfully supported infant male circumcision. Sarah Waldeck points out
that “when circumcision rates in the United States were more than 70%, nearly 10%
of parents thought the procedure was required by law, much like . . . the installation
of silver nitrate drops into a newborn’s eyes shortly after birth.”1 Mythology such
as scientific misinformation and misplaced desire that a son “look like” his father
has further facilitated the continued persistence of this Victorian holdover.2
Genital cutting persists because it is perceived to provide real or imagined
benefits and to connect the cut individual to society along a variety of dimensions—
cultural, economic, class-related, medical, mythological, psychological, sexual,
religious, “scientific,” etc. Desired societal values that may help justify and institutionalize mutilations encompass courage, pride, fulfillment of the assigned sexual
role, religious devotion, willingness to sacrifice oneself for society’s greater good,
and many others.3 Regarding MGC in primitive cultures, Paige and Paige comment
that “the boy who is circumcised is not himself the object of the ceremony, which is,
in fact, conducted to impress others. . .”4 This observation calls to mind Ford’s apt
observation regarding intersex surgeries on infants, which is every bit as applicable
to male circumcision: “It is the parents and doctors of intersexed infants who are
experiencing a medical emergency, not the intersexed infant.”5 Circumcision, therefore, “solves” a non-existent problem, utterly failing to address the infant’s needs
while treating the child as a means to society’s ends rather than an end in himself,
thereby violating Kantian ethics.
Male circumcision, like female circumcision, as Prescott notes, never has been
primarily a medical issue. Rather, its roots go deep into powerful religious beliefs
and social customs that defy rational analysis.6 As Voskuil shows, menstrual blood
and male genital bleeding are closely connected. As one of many examples, “in
ancient Egypt boys going to be circumcised wore girls’ clothes and were followed
by a woman sprinkling salt, a common substitute for menstrual blood.”7 Romberg
notes, “One possible, intriguing motivation for male genital mutilation (both foreskin amputation and subincision—the ritual slashing of the underside of the penis)
is menstrual envy.”8 As Bettelheim discusses, penile subincision is called “men’s
menstruation.” Thus, men mimicked women’s power in the very ritual that affirmed
their maleness, their entitlement to exclude women from positions of importance in
the tribe and in religious leadership.9
The transformational power of genital modification must be appreciated to understand these practices’ persistence. A Nineteenth century physician’s medical journal
article by S.G.A. Brown states in all seriousness that, “Fully three-fourths of all
male babies have abnormal prepuces.”10 Such a redefinition of normality is inherent in the process of genital modification, and can be one of its goals. MGC purges
the male body of the “female” foreskin, while FGC purges the female body of the
“male” clitoris. Genital modification can promise to redefine normality by turning a
boy into a man, a girl into a woman, or a non-virgin back into a virgin. Our S.G.A.
Brown for the modern era may be the notorious Brian J. Morris, writing on “Why
circumcision is a biomedical imperative for the twenty-first century.”11
1
“Three-Fourths Were Abnormal”—Misha’s Case, Sick Societies, and the Law
3
The exoticization of “African” FGC contrasts with the normalization of
“American” MGC. An almost missionary evangelism characterizes anti-FGC
activists’ opposition to these practices, while a culturally inert prurience regarding
male circumcision reinforces the status quo. Law helps both processes by reifying and reinforcing social norms. Circumcision is tied up with three of the most
powerful discourses in modern society—science, medicine, and religion, and a
variety of other uncomfortable, controversial and deeply emotional issues including psychological denial and parental authority. No wonder there is so much
argument.12
Genital cutting presents a cluster of interwoven discriminations—racial, genderbased, age-based, and class-based—that violate law, human rights, and ethics. We
know that human rights treaties—the supreme law of the land and applicable either
through ratification or through customary law—forbid circumcision based on such
important principles as the rights of the child, the right to freedom of religion, and
the right to the highest attainable standard of health. Human rights treaties are binding in the US either through ratification (as with the International Covenant on
Civil and Political Rights and the International Covenant on Economic, Social, and
Political Rights) or through customary law (as with the Convention on the Rights
of the Child, of which we remain the only non-ratifying country in the world with a
functioning government). The United Nations has already endorsed in official documents the principle that male genital cutting (MGC) qualifies as a human rights
violation, at least under certain circumstances.13,14 A presentation by Attorneys for
the Rights of the Child and the National Organization of Circumcision Information
Resource Centers centrally addresses male circumcision as a human rights violation
and is part of the official UN record.15
The legal status quo, whereby female genital cutting (FGC) is severely punished while MGC is not punished either criminally or civilly as long as it is done
“competently” and with “consent” of the parents, must be unstable. Differential
terminology—MGC and FGC—facilitates differential treatment. We do not speak
of male rape and female rape. We do not speak of female incest and male incest.
A priori, there is no reason (and no justification) for this gender-stratified taxonomy.
Of course, it does help to obscure the clear violation of equal protection that otherwise might become evident whenever a legal action relating to MGC makes it into
court.
One recent lawsuit has already become the most famous circumcision-related
legal case ever. In Boldt v. Boldt, the Oregon custody case filed in 2004 in which a
recently converted Jewish father had been seeking the circumcision of his son Misha
against the wishes of the boy’s mother, the Oregon Supreme Court (OSC) reversed
the trial court’s and the court of appeals’ previous decisions in favor of the father.
The OSC remanded (returned) the case to the trial court for further proceedings,
including a determination of the boy’s wishes in the matter. The final paragraph of
the OSC’s ruling held:
If the trial court finds that M agrees to be circumcised, the court shall enter an order denying
mother’s motions. If, however, the trial court finds that M opposes the circumcision, it must
4
J.S. Svoboda
then determine whether M’s opposition to circumcision will affect father’s ability to properly care for M. And, if necessary, the trial court then can determine whether it is in M’s
best interest to retain the existing custody arrangement, whether other conditions should be
imposed on father’s continued custody of M, or change custody from father to mother.16
At the remand hearing, held in April 2009, the then 14-year-old boy testified
privately to the judge with neither parent present. Misha told the judge he did not
want to be circumcised, nor did he want to be Jewish, and the judge accepted that
testimony on the record in the courtroom. In June 2009, she issued an order finding
significant cause to warrant testimony as to whether custody should be returned
to the mother. The great irony, as attorney John Geisheker points out, is that the
unconscionable delay may be the very factor that saved him, giving him time to
grow and develop self-confidence to the point where no one could fail to be swayed
by his desires.17 Thus the most obvious solution, to let the boy grow old enough to
make his own decision, was reached not deliberately but more or less by default and
through the passage of time.
Despite the happy end result, Geisheker was troubled
by the gratuitous linkage of circumcision with custody. Ironically, this procedural point may
be precisely what got the case onto the Oregon Supreme Court docket in the first place,
as family law matters are rarely reviewed by courts of general jurisdiction [and in fact are
exempt from such review]. It is appalling to put the child in the position of choosing surgery
to stay with dad, or freedom from surgery with his mom.
Geisheker notes that the Court mentioned only the child’s right to be heard, but
did not recognize its paramount duty to protect him.18 Misha’s case is a sad commentary upon American life and constitutional principles. Boldt v. Boldt eloquently
demonstrates that in the US, at least, the law to date has not been able to effectively
grapple with such a heavily contextual and cultural practice as male circumcision.
To date, with one known exception, all awards and settlements have occurred
in cases involving either a “botched” procedure or a lack of informed consent.
At least three times, courts have avoided squarely addressing the legality of male
circumcision by diverting the discussion into such peripheral, procedural issues as
standing. Judicial views of standing are politically and culturally shaped in response
to social mandates. Although MGC is currently illegal under existing laws and
human rights treaties, if properly and objectively interpreted free of cultural bias,
American cultural blindness has prevented recognition of this.19 Elsewhere in the
world, Tasmania’s Law Review Commission recently released a lengthy issues
paper questioning the legality of male circumcision.20 Sweden has regulated circumcision and the practice was recently made illegal in South Africa, with religious
and medical exceptions included that threaten to swallow the rule. While the practice
is not otherwise explicitly prohibited anywhere in the world, it is of course illegal
worldwide under a broad range of prohibitions imposed by statute, common or civil
law, human rights treaties, and customary law.”
By contrast, world opinion has determined that girls’ bodies are more important than tradition, and that any cutting of the female genitals is female genital
mutilation, now banned by law in many countries. Under the reigning paradigm,
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discrimination against men is regarded far less seriously than discrimination against
women. Despite a blatant violation of the equal protection principles enshrined in
the United States Constitution and human rights treaties, courts are reluctant to
affirm claims of equal treatment not yet socially approved. A movement brought primarily or exclusively on behalf of males seems to cause discomfort to individuals,
institutions, and society.21
However, signs are appearing on the horizon that such balancing acts are becoming more difficult to sustain. Numerous authors from a variety of disciplines are
concluding that, due to basic issues of justice as well as equal protection principles, genital cutting is genital cutting, whether done on a male or female body.22
Two commentators have forcefully argued that given the American laws against
FGC, MGC must also be illegal under the US constitutional principle of equal
protection.23,24 After an exhaustive review of legal and human rights implications
of circumcision, European human rights scholar Jacqueline Smith concludes that
the differential treatment is simply indefensible. “By condemning one practice and
not the other, another basic human right, namely the right to freedom from discrimination, is at stake. Regardless of whether a child is a boy or a girl, neither
should be subject to a harmful traditional practice.”25 Dena Davis finds “troubling
implications for the constitutional requirement of equal protection, because the law
appears to protect little girls, but not little boys, from religious and culturally motivated surgery.”26 Sirkuu Hellsten concludes that “from a human rights perspective,
both male and female genital mutilation, particularly when performed on infants or
defenseless small children . . . can be clearly condemned as a violation of children’s
rights.”27
Anthropologist Kirsten Bell notes the contradictory policies of international
health organizations, “which seek to medicalize male circumcision on the one
hand, oppose the medicalization of female circumcision on the other, while simultaneously basing their opposition to female operations on grounds that could
legitimately be used to condemn the male operations.”28 R. Charli Carpenter criticizes the United Nations’ double standard with regard to “harmful traditional
practices,” a term the UN defines to exclusively address women and girls while
ignoring “the most obvious one of all—the genital mutilation of infant boys,
euphemistically known as . . . circumcision.”29
In addressing male circumcision within an article primarily devoted to female
circumcision of Egyptian Nubians, Fadwa El Guindi calls feminists to task for
their “arrogant and ethnocentric” focus on saving ostensibly helpless African
women while ignoring “the cruelty of American male infant circumcision.30 One
of the anthropologists who has been working on FGC the longest, Janice Boddy,
forthrightly asks, “Why is there no outrage remotely parallel to that which leads
some writers to insist that circumcised women are entirely alienated from the
essence of the female personality [citations omitted]? Is it because these excisions
are performed on boys, and only girls and women figure as victims in our cultural
lexicon?” A bit later in her article, Boddy proffers a possible explanation for the
widely disparate views: “intuitively, men and boys are not ‘natural’ victims.”31 Fox
and Thomson suggest a possible reason for this collective failure of our intuition.
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J.S. Svoboda
They write that a “harm/benefit assessment [footnote omitted] lies at the heart of the
male circumcision debate,” contending that legal and ethical tolerance of male circumcision can be attributed to traditional constructions of male bodies as resistant
to harm or even in need of being tested by painful ordeals, and of female bodies, by
contrast, as highly vulnerable and thus in need of greater protection.32
Oddly enough—and demonstrating the pervasive power of the “tough male”
stereotype—although Fox and Thomson emphasize that MGC is always risky
surgery, mentioning adverse outcomes, they neglect the most obvious harm of all:
the harm of being deprived of an integral and erotically significant part of the penis.
Sami A. Aldeeb Abu-Sahlieh argues forcefully and simply. “The right to physical
integrity is a principle. We must accept or reject genital cutting in totality. If we
accept this principle, we must refrain from cutting of children’s genitals regardless of their sex, their religion, or their culture.”33 Audrey Macklin34 and Christine
Mason35 reach similar conclusions.
From an ethical perspective, the procedures look even more analogous, for,
as Bell comments, “each operation involves an unnecessary bodily violation that
entails the removal of healthy tissue without the informed consent of the person
involved.”36 Moreover, as ritual forms of MGC are medicalized under the influence
of western health agencies and educational institutions, defenders of male circumcision justify the procedure with medical rationales that are strikingly similar to those
used to support excision of female genitalia.
Ylva Hernlund and Bettina Shell-Duncan note another disturbing form of
unequal protection, an exception from the harsh treatment of FGC practices by foreigners that is carved out, as it were, for the benefit of usually wealthy women
practicing cosmetic versions of FGC that are becoming popular in the US:
If contradictory responses to nonconsensual genital surgeries on female and male minors
respectively reveal inconsistencies, the same can be said when comparing FGC and an
increasingly common type of plastic surgery, popularly referred to as female genital
cosmetic surgeries or ‘designer vaginas.’ Such procedures include labia minora reduction, labia majora remodelling, pubic liposuction and lifts, and clitoral reduction (see
www.altermd.com), some of which resemble quite closely—in results, if not in the context
of the surgeries—genital cutting procedures done ‘traditionally’ in African societies.37
Fuambai Ahmadu finds physical parallels that belie the attempted distinction of
the practices:
Ironically, in the name of sexual liberation, these wealthy or middle-class Western women
spend thousands of dollars to become as ‘closed’ as virgins, while ordinary Somali immigrants in Norway line up at hospitals to be ‘opened’ at public expense, under the same
banner. Unlike these ‘mutilated’ African women, no one seems to question the credibility
of Western women with surgical ‘designer vaginas’ who report increased psychological and
physical sexual satisfaction after drastic genital operations.”38
Such clashes in interpretation cannot be reduced to theoretical conundrums but
impact lives in concrete ways. In a fascinating turn of events, Somali women in
Sweden who wished to perform a minor form of sunna circumcision that removes
essentially no tissue from the girls were bewildered to be told that this was illegal.
They found this hard to understand because pricking
1
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the clitoris to induce minor bleeding does not, generally speaking, lead to permanent
changes. Besides that, such a procedure is far less invasive than what is done to male infants
at Swedish hospitals during male circumcision and what is permitted on young women who
have their genitals pierced, as well as on women who go through genital plastic surgery. In
a strictly medical sense, then, there is no reasonable motive to forbid pricking girls’ genitalia while permitting male circumcision, genital plastic surgery, and genital piercing for
aesthetic or erotic reasons.39
Thus, the equal protection puzzle has gotten one step more bizarre. To paraphrase
Orwell, it is no longer simply “cut male genitalia good, cut female genitalia bad,”
but rather now, “cut male genitalia good, cut Western female genitalia also good,
cut African female genitalia bad.”
Ahmadu, born in Sierra Leone and educated in the US, who returned to her
homeland for a circumcision as an adult, is perhaps the person best positioned to
comment on such disjunctions: “[T]he greatest irony of all is the increasing number
of clinical female genital surgeries performed on women in the West for cultural
reasons when the same are condemned for African women because ‘culture is no
excuse for mutilation.’”40 Sally Sheldon and Stephen Wilkinson cogently ask if
this differential treatment of FGC and cosmetic genital surgery can be justified.
The authors propose several possible theories for distinguishing the two—consent,
oppressiveness, injury, and offensiveness of the practices—and, one by one, demolish each of them. They conclude that each reduces to cultural privileging of certain
practices over others.41 Lois Bibbings argues, reasonably enough, that: . . .any legal
regulation of body-altering practices should be consistent. In addition if restrictions
are to be imposed they should be constructed according to valid health concerns
and should treat the practices according to the risks involved, rather than merely
enforcing dominant notions of the acceptable body.”42
The parameters of the issues discussed often predetermine the conclusions
reached. As Fox and Thomson note, pain is often entirely omitted from the discussion of MGC’s effects. Astoundingly, even Fox and Thomson neglect any discussion
of loss of tissue, inadvertently following in the path of countless prior authors, who
limit themselves to toting up “risks” v. “benefits.” If, as Fox and Thomson argue,
the male body in general is regarded as less susceptible to injury than the female,
the penis seems to be the most invulnerable part of all, nearly any injury to which
(short of amputation) is construed as harmless. As Juliet Richters points out, dulling
ourselves to the harm caused by loss of the foreskin is facilitated by conceiving
of the penis as a battering ram (rock-hard and actively “masculine”), not an organ
expected to receive pleasurable sensation (potentially implying softness and passive “femininity”).43 Margaret Somerville astutely observes that, while we would
be shocked by the notion of amputating girls’ breasts to protect against later breast
cancer, as a society we accept the idea of removing the foreskin as a prophylactic
against cancer of the penis or HIV. The reason is simple.
[W]e value breasts—we see it as a serious harm to women to lose them—and we do not
value foreskins, in fact they are often devalued—spoken of as ugly, unaesthetic and unclean.
Yet both are part of the intact human body, and both have sexual and other functions.44
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J.S. Svoboda
The evidence thought to show a “potential health benefit” for MGC may in fact
be an artifact of its cultural acceptability and long history in American society. As
Miller45 and Waldeck46 have eloquently argued, MGC in the United States, despite
the hospital setting, is more of a cultural ritual than a health measure, as most parents
agree to the operation out of habit [and based on social mandates], because other
parents agree to it, because they are accustomed to the appearance of the cut penis,
and because they do not want their boys to look different.
Regardless of one’s views about adults, one tends to see male babies and female
babies as both equally innocent and equally vulnerable. It is now evident that
activists against FGC agree on this point. In July 2008, I was in the audience at
a London press conference as Efua Dorkenoo frankly told us that she wholeheartedly supported the genital integrity movement, and that the anti-FGC movement had
simply made a strategic decision not to openly support intactivism as doing so would
make protection of females harder. Two months later, on the eve of the symposium
at which this talk was presented, two prominent UK organizations that hitherto have
labored on opposite gender sides of the genital integrity battlefront, FORWARD and
NOHARM-UK, launched a new joint campaign promoting the right of all men and
women to say no to unnecessary genital surgery. This is a landmark development. At
the press conference announcing this collaboration, FORWARD echoed Dorkenoo
in noting that in the 1980s, the anti-FGC movement made a strategic decision not
to support intactivism. FORWARD affirmed that male genital integrity is equal in
importance to female genital integrity.
Today the most striking asymmetries between male and female genital cutting
lie in the fact that powerful international agencies are promoting the first as a
“scientifically proven” health precaution while campaigning against the latter as
a significant threat to health. The UNAIDS and WHO have failed to acknowledge
the well-established fact that rates of new HIV infection have been declining for
over a decade as the disease comes under increased control. AIDS is not, and never
will be, a critical public health problem in developed countries, where the disease
remains largely confined to the traditional sub-cultures: gay men and intravenous
drug users.47 Even if the African studies are valid, their results are totally inapplicable to the developed world because the virus is a different strain, and because of
radical differences in methods of transmission and in access to education, hygiene,
and healthcare. Moreover, Lawrence Green et al., showed in Future HIV Therapy
that, relative to circumcision, condoms are 95 times more cost-effective at preventing HIV. Posing circumcision as a vaccine may make it easier to compel its adoption,
though as we move closer and closer to a genuine vaccine against HIV, they also may
highlight the utter failure of this fanciful metaphor.48
And compelling its adoption is exactly the goal the US Centers for Disease
Control (CDC) has, until recently, been vigorously pursuing. However, due to the
worldwide pro-intact trends in media statements and popular opinion regarding
intact rights, in September 2009 the CDC found itself forced to issue a statement
on its website affirming its commitment to hearing both sides of the issue.49 To
date, this promise remains unfulfilled. Only one token representative of intact rights
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has had any participation in the CDC’s process, while it has consulted a panoply of
“experts” with anti-foreskin views.
CDC edicts tend to be faithfully followed by US doctors and hospitals. If the
CDC were to issue a pro-circumcision recommendation, circumcision could go the
route of Hepatitis B vaccines in the US. After the CDC recommended that the first
Hepatitis B shot be given to newborns while still in hospital (despite the fact that the
virus is sexually transmitted and thus newborns are not at risk unless their mother is
positive). Nurses and doctors then virally passed on the CDC recommendations to
parents, to the point where today parents are informed at the hospital that a Hepatitis
B shot is required, and all US newborns receive the shot more or less automatically right after birth. If this dire scenario came to pass with MGC, it would mean
that circumcision would once again predominate among the vast majority of US
newborns.
Commonalities between the very diverse cultures that practice genital cutting are
astonishing. In a study by Reed Riner of 144 pre-industrial cultures, genital cutting
was performed in 23. Of the 23, some cultures cut the genitals of both boys and girls,
or boys but not girls, but not a single culture cut girls and not boys. “This suggests,”
Riner comments, “that female genital modification is somehow dependent on the
cultural presence of male genital modification, and that if we explain the latter we
have, for the most part, explained the former.”50 Clearly a powerful process of association is at work, contradicting current legal and popular conceptions of FGC and
MGC as radically different phenomena.
All of these 23 cutting cultures, without exception, and none of the 121 nonpracticing cultures, can be described, to quote another observer’s formulation,
as subsistence “societies with powerful and sometimes massive fraternal interest
groups, chronic internal warfare and feuds, and tight contractual control over women
and marriage.”51 Cutting cultures invariably provide special training in aggression,
in the manly behaviors associated with warfare, and the male role, for the boys.
MGC thus represents a permanent, dramatic, bloody, public ritual of submission
of the individual to the group, of the father to his “fathers.” Along similar lines,
Hellsten observed that all forms of genital cutting are derived from ideas of the
place of human sexuality in society, are intended to alter sexual function in some
way, and are performed in the belief that the procedure—no matter how physically
injurious—will in some way improve the subject’s life.52
In our society, circumcision’s popularity may have been facilitated by our tendency to solve problems by cutting things, often by cutting things out.53 Episiotomy,
circumcision, and Caesarian sections are the most common forms of cutting, and all
involve the genital tract. As famed anti-FGC activist Hanny Lightfoot-Klein demonstrated, parallel justifications buttress alteration of male genitals and of female,
including claimed enhancement of physical beauty, medical reasons, improving
sex, asserted universality, as an initiation rite, cleanliness, religion, and looking like
other modified humans. Similarly, Dr. Robert S. Van Howe observes that “the reasons cited by families for altering the genitalia of their children are nearly identical
whether it is a girl in Africa or a boy in the United States,” namely, “cleanliness,
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J.S. Svoboda
preventing illness, religion, looking like other children or like their parents, fear
of promiscuity, and acceptance of the altered genitalia as more attractive by the
opposite sex.”54 As Henrietta Moore aptly summarizes matters, “The West, it turns
out, has culture like everyone else.”55
In a recent article summarizing these issues inadvertently, as it were, famed
author and new mother Erica Jong lays out her numerous “misgivings about circumcision,” but nevertheless in the end, offering no explanation, she allows her son’s
genital cutting to proceed against her own instincts. “Don’t mark him! I wanted to
shout, but instead I laughed hysterically at all the mohel’s jokes.”56 We cannot help
but note Jong’s fascinating yet chilling mention of “hysteria,” a word that is etymologically and subconsciously related to hystera (womb) and thus to hysterectomy,
itself another excision of a sexual organ to solve a perceived social problem and a
procedure that is often unnecessary.
The truth comes out. Regardless of the efforts of those who would keep it in,
sooner or later, human compassion comes into full play, and the truth comes out.
Notes
1. Waldeck S. (2003) Using circumcision to understand social norms as multipliers. Univ
Cincinnati Law Rev. 72:455–526 (citing Stein et al. 1982).
2. Scott S. (2006) Circumcision mythologies in conflict with logic, reason, and common sense.
Presented at Ninth International Symposium on Circumcision, Genital Integrity, and Human
Rights, Seattle.
3. Svoboda JS. (2001) The limits of the law: Comparative analysis of legal and extralegal methods to control child body mutilation practices. In: Denniston GC, Hodges FM, Milos MF.
(eds.) Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional
Problem. London: Kluwer Academic/Plenum Press.
4. Paige KE, Paige JM. (1981) The Politics of Reproductive Ritual. Berkeley, CA: University of
California Press, p 149.
5. Ford K-K. (2000–2001) ‘First, do no harm’—The fiction of legal parental consent to genitalnormalizing surgery on intersexed infants. Yale Law Rev. 19:469–488 [here, p 477].
6. Prescott JW. (1989) Genital pain v. genital pleasure—Why the one and not the other? Truth
Seeker. 1(3):14–21.
7. Voskuil D. (1994) From genetic cosmology to genital cosmetics: Origin theories of
the righting rites of male circumcision. Presented at Third International Symposium on
Circumcision, College Park, Maryland [cited November 12, 2009]. Available at URL:
www.nocirc.org/symposia/third/voskuil.html
8. Romberg R. (2005) Male circumcision as a feminist issue [cited November 12, 2009].
Available at URL: www.noharmm.org/feminist.htm
9. Bettelheim B. (1965) Symbolic wounds. In: Lessa WA, Vogt EZ. (eds.) Reader in
Comparative Religion. New York, NY: Harper & Row, pp 237–238.
10. Brown S.G.A. (1896–1897) The mosaic rite of circumcision: A plea for its performance
during childhood. J Orificial Surg. 5:299–304.
11. Morris B. (2007) Circumcision: An evidence-based appraisal. Bioessays. 29:1147–1158.
12. Svoboda JS, Darby R. (2009) A rose by any other name?—Symmetry and asymmetry in male
and female genital cutting. In: Zabus C. (ed.) Fearful Symmetries: Essays and Testimonies
Around Excision and Circumcision. Amsterdam and New York, NY: Rodopi, pp 251–297.
13. United Nations Commission of Experts’ Final Report. (1994) UN Doc. No. S/1994/674
(1994), section IV.F
1
11
14. United Nations. (2002) Fourth Report on War Crimes in the Former Yugoslavia (Part II):
Torture of Prisoners [cited November 12, 2009]. Available at URL: www.ess.uwe.
ac.uk/documents/sdrpt4b.htm
15. Written statement submitted by the National Organization of Circumcision Information
Resource Centers (NOCIRC), a non-governmental organization on the Roster. (2002) [cited
November 12, 2009]. UN Doc. No. E/CN.4/Sub.2/2002/NGO/1. Available at URL: www.
unhchr.ch/Huridocda/Huridoca.nsf/(Symbol)/E.CN.4.Sub.2.2002NGO.1.En?Opendocument
16. In the Matter of the Marriage of Boldt and Boldt. (2008) Oregon Supreme Court
Case No. S054714 [cited November 12, 2009]. Available at URL: www.publications.
ojd.state.or.us/S054714.htm
17. Geisheker J. (2009) Boldt case update. Atty Rights Child Newslett. 7(3):8–9 [here, p 8].
18. Geisheker J. (2008) Special section—Boldt case commentary. Atty Rights Child Newslett.
6(3):6.
19. Smith J. (1998) Male circumcision and the rights of the child. In: Bulterman M, Hendriks A,
Smith J. (eds.) To Baehr in Our Minds: Essays in Human Rights from the Heart of
the Netherlands. Utrecht: Netherlands Institute of Human Rights (SIM Special No. 21),
pp 465–498 [cited November 12, 2009]. Available at URL: http://www.cirp.org/library/
legal/smith/
20. Tasmania Law Reform Institute. (2009) Issues Paper 14: Non-Therapeutic Male Circumcision
[cited November 12, 2009]. Available at URL: http://www.law.utas.edu.au/reform/
malecircumcision.htm
21. Svoboda JS. (2006) Genital integrity and gender equity. In: Denniston GC, Gallo PG,
Hodges FM, Milos MF, and Viviani F. (eds.) Bodily Integrity and the Politics of
Circumcision—Culture, Controversy, and Change. New York, NY: Springer, pp 149–164.
22. Svoboda JS, Darby R. (2009) A rose by any other name?—Symmetry and asymmetry
in male and female genital cutting. In: Zabus C. (ed.) Fearful Symmetries: Essays and
Testimonies Around Excision and Circumcision. Amsterdam and New York, NY: Rodopi,
pp 251–297.
23. Povenmire R. (1998) Do parents have the legal authority to consent to the surgical amputation
of normal, healthy tissue from their infant children? J Gend Soc Policy Law. 7:7–123.
24. Bond SL. (1999) State laws criminalizing female circumcision: A violation of the equal
protection clause of the fourteenth amendment. John Marshall Law Rev. 32:353–380.
25. Smith J. (1998) Male circumcision and the rights of the child. In: Bulterman M, Hendriks A,
Smith J. (eds.) To Baehr in Our Minds: Essays in Human Rights from the Heart of
the Netherlands. Utrecht: Netherlands Institute of Human Rights (SIM Special No. 21),
pp 465–498 [cited November 12, 2009]. Available at URL: www.cirp.org/library/legal/smith/
26. Davis DS. (2006) Genital alteration of female minors. In: Benatar D. (ed.) Cutting to the
Core: Exploring the Ethics of Contested Surgeries. Oxford: Rowman & Littlefield Publishers,
pp 63–75. Davis also finds a violation of free association under the First Amendment, in that
some religions’ practices are lawful and other religions’ practices are criminalized.
27. Hellsten S. (2004) Rationalising circumcision: From tradition to fashion, from public health
to individual freedom—Critical notes on the cultural persistence of the practice of genital
mutilation. J Med Ethics. 30:248–253.
28. Bell K. (2005) Genital cutting and Western discourses on sexuality. Med Anthropol Quart.
19(2):125–148 [here, p 131].
29. Carpenter RC. (2004) A response to Bronwyn Winter, Denise Thompson and Sheila Jeffreys,
‘The UN approach to harmful traditional practices: Some conceptual problems’: Some other
conceptual problems. Int Fem J Polit. 6:2:308–313 [here, p 309].
30. El Guindi F. (2007) Had this been your face, would you leave it as is—Female circumcision
among the Nubians of Egypt. In: Abusharaf RM. (ed.) Female Circumcision: Multicultural
Perspectives. Philadelphia, PA: University of Pennsylvania Press, pp 27–46 [here, p 42].
31. Boddy J. (2007) Gender crusades: The female circumcision controversy in cultural perspective. In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting in
Global Context. New Brunswick, NJ: Rutgers University Press, pp 46–66.
12
J.S. Svoboda
32. Fox M, Thompson M. (2005) A covenant with the status quo: Male circumcision and the new
BMA guidance to doctors. J Med Ethics. 31:463–469 [here, p 467].
33. Aldeeb Abu-Sahlieh SA. (2007) Male and female circumcision: The myth of the difference.
In: Abusharaf RM. (ed.) Female Circumcision: Multicultural Perspectives. Philadelphia, PA:
University of Pennsylvania Press, pp 47–72 [here, p 72].
34. Macklin A. (2007) The double-edged sword: Using the criminal law against female genital mutilation in Canada. In: Abusharaf RM. (ed.) Female Circumcision: Multicultural
Perspectives. Philadelphia, PA: University of Pennsylvania Press, pp 207–223 [here,
pp 211–212].
35. Mason C. (2001) Exorcising excision: Medico–legal issues arising from male and female
genital surgery in Australia. J Law Med. 9:58–67 [here, p 67].
36. Bell K. (2005) Genital cutting and western discourses on sexuality. Med Anthropol Quart.
19(2):125–148 [here, p 130].
37. Hernlund Y, Shell-Duncan B. (2007) Transcultural positions: Negotiating rights and culture. In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting
in Global Context. New Brunswick, NJ: Rutgers University Press, pp 1–45 [here, p 19].
38. Ahmadu F. (2007) Ain’t I a woman too? Challenging myths of sexual dysfunction in circumcised women. In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital
Cutting in Global Context. New Brunswick, NJ: Rutgers University Press, pp 278–310 [here,
p 284].
39. Johnsdotter S. (2007) Persistence of tradition or reassessment of cultural practices in exile? In:
Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting in Global
Context. New Brunswick, NJ: Rutgers University Press, pp 107–134 [here, p 126].
40. Ahmadu F. (2007) Ain’t I a woman too? Challenging myths of sexual dysfunction in circumcised women. In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital
Cutting in Global Context. New Brunswick, NJ: Rutgers University Press, pp 278–310 [here,
p 285].
41. Sheldon S, Wilkinson S. (1998) Female genital mutilation and cosmetic surgery: Regulating
non-therapeutic body modification. Bioethics. 12(4):263–285.
42. Bibbings L. (1996) Touch: Socio-cultural attitudes and legal responses to body alteration. In:
Bentley L, Flynn L. (eds.) Law and the Sense. London: Pluto, pp 176–198 [here, p 188].
43. Richters J. (2006) Circumcision and the Socially Imagined Sexual Body. Health Sociol Rev.
15:248–257.
44. Somerville M. (2000) The Ethical Canary: Science, Society and the Human Spirit. Toronto,
ON: Viking, p 204.
45. Miller G. (2002) Circumcision: Cultural-Legal Analysis. Va J Soc Policy Law. 9:497–585.
46. Waldeck S. (2003) Using circumcision to understand social norms as multipliers. Univ
Cincinnati Law Rev. 72:455–526.
47. See Chin J. (2007) The Aids Pandemic: The Collision of Epidemiology with Political
Correctness. Oxford: Radcliffe Publishing.
48. HIV Vaccine Trials Network. (2009) AIDS Vaccine Study Reassures Skeptics [cited
November 12, 2009]. Available at URL: www.hvtn.org/media/news.html#thailand
49. Centers for Disease Control and Prevention. (2009) Status of CDC Male Circumcision
Recommendations [cited November 12, 2009]. Available at URL: www.cdc.gov/hiv/
topics/research/male-circumcision.htm
50. Riner RD. (1989) Circumcision: A riddle of American culture. Presented at First International
Symposium on Circumcision, Anaheim, CA. [cited November 12, 2009]. Available at URL:
www.nocirc.org/symposia/first/riner.htm
51. Paige KE, Paige JM. (1981) The Politics of Reproductive Ritual. Berkeley, CA: University of
California Press, p 123.
52. Hellsten S. (2004) Rationalising circumcision: From tradition to fashion, from public health
to individual freedom—Critical notes on the cultural persistence of the practice of genital
mutilation. J Med Ethics. 30:248–253 [here, pp 249–250].
1
13
53. Noble E. (1991) Just say no: Issues of empowerment. Presented at Second International
Symposium on Circumcision, San Francisco, CA. [cited November 12, 2009]. Available at
URL: www.nocirc.org/symposia/second/noble.html
54. Hernlund Y, Shell-Duncan B. (2007) Transcultural positions: Negotiating rights and culture. In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting
in Global Context. New Brunswick, NJ: Rutgers University Press, pp 1–45 [here, p 19].
55. Hernlund Y, Shell-Duncan B. (2007) The failure of pluralism? In: Shell-Duncan B,
Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting in Global Context. New
Brunswick, NJ: Rutgers University Press, pp 311–330 [here, p 311]
56. Jong E. (2008) Next time boychick, we take the whole thing. Huffington Post [cited November
12, 2009]. Available at URL: www.huffingtonpost.com/erica-jong/next-time-boychick-wetak 1_b_83994.html
Chapter 2
Older Minors and Circumcision: Questioning
the Limits of Religious Actions
Marie Fox and Michael Thomson
Abstract On two occasions the Court of Appeal in England has addressed the legality of non-therapeutic circumcision performed on a minor unable to provide consent.
Both cases involved disputes in post-separation families where one parent sought a
male child’s circumcision against the wishes of the other parent. In January 2008,
the Supreme Court of Oregon was faced with a similar factual situation in the case
of Boldt v Boldt. However, the boy at the center of the dispute in Boldt was significantly older than in the English cases. The Supreme Court therefore concluded
that the testimony of the boy himself, who is now 13, was required and remanded
the case for a re-hearing in order that the trial court could specifically address his
wishes with regard to circumcision. In this paper, we offer a critique of the Oregon
Court’s somewhat elliptical reasoning in the Boldt case. We argue that cases involving male circumcision of older children raise important ethico-legal issues, which
the Boldt judgments gloss over, and which English courts have yet to confront in the
context of circumcision. Consequently, our aim in this paper is to use Boldt as a lens
through which to explore and inform UK practice. We argue that this case fits into a
characteristic pattern according to which judges, law makers, and professional bodies shy away from confronting key ethico-legal questions raised by the tolerance in
Anglo-American society of non-therapeutic genital cutting of male infants. In raising explicitly for the first time the position of older minors, the factual situation in
Boldt affords us an opportunity to begin to address the limits of parents’ rights to
determine the future religious identity of their children. In seeking to analyze how
Boldt and the questions to which it gives rise might inform UK law we focus on
three issues. The first is the right of the boy at the center of the dispute to determine which medical treatments or interventions to his body are permissible. The
M. Thomson (B)
School of Law, University of Keele, Staffordshire, UK
This paper, presented at the Keele University Symposium on Circumcision, Genital Integrity, and
Human Rights (September 2008), was first published in Medical Law International, 2008, Vol. 9,
pp 283–310 © 2008 A B Academic Publishers. It is edited here for inclusion in the publication of
our symposium papers.
15
16
M. Fox and M. Thomson
father’s subsequent petitions for reconsideration and for certiorari mean that, when
the boy’s testimony is finally heard by a court, it is likely that he will be 14 or 15
years of age. We aim to assess how a UK court might respond if faced with the task
of determining whether a minor could choose circumcision for himself in such a
scenario. A subsidiary question here is the extent to which circumcision procedures
are appropriately categorized as “medical treatment.” Finally, we offer some more
tentative thoughts on what limits may legitimately be placed on parental rights to
make choices for their children when their choices are motivated by religious belief.
Keywords Informed consent · Law · Human rights · Medical ethics · Male
circumcision
Introduction
In the UK, a very limited body of case law has addressed the legality of male circumcision. The issue has been confronted explicitly only in the context of disputes
about the practice in post-separation families. Thus in two appellate level cases UK
courts have been required to intervene where one parent—motivated by an understanding of the requirements of religious observance—has expressed an intention to
circumcise a minor against the wishes of the other parent.1 In both cases the Court
of Appeal emphasized that such an “important” and “irreversible”2 decision should
not be taken against the wishes of one parent, and ruled that the children concerned
should not be circumcised. This position is also adopted in the British Medical
Association’s guidance on the issue, which stresses that “where a child has two
parents with parental responsibility, doctors considering circumcising a child must
satisfy themselves that both have given valid consent.”3 Where healthcare providers
are aware of a conflict the issue must be referred to the High Court.4
The focus of our work on circumcision to date has considered secular and
non-therapeutic neonatal circumcision—that is, those neonatal circumcisions that
express non-religious parental choices. This work has been informed by feminist
ethics, which values bodily integrity and embodied choices, and adopts the position
that the legal status of non-therapeutic circumcision is less legally clear cut than is
often assumed. In earlier work, and in the context of non-religious practice, we have
questioned the extent to which courts and professional guidance have adopted an
unduly narrow focus and sidestepped the fundamental issue of whether circumcision can ever be regarded as in the best interests of a child when not therapeutically
indicated.5 Sherry Colb has observed that it is only parental conflict that “allows
scrutiny of practices that would ordinarily go unexamined and permits us to ask a
question that we usually refrain from asking: Is circumcision in the best interests of
the child?”6 We would argue that her observation is equally applicable to UK law.
Notwithstanding the dominance of the best interests standard in UK child law and its
statutory enshrinement in s 1(1) of the Children Act 19897 pervasive common sense
notions that male circumcision is a routine, accepted and safe procedure8 mean that
the question Colb poses rarely surfaces explicitly.
2
Older Minors and Circumcision: Questioning the Limits of Religious Actions
17
Colb’s point is exemplified in the leading UK case, which concerned a dispute
over a 5-year-old boy. His father—a non-practicing Turkish Muslim—wanted J to
be circumcised so as to identify him with his father and confirm him as a Muslim.
Having considered J’s probable upbringing, the Court of Appeal concluded that J
should not be circumcised because he was not, and nor was he likely to be, brought
up in the Muslim religion. Rather he had a mixed heritage and “an essentially secular
upbringing”9 and was unlikely to have such a degree of involvement with Muslims
as to justify circumcising him for social reasons. Wall J. consequently ruled that
“The strained relationship between the parents, and the fact that as a circumcised
child J would be unlike most of his peers, increases the risk that J will suffer
from adverse psychological effects from being circumcised.”10 However, the judge
accepted that the position was different where the parents were in agreement that
the procedure be performed, notwithstanding his acknowledgement that “a case can
be made for describing ritual male circumcision without any medical need for it as
an assault on the bodily integrity of the child.”11 We argue that the court’s implicit
assumption that where the family unit is intact the parents are best placed to decide
is problematic. Given the tacit nature of this acceptance, it is perhaps unnecessary to
add that the court failed to set out the parameters of this parental liberty or impose
any limitations on it.
The recent US decision by the Oregon Supreme Court in the case of Boldt v
Boldt12 has prompted us to re-visit this fundamental issue of where appropriate limits may be placed on the exercise of parental rights to choose this procedure. Male
circumcision is a contentious practice, which raises a host of ethico-legal concerns.
The questions it prompts include, on what basis, if any, should elective surgery with
its accompanying risks be carried out on healthy children? How are the risks and
benefits of surgery to be calculated and to what extent, if at all, may documented
medical risks be outweighed by putative social or cultural benefits, such as a sense of
community or religious belonging? In deciding on surgical modification, how much
value should be accorded to the notion of bodily integrity? Whose views should prevail when parents or those with parental responsibility disagree? In a multi-cultural
society how far should religious practices be open to critical scrutiny, and what role,
if any, should law play in scrutinizing choices made on the basis of religious belief?
Clearly we cannot hope to do justice to such wide-ranging concerns within the compass of this paper. However, we argue that it is indefensible that courts on both sides
of the Atlantic entrusted with resolving these disputes on the basis of the child’s best
interests consistently downplay or ignore such questions. In particular, we contend
that it is problematic for the Oregon Supreme Court to wholly disregard the central
issue of what precisely is so compelling about religious beliefs that, prima facie,
they seem to allow parents to choose non-therapeutic procedures that require their
child to run risks and suffer pain, in order to excise healthy tissue for no proven
health benefit?13 Scant attention has been accorded to this issue in the two English
decisions, although we shall argue that in comparison to the US position, English
law, while far from satisfactory, does at least offer greater safeguards to protect the
minor’s decision-making power over his body.
In seeking to analyze how Boldt and the questions to which it gives rise might
inform UK law, we are concerned with three particular issues. The first is the right
18
of the boy at the center of the dispute to determine which medical treatments or
interventions to his body are permissible. Petitions by the father for reconsideration
and for certiorari, which have now been denied, mean that when the boy’s testimony is finally heard by a court it is likely that he will be 14 or 15 years of age. We
aim to assess how a UK court might respond if faced with the task of determining
whether a minor could choose for himself in such a scenario. Specifically, given that
this case concerns a minor on the threshold of adolescence, our aim is not to question legal responses to religious circumcision per se, but rather to consider at what
point a minor may be entrusted with the decision himself. A subsidiary and linked
question here is the extent to which circumcision procedures are appropriately categorized as “medical treatment.” Finally, we offer some more tentative thoughts on
what limits may legitimately be placed on parental rights to make choices for their
children when those choices are motivated by religious belief, and would entail surgical alteration. We examine the efforts of legal scholars who have attempted to
formulate a framework to guide such balancing exercises. However, the problems
which bedevil such accounts lead us to confine our exploration here to the narrower
question of how the interests of religious parents can be balanced with the developing interests of a minor who is sufficiently mature to understand the procedure and
its effects—both real and potential—on his embodied choices.14
In beginning our exploration of circumcision as an aspect of faith and how this
marries with values that Anglo-American law claims to embody, such as respect
for autonomy and bodily integrity, we start by outlining the Oregon case in order to
explore the degree to which the case extends some of the issues raised in the English
case law. It should be stressed that we are not offering a comparative analysis.
Rather Boldt is being relied upon as a factual situation, which foregrounds questions English law has yet to address in this context.15 The analysis we offer focuses
on omissions in the reasoning of the Oregon courts. Finally, we address how the
judgment in the second of the two English cases—Re S—may sketch a way forward
for the balancing of children’s rights and the collective religious or cultural interests
of communities. In addressing this balancing or negotiation of interests, our starting
point is a desire to reach decisions that will promote so far as possible the interests and autonomy of minors. To that end, in balancing the individual and collective
interests at stake, we attempt to respond to a question posed by Priscilla Alderson
when considering “who should decide and how” regarding surgical interventions on
children. She poses the crucial question, “could we promote more just, benign, and
efficacious ways of making decisions about surgically shaping children?”16
Boldt: Disputing Custody
On 25 January 2008, the Supreme Court of Oregon reversed an earlier decision
of the Court of Appeals and the judgment of the circuit court and remanded
back to Jackson County Circuit Court the case of Boldt v Boldt. Specifically, the
Supreme Court required the lower court to resolve the factual issue of whether
Misha, the 12-year-old son of the estranged parties to the action, consented to the
2
19
circumcision, which lay at the heart of the dispute. Although the circumcision
procedure constituted only part of an ongoing custody battle in the Oregon case,
Boldt nevertheless replicates aspects of the UK case law, particularly given the
nature of the parties’ religious commitment. During the parties’ marriage, Misha
was raised in the mother’s faith as a member of the Russian Orthodox Church.
On dissolution of the marriage the father converted to Judaism under the United
Synagogue of Conservative Judaism. Having informed Misha’s mother of his own
conversion, he raised with her the possibility that the boy, who resided with his
father, would also convert and the necessity of circumcision in this event.
The protracted litigation in Boldt prompted a complex set of hearings and rulings. The particular dispute regarding Misha’s circumcision commenced on 1 June
2004. On that date, the mother filed a motion for a temporary restraining order to
prevent the father from having Misha circumcised that evening. In response, the
father (who was legally qualified and represented himself) asserted that as sole custodian he had the (sole) authority to make the decision. Further, he claimed that
Misha wanted the circumcision in order to convert to Judaism and that the boy’s
doctor had recommended the procedure for medical reasons, and was prepared to
perform the circumcision. In reply, the mother submitted an affidavit alleging that
the father intended to have Misha circumcised against the boy’s wishes and claiming
that Misha was afraid to contradict his father on the issue. She expressed concern
about the possibility of permanent injury to her son, and sought a change in custody
(supporting the ongoing action for such a change).
Responding, the father contended that the court lacked authority to grant the
mother’s motions, as it would breach his constitutionally protected freedom of
religion. He also denied that there had been the requisite substantial change of circumstances that would justify a change in custody, and claimed that such a change
would be contrary to Misha’s best interests in any event. He reiterated that surgery
was medically advisable independent of the religious justifications, and claimed that
although the child’s wishes were “legally irrelevant,”17 Misha wanted to be circumcised. In support of this final claim, he provided affidavits from his new domestic
partner and from Misha’s half-brother. An affidavit was also submitted from Misha’s
urologist, Dr Ellen, who stated that Misha understood the nature of the procedure
and did not appear to be coerced. The medic also pointed to medical concerns that
would justify the procedure, suggesting that Misha’s circumcision would greatly
reduce his risk of penile cancer and certain infections.
Following the filing of briefs and a hearing conducted by telephone, the court
concluded both that it had jurisdiction over the parties and (in sharp contrast to the
position in English law as outlined in Re J) that the decision whether a child should
have elective surgery was reserved to the custodial parent. Nevertheless, given that
the parties’ previous custody order appeals were still pending, the court prohibited
Misha’s circumcision until those appeals were decided. Finally, the court held that
the mother had not demonstrated sufficient grounds for an emergency change of
custody.
The form of the judgment was objected to by both parties. A further hearing was
conducted by telephone, which resulted in a supplemental judgment affirming the
20
court’s finding that his father’s decision to have Misha circumcised was not a change
of circumstances sufficient to trigger an evidentiary hearing. The mother further
appealed this supplemental judgment, leading to the Court of Appeals affirming
without opinion. The Supreme Court allowed review of this decision.
Concurring with the trial judge, the Supreme Court held that decisions regarding elective surgery for a child are reserved to the custodial parent. This supported
the father’s contention that his decision to circumcise was insufficient basis for
changing a custody order or holding an evidentiary hearing on the issue. In
his action, the father was joined by amicus curiae American Jewish Congress,
American Jewish Committee, Anti-Defamation League, and the Union of Orthodox
Jewish Congregations of America in support of the position that Misha’s attitude to the circumcision was “legally irrelevant.” In addition, the Court stated that
notwithstanding the extensive medical evidence, which both parties and amici had
presented (the mother and Doctors Opposing Circumcision noting “significant medical risks,”18 the father describing associated risks as de minimus19 ) the Court need
not decide which evidence regarding the attendant risks and benefits was more
persuasive. The Court concluded:
[A]lthough circumcision is an invasive medical procedure that results in permanent physical alteration of a body part and has attendant medical risks, the decision to have a male
child circumcised for medical or religious reasons is one that is commonly and historically
made by parents in the United States. We also conclude that the decision to circumcise a
male child is one that generally falls within a custodial parent’s authority, unfettered by a
noncustodial parent’s concerns or beliefs—medical, religious or otherwise.20
Consequently, it ruled that, had the mother asserted a change in circumstances
solely on the basis of her concerns or beliefs regarding circumcision this would
have been insufficient. However, her assertion that Misha himself objected to the
circumcision, prompted the Court to rule that:
In our view, at age 12, M’s attitude regarding circumcision, though not conclusive of the custody issue presented here, is a fact necessary to the determination of
whether mother has asserted a colorable claim of a change of circumstances sufficient to warrant a hearing concerning whether to change custody. That is so because
forcing M at age 12 to undergo the circumcision against his will could seriously
affect the relationship between M and father, and could have a pronounced effect on
father’s capability to properly care for M. . .. Thus if mother’s assertions are verified
the trial court would be entitled to reconsider custody.21
Ultimately, the case was remanded to the trial court in order to determine Misha’s
state of mind regarding the procedure. In the meantime the father issued petitions
which seek: first that the Supreme Court of Oregon re-consider its decision and
secondly, a Writ of Certiorari that the Supreme Court of the United States consider whether the Oregon Supreme Court’s decision violates the First Amendment
of the US Constitution (protecting free exercise of religion) and whether it violates the father’s parental rights, which are guaranteed by the Due Process Clause
of the Fourteenth Amendment to the US Constitution. In October 2008, these petitions were refused.22 Although no reasons were stated by the Supreme Court for
its refusal and the Boldt case undoubtedly raises important constitutional issues,
2
21
there is a general reluctance on the part of Federal courts to intervene in custody
disputes, which are left to individual States to determine23 When the case is eventually re-heard by the Jackson County Circuit court, should that court find that Misha
did oppose the procedure it would then have to determine whether his opposition
is such that it will affect his father’s ability to care for him properly. If necessary,
the court would then have to decide whether it would be in Misha’s best interests to
nevertheless retain the existing arrangement, or whether conditions would have to
be imposed on the father’s continued custody, or whether the court should order a
change in custody to the mother.
Hence, in view of Misha’s age, the Boldt case poses important questions, which
English courts have yet to confront in the circumcision context, particularly regarding the limits of parental decision-making powers over an older child. In this paper,
our focus is on the two novel issues that it raises—when the rights of older minors to
make embodied choices accrue? and what, if any, limits may law place on parental
rights to choose irreversible bodily interventions for their children? Although, as we
discuss below, these questions have arisen in UK courts in other contexts—such as
transplantation, blood transfusions, sterilization and abortion—they have not before
been raised in a circumcision case. For reasons that we outline below, this procedure
raises issues, which differ in significant respects from the earlier precedents. With
regard to both novel issues raised by Boldt, we suggest that the Oregon courts left a
number of important aspects of the case unexplored.
Acts and Omissions
We contend that Boldt v. Boldt is most insightfully read as a narrative characterized by omissions: the trial court omitted to ask Misha directly his wishes regarding
the circumcision or to determine whether he was competent to decide for himself;
at each level the judgments omitted any consideration of whether his circumcision
was therapeutic or non-therapeutic; similarly the judgments failed to carry out an
adequate cost/benefit assessment of claimed benefits and risks in order to determine whether performance of a (non-therapeutic) circumcision was in Misha’s best
interests, and finally each of the courts omitted to propose any limits on parental
decisions made in accordance with religious belief. Our primary concern for the
purposes of this paper is the omission to consult Misha or seek to determine his
capacity to reach this decision for himself.
Misha’s Wishes and Competence
Determining Misha’s state of mind regarding the circumcision appears to have been
an afterthought24 ; worthy of consideration only when the litigation reached the
Oregon Supreme Court. From a UK perspective, this complete disregard of the child
at the center of the dispute seems startling, given the boy’s relatively advanced age
and the emphasis placed by UK law on prior consent to medical treatment in order
22
to protect self determination and bodily integrity.25 The failure to consult Misha is
particularly surprising given the parents’ sharply divergent accounts of his views.
Moreover, it is difficult to reconcile with international standards, although it does
chime with the US failure to ratify the International Convention on the Rights of the
Child. Apart from Somalia, the US is the only nation that has yet to do so. Doris
Buss has argued that the US failure to ratify is motivated in part by Christian Right
fears that it will undermine parental rights by allowing States (or the UN) greater
freedom to intervene in families.26 Certainly, although one needs to be wary about
generalizing in relation to US law, the reasoning underpinning decisions reached in
US state courts suggest a reluctance to interfere with parental rights, and indicate
that US courts lag significantly behind the UK in their readiness to accept that children are not the property of their parents and have interests that are separable from
their parents. For instance, a 1990 Alaskan judgment contained the following dicta:
In such matters as deciding on the need for surgical or hospital treatment, the wishes of
young children are not consulted, nor their consent asked when they are old enough to give
expression thereto. The will of the parent is controlling, except in those extreme instances
where the state takes over to rescue the child from parental neglect or to save its life.
Similarly the right to grant or refuse a medical examination of a child belongs not to the
child but to the parents.27
In the light of such dicta, it is perhaps unsurprising that US courts should cling
to essentialist views that children are not to be entrusted with choices about medical
interventions, and that it is age rather than an enquiry into capacity that determines where the locus of decision-making power lies. By contrast, we share Sarah
Elliston’s view that determinations of capacity grounded in age alone are overly
crude, so that:
if respect for autonomy has the central value generally accorded to it in law and health
care. . . those who are capable of exercising it should not be denied the freedom to do so
simply because they have not met whatever age it is that is set for adulthood.28
The relevant UK case law that engages with the assessment of adolescent autonomy following Gillick29 has concerned minors aged between 14 and 17 who refuse
medical treatment. In a now extensive line of cases, the courts have been reluctant to spell out exactly what the minor in question should understand in order to be
deemed sufficiently mature to be entrusted with decision-making powers. The clearest attempt to do so remains a statement by Lord Scarman in Gillick itself, where
he refers to “the attainment by a child of an age of sufficient discretion to enable
him or her to exercise a wise choice in his or her own interests,”30 and to the minor
achieving “a sufficient intelligence to enable him or her to understand fully what is
proposed.”31 As Simon Lee has noted, this standard seems to set the threshold of
understanding so high that many adults would fail to satisfy the test.32 Perhaps it is
not surprising, then, that post-Gillick English law has consistently undermined the
choices of seemingly Gillick-competent adolescents aged 14–17, at least where they
refuse treatment.33 Michael Freeman has summarized the implications of this line
of case-law:
2
23
A child can say “yes” to medical treatment but cannot say “no.” This is the simple, indeed
trite, conclusion to which one comes after an examination of the cases.34
The facts of Boldt are therefore an interesting prompt to consider whether a UK
court might deem a 12- or 13-year-old competent to decide for himself whether
to undergo irreversible surgery that involves the removal of healthy tissue. In the
UK circumcision cases, the children involved were younger, allowing the courts to
assume that competence was not an issue. Given the complex nature of the risk
and benefits involved, this is supportable with regard to the 5-year-old subject of
Re J, but it is at least arguable that more attention should have been devoted to the
competence issue in Re S. Here, in relation to age, Baron J simply ruled that the
children—then aged ten and almost nine years of age—were “too young to seek to
favor one of their religions of origin in favor of the other.”35 It may well be true that
a choice about the practice of religion requires greater maturity than a nine-yearold child will typically possess, and it is understandable that judges should prefer
to engage with a definite criterion such as biological age. However, commentators
have argued persuasively that relevant experience of illness, treatment, or disability may be a more salient factor than age in the acquisition of competence.36 This
suggests that, in assessing competence, key factors are the situation in which children find themselves, how they are informed about the implications of a medical
procedure, and the support they receive in reaching a decision about it. Provided
such support is available, Alderson and Montgomery’s research with sick children
suggests that even children as young as five years old may be capable of reaching at least some health decisions for themselves.37 In the case of circumcision, as
recognized in Re J38 and the BMA’s 2006 guidance on the topic,39 the determination of best interests is complex, requiring medical risks to be weighed against
social and cultural benefits. Nevertheless, we would argue that some older minors
will be sufficiently mature to be entrusted with this decision themselves and that it
is incumbent on courts to attend to this possibility. Our contention is supported by
the ruling in Re S—that the decision should be deferred until the minor has attained
legal competence, when he should be permitted to reach his own informed decision
whether to be circumcised.40 We would argue that in reaching this conclusion the
Court of Appeal exhibits a more informed understanding of the implications of surgical interventions for the older child than the Oregon courts. In Re S, of course,
postponing the decision until the minor had attained capacity meant that the judges
did not have to grasp the nettle and engage in an assessment of the minor’s capacity
to decide about circumcision, though it did make it more likely that at some stage in
the future UK courts will be faced with a dispute similar to Boldt. It is our contention
that a UK court, faced with this issue, would, unlike the Oregon courts, be obliged
to assess the ability of the minor to decide for himself whether the circumcision
should proceed.
Yet, even if a 12- or 13-year-old was deemed Gillick-competent, we accept that it
would not necessarily follow that his wishes would be determinative—as the Oregon
Supreme Court makes clear. This is also the legal position in the UK, where three
of the most troubling English cases—Re E, Re S, and Re P41— have involved courts
24
over-ruling the refusal of treatment on the basis of the adolescent’s religious beliefs.
In each of these cases, the minors concerned seemed to possess the requisite maturity and understanding to decide for themselves, and were supported in their refusal
by their parents; yet their wishes were disregarded in each case. In Re P, for instance,
a 17-year-old’s refusal of blood products to treat his hypermobility syndrome was
overridden, albeit with reluctance, by Johnson J., who acknowledged that P was
almost an adult and that throughout his life he had been a “staunch and committed” Jehovah’s Witness.42 No justification is offered for disregarding the minor’s
wishes in the light of these findings. One possible (unarticulated) reason may, however, be an unwillingness to accept that a child raised in a religious household could
remain uninfluenced by such an upbringing. Such reasoning emerges more clearly
in the case of Re E, where Ward J. stated, of a case involving a refusal of blood
transfusions by a 15-year-old Jehovah’s Witness:
Without wishing to introduce into the case notions of undue influence, I find that
the influence of the teaching of the Jehovah’s Witnesses is strong and powerful. . .
I am far from satisfied that at the age of 15 his will is fully free. He may assert it, but
his volition has been conditioned by the very powerful expressions of faith to which
all members of the creed adhere.43
This observation supports Margaret Somerville’s argument in relation to a
comparable Canadian case:
In our turn-of-the-millennium secular societies, a young person’s maturity is often assessed
by how autonomous, independent, self determined and individualistic that person is. On
these criteria a child from a family such as the Duecks’ [who were committed Christians]
is unlikely to be found sufficiently mature to be held competent to consent to or refuse
treatment.44
In the refusal of medical treatment cases, therefore, a key difficulty in assessing
competence will be the complex judgment concerning the probable impact of the
child’s religious upbringing on his competence to make an informed choice.
Medical Evidence and the Therapeutic/Non-therapeutic
Boundary
Grounds clearly exist for distinguishing the Boldt scenario from cases involving
refusal of medical treatment by Jehovah’s Witness adolescents. The main distinction concerns the nature of medical evidence. In the refusal of treatment cases just
cited, the refusal by the minor was potentially life-threatening and clearly flew in
the face of well-substantiated medical evidence. The medical evidence in Boldt was
much less compelling, and we argue that the cursory and unchallenged account of
the medical evidence presented also fits into a familiar trajectory in debates about
circumcision. We have contended elsewhere that circumcision has long existed as a
procedure in search of a medical rationale.45 At different times, it has been promoted
as a remedy for alcoholism, epilepsy, asthma, curvature of the spine, paralysis, malnutrition, night terrors, clubfoot, eczema, convulsions, promiscuity, syphilis, and
2
25
cancer.46 These justifications have all been debunked, while contemporary efforts to
justify the practice have proven inconclusive and frequently are based on methodologies that have been contested.47 Only in very rare cases can circumcision be
categorized as therapeutic treatment and therefore the evidence cited by Dr. Ellen—,
“that M’s circumcision would greatly reduce M’s risk of penile cancer and certain
infections,”48 should not have gone unchallenged by the Oregon courts. While there
is some evidence that chances of contracting penile cancer are reduced by circumcision, such cancers are extremely rare and once the benefit is quantified it is likely
that it is outweighed by the direct and quantifiable risks of the procedure. Similarly,
Dr. Ellen’s extremely vague reference to risk of “certain infections,”49 seems to
hark back to (outdated) notions of the foreskin as unhygienic and a reservoir of
disease, which continue to re-surface periodically.50 No evidence is presented that
Misha suffered from any of the conditions—such as pathological phimosis, balanoposthitis and paraphimosis—which might indicate that a medical justification
for this procedure (or one of the non-surgical alternatives) in fact existed; with the
only evidence pointing to “glandular adhesions” on his penis. We speculate that if
the Oregon Supreme Court had considered critically the nature of the medical evidence it would have been forced to the conclusion that this procedure was in reality
being performed for non-therapeutic reasons.51
Clearly a determination that a procedure is non-therapeutic has legal effects.
We would suggest that in circumcision cases the first step should therefore be for
the judge to assess whether the procedure is therapeutic or non-therapeutic; and
to require much more compelling reasons for the determination that it is medically indicated than those advanced in Boldt. If it is accepted that surgery is
non-therapeutic, judges, in our view, should be reluctant to authorize the procedure
in the absence of clear evidence that it is sought by the minor. This contention seems
particularly compelling if any refusal or ambivalence on the part of the minor is supported by one of the parents. We accept that very different issues are raised where
the refusal is of life-saving treatment (although the line at which a refusal becomes
life-threatening is inevitably contested).52 UK case law states that tests of capacity will vary according to the gravity of the treatment proposed.53 While Elliston is
surely right to argue that it is “the complexity of the decision, rather than the gravity of the treatment or the outcome, which demands greater intellectual capacity and
discrimination,”54 the fact that a refusal of a circumcision is not life-threatening and
could always be revisited at a later stage supports our contention that the refusal of
such a procedure by a 12-year-old should be respected, as should any ambivalence
he displays.
As a result of its failure to specifically address Misha’s decision-making capacity, the Boldt judgment left open the question of whether it would be possible for a
parent to sanction the circumcision of a 12-year-old against his wishes. Although it
found that the boy should have been consulted, the judgment gave no indication that
his wishes would be determinative. Indeed, the judges seemed to implicitly accept
that electing to have a child circumcised is a legitimate parental action regardless of
the child’s wishes. If this is indeed true, when is parental choice limited by a minor’s
objections? At 14 or 15 years? English courts have only fleetingly addressed the
26
limits to a parent’s power to consent where procedures are non-therapeutic. In Re B
Lord Templeman stated that “sterilization of a girl under the age of 18 should only
be carried out with the leave of a High Court judge” with the parents being made
parties to the action if they wish to appear.55 In the case of Re P, where parents
opposed their 15-year-old daughter having an abortion on religious grounds, ButlerSloss J. directed that the pregnancy should be terminated in accordance with the
girl’s wishes notwithstanding an acknowledgement that “I must give great weight
to [the parents’] feelings. . . and I must take into account their deeply and sincerely
held religious objection. . .”56 By contrast, in none of the cases on non-therapeutic
circumcision have judges sought to place any limits on parental choices. However,
the fact that parental wishes cannot be determinative seems to be enshrined in the
BMA guidance, which notes that circumcision has medical and psychological risks
and that it is essential that the procedure is carried out only where it is demonstrably
in the child’s best interests.57 While stressing the importance of respecting parental
rights, the guidance pays considerable attention to how the child’s best interests are
to be assessed. It states unambiguously that parental preference alone is insufficient
to justify circumcision—parents must explain and justify their preference with reference to the child’s interests. Relying on its publication, Consent, rights and choices
in health care for children and young people,58 and thus offering a valuable insight
into guidelines for wider medical practice, the BMA provides a checklist of factors
that may be relevant to a best interests assessment for non-therapeutic circumcision. The criteria listed extend well beyond the medical and have an unambiguous
focus on the patient. The guidelines foreground the relevance of the patient’s own
wishes, feelings, and values; the patient’s ability to understand what is proposed
and weigh up the alternatives; and the patient’s potential to participate in the decision if provided with additional support or explanations.59 This emphasis on the
patient highlights the ethical desirability of patients being supported to make decisions about their own bodies where possible, rather than deferring to the judgments
of others, including their parents.
What if Misha Chose Circumcision?
As we have noted, UK case law addressing adolescent autonomy generally has been
concerned with refusal of treatment or procedures. This makes it intriguing to speculate on how a court would respond to a 12- (or 13- or 14-) year-old who purports
to consent to an invasive and irreversible procedure like circumcision. It follows
from our starting point, which seeks to promote autonomous decision-making that
an adolescent should be free to make this choice provided he is sufficiently mature
and well informed. In facilitating his decision-making, however, we think it would
be important to acknowledge that a minor caught up in such a custody dispute is
more likely to feel ambivalence than certainty about his decision. We also believe
a court should bear in mind that electing to undergo the procedure has irreversible
consequences, whereas refusing it does not. Whereas it would always be open to
an intact boy to elect to be circumcised in the future, the child who is circumcised
2
27
lacks any meaningful choice once he has attained competence.60 Thus, in an interesting reversal of the general position in English law, choosing the procedure would
seem to demand a higher level of competence than refusal, given the way that its
irreversibility limits future choices. As we discuss below, recognition of the implications of such a choice is one of the positive features of the judgments by the
English courts in the case of Re S.
Furthermore, given our argument that the proposed circumcision in Boldt was
non-therapeutic, such a choice seems more analogous to choosing other cosmetic
body modifications than consenting to medical treatment. This poses the question of
what, if anything, differentiates male circumcision from other bodily practices that
many jurisdictions, including the UK, do not allow minors to consent to until they
reach 16 or 18? Thus, for instance, no one under 18 can consent to be tattooed,61 and
under UK law even a competent adult woman is deemed unable to validly consent
to excision or other “mutilation” of her genitalia.62 Although it remains unclear
whether UK legislation permits women to consent to cosmetic surgery on their
genitalia,63 doctors in this jurisdiction would not accede to a request for transgender surgery from an adolescent.64 We would also question whether a girl under the
age of 16 would be able to validly elect surgery purely in order to have a “designer
vagina,” given the risks of such surgery.65 Nevertheless, given the hazy dividing
lines between cosmetic and reconstructive surgeries and the inadequate regulation
of private providers of various genital surgeries66 it is not inconceivable that such
procedures would be carried out privately. It is interesting therefore to speculate on
what approach a court might take in the event of litigation. We would suggest that, in
line with the legislative prohibition on tattooing, English courts would be reluctant
to find that a minor, however mature, could validly consent to such surgeries, even
though transgender surgery may be considered therapeutic. If we are correct in this
assertion, it begs the question of what, if anything would distinguish the choice of a
minor to be circumcised, other than a specific exemption for religious beliefs. Thus,
if the Boldt scenario were to arise in the UK, and a court found that, having reflected
carefully, the boy wanted to be circumcised, to permit such a choice the court would,
in our view, have to acknowledge a religious exemption to current criminal law standards. As we have noted, our starting position rooted in the promotion of adolescent
autonomy suggests that a free, persistent, and properly informed choice of circumcision by a competent 12- or 13-year-old merits respect. However, the complexities of
this decision, and analogies that may be drawn with other surgeries, some of which
are legally prohibited, leads us to argue that the field of consent to various forms of
bodily intervention and the age at which they may legitimately be chosen merits a
fuller policy consideration. Currently, under both common law and statute the regulation of a range of forms of bodily interventions varies considerably—ranging from
prohibition through oversight by a court to parental freedom to decide, and in our
view such inconsistency is undesirable. Yet the UK Government’s failure to revisit
the recommendations of the English Law Commission’s 1990 Consultation paper
on the issue suggests that little political will exists to do so.67 In the meantime we
would suggest that some form of court oversight is required when an older minor
presents for a non-therapeutic circumcision and that good ethical practice requires
28
a health professional to refer the decision to court.68 This at least means that the
minor’s understanding of the documented risks that accompany the procedure,69
and the pain that an adolescent is likely to experience,70 as well as his motivations,
can be fully examined.
Omitting Religious Freedoms
The complex nature of the decision-making in such cases is complicated further
when the religious rights of parents, accorded protection in the US under the First
Amendment to the Constitution and in the UK under the Human Rights Act 1998
by Article 9 of the ECHR, are at stake. As James Dwyer notes, “Many people,
including judges, find parents’ claims to exclusive child-rearing authority to be at
their most compelling when motivated by religious belief.”71 In common with the
other omissions we have identified, the Oregon Supreme Court side-stepped claims
regarding the father’s exercise of his protected religious beliefs and practices. The
father and amici argued that he had a “constitutionally protected right to circumcise
his son”72 grounded in circumcision’s fundamental and sacred place in the Jewish
tradition. The father further asserted that an evidentiary hearing would usurp the
role of the custodial parent and violate his constitutionally protected rights.73 The
Court explicitly accepted his contention regarding his rights as custodial parent, but
failed to address itself to the question of his First Amendment rights.
In accepting the primacy and exclusivity of the custodian parent’s authority and
in failing to consider the question of the father’s religious freedoms, the (expansive)
parameters of these rights and freedoms are left unclear. While we see the court’s
reluctance to engage with this issue as regrettable, once again it is understandable,
given the contested terrain it would require judges to negotiate. As Herrara notes,
in adjudicating disputes between the state and religiously-motivated parents over
medical treatment of their children:
From a legal perspective, there exists no consistent body of principles or precedent that the court might enforce. . . From an ethical standpoint, it is hard to think
of an action that the state might take that would not be problematic in light of its
competing responsibilities. Central among the state’s duties are the need to protect
the vulnerable and the need to protect the fragile structure of religious freedom.74
Since the balance between these values is so difficult to maintain it is unsurprising that judges want to duck the task of engaging in this exercise. Significantly, to
the extent that the judges and legal scholars have sought to articulate these competing responsibilities, it has once again been in the context of refusal of life saving
treatment by parents. Given this context, it is no surprise to find that the litigated
cases have concerned minority faiths rather than established ones like Christianity
or Judaism. Equally it is unsurprising that the outcome has been a judicial willingness to over-ride the beliefs of Jehovah’s Witnesses75 and members of the Amish
community.76 As Herrara states, the “most familiar conflicts involve families affiliated with Amish, Christian Science and Jehovah’s Witness religions.”77 In fact
this observation perhaps serves to question her assertion that religious freedom is
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“fragile,” since in Anglo-American law it seems it is only fragile where the religion
is not an established one, such as Christianity or Judaism. As Dwyer points out, in
fact when it comes to established religions their practices are typically construed as
simply not being harmful:
We commonly excuse parents, legally and morally, for inflicting upon their
children what most people would regard as harm, when parents act on the basis
of religious belief. While states have prosecuted some parents for causing their
children to die by failing to obtain necessary medical care, even though the parents had sincere religious objections to medical care, these cases represent only
the most extreme situation and mask a quite widespread but generally overlooked
phenomenon.78
Aside from refusal of life saving treatment, the only other context in which courts
have addressed the issue of parental rights to determine their children’s healthcare is where parents refuse to have their children vaccinated on religious grounds.
Here, as Silverman and May note, judges “have consistently held that public health
concerns override religious beliefs. . . [and] found it legitimate. . . to evaluate the sincerity, strength and religious basis of a person’s beliefs in deciding whether to grant
exemption from mandatory childhood vaccination.”79 Once again, it is notable that
parents who oppose immunization have tended not to belong to established faith
traditions,80 reinforcing the suspicion that law is less likely to protect the religious
beliefs of those whose faith community is not well settled in law.
A more intractable dilemma arises if one seeks to interrogate religious justifications for a procedure—such as male circumcision—which, in most cases, does not
pose a life-threatening risk and is practiced by well-established religious communities. Questioning the legitimacy of these procedures becomes still more difficult
where they are commonly and historically accepted to the point where, as Caroline
Bridge notes, they have become “almost part of the mainstream.”81 In this paper,
space precludes a full consideration of religious justifications for circumcision and
of the limits that may be placed on a parent’s right to vindicate their religious beliefs.
We do, however, endorse Dwyer’s argument that where religious beliefs are cited by
parents in healthcare cases, this often results in a failure to separate out the interests
involved in a way that would recognize the “separate personhood and distinct interests of children.”82 He notes that “lower federal and state courts have consistently
interpreted the Free Exercise Clause of the First Amendment to guarantee parents
a right to control the mental and physical lives of their children.”83 In our view,
Boldt certainly fits into this pattern whereby children seem to be treated in law as
objects rather than subjects.84 Yet, while we believe it is crucial to scrutinize the
limits of parental rights to surgically alter their children’s bodies on the basis of
religious beliefs, the dangers of addressing this question in the abstract are evident
in those rare articles where legal scholars have attempted to suggest ways of legally
regulating parental choices to circumcise male children.
At the outset, we suggested the desirability of formulating a framework within
which to consider limits to parental rights to choose for their children on the basis
of religious beliefs. Such a project is too ambitious to attempt within the space constraints here, so instead we limit ourselves to some thoughts on attempts by these
30
other scholars to do so. The most thoughtful attempt to frame a legal response to parents’ choice to circumcise their sons is provided by Margaret Somerville.85 We have
much sympathy with Somerville’s ethical stance, and with the difficulties of her
task, but here we use her framework to demonstrate how such attempts can lead to
problematic, and in all probability counter-productive, legal proposals. Somerville
suggests that “as our knowledge of the risks and harms of circumcision expands, the
range of circumstances in which undertaking routine circumcision on any child is a
breach of a reasonable standard of medical care also expands.”86 Having surveyed
Canadian law, which is similar to UK law in relevant respects,87 she concludes that,
given the limitations on parental rights to refuse treatment on religious grounds, “it
is far from clear that the parent’s right to freedom of religion would validate infant
male circumcision carried out for religious reasons,”88 and that circumcision would
often amount to assault. Turning to the limits the state might place on parents’ rights
to inscribe religious beliefs on the bodies of their children, Somerville proposes a
seven-stage framework for addressing the competing societal interests in promoting
religious freedom while protecting the rights of the vulnerable. Some of these proposals are eminently sensible—including her arguments that it is necessary to start
from the position of respecting religious beliefs; and that coercive methods to interfere with religious practices should not be used unless there is evidence that serious
harm to children cannot otherwise be avoided. However, others are more problematic. For instance, her proposal for religious exemptions to a general prohibition on
male circumcision,89 seems to contradict her earlier assertion that religious belief
cannot validate infant male circumcision. Similarly, Somerville contends that:
when infant male circumcision is carried out as an absolute religious obligation, the burden
of proof, which is usually on those carrying out infant male circumcision to show that the
surgical procedure is justified, would shift to those opposing it to show that it should be
prohibited.90
Leaving aside the inevitable quibbles about how an “absolute religious obligation” would be interpreted, this religious exemption and shift in the burden of proof
seems to confront us squarely with the very question the Boldt judgments ignored,
of what makes religious beliefs unique in that prima facie they can or should justify parents consenting to non-therapeutic procedures that require their child to run
risks and suffer pain, in order to excise healthy tissue for no health benefit?91 In a
UK context, Howard Gilbert has argued that the court in Re J erred in finding male
circumcision lawful. In his view, the ruling failed to protect a vulnerable class of
children and is inconsistent with the ECHR. In response, Gilbert proposes a range
of legislative “solutions”:
Parliament is faced with at least three possible options: (i) to prohibit male circumcision unless it is justified as medically necessary; (ii) ritual circumcision is only
to be carried out on a male who can give his lawful consent; (iii) ritual circumcision
is lawful provided it is carried out in accordance with the guidelines laid down by
Parliament [e.g. that the procedure be performed by a registered physician].92
As with Somerville’s mooted framework, there is a failure to adequately flesh out
how any of these schemes would work. More problematic is his invocation of the
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criminal law to ban the practice, which fails to acknowledge the ineffective history
of colonial attempts to stamp out circumcision in other countries. Such histories
show that attempts to outlaw common practices almost inevitably generates reactance that simply mobilizes support for the procedure amongst the communities
affected.93
These examples make us very conscious that to question whether limits should
be imposed on parental rights to choose circumcision can easily lead one to propose
sweeping, unworkable, or overly punitive recommendations. Thus, in recognition
of the fine line we are treading, we limit our analysis here to the narrower question
of what limits to religious expression might be suggested by the Boldt situation.
Specifically, and returning to where we started with Priscilla Alderson, how can we
promote more just and benign ways of making decisions about surgically shaping
children,94 particularly where those children are approaching the age at which they
can reach decisions for themselves? In the following section, we argue that where
the minor is competent to decide for himself he should be entrusted with the decision, and in the case of an older minor on the threshold of competence the decision
should be deferred until he has acquired sufficient maturity. This position goes some
way to answering Alderson’s question:
In cases of uncertainty and disagreement, are parents always the best choice makers?
Surgically shaping children throws into extra sharp relief questions about coercion, rights,
moral choice, and the “intimate family”. . .. But if parents override children’s reasonable
views about their own body, the family is hardly intimate in terms of loving equality.95
In arguing for the inclusion of older minors in the decision making process (or
indeed allowing competent minors to make the decision), we turn to a fuller consideration of the second of the two English cases to have considered circumcision
decision-making in the post-separation family.
Deciding with Older Minors
As in Re J and Boldt, Re S negotiated a dispute between parents, which stemmed in
part from the parent’s different religious traditions. While the marriage endured, the
children—a 10-year-old girl and 8-year-old boy—were brought up according to the
tenets of the Jain faith. Upon separation, a joint residence order was made, and the
High Court considered the mother’s application to circumcise the boy and convert
him and his sister to the Muslim faith. The application was opposed by the children’s
father, who was a Jain Hindu. The High Court judge, Baron J, whose ruling was
upheld by the Court of Appeal, seemingly based her refusal of the application in
part on the following finding:
The mother is a devout Muslim but she has put her religion in second place when it has
suited her. Her relationship with the father lasted from 1982 until 1998 and they continued
in the same household until 2002. Whilst living with the father the household style was not
Muslim but predominantly Jain.96
32
Whilst it might be easy to read a convenient enmity into the judge’s characterization of the mother’s faith (a reading which would necessarily be pared of its
specificity in the details of the parties before the court) the judgment deserves an
open reading.
Compared with the elliptical nature of the reasoning in Boldt, the judgment of
Baron J., which was endorsed by the Court of Appeal in Re S, compares favorably.
In the first place it is clear that a child may not be circumcised without reference to
the court where one of his parents is opposed to the procedure. As we have argued
above, this requirement could usefully be extended to all cases where an older child
presents for a non-therapeutic circumcision. Secondly, in contrast to Boldt, the judgment seeks to disentangle the interests of parents and children, rather than assuming
that they are synonymous. Thus, the judge observes that “the current problem stems
not from the children’s needs but from the need of the mother to portray her marriage
as being to a Muslim man.”97
Thirdly, as we have noted above, the Court’s recognition that the decision properly belongs to the boy himself when he reaches the stage of Gillick-competence
squares with a better understanding of the embodied experiences of adolescents and
a more robust defense of the values of autonomy and bodily integrity. Thus Baron J.
observes that:
Circumcision once done cannot be undone. It may have an effect on K if he wishes to
practice Jainism when he grows up. He has been ambivalent about his religion and is not
old enough to decide or understand the long-term implications. It is not in his best interests
to be circumcised at present. . . By the date of puberty K would be Gillick competent and so
he could make an informed decision.
We also suggest that this proposal accords with recent campaigns challenging the current paradigm for the surgical treatment of children born with intersex
conditions,98 and which is gaining acceptance as the most appropriate approach in
the case of male circumcision.99 Indeed, such an approach has also emerged in communities where circumcision is part of religious practice.100 This growing consensus
on the desirability of postponing non-therapeutic surgeries until the child is competent to decide, has, as we have argued elsewhere, been the product of a movement to
uncover the harms inflicted by early non-consensual intersex surgery. In the case of
male circumcision, clearly much work remains to be done on this process of uncovering harms, given that so many of the harms of the practice are rendered invisible
even to “caring” or “good” parents, and that the legitimizing power of legal culture
and religious faith causes harms that it fails to recognize to effectively disappear.101
Concluding Thoughts
The discourse of the intimate family that tries to exclude a public ethic of justice, by
denying children’s rights, paradoxically invokes public concepts of parents’ rights,
and thereby invites justice to reenter by the back door in its most dangerous form of
defending the status quo, in which unaccountable power falls to the powerful.102
2
33
It is notable that circumcision is slowly gaining more attention in academic and
medical publications and in the general media. In general, such discussion and
reporting is limited to and focuses on (disputing or confirming) some of the medical risks briefly outlined above. Whilst this development is welcome and clearly
contributes to the uncovering of harms that is required, it is also necessary for
commentators (and indeed decision-makers) to take into account issues of bodily
integrity,103 the desirability of keeping future choices open, and the possibility of
psycho-sexual harms, as well as possible negative effects on future sexual experience and enjoyment. Such issues can be brought to the fore if we pay attention to
accounts of the ways in which some men have experienced their circumcision status.
Qualitative studies, such as that conducted by Hammond in the US and published
in the British Journal of Urology International in 1999, do much to complicate
the idea that male circumcision is sufficiently de minimus that it should be left to
parental choice.104 Hammond’s study ably details the range of negative physical,
sexual and emotional effects that may follow routine juvenile circumcision. While
acknowledging the particularity of such experiences, simultaneously we need to recognize that a general failure to unpack these harms may be attributed not only to the
unwillingness of doctors and parents to see them, but also to deeper rooted problems
with the concept of harm. For this reason, although we find much of the critical discourse around female circumcision and the punitive legal response to it problematic,
we would contend that one positive feature of how female circumcision is legally
regulated is the unambiguous acceptance that the procedure is harmful. We would
certainly argue that all forms of harm inflicted on young children whose bodies
are molded and redesigned by surgeons are comparable, regardless of whether the
motivation is to “normalize” or “perfect.”
The harms of male circumcision have been rendered less visible and contentious
by the long history and widespread acceptance of the practice in North America, the
United Kingdom and Australia. We would argue that legal, medical and religious
cultures have contributed to this. Stipulating that decision-making must include the
older minor and deferring decisions until they can be taken by a competent minor,
in our view marks a necessary shift to articulating the factors that are pertinent to
regulating this form of genital cutting and promoting a more open dialogue about
how harm is to be quantified.
Acknowledgements We would like to thank Rohee Dosgupta for research assistance on this article, which was funded by the AHRC Centre for Law, Gender and Sexuality and the anonymous
reviewer for helpful input. We also thank the following colleagues for offering helpful comments on earlier drafts and/or access to materials: Georganne Chapin, John Geisheker, Manolis
Melissaris, Jean McHale, Shaun Pattinson, David Smith, and Steven Svoboda.
Notes
1. Re J (Specific Issue Orders: Muslim Upbringing & Circumcision). (1999) 2 FLR 678
[Family Division]; Re J (A Minor) (Prohibited Steps Order: Circumcision), sub nom Re J
(Child’s Religious Upbringing and Circumcision) and Re J (Specific Issue Orders: Muslim
Upbringing & Circumcision) [2000] 1 FLR 571 [Court of Appeal]; Re S (Specific Issue
Order: Religion: Circumcision) [2005] 1 FLR 236 [Family Division]; S (Children) [2004]
EWCA Civ 1257 [CA].
34
2. Per Butler-Sloss P in Re J [CA], ibid., p 577.
3. British Medical Association. (2006) The Law and Ethics of Male Circumcision:
Guidance for Doctors. London: BMA (unpaginated) available at www.bma.org.uk/
ap.nsf/Content/malecircumcision2006 (last accessed 19 August 2008).
4. Ibid.
5. Fox M, Thomson M. (2005) A covenant with the status quo? Male circumcision and the
new BMA guidance to doctors. J Med Ethics. 31:463–469; Short changed? The law and
ethics of male circumcision. Int J Child Rights. 13:161–181 (2005); Reconsidering “best
interests”: Male circumcision and the rights of the child. In: Milos M. (ed.) Human Rights
and Circumcision. New York, NY: Springer (2008).
6. Colb S. (2007) Divorce, religion, and circumcision: What a conflict tells us about parental
rights. Find Law: Legal News and Commentary. November 28 (unpaginated).
7. See Elliston S. (2007) The Best Interests of the Child in Healthcare. London: RoutledgeCavendish.
8. See Buss D. (2000) The christian right and the international rights of the child. In:
Bridgeman J, Monk D. (eds.) Feminist Perspectives on Child Law (London: Cavendish)
for the argument that the US failure to sign this document has been motivated in part by
Christian Right fears that it will undermine 306 parental rights by allowing the state (or the
UN) to intervene in families, thereby undermining parental rights, as well as by broader
concerns regarding threats to US sovereignty.
9. Per walljinrej [FD], supra n. 1, p 699.
10. Ibid., p 697.
11. Ibid., p 688.
12. Boldt and Boldt, p 344 Ore. 1; 176 P.3d 388 (2008).
13. Gey S. (1990) Why is religion special? Reconsidering the accommodation of religion under
the religion clauses of the first amendment? Univ Pittsbg Law Rev. 52:1549–1595.
14. For a consideration of legal responses to bodily interventions and embodied choices see
Fletcher R, Fox M, McCandless J. (2008) Legal embodiment: Analysing the body of
healthcare law. Med Law Rev. 16:321–345.
15. We shall argue below that the decision to circumcise may differ in significant ways from
other contexts, such as organ transplantation, blood donation or sterilization, in which
English courts have, at least to a limited extent, confronted the older child’s right to decide
for him or herself.
16. Alderson P. (2006) Who should decide and how? In: Parens E. (ed.) Surgically Shaping
Children: Technology, Ethics and the Pursuit of Normality. Baltimore, MD: John Hopkins
University Press, pp 157–175 at 157.
17. Boldt, supra n. 12, p 391.
18. Ibid., p 393.
19. Ibid.
20. Ibid., p 394.
21. Ibid.
22. Green AS. (2008) US Supreme Court rejects Oregon’s circumcision, abortion cases. The
Oregonian. October 7, Both petitions are on file with the authors.
23. See, for instance, Newdow V. (2004) United States Congress, Elk Grove Unified School
District et al., p 542 US 1.
24. See note 27 below for an indication of the reasoning underpinning disputed health choices,
which seems to indicate that this failure to consult Misha may be characteristic of the
practice in US courts.
25. On the central value of autonomy, see, for instance, Brazier M. (2006) Do no harm – Do
patients have responsibilities too? Camb Law J. 397–422; Morgan D. (2001) Where do I
own my body and how. In: His Issues in Medical Law. London: Cavendish, pp 83–104.
26. See Buss D. (2000) “How the UN stole childhood”: The christian right and the international
rights of the child. In: Bridgeman J, Monk D. (eds.) Feminist Perspectives on Child Law.
London: Cavendish, pp 271–294.
2
35
27. J.D. v. Vaughan Clinic, P.C. 572 So. 2d 1225 (Ala., 1990). Dicta to similar effect are to be
found in Feldman v. Feldman 378 NJ Super 83, 874 A2d 606 (2005) at 611 and Bencomo
v. Bencomo 112 Ha 511, 147 P3d 67 (2006) at 72. Unsurprisingly, these authorities are
relied on by the father in Boldt in his petition to the US Supreme Court.
28. Supra n. 7, p 75.
29. The landmark House of Lords ruling. In: Gillick v. West Norfolk and Wisbeck Area Health
Authority [1985] 3 All ER 402 held that parental rights to decide should yield to the rights of
a child who possessed sufficient maturity and understanding to appreciate the implications
of the decision.
30. Per Lord Scarman in Gillick, ibid., p 424.
31. Ibid., p 423.
32. Lee S. (1987) Towards a jurisprudence of consent. In: Bell J, Eekelaar J. (eds.) Oxford
Essays in Jurisprudence, 3rd Series (Oxford: OUP). On the test for adults see s.1 Mental
Capacity Act 2005.
33. Re R (A Minor)(Wardship: Medical Treatment) [1992] 1 F.L.R. 190; Re W (A Minor)
(Medical Treatment: Court’s Jurisdiction) [1992] 2 F.C.R. 785; South Glamorgan County
Council v. W and B [1993] 1 F.L.R. ; Re E (A Minor) (Wardship: Medical Treatment) [1993]
1 F.L.R. 386; Re S (A Minor: Medical Treatment) [1994] 2 F.L.R. 1065; Re L (Medical
Treatment: Gillick Competency) [1998] 2 F.L.R 810 Re M (child: refusal of medical treatment) [1999] 2 F.C.R. 577; Re P (Medical Treatment: Best Interests) [2004] 2 F.L.R. 1117.
For discussion of the retreat from Gillick and limits to the parental power to consent, see
McHale J, Fox M. (2007) Healthcare Law: Text and Materials, 2nd ed. London: Sweet and
Maxwell, pp 451–477.
34. Freeman M. (2005) Re-thinking Gillick. Int J Rights Child. 13:211–217 at 211.
35. Per Baron J in Re S [FD], supra n. 1, p 256.
36. For example, Hammond L. et al. (1993) Children’s Decisions in Health Care and Research.
London: Institute of Education.
37. Alderson P, Montgomery J. (1996) Health Care Choices: Making Decisions with Children
London: Institute for Public Policy Research.
38. Re J, supra n. 1.
39. Supra n. 3.
40. Re S, supra n. 1.
41. For citations supra see n. 33.
42. Re P, supra n. 33, p 1120.
43. Re E, supra n. 33, p 389.
44. Somerville M. (2000) The Ethical Canary: Science, Society and the Human Spirit. Toronto,
ON: Viking/Penguin Canada, p 192 (discussing the case of Tyrell Dueck, a thirteen year old
boy who was refusing chemotherapy on the basis of his Christian beliefs.)
45. Supra n. 5.
46. Miller GP. (2002) Circumcision: Cultural-legal analysis. Va J Soc Policy Law. 9:497–537 at
502–503.
47. In terms of the historically persistent claim that neonatal circumcision protects from sexually transmitted infections see Dickson NP, Van Roode T, Herbison P, Paul C. (2008)
Circumcision and risk of sexually transmitted infections in a birth cohort. J Pediatr.
122(3):383–387. This study concluded that its findings were consistent with recent
population-based cross-sectional studies in developed countries, which found that early
childhood circumcision does not markedly reduce the risk of the common STIs in the
general population in such countries.
49. Ibid.
50. See Miller, supra n. 46.
51. Critics of routine circumcision have noted the tendency to characterize circumcisions
performed for social, cultural, or religious reasons as therapeutically indicated: see, for
36
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
example, Derby R, Svoboda JS. (2007) A rose by any other name? Rethinking the similarities and differences between male and female genital cutting. Med Anthropol Quart.
21:301–323 at 304.
See Bridgeman J. (1993) Old enough to know best? Leg Stud. 13:69.
Re Wand, Re R, supra n. 33.
Supra n. 7, p 80.
Re B (A Minor) (Wardship: Sterilisation) [1988] 1 A.C. 199.
In Re P (a minor) (1981) L.G.R. 301.
Supra n. 3. Similarly in recently issued guidance the GMC emphasizes that [i]f you are
asked to circumcise a male child, you must proceed on the basis of the child’s best interests
and with consent’: GMC, Personal Beliefs and Medical Practice March 2008, para 14.
BMA. (2001) Consent, Rights and Choices in Health Care for Children and Young People.
London: BMJ Books.
The remaining relevant criteria that are listed are: • the patient’s physical and emotional
needs; • the risk of harm or suffering for the patient; • the views of parents and family; •
the implications for the family of performing, and not performing, the procedure; • relevant
information about the patient’s religious or cultural background; and • the prioritizing of
options which maximize the patient’s future opportunities and choices.
Attempts at foreskin restoration are enduring: see Gilman S. (1999) Making the Body
Beautiful: A Cultural History of Aesthetic Surgery. Princeton, NJ: Princeton University
Press, pp 137–144; but have not proven successful: see Section 6 Foreskin restoration: Historical and contemporary considerations. In: Denniston GC, Hodges FM, Milos
MF. (eds.) Male and Female Circumcision: Medical, Legal and Ethical Considerations.
New York, NY: Kluwer/Plenum, 1999.
The Tattooing of Minors Act 1968, s. 1
The Female Genital Mutilation Act 2003, s.1(1).
Sullivan N. (2007) “The price to pay for our common good”: Genital modification and the
somatechnologies of cultural (in)difference. Soc Semiotics. 17:395.
See Groskop V. “My body is wrong” The Guardian August 14, 2008. Indeed even the less
invasive option of administering puberty-suppressing drugs remains highly controversial,
and in the UK is not available to those under 16: Giordano S. (2008) Lives in a chiaroscuro.
Should we suspend the puberty of children with gender identity disorder? J Med Ethics.
34:580–584.
For a discussion of the tensions that exist in legal responses to “Female Genital Mutilation”
and cosmetic genital surgery see Sullivan, supra n. 63.
On the inadequate regulation of cosmetic surgery more generally see Latham M. (2008)
The shape of things to come: Feminism, regulation and cosmetic surgery. Med Law Rev.
16:437–457.
See Consent in the Criminal Law, Consultation Paper 139 (London: Law Commission,
1995). Notwithstanding the wide-ranging nature of the consultations and the considerable
academic literature it spawned—see for instance, Ormerod D, Gunn M. (1996) Second
law commission consultation paper on consent: Consent—a second Bash? Crim Law Rev.
694–703—no proposals for legislation in the field have emerged. In the minutes of a Law
Commission meeting on “Consent as a Defence” on May 28, 1998 it was noted that “The
responses to the consultation papers were highly polarized, particularly on the issue of consent for non-sexual offences, and no consensus emerged. Bearing in mind the matters we
have already reported on, the amount of work that would be required to reach conclusions
on the very difficult and sensitive issues involved and the urgency attaching to our work, we
have decided that it would not be worthwhile for us to produce any further report on this
topic” [copy on file with authors].
However it should be noted that the GMC guidance to doctors stipulates only that “if parents
cannot agree and disputes cannot be resolved informally, you should seek legal advice about
whether you should apply to the court” supra n. 57, para 14.
2
37
69. While complication rates from routine circumcision are low, the chances of these complications being mutilatory, infective, or haemorrhagic are high: Williams N, Kapila L. (1993)
Complications of circumcision. Br J Surg. 80:1231–1236; Gerharz EW, Haarmann C. (2000)
The first cut is the deepest? Medicolegal aspects of male circumcision. BJU Int. 86:332–338.
Indeed, complications are potentially catastrophic, since death, gangrene, and total or partial
amputation are known adverse outcomes: Hodges FM, Svoboda JS, Van Howe RS. (2002)
Prophylactic interventions on children: Balancing human rights with public health. J Med
Ethics. 28:10. For a recent reported instance of death as a result of circumcision in the UK
see Moyes S. “7-Day-Old Died After Circumcision” Daily Mirror February 15, 2007.
70. In this regard, it is interesting that advocates of neonatal male circumcision tend to argue —
despite evidence to the contrary—that newborns do not experience pain: Benatar M,
Benatar D. (2003) Between prophylaxis and child abuse: the ethics of neonatal male circumcision. Am J Bioeth. 3:35–48 at 37–38 and accompanying references; Warnock F, Sandrin D.
(2004) Comprehensive description of newborn distress behavior in response to acute pain
(newborn male circumcision). Pain 107:242–255.
71. Dwyer J. (1994) Parents religion and children’s welfare: Debunking the doctrine of parents’
rights. Calif Law Rev. 82:1371–1347 at 1377.
73. Ibid.
74. Herrera CD. (2005) Disputes between state and religion over medical treatment for minors.
J Church State. 47:823–839 at 824.
75. See e.g. Jehovah’s Witnesses v. King County Hospital 390 US (1968).
76. See e.g. Wisconsin v Yoder 406 US 205 (1972).
77. Supra n. 74, p 823.
78. Dwyer JG. (1996) The children we abandon: Religious exemption to child welfare and education laws as denials of equal protection to children of religious objectors. North Carol
Law. 74:1321 at 1322.
79. Silverman RD, May T. (2001) Private choice versus public health: Religion, morality and
childhood vaccination law. Margins. 1:505–521 at 505–506.
80. In a UK context see Re C (Welfare of Child: immunisation) [2003] 2 F.L.R. 1095.
81. Bridge C. (2002) Religion, culture and the body of the child. In: Bainham A, et al. (eds.)
Body Lore and Laws. Oxford: Hart, pp 265–287 at 284.
82. Supra n. 78, p 1398.
83. Ibid, p 1403. In similar vein, Paula Monopoli writes that “Children in this country [the US]
are still being martyred on the alter of their parents religious beliefs”. (1991) Allocating the
costs of parental free exercise: Striking a new balance between sincere religious belief and
a child’s right to medical treatment. Pepperdine Law Rev. 18:319–352 at 319.
84. O’Donovan K. (1993) The child as legal object. In: Family Law Matters. London: Pluto.
85. See her Altering baby boy’s bodies: The ethics of infant male circumcision. In: The Ethical
Canary, op. cit. n. 44, pp 202–219.
86. Ibid., p 212.
87. The law governing assault in the Canadian Criminal Code is similar in relevant respects to
the definitions of assault under the Offences against the Person Act 1861, as is the prevalence
of the best interests test.
88. Supra n. 85, p 212.
89. Not only are the boundaries of such exemptions difficult to police, but they have been
attacked as undermining the entire principle of child welfare/protection in other contexts
such as education: see Monopoli, supra n. 83.
90. Supra n. 85, pp 216–217.
91. See Gey, supra. n. 13.
92. Gilbert H. (2007) Time to reconsider the lawfulness of ritual male circumcision. Eur Hum
Rights Law Rev. 279–294 at 291.
93. See Zabus C. (2007) Between Rites and Rights: Excision in Women’s Experiential Texts
and Human Contexts. California, CA: Stanford University Press, pp 35–37.
38
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
Alderson, supra, 16, p 157.
Ibid., p 170.
Per Baron J in Re S [FD], op. cit. n. 2, p 256.
Ibid.
Domurant Dreger A. What to expect when you have the child you weren’t expecting. In:
Parens E. (ed.) supra n. 16, pp 523–566 at 259.
Fortin J. (2005) Children’s Rights and the Developing Law, 2nd ed. London: Butterworths,
pp 329–32, Elliston, supra. n. 7, pp 98–99; Hinchley G. (2007) Is infant male circumcision
an abuse of the rights of the child? BMJ. 335:1180.
Hinchley, ibid. Goldman R. (1998) Questioning Circumcision: A Jewish Perspective.
Boston, MA: Vanguard Publications.
See for a fuller discussion, West R. (1997) Caring for Justice. New York, NY: University
Press and Fox and Thomson, “Short Changed?” Supra n. 5.
Alderson, supra n. 16, p 170.
Darby and Svoboda have argued that the “most obvious and universally experienced harm of
all [is] the deprivation off an integral, visually prominent, and erotically significant feature
of the penis”: supra n. 51, p 304.
Hammond T. (1999) A preliminary poll of men circumcised in infancy or childhood.
83(Supp 1) BJU International 85. See also, Darby R, Cox L. (2007) Objections of a sentimental character: The subjective dimension of foreskin loss. unpublished paper (copy on
file with authors).
Chapter 3
These Goalposts Don’t Move: Non-Medical
Circumcision of Boys in the Tasmanian
and Australian Context
Paul Mason
Abstract This paper examines reasons given by proponents for circumcision of
minors, which include clinical indications, prophylaxis, religion, and culture. It
examines the legal authority by which the professional or lay operator performs
surgery on a person with that person’s consent. The paper focuses on the capacity
of a parent to give valid consent for surgery performed on children, in the context of Tasmanian and Australian Statute and common law, and the fountains of
English common law. It considers the relevance of “Gillick-competence” of the
child patient and discusses whether a legal response based on notions of residual parental “rights,” of “family rights,” and of “cultural/religious rights” and the
paramountcy principle of the child’s best interests are consistent tests by which to
protect the rights of the child. These rights issues are routinely absent from the
reductionist arguments of proponents. The paper concludes that the only consistent
way to challenge the arguments of child circumcision proponents is to insist on the
individual rights of the individual child, including rights to choose a religion, rights
to protection from cruel treatment and abuse, rights to be consulted in decisions that
have permanent effects on the child’s life experience, and a right emerging from the
international response to FGM—the right of genital autonomy.
Keywords Genital autonomy · Informed consent · Law · Human rights · Medical
ethics · Male circumcision
Human Rights Legal Context
Australia does not have a Bill of Rights: rights are protected through legislation,
common law, policy, and education.
P. Mason (B)
Commissioner for Children, Tasmania, Australia
39
40
P. Mason
A federal constitutional system—legislative, executive, and judicial powers—
is distributed between various federal institutions and six states (Tasmania is
one) and two self-governing Territories. Treaty-making power remains with
the Commonwealth/Australian Government, but States may be responsible for
legislation that affects compliance with treaty implementation (e.g., general criminal
law of assault, murder, etc.).
International law, including treaty law in the absence of legislation expressly
applying it to domestic law, cannot impose obligations on individuals nor create
rights in domestic law. It remains a legitimate and important influence on the
development of the common law; may be used interpreting legislation and the
common law. So, for instance, if a decision rests on a test of “reasonableness” or
“best interests,” Australia’s international commitments will be an important head of
argument.
• Before ratification of a treaty, Commonwealth Government assesses conformity
or consistency of existing legislation against treaty obligations,
If State legislation is inconsistent with treaty obligations, the Commonwealth
Government may consider passing its own legislation to bring Australia’s laws back
into line with international obligations.
• Australia is a party to various international human rights instruments, including the United Nations Convention on the Rights of the Child (UNCROC), and
an international obligation on Australian Government to “respect and ensure the
rights set forth in the present Convention to each child within . . . jurisdiction
without discrimination of any kind”1 and to “undertake all appropriate legislative,
administrative and other measures for the implementation of the rights recognized
in the present Convention.”2
Genital cutting of children for reasons not medically indicated amounts to a
breach of rights set out in the UNCROC and other international conventions despite
acknowledgement in UNCROC of the need to “respect the responsibilities, rights,
and duties of parents . . . or other persons legally responsible for the child, to provide,
in a manner consistent with evolving capacities of the child, appropriate direction and guidance in the exercise by the child of the rights recognized in the . . .”
Convention.3
Routine circumcision for religious, cultural, or social reasons is a breach of
Article 19 of UNCROC (State parties to take all appropriate measures “to protect the
child from all forms of physical or mental violence, injury or abuse, maltreatment”)
and of Article 24 (right to health, which obliges State parties to take all effective
and appropriate measures with a view to abolishing traditional practices prejudicial
to the health of children).4
Article 14 of UNCROC provides that State parties “shall respect the right of the
child to freedom of thought, conscience and religion.”
3
Non-Medical Circumcision of Boys in the Tasmanian and Australian Context
41
Parental Authority
Even if it is within the scope of parental authority and responsibility (in the sense
described in Article 5 of UNCROC) to provide religious guidance and direction,
does this extend to taking action that amounts to an irreversible marking of a child
to conform to religious tenets and beliefs?
Especially so where the child is of an age and maturity to be capable of expressing an opinion on the matter as provided in Article 12 of UNCROC (State parties
“shall assure to the child who is capable of forming his or her own views the right
to express those views freely in all matters affecting the child, the views of the child
being given due weight in accordance with the age and maturity of the child”).
There is no effective remedy for a child seeking to enforce any provision of
UNCROC directly in an Australian court. A limited avenue of redress exists under
the Human Rights and Equal Opportunity Commission Act 1986 (HREOCA).
The Human Rights and Equal Opportunity Commission has the function of
inquiring into acts or practices that may be inconsistent with or contrary to the
rights set out in the human rights instruments scheduled to or declared under the
HREOCA, one of which is UNCROC.
Where the Commission is of the opinion that an act done or a practice engaged
in by a person is inconsistent with or contrary to any human right, it is required to
report to the Attorney General in relation to the inquiry (leads to report tabled in
Parliament).
Relevant acts and practices are limited to an act or practice done by or on behalf
of the Commonwealth or an authority of the Commonwealth.
The Commission is required to perform this inquiry function when requested to
do so by the Minister, when a complaint is made in writing to it that an act or practice
is inconsistent with or contrary to any human right, or it appears to the Commission
to be desirable to do so.
There is no complaint avenue to the UN Committee responsible for monitoring
compliance with UNCROC.
Domestic Protection
• Reliance on criminal law and common law of each State and Territory with regard
to assault, parental consent to surgery, or medical treatment of children unable to
consent because of age and maturity, and it is the jurisdiction of Family Court
to resolve disputes between parents about issues of parental responsibility and/or
authorize performance of “special medical procedures” on children in circumstances where it is beyond the scope of parental authority to consent to such
procedures.
• The criminal law in Tasmania criminalizes “female genital mutilation”5 and provides that the consent of the person upon whom the operation was performed or
42
P. Mason
of that person’s parent or guardian is not a defense to a charge under the relevant
section. Section 178C of the Criminal Code:
◦ excuses “a surgical procedure for a genuine therapeutic purpose” or “ a sexual
reassignment procedure”
• provides that the fact that a surgical procedure is performed as, or as part of,
a cultural, religious, or other social custom is not, of itself, a genuine therapeutic purpose. There are no equivalent provisions specifically criminalizing (or
permitting) the performance of non-therapeutic genital cutting of boys.
• The sexual reassignment procedure exception is open ended and contains no
safeguards that would ensure that performance of the procedure is in the best
interests of the child as distinct from an attempt, however well meaning, to
“normalize” that child’s genitalia.
Pros and Cons: The Medical Argument
Proponents of routine circumcision of healthy baby boys and male children argue
that the procedure is in the best interests of the child for medical reasons and cite
endless studies and statistics to support their contentions that routine circumcision
“confers a lifetime of medical, health and sexual benefits.”6 Many, if not all, of the
claimed benefits of routine circumcision or male genital cutting have been questioned or disproved. It is beyond the scope of this paper and outside the expertise of
the author to undertake a detailed analysis of the claims and counter claims.
The Royal Australasian College of Physicians 2004 Policy Statement on
Circumcision accepts that there is no medical indication for neonatal circumcision
and sets out the accepted remaining indications for it.
This Policy has been labeled as “ill-conceived”7 on the basis that it “downplays the wide-ranging lifelong benefits of circumcision in prevention of urinary
tract infections (UTI’s), penile and cervical cancer, genital herpes and chlamydia
in women, HIV infection, phimosis and various penile dermatoses, and at the same
time overstates the complication rate. . ..”
A response8 published in the same journal raises issues about definitions used in
studies relied upon, statistics, assumptions inherent in the critique by Morris et al.,
and raises other questions completely ignored by Morris et al., such as “the genuine
ethical concerns of parents about whether they have the right to consent on behalf
of an infant to a procedure involving the permanent removal of a body part.”9
Proponents of male circumcision routinely assert in publications that “male circumcision is lawful.” Judges at all levels, from first instanced judges to ultimate
appeal judges, routinely say the same thing, but always as obiter dicta, that is, an
aside not essential to the logical process that resolves the immediate issue before the
Court (the ratio decidendi). The consistent failure to give any reason for including
circumcision in these asides indicates prejudice rather than impartial and balanced
consideration.
3
43
It is the shame of the legal profession that judges continue to make this pronouncement with no proper authority according to their own rules of analysis and
judicial reasoning.
Effective Consent
The legal position of a medical professional performing a non-therapeutic circumcision on an otherwise healthy male baby or male child is unclear.
A fundamental common law right to bodily integrity underpins the criminalization of unlawful assaults and has been endorsed by the Australian High Court and
Family Court in the context of consideration of the appropriateness or otherwise of
“non-therapeutic sterilization” and other “special medical procedure” cases under
the Family Law Act 1975.
The Tasmanian Criminal Code Act 1924 provides that any person who unlawfully
assaults another is guilty of a crime but that an assault is not unlawful where a person
consents (subject to situations where consent is ineffective because of public policy
reasons).
Generally speaking, any medical treatment or surgical operation requiring
contact with the body of a patient has the potential to be an assault.
If non-therapeutic male circumcision is a “surgical operation,” a medical practitioner can lawfully carry out that procedure so long as:
• the operation is performed in good faith and with reasonable care and skill
• the operation is performed with the consent and for the benefit of the patient.
Where the patient is a child who is too young to exercise a reasonable discretion,
consent may be given by the child’s parent or by any person having the care of
the child
• the performance of the operation is reasonable having regard to all the
circumstances.10
The circumstances in which a child or young person has the right to make his or
her own decision about medical treatment are not clearly delineated.
The High Court of Australia in Marion’s case11 :
“The common law in Australia has been uncertain as to whether minors under 16 can consent to medical treatment in any circumstances.”(27) See the analysis by Devereux, “The
Capacity of a Child in Australia to Consent to Medical Treatment—Gillick Revisited?”
(1991) 11 Oxford Journal of Legal Studies 283 (hereafter “Devereux”), at pp 284–287.
However, the recent House of Lords decision in Gillick v. West Norfolk AHA(28) [1985]
UKHL 7; (1986) AC 112 is of persuasive authority. The proposition endorsed by the majority in that case was that parental power to consent to medical treatment on behalf of a
child diminishes gradually as the child s capacities and maturity grow and that this rate of
development depends on the individual child. Lord Scarman said (29) ibid., at pp 183–184:
Parental rights . . . do not wholly disappear until the age of majority. . .. But
the common law has never treated such rights as sovereign or beyond review
44
P. Mason
and control. Nor has our law ever treated the child as other than a person with
capacities and rights recognized by law. The principle of the law . . . is that
parental rights are derived from parental duty and exist only so long as they
are needed for the protection of the person and property of the child.
A minor is, according to this principle, capable of giving informed consent when he or she
“achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed” (30) ibid., at p 189, and see pp 169, 194–195 (emphasis
added).
• Neither a parent nor a fully competent minor can give an effective consent to all
types of surgical operations or medical treatments. If the nature of the proposed
treatment is invasive, irreversible and major surgery, and for non-therapeutic
reasons, then court approval is required before such treatment can proceed.12
Marion’s case involved an application to the Family Court of Australia for an
order authorizing performance of a hysterectomy and ovariectomy on Marion, who
was a 14-year old intellectually disabled child. The purposes of the proposed procedures were prevention of pregnancy and menstruation and attendant psychological
and behavioral consequences and to stabilize hormonal fluxes with the aim of helping to eliminate consequential stress and behavioral responses. The High Court
decided that Marion’s guardian could not lawfully authorize the carrying out of
the procedure without a Court authorization. The majority Judges in Marion’s case
said:
In a case such as the present one, it is primarily the prospect of surgical intervention which
attracts the interest of the law. This is because the law treats as unlawful, both criminally and
civilly, conduct which constitutes an assault on or a trespass to the person. Therefore it is
the legality of the specific medical treatment amounting to a hysterectomy and ovariectomy
. . . which must be the focus of this inquiry. However to characterize intervention compromising sterilization as ‘medical treatment’ is already to make assumptions and to narrow the
inquiry, perhaps inappropriately. As will become clear, it is the very fact that sterilization
implies more than medical, or surgical, treatment that is crucial to the central issue in this
case13 (my emphasis).
The High Court went on to say:
There are features of a sterilization procedure, or more accurately, factors involved in a
decision to authorize sterilization of another person, which indicate that, in order to ensure
the best protection of the interests of a child, such a decision should not come within the
ordinary scope of parental power to consent to medical treatment.14
• The crux of the High Court’s decision is that Court authorization is required for
a medical procedure that:
◦ Requires invasive, irreversible, and major surgery; and
◦ Is not for the purpose of curing a malfunction or disease
◦ Court authorization is required because of:
3
45
• the significant risk of making the wrong decision, either as to a child’s present
or future capacity to consent or about the best interests of a child who cannot
consent; and
◦ the consequences of a wrong decision are particularly grave.
Subsequent cases about “special medical procedures” illustrate that the principles are not limited to sterilization and that there is a need to consider the specific
procedure being contemplated from the perspective of what is in the best interests
of the particular child. Other cases have concerned sex change therapy and surgery,
again in pubescent and adolescent children.
The Queensland Law Reform Commission15 concluded:
The common law operating in Queensland appears to be that if the young person is unable,
through lack of maturity or other disability, to give effective consent to a proposed procedure
and if the nature of the proposed treatment is invasive, irreversible and major surgery and for
non-therapeutic reasons, then court approval is required before such treatment can proceed.
The court will not approve the treatment unless it is necessary and in the young persons’ best
interests. It is not clear whether the test applied by the High Court is capable of extension
to non-therapeutic circumcision of healthy boys.
Even if Court approval is required, the Family Court’s parens patriae does not
extend to children whose parents have never married. If Marion represents the law,
and if it applies to routine circumcision, then the Court of competent jurisdiction
will be the Supreme Court of the State in which the child is resident.
Relevance of Paramountcy Principle—Best Interests
The Family Court does have jurisdiction to determine disputes between parents
(married or not) over “specific issues” relevant to parental responsibility, including
circumcision.
His Honor Strickland J in K and H [2003] Fam CA 1364 rejected a father’s application for an order permitting circumcision of an approximately 18-month-old boy
for cultural and religious reasons and granted an application by a mother for an
injunction restraining the father from permitting or causing to permit the child to
be circumcised. The father, who was born in Tanzania and was raised a Muslim,
argued that his Islamic faith and cultural issues obliged him to ensure his son was
circumcised. Strickland J did not question that this was a procedure that parents are
able to consent to as an aspect of their parental authority “unlike, for example, sterilization for non-therapeutic purposes.” Court involvement occurred simply because
the parents could not agree. The Judge decided it was not in the best interests of
the child to be circumcised, a procedure described as one that “is not medically
indicated.” Factors of relevance included uncertainty about which religious path the
child would follow, his ability to continue to be exposed to his father’s religion and
culture even if uncircumcised, the fact he would be predominantly exposed to his
mother’s culture and religion.
46
P. Mason
Medical Ethics
The Royal Australasian College of Physicians 1998 publication “Ethics: A Manual
for Consultant Physicians” lists the four moral values or obligations of most
relevance in medicine as autonomy, beneficence, non-maleficence, and justice.16
Autonomy
Autonomy (or self rule) has been defined as the capacity to think and decide, and the
capacity to act on the basis of such thought freely and independently. It is a basic moral
obligation to respect each person’s autonomy. Respect for the autonomy of a patient is the
moral principle on which the debate on informed consent has hinged.
Beneficence
The principle of beneficence relates to the obligation to do good/to act in the patient’s best
interest.
Non-maleficence
Non-maleficence refers to the duty of not doing harm. Harm can include psychological,
emotional, or social harm as well as physical damage.17
Justice
This principle is related to the fair distribution of resources.
“Autonomy” is defined in the Concise Medical Dictionary18 as “selfdetermination, or the freedom to behave in ways that accord with one’s own values
and objectives. Respect for the autonomy of the patient is one of the four principles
of medical ethics.”
What Next?
The Tasmanian Law Reform Institute is undertaking a project to review the current
law regulating the circumcision of male children in Australia, with particular reference to Tasmania. The project will examine the criminal and civil responsibility
of those who perform, aid, or instigate the procedure and will consider many of
the issues raised above. This topic for law reform was suggested by the Tasmanian
Commissioner for Children. An issues paper will be released in 2009.19
Notes
1.
2.
3.
4.
Article 2 UNCROC.
Article 4 UNCROC.
Article 5 UNCROC.
Refer Narulla R. (2007) Circumscribing circumcision: Traversing the moral and legal ground
around a hidden human rights violation. Aust J Hum Rights. 12(2):89–118, April 2007.
5. Section 178A of the Criminal Code Act 1924.
6. Taken from www.circinfo.net visited July 14, 2008.
7. Morris B, Bailis S, Castellsague X, Wiswell T, Halperin D. (2006) RACPs policy statement
on infant male circumcision is ill-conceived. Aust N Z J Public Health. 30(1):16–21.
3
47
8. Richters J. (2006) A critical commentary on RACP policy statement on infant male
circumcision: A response. Aust N Z J Public Health. 30(1):2–24.
9. Ibid., p 23.
10. S51 Criminal Code Act 1924 (Tasmania).
11. Department of Health and Human Services v JMB and SMB (Marion=s case) [1992] HCA
15 per Mason CJ, Dawson J, Toohey J and Gaudron J at p 7.
12. Ibid.
13. Marion=s case op cit at p 4.
14. Ibid., p 20.
15. QLRC Circumcision of Male Infants@ Miscellaneous Paper December 1993 at p 38.
Statement of the law is based on the High Court of Australia decision Secretary Department
of Health and Community Services v JWB and SMB (Marion=s case) (1992) 175 CLR 218.
16. Refer p 8 of the publication Ethics: A Manual for Consultant Physicians@ Ethics Committee
of the RACP December 1998.
17. Concise Medical Dictionary. Oxford University Press 2007. Oxford Reference Online. Oxford
University Press. State Library of Tasmania.
18. Aautonomy. (2007) n@ Concise Medical Dictionary. Oxford University Press. Oxford
Reference Online. Oxford University Press. State Library of Tasmania.
19. http://www.law.utas.edu.au/reform/malecircumcision.htm
Chapter 4
Mass Campaigns of Male Circumcision for HIV
Control in Africa: Clinical Efficacy, Population
Effectiveness, Political Issues
Michel Garenne
Abstract This paper reviews the demographic evidence for the relationship
between male circumcision and HIV infection in national or sub-national African
populations. A meta-analysis based on 18 countries, representing more than half
of the population of sub-Saharan Africa, shows no relationship [standardized odds
ratio = 1.00; 95% CI: 0.96–1.05]. There were even more countries in which HIV
prevalence was higher among circumcised persons than countries where it was
lower. In only five countries, the odds ratio of HIV prevalence (circumcised/intact)
was significantly different from 1.0; three countries where it was higher, and two
countries where it was lower. The contrast between lack of demographic impact
and results from clinical trial is striking, and can probably be explained by the low
clinical efficacy in situations of intense and repeated exposure, and by the interactions with the many other determinants of HIV spread. This paper also addresses
some ethical and political issues, and in particular raises the question of power
abuse, which may lie in the practice of genital mutilations and relevant international
recommendations.
Keywords Male circumcision · HIV/AIDS · Clinical efficacy · Population
effectiveness · Randomized controlled trials · Ecological studies · Sub-Saharan
Africa
Introduction
In the study of the impact of public health interventions, two types of evidence
can be opposed: the measure of “clinical efficacy,” or “biological effect,” shown in
general by clinical trials or epidemiologic studies, and the measure of “population
effectiveness,” or “demographic impact,” shown by their effect in large populations
M. Garenne (B)
IRD (French Institute for Research and Development) and Institut Pasteur, Paris, France
49
50
M. Garenne
or by comparison between populations. Clinical trials aim primarily at demonstrating a biological effect, but they do not guarantee a large demographic impact.
Conversely, a demographic impact is sometimes observed even when clinical trials
tend to indicate a low effect. When clinical efficacy is very high (say above 95%),
the population impact is usually marked, and close to what can be expected from
clinical trials. When clinical efficacy is moderate (say around 50%), the population
impact is often small, when not negligible. In rare studies, one also finds cases of
population impact despite low clinical efficacy.
Let us give a few examples in the field of vaccines. The measles vaccine has
a very high clinical efficacy, considered to be above 95%. This has been shown
repeatedly in numerous randomized clinical trials all over the world, and similar
values are found in case control studies (Redd et al., 1999). The measles vaccine is also an “efficient” vaccine: when administered on a large scale, not only
does it protect those who received it, but it also tends to reduce the transmission, and even to stop epidemics through herd immunity. Measles was virtually
eradicated from the United States in the early 1980s by mass vaccination campaigns, and came back only because it was re-introduced from foreign countries
(Wood and Brunell, 1995). The cholera vaccine has an efficacy of about 50%
in clinical trials, but has virtually no demographic impact: it does not stop epidemics, and its protection is short lasting (Tacket and Sack, 2008). This is why
it is not recommended in public health programs. The pertussis vaccine (whoopingcough) is a vaccine that has a very low efficacy in clinical trials, and has been
shown to provide no protection against infection by the germ (Bordetella pertussis). However, it has a very large population effect, stopping epidemics and
protecting individuals against the severe forms of the diseases, and its population
effectiveness is close to that of the measles vaccine (Edwards and Decker, 2008;
Pollard, 1980). This is why it is used in most vaccination programs, and it is part
of the Expanded Program on Immunization recommended by the World Health
Organization.
Similar comparisons can be made in the field of contraception, an issue more
closely related to the control of sexually transmitted infections (STIs). The hormonal contraceptives (pill, injectables, implants) or the barrier methods, such as
the Intra-Uterine-Device (IUD), have a very high efficacy in clinical trials, usually
above 99%. They also have very high population effectiveness: women who use
them properly have no unwanted pregnancy, and populations who use them on a
large scale have a low fertility, close to that desired by couples. On the contrary,
the Rhythm Method (Knauss-Ogino Method), which is based on very sound biological evidence and has a moderate efficacy in clinical trials (around 50%), has
virtually no population effect nor any individual effect: women who use it tend
to become pregnant sooner or later, and no country was able to control its fertility only with this method (Labbok and Queenan, 1989). Its only visible effect is a
lengthening of birth intervals, which does not permit to bring fertility from 7 or 8
children to 2 children, as do very effective methods. The withdrawal method (coitus
interruptus) will never be investigated in clinical trials since it involves primarily
4
Mass Campaigns of Male Circumcision for HIV Control in Africa
51
a very personal behavior, but was shown empirically to have a major population
impact since this was the most common method to control fertility in Europe before
1950. The case of efficacy and effectiveness of male circumcision for controlling
HIV transmission bears some similarity with that of the rhythm method to control
fertility.
In a series of recent clinical trials, male circumcision was found to have an average clinical efficacy against HIV transmission (Auvert et al., 2005; Bailey et al.,
2007; Gray et al., 2007). Is this enough to make recommendations for general use?
Beyond clinical efficacy and demographic impact, are there not other issues related
with such a practice?
In this paper, we will focus on a lack of evidence showing a demographic impact
of male circumcision on the HIV epidemics in sub-Saharan Africa, the continent
most hard hit by the disease. We also address briefly some of the ethical issues raised
by the recommendation for male circumcision (WHO/UNAIDS, 2007), viewed
from an international health perspective.
Methods
In order to investigate the population impact of male circumcision, we will use
several comparisons:
– Comparing population groups that are circumcised and not circumcised in the
same country, which assumes comparable exposure to the disease (prevalence or
incidence);
– Comparing sub-groups known to have different risks, in the same way;
– Comparing countries that are practicing or not practicing circumcision.
There are serious caveats involved in these comparisons. In Africa, sub-groups
practicing—or not practicing—male circumcision are usually defined by ethnicity
or religion, sometimes associated with social status or urban residence, and may
not be comparable in terms of exposure, since they have different value systems,
different marriage patterns, and different sexual behaviors. The case is even worse
for country comparisons, where many other factors could bias the comparisons, and
we will see some examples later.
Nevertheless, when a public health intervention is very efficient, its demographic
impact is largely independent of any social variable, such as social status, religion, or
ethnicity. There are many examples in the literature, and they apply similarly to the
fields of vaccination, contraception, or medical treatments. The effect of vaccines,
hormonal contraceptives, antibiotics, antimalarial drugs, etc., is basically the same
in all countries in the world, and their population effect is simply proportional to the
population coverage. Therefore, when there is no visible demographic impact, one
can seriously question the usefulness of a public health intervention.
52
M. Garenne
Results
HIV Prevalence and Proportion Circumcised at National Level
The first comparison deals with HIV prevalence between circumcised and intact
men in generalized epidemics, some 20–25 years after the onset of the HIV epidemic, that is the situation in years 2002–2007. It measures basically a net effect
of circumcision, before changing behavior (condom use, reducing number of partners) really took off and changed the ecological correlations. The data are drawn
from the Demographic and Health Surveys (DHS), which are large scale surveys
based on representative samples of African populations [all available on the DHS
website], and on a similar survey conducted in South Africa, not part of the DHS
program (South Africa, 2002). For a statistician, this is the best scenario for testing
a potential demographic impact, since the surveys display at the same time the HIV
serologic status and the circumcision status for men aged 15–49 or 15–59 years.
A first analysis was done a few years ago, and published in 2008 in the African
Journal of AIDS Research (Garenne, 2006, 2008). The data were updated with more
recent surveys (Congo, Zambia, South Africa), so that 18 countries’ surveys are now
included, covering about 55% of the population of sub-Saharan Africa.
Table 4.1 HIV seroprevalence by circumcision status in African countries
Percent
Percent HIV+
Ratio circumcised/intact
Country
Circumcised
Circumcised
Intact
RR
Burkina Faso
Cameroon
Côte d’Ivoire
Congo Kinshasa
Ethiopia
Ghana
Kenya
Lesotho
Liberia
Malawi
Niger
Rwanda
South Africa
Swaziland
Tanzania
Uganda
Zambia
Zimbabwe
Meta-analysis
89.7
91.8
96.0
97.7
92.3
95.3
83.4
48.6
97.8
20.7
99.5
11.1
35.3
8.2
69.7
24.9
12.5
10.5
1.8
4.1
2.8
1.0
0.9
1.6
3.0
22.8
1.1
13.2
1.0
3.5
12.3
21.8
6.5
3.8
10.8
16.6
2.9
1.1
3.8
0.0
1.1
1.4
12.6
15.2
0.0
9.5
0.0
2.1
12.0
19.5
5.6
5.6
12.5
14.2
0.62
3.73
0.74
1.00
0.82
1.14
0.24
1.50
1.00
1.39
1.00
1.67
1.03
1.12
1.16
0.68
0.86
1.17
1.00
Significance
NS
∗
NS
NS
NS
NS
∗
∗
NS
∗
NS
NS
NS
NS
NS
∗
NS
NS
NS
Note: Sources of data are published DHS reports and HSRC study for South Africa.
∗ p < 0.05.
4
53
Results show no effect of male circumcision in national African populations: the
standardized odds-ratio was 1.00 (95% CI: 0.96–1.05), which means that, on the
average, circumcised and intact men have the same HIV prevalence (Table 4.1).
Out of the 18 countries studied, 12 have an odds ratio equal or higher than one
(more HIV among circumcised men), 3 of them statistically significant (Cameroon,
Lesotho, Malawi), and 6 have an odds ratio lower than one (less HIV among circumcised men), 2 of them statistically significant (Kenya and Uganda). Note that
these results are based on large numbers: some 73,800 men sampled, who are representative of the general population. This is the most reliable evidence that we have
on the population impact of male circumcision in Africa.
Case Studies
Let us give a closer look at a few selected countries, for which, contrary to expectations, the risk ratio of HIV prevalence (circumcised/intact) is higher than 1. In
Tanzania, HIV prevalence is moderate, with some 6.3% of men infected. The epidemic has been going on for about 25 years, since the western part of the country is
close to the epicenter of the epidemic, located around Lake Victoria. There are some
110 ethnic groups recorded in Tanzania, some 70% practicing male circumcision.
This is a quasi-experimental situation. In Tanzania, HIV prevalence is higher among
the circumcised groups (6.5% versus 5.6%). This is due in part to a correlation with
urbanization: urban areas are at the same time more circumcised and have more
HIV. But even if one controls for urbanization, the HIV prevalence is the same in
the two groups: 9.7 and 9.5% in urban areas; 5.2 and 4.6% in rural areas, none of
these differences being significant (Tanzania, 2005).
Lesotho is a tiny country embedded in South Africa. The main feature of Lesotho
is its ethnic homogeneity, all people belonging to the same group: the Southern
Sotho. The country has been exposed for about 15 years to HIV, and prevalence is
very high, with 19.3% of adult men infected. About half of the men are circumcised,
which is again a quasi-experimental situation, almost ideal given the homogeneity
of the ethnic composition. Here again, the profile of HIV prevalence is contrary
to expectations: circumcised men are more infected by HIV: 22.8% versus 15.2%
for intact men, and this is true in both urban (28.6% versus 17.3%) and rural areas
(21.8% versus 14.5%), in the various ecological zones, and for various measures of
social status (Lesotho, 2005).
Malawi is a country located in South-Eastern Africa. Malawi has a rather high
prevalence, with about 10% men infected, and the epidemic has been going on for
about 20 years. Malawi is characterized by a strong dichotomy between North and
South, and the dozen of ethnic groups recorded have major differences in demographic profiles and sexual behavior. The North is less circumcised and has less
HIV, whereas the South is more circumcised and has more HIV, again contrary
to expectations. As was the case in other countries, controlling for urbanization does not change the main picture: more HIV among the circumcised men.
Ironically, when stratified by region, the relationship between circumcision and HIV
54
M. Garenne
prevalence is inverted: the more circumcised in a region, the higher is the seroprevalence (Malawi, 2005).
A recent publication, based on a 2002 survey, also showed a similar pattern in
South Africa, where about a third of the population is circumcised and HIV prevalence amongst the highest on record: there was no difference in HIV prevalence
in 2002 between the two groups, even after controlling for a variety of factors
(Connolly et al., 2008).
HIV Incidence, and Dynamics of the HIV Epidemic
in South Africa
Some authors have argued that male circumcision could change the dynamics of
the epidemic by strongly reducing incidence and the net reproduction rate (Ro).
This is not the case in South Africa, the only country where one can pursue this
type of analysis, because routine HIV prevalence is recorded every year and published over a long period of time. South Africa also has a useful feature for analysis:
about one third of men are circumcised; circumcision is primarily ethnic specific,
and provinces are also largely ethnic specific. So, by comparing the dynamics of the
HIV epidemic by province, one may infer the effect (or lack thereof) of circumcision in the general population. The nine provinces were classified into three groups:
low, medium and high level of circumcision. Two indicators of the dynamics of
the epidemic were computed: the average incidence between 1994 and 2004, and
an estimate of the net reproduction rate of the epidemic between 1994 and 2004.
Results again show no clear relationship between the prevalence of male circumcision and the prevalence of HIV: differences in incidence were small: 2.0, 2.5,
2.1%, and differences in net reproduction rates were even in the opposite order:
higher in provinces with high level of circumcision than in those with low level
(see details in Garenne, 2008). If one compares two contrasted provinces: one with
no circumcision, the North-West province, populated by Tswana, and one with
widespread circumcision, the Eastern Cape province, populated by Xhosa, one finds
no difference in the dynamics of the epidemic from 1994 to 2004, and levels of
seroprevalence were basically the same in 2004.
In conclusion, large-scale demographic surveys, as well as routine seroprevalence surveys among pregnant women, do not show any consistent population
impact of male circumcision on either HIV prevalence or HIV incidence. Male circumcision does not appear to be the “Magic Bullet” presented by other researchers
and based on results from clinical trials.
Other Evidence of a Lack of Demographic Impact
These findings are not really new, and could have been anticipated. Robert Van
Howe conducted a large scale meta-analysis of the effect of male circumcision on
4
55
HIV and other STIs in many risk groups, and found no protective effect. He even
found a small increased risk in his meta-analyses (Van Howe, 1999a, b).
Comparing the United States, where male circumcision is widespread, to Europe
where it is rare, also goes rather in the opposite direction: more HIV in the former, and even more HIV transmitted heterosexually if one excludes cases imported
from Africa in Europe. Even in the USA, the African-American population is more
circumcised than average, and it is also more affected by HIV (Siegfried et al.,
2007).
Let us also remember that, in Africa, about 70% of men are already circumcised, probably the highest rate in any continent: this did not hamper Africa to
host the largest epidemic in any continent. A quick comparison with Eastern Asia
(China, Japan) where virtually no men are circumcised and where HIV prevalence
is extremely low is illuminating: the correlation goes in the opposite direction—
the less circumcision, the less HIV prevalence. In contrast, when one makes similar
comparisons with vaccination coverage for diseases or with contraceptive use for
fertility, one finds the expected correlations.
Controversy About Geographical Correlations
Several studies conducted in the 1980s argued that African countries more affected
by HIV were also less circumcised (Bongaarts et al., 1989; Moses et al., 1990;
Weiss et al., 2000). This has been confirmed by recent population based studies, but is obviously correlated with other important confounding factors affecting
sexual behavior, in particular, religion: Islam recommends male circumcision,
but is very much opposed to any form of premarital and extramarital intercourse for women, therefore strongly reducing the risk of sexual transmission of
diseases.
In another paper, we argued that HIV was more closely related with marriage
pattern and permissiveness, both being measured simultaneously by premarital fertility (having a birth prior to first marriage). The map displaying premarital fertility
levels is in fact close to the map of HIV prevalence levels, revealing the other confounding factors (Zwang and Garenne, 2008). Therefore, the ecological correlation
between HIV prevalence and male circumcision appears misleading, and seems to
reflect primarily other determinants of HIV spread.
However, one should note that no country for which we have reliable data where
male circumcision is widespread (>85% circumcised), including non-Muslim countries, such as Congo-Kinshasa, had a high level of seroprevalence (>5% among
adults 15–49). This fact has never been properly explained, and deserves more
research.
In summary, whatever the correlations, one has to remember that even a country
half circumcised, such as Lesotho, can have a very large epidemic, with levels of
seroprevalence close to the highest on record. This seems to give a far better picture
of what could be the potential impact of mass circumcision campaigns: basically
negligible in generalized epidemics.
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M. Garenne
Population Impact Versus Clinical Efficacy
The difference between the effect of male circumcision in clinical trials and the
lack of any significant demographic effect may seem puzzling at first glance. The
main reason seems to be the low level of clinical efficacy: a 50% reduction in risk is
likely to have only a small demographic effect. Indeed, under repeated exposure, any
circumcised man will eventually become infected, as will intact men. Circumcision
does not really provide any protection, but simply reduces the risk at each exposure.
This may delay the time to infection, but will rarely change the ultimate outcome, a
situation similar to the effect of the rhythm method for contraception. The potential
effect of mass circumcision campaigns will lead only to a very small impact, which
will be buried into the many other factors of HIV transmission. If male circumcision
had a 99% protective efficacy, the situation would have been different.
Discussion
Rationale for Making Public Health Policies
Let us ask now a simple question, based on the findings of the clinical trials: is
a 50% reduction in risk enough to make a policy? The answer is clearly no. For
instance, if one compares with the field of contraception: the rhythm method is also
50% efficient in clinical trials, but is not recommended, because there are much
better strategies available for birth control. Likewise, the cholera vaccine is also
50% efficient in clinical trials, but is not recommended, because there are much
better strategies available for controlling cholera. There are also better alternative
strategies to control HIV, summarized under the acronym “ABC” (for Abstinence,
Be faithful, Condom use), which have worked in Africa and elsewhere: changing
risky behavior worked well, for instance, in Uganda (Low-Beer, 2002; Low-Beer
and Stoneburner, 2003), and condom use worked extremely well in Thailand (Brown
et al., 1994). We do not have a full account of what has been happening in Africa
since year 2000, but in almost all countries for which data are available, prevalence
and incidence among young adults have been going down over the past 10 years,
as a result of changing behavior. These ABC strategies seem to be able to change
the course of the HIV epidemics. On the other hand, no country has ever been able
to control an STI with male circumcision only. Let us remember the case of Japan:
this country has among the lowest rates of HIV and of any STI, and makes a very
wide use of condoms. This seems to be a far better strategy for controlling sexually
transmitted infections.
Ethical Considerations
This paper focuses on the lack of demographic impact to be expected from
male circumcision. Of course, there are many other dangers associated with mass
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circumcision campaigns. Firstly, at population level, shifting from ABC strategies,
which, from experience, are the most likely to change the course of the epidemic to
a strategy that has no chance of doing so, seems to be a serious mistake. Secondly, at
the individual level, giving the impression that male circumcision “protects” against
HIV transmission may have adverse effects: by giving a false sense of protection, it
may induce riskier behaviors, and ultimately increase transmission. In this case, it
will also have negative effects on the confidence that individuals have in the health
system and in health education messages.
Ultimate Rationale of Male Circumcision
Male circumcision is a form of genital mutilation with numerous implications,
amply documented in this book and in the ten international symposia organized
over the past 20 years. This in itself raises many ethical issues, widely documented
elsewhere (Aggleton, 2007; Doctors Opposing (male) Circumcision, 2006; Clark,
2006).
Beyond individual cases when it is recommended for medical reasons, at population level male circumcision appears as a form of power abuse, especially when
made compulsory, or at least strongly recommended. It is especially questionable
when used on infants, children, or adolescents since it violates their rights, but is
also questionable when recommended for consenting adults.
Numerous studies have highlighted the stakes behind this practice. For traditional
societies, where circumcision is compulsory for adolescents, the power abuse comes
from the elders. This is best expressed by Margaret Mead (1949), who had such a
powerful insight on male circumcision. In her famous book, Male and Female, she
says:
. . . in South America, in Africa and in the South Seas, there are tribes in which the old
men’s antagonism to the springing sexuality of the young induces fears that are later reduced
in pantomine, cruel initiatory rites in which the young men are circumcised, their teeth
knocked out, and, in various ways they are reduced and modified and humbled, and then
permitted to be men.
When religious leaders recommend circumcision for newborns or young boys,
the power abuse comes from religious hierarchy and applies to the whole society: by requesting the parents to accept the circumcision of their sons, the religious
establishment ensures its power over the whole family.
Robert Darby (2005) in his book, A Surgical Temptation, showed that the
development of male circumcision for newborn infants in Victorian England is
also a form of power abuse, this time coming from the medical establishment
over the families. This came at a time when the political power of physicians
and surgeons in society increased dramatically, and a new form of “biopower”
emerged.
The question that can be raised now is whether recommending mass circumcision campaigns for Africans, in the absence of clear evidence of any demographic
impact, is not a new form of power abuse, this time from newly established groups:
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M. Garenne
international institutions and lobbies? This question certainly deserves further
comments and in-depth discussions.
References
Aggleton P. (2007) Just a snip? A social history of male circumcision. Reprod Health Matters.
15(29):15–21.
Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. (2005) Randomized,
controlled intervention trial of male circumcision for reduction of HIV infection risk: The
ANRS 1265 trial. PLOS Med. 2(11):e298, 1–111.
Bailey RC, Moses S, Parker CB, Agot K, MacLean I, Krieger JN, Willams CFM, Campbell RT,
Nidnya-Achola JO. (2007) Male circumcision for HIV prevention in young men in Kisumu,
Kenya: A randomised controlled trial. Lancet. 369:643–656.
Bongaarts J, Reining P, Way P, Conant F. (1989) The relationship between male circumcision and
HIV infection in African populations. AIDS. 3(6):373–377.
Brown T, Sittitrai W, Vanichseni S, Thisyakorn U. (1994) The recent epidemiology of HIV and
AIDS in Thailand. AIDS. 8(Suppl 2):S131–S141.
Clark PA. (2006) To circumcise or not to circumcise? Health Prog. 87(5):1–9.
Connolly C, Simbayi LC, Shanmugam R, Nqeketo A. (2008) Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002. S Afr Med J.
98(10):789–794.
Darby R. (2005) A Surgical Temptation: The Demonization of the Foreskin and the Rise of
Circumcision in Britain. Chicago, IL: University of Chicago Press.
Demographic and Health Surveys. Web site: www.measuredhs.com
Doctors opposing male circumcision. (2006) Medical Ethics and the Circumcision of Children.
Report, 2006. Available on web site: http://www.doctorsopposingcircumcision.org/pdf/A4MedicalEthicsReport.pdf
Edwards K, Decker M. (2008) Cholera vaccine. In: Plotkin SA, Orenstein WA. (eds.) Vaccines.
Philadelphia, PA: Elsevier-Saunders.
Garenne M. (2006) Male circumcision and HIV control in Africa. PLoS Med. 3(1):e78.[Letter]
Garenne M. (2008) Long-term population effect of male circumcision in generalized HIV
epidemics in sub-Saharan Africa. Afr J AIDS Res. 7(1):1–8.
Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, Kiwanuka N, Moulton LH,
Chaudhary MA, Chen MZ, Sewankambo NK, Wabwire-Mangen F, Bacon MC, Williams CFM,
Opendi P, Reynolds SJ, Laeyendecker O, Quinn TC, Waver MJ. (2007) Male circumcision for
HIV prevention in men in Rakai, Uganda: A randomised controlled trial. Lancet. 369:657–666.
Labbok MH, Queenan JT. (1989) The use of periodic abstinence for family planning. Clin Obstet
Gynecol. 32(2):387–402.
Lesotho – Ministry of Health and Social Welfare (MOHSW), Bureau of Statistics (BOS), and ORC
Macro. (2005) Lesotho Demographic and Health Survey 2004. Calverton, NY: MOH, BOS, and
ORC Macro.
Low-Beer D. (2002) HIV incidence and prevalence trends in Uganda. Lancet. 360(9347):1788.
Low-Beer D, Stoneburner RL. (2003) Behaviour and communication change in reducing HIV: Is
Uganda unique? Afr J AIDS Res. 1(2):9–21.
Malawi – National Statistical Office (NSO), and ORC Macro. (2005) Malawi Demographic and
Health Survey 2004. Calverton, NY: NSO and ORC Macro.
Mead M. (1949) Male and Female: A Study of the Sexes in a Changing World. New York, NY:
[Reprinted by Harper-Collins, 2002].
Moses S, Bradley JE et al. (1990) Geographical patterns of male circumcision practices in Africa.
Int J Epidemiol. 19(3):693–697.
Pollard R. (1980) Relation between vaccination and notification rates for whooping cough in
England and Wales. Lancet. 1(8179):1180–1182.
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Redd SC, Markowitz LE, Katz SL. (1999) Measles vaccine. In: Plotkin SA, Orenstein WA. (eds.)
Vaccines. Philadelphia, PA: W.B. Saunders, pp 222–266.
Tacket C, Sack D. (2008) Cholera vaccine. In: Plotkin SA, Orenstein WA. (eds.) Vaccines.
Philadelphia, PA: Elsevier-Saunders.
Siegfried N, Muller M, Volmink J, Deeks J, Egger M, Low N, Weiss H, Wlaker S, Williamson P.
(2007) Male circumcision for prevention of heterosexual acquisition of HIV in men (Review).
The Cochrane Library.
South Africa. (2002) The Nelson Mandela/HSRC study of HIV/AIDS, 2002. Human Science
Research Council, Cape Town, South Africa. [available on web site: www.hsrcpress.ac.za]
Tanzania – Commission for AIDS (TACAIDS), National Bureau of Statistics (NBS), and ORC
Macro. (2005) Tanzania HIV/AIDS Indicator Survey 2003–2004. Calverton, NY: TACAIDS,
NBS, and ORC Macro.
Van Howe RS. (1999a) Does circumcision influence sexually transmitted diseases? A literature
review. BJU Int. 83(Supp 1):52–62.
Van Howe RS. (1999b) Circumcision and HIV infection: Review of the literature and metaanalysis. Int J STD AIDS. 10:8–16.
Weiss HA, Quigley MA, Hayes RK. (2000) Male circumcision and risk of HIV infection in subSaharan Africa: A systematic review and meta-analysis. AIDS. 174:2361–2370.
Wood DL, Brunell PA. (1995) Measles control in the United States: Problems of the past and
challenges for the future. Clin Microbiol Rev. 8(2):260–267.
WHO/UNAIDS. (2007) Recommendations from expert consultation on male circumcision for HIV
prevention. Available at: http://www.who.int/hiv/mediacentre/news68/en/index.html
Zwang J, Garenne M. (2008) Premarital fertility and HIV/AIDS in Africa. Afr J Reprod Health.
12(1):64–74.
Chapter 5
AIDS XVII, Mexico City: Reason for Hope
or Panic?
John Geisheker
Abstract The XVIIth International Conference on AIDS in Mexico delivered
a pleasant surprise to those of us who exhibited on behalf of the International
Coalition for Genital Integrity: most of the African women delegates to whom we
spoke, AIDS workers on the front lines, were skeptical that male circumcision (MC)
would prove an HIV panacea of any worth. Indeed, many delegates described MC
as a double trap for women. They worried aloud that “medically circumcised” men
will tout themselves as uniquely immune to HIV and thus in no need of a condom. Delegates also noted that circumcision only protects HIV(–) men from HIV+
women, to only 60%, if it does that. It delivers no protection to HIV(–) women
from infected men. Well-financed proponents of MC locked out any discussion or
open forum on the issue in Mexico, and were quick to claim, “the train has already
left the station.” How soon this first-time public health condemnation of a normal
body part, an apparent well-financed fait accompli, stumbles remains the interesting
question.
Keywords Genital integrity · HIV · AIDS · Male circumcision · Cost benefits ratio
In August 2008, three of us—the author, along with Georganne Chapin and Brian
O’Donnell—traveled to Mexico City to staff a booth at the XVIIth International
AIDS Conference. Georganne and I are lawyers by training. Georganne also runs
Intact America and another nonprofit organization. Brian is a Physician Assistant,
certified as an HIV specialist by the American Academy of HIV Medicine. Our
intent was to highlight the risks and foolishness of the plan, floated by the
World Health Organization (WHO), the US President’s Emergency Plan for AIDS
Relief, the Joint United Nations Program on HIV/AIDS (UNAIDS), and the Gates
Foundation, to introduce male circumcision (MC) as a putative HIV preventative.
Our 10-foot banner, Male Circumcision: A Dangerous Distraction of Poor Ethics
and Bad Medicine, stretched directly across from the main elevator, and—through
J. Geisheker (B)
Doctors Opposing Circumcision, Seattle, WA, USA
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J. Geisheker
pure good fortune—was the first thing the delegates saw upon entering the exhibit
hall. Our message was highly controversial. Often, our booth was crowded with
conference delegates waiting to engage us, and visitors, including other conference
exhibitors, wanting to chat before and after official hours. Multiple delegates from
virtually every country in Africa, except Liberia and Tunisia, and many others from
around the world sought us out.
Our most effective argument, if confined to 60 or 90 seconds, was a simple and
effective four-part critique, which we adapted as the occasion warranted:
1. The cost of male circumcision (MC) would siphon off much of the available
AIDS funding. Money should properly go to condoms and education, which
are affordable and have been proven effective. These simple methods only wait
strong endorsement from local governments. Such plans barely have been implemented, and have also been thwarted by previous US administrations, apparently
responding to pressure from religious interests.
2. MC carries substantial risks in village settings, where trained personnel, antiseptic conditions, and even clean water are scarce, and where follow-up care for
infection and botches are non-existent.
3. Even if MC confers the 60% protection for men claimed by its advocates, this
is not vaccine-level protection. Presenting MC as a “magic bullet” yielding
“lifetime protection” as proponents have done is an irresponsible and unethical invitation to an epidemiological disaster if proven methods of sexual hygiene
are not also practiced rigorously. Moreover, if simple methods of sexual hygiene
are necessary to decrease the risks of infection even in a circumcised male, why
bother with the cost and risks of MC?
4. MC increases—inarguably and obviously—the risk of infection to women. Even
the claimed effect only protects men from infected women and then only to
60%—if you believe the studies. Even if we accept the findings of the three
randomized controlled trials that allege a protective effect for circumcision (and
there is much criticism of the methodology in the scientific press), circumcision would do nothing to protect an HIV-negative woman from an infected male.
Thus, we were able to argue that medically circumcised men are likely to present
themselves, especially to poor or illiterate village women, as rendered surgically
immune to HIV.
This last point seemed to resonate best with those delegates with whom we spoke.
To visitors who remained longer at our booth, we offered the following additional
arguments:
Some men are likely to boast that their “medical” circumcision confers unique
protection from HIV, and is thus superior to tribal or bush initiation rites.
Indeed, the white, North American proponents of MC for Africa publicly
claimed in Mexico City that traditional African MC methods “are not thorough enough,” raising the lucrative, and for some proponents, a giddily
titillating prospect of re-circumcising all of the hundreds of millions of
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63
already ritually circumcised males in Africa. Their own studies showed that
circumcised men felt “confident” they would not catch HIV, which suggests a
dangerous, misguided reliance on Western medicine. Proponents apparently
sensed neither the risk nor the irony.
Focusing on MC creates a parallel disincentive to use condoms, which provide
other benefits—notably preventing unwanted pregnancies, as well as control
of other sexually transmitted infections. Brian O’Donnell, who had worked
in HIV programs in South Africa, observed that promoting condoms and
emphasizing their correct use has never been made a priority. In that country, for example, the only condom available for free (and ironically called
“CHOICE”) smelled medicinal, and was available in only one size. Two or
three health ministers who stopped by our booth remarked that they were
afraid that if the word got out in their predominantly Muslim countries that
circumcision protected men from HIV, all the work they had done to encourage the use of condoms would be forgotten and the incidence of HIV and
other STDs would go up. Many predicted that HIV would also increase in
Sub-Saharan Africa, as a result of men believing that their newly performed
circumcisions will confer protection.
Medical care in Africa has already proved a vector for HIV infections, as
expensive one-use supplies are routinely re-used, when HIV-infected men
and women, not yet tested or as yet undetectable, seek medical attention for
any reason.1 This problem will explode with mass circumcision, as the supposed “single-use” surgical kits will be redeployed within populations with
high HIV prevalence.
The shortage of skilled circumcisers will be an ongoing problem, and will exacerbate the already significant risks and harms of circumcision. Proponents
of MC admitted that there will never be sufficient resources, financial or
human, to enlist physicians or surgeons for their massive, continent-wide
plan. Instead, they conceded that the best they could do is train paraprofessionals to perform this single procedure and no other. In fact, they admitted
in Mexico City that most likely to be trained are “bush” circumcisers, men
who for centuries have used unsanitary techniques that kill a hundred or more
South African young men each year. It is unlikely those same practitioners
will observe consistent antisepsis let alone be trained to deal with the many
complications that MC creates even in the modern hospital settings of the
developed world.
“Bush” circumcisions are themselves a proven vector for HIV. Bush circumcisers will not suddenly begin to autoclave their pot shards, sharpened sticks,
and discarded razor blades, simply because US medical consultants request
they do so.2
Male genital cutting (MGC) might halt the progress made in discouraging
female genital cutting (FGC), or worse, may cause it to spring up unbidden where it never flourished before. One reason is that, if mucosal tissue is
the culprit, women have much more of the “warm, moist, mucosa,” so feared
by male circumcision proponents, than men. Example: A Tanzanian study of
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J. Geisheker
circumcised women shows a similar protective effect, though that study has
received very little press for obvious reasons.3 We repeatedly emphasized
that, from an ethical standpoint, there is no distinction between male and
female cutting, and others were also pointing this out. Georganne reported
that, at one session she attended, an African woman in the audience at a
panel on male circumcision asked the question: “How shall we tell our people that girls must be left with the bodies that God gave them, while at the
same time we propose to cut all of our boys?” Unfortunately, this perspective
was not featured at the conference.
Promoting MC pits one culture against another. In Kenya, the Luo tribe
(the tribe of Barack Obama’s father) does not circumcise, yet they are
being blamed for the HIV epidemic by the Kikuyu, who do practice circumcision. During recent hostilities, Kikuyu men kidnapped and forcibly
circumcised any Luo men or boys they could entrap.4 Such tribal tensions
will be exacerbated if circumcision is introduced indiscriminately, risking the
same genocide that ravaged the Hutu and Tutsi in Uganda. Indeed, the Luo
already blame white researchers for the perception that they are the source of
HIV/AIDS.
MC will enforce and propound genital cutting traditions for centuries to come.
Anthropologists note that genital cutting, especially of children, is invariably
intractable, as its victims grow up to impose it on the young and powerless as
it was imposed on them. This cycle, as FGC opponents have noted, is difficult
to break. Thus, the WHO HIV plan will have a tragic side-effect: genital cutting rituals, which South Africa, for instance, has tried to outlaw for minors,
will become “medicalized” and normalized, blessed by the Western medical
establishment, and hence nearly impossible to eradicate. The United States
itself is an example of this phenomenon, with its 140-year genital-cutting
tradition (girls were included for many decades) brokered and sustained by
the medical establishment entirely for reasons of its own.
The belief that genital amputations are the ultimate and preferred solution to
sexually transmitted diseases will become a deeply rooted and unquestioned
custom in Africa, which already has many different and ancient traditions
of genital cutting imposed on children. Even if the WHO/PEPFAR/Gates
Foundation plan eventually fails, for reasons of cost, or morbidity, or
“patient” resistance—or an AIDS vaccine is eventually found—the notion
of genital cutting as a first-line medical intervention will have done massive
anthropological damage. It may take centuries to recover from this Western
interference in diverse African cultures, and tens of millions of children are
likely to pay the highest price.
After 5 days of engaging about 800 people—many of whom were AIDS workers
on the front lines in Africa—at our booth, in elevators, and on our daily bus-ride,
we were able to draw some sobering conclusions:
Europeans from all countries and backgrounds with only rare exceptions agreed
with our message. Our few vocal critics were invariably North Americans,
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AIDS XVII, Mexico City: Reason for Hope or Panic?
65
some doubtless with a financial, professional, personal, or religious stake in
legitimizing and promoting male circumcision.
African women were the most astute in their instant recognition of the social
risks; African men were less so, as you might expect. The vast majority of
these women—to be fair, educated, traveled, and urbane—thought the WHO,
UNAIDS, PEPFAR, Gates Foundation plan was not only wasteful, but also
a “trap” for village women. They often arrived already skeptical and took
little effort to convince. The question remains whether their resistance will
make a difference at the local level or whether they will be marginalized or
steamrolled by the huge sums of money flowing toward their local officials
from the proponents of MC.
All in all, this was an inspiring, if exhausting, experience. The conundrum
remains how First-World circumcision proponents can remain so single-minded and
intransigent while individual citizens of the target countries they claim to be “saving” understand the village-level risks and costs. We think this is simply a modern
example of colonial medicine, complicated by a failure to learn from past failed
efforts, such as vasectomy programs in India and an almost exclusive medical-model
approach. A number of social scientists present complained to us that their warnings had been ignored in favor of purely biomedical computer modeling. Most of all,
though, the increasing focus on male circumcision is due to the huge sums, hundreds
of millions, made available by the Gates Foundation and UNAIDS, and publicly
represented by former US president Bill Clinton, who appeared again, as he had
in Toronto in 2006. We wonder whether a Health Minister of a small, impoverished
African country (or a Johns Hopkins or Harvard professor reeling in lucrative grants)
would turn away billions of dollars, no matter how it was earmarked. Indeed, we
observed that much of that money is likely to evaporate through graft and political
corruption and will never be used for its stated purpose.
Flying back to the States, by chance I found myself seated next to Dr. Marcus
Conant, an HIV physician from San Francisco (featured in the film And the Band
Played On), who, before the advent of anti-retroviral therapies (ART), lost thousands of patients to AIDS. Initially, I did not know who he was. When he asked me
whether I was at the conference, I offered him my Doctors Opposing Circumcision
business card, to which he said, “Well, meet another doc opposing circumcision.”
He went on to say, “I do not feel that widespread circumcision is a panacea for
stopping the AIDS epidemic.”
And, indeed, WHO and UNAIDS are already floating that plan, without the
slightest qualm, having moved swiftly, in barely five years, from voluntary adult
circumcisions (about which, epidemiological worries aside, there is little to say if
there is honest informed consent) to MC for infants, where consent is irrelevant,
mandates easy to impose, and the bioethics disgraceful.
Since August of 2008, several interesting developments have changed the scheme
to impose circumcision as a panacea for HIV:
The recent Wawer study showed that circumcised men were more likely to transmit HIV to the female partner than the uncircumcised male, 21% vs. 13%, more
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than a 150% differential. The study was aborted due to “futility.” It would be interesting to know what the long-term sero-conversion results might have been. Surely,
this rate would rise over time. The author of the study, an admitted “MC-for-Africa”
proponent, confessed that she was “disappointed” but admitted, “the data are what
they are.”5
An HIV vaccine, actually a combination of two vaccines previously found ineffective individually, has shown a 30% reduction in HIV, though that conclusion has
been hotly contested.6 If proven, even a vaccine showing a 30% reduction is in
practice better than the 60% claim of prophylaxis via circumcision, since a vaccine
has the potential to protect everyone in all directions, every vector—male, female,
adult, or child, regardless of infection source or sexual practice. By contrast, even
MC proponents admit that the African randomized controlled trials, if they are to
be believed, indicate that MC only protects heterosexual men from infected women,
a single, one-way vector among many. We strongly doubt, however, the veracity of
the results of these studies.
Campaigns to encourage condom use, “all the time, every time,” have been successful in Eastern Uganda, Senegal, Swaziland, and Thailand, and death rates and
new infections are dropping due to better access to anti-retroviral therapies.7
Of course, a vaccine with an effective rate of 90% or more would still be the
goal and, at that point, mass circumcision campaigns, by comparison, would be so
expensive and cumbersome to implement they would be ludicrous to promote and
would soon perish. Nevertheless, before that day finally arrives, how many African
cultures and how many millions of men and boys will be damaged by circumcision?
Acknowledgments I wish to thank my colleagues, Georganne Chapin and Brian O’Donnell, for
their fellowship in Mexico City as well as their assistance in preparing this analysis of our advocacy
there.
Notes
1. Brody S, Potterat JJ. (2005) HIV epidemiology in Africa: Weak variables and tendentiousness
generate wobbly conclusions. PLoS Med. 2(5):e137.
2. Hrdy DB. (1987) Cultural practices contributing to the transmission of human immunodeficiency virus in Africa. Rev Infect Dis. 9(6):109–119.
3. Female Circumcision and HIV Infection in Tanzania: For Better or for Worse? Rebecca
Y. Stallings, 2 Statisticus Consultoris, USA and Emilian Karugendo, National Bureau of
Statistics, Tanzania. And see: http://www.ias-2005.org/planner/Presentations/ppt/3138.ppt
4. http://afp.google.com/article/ALeqM5gkiZSdchTFFEy7rFhYWAK4z6Zc8Q
http://africanarguments.org/2009/07/watu-wazima-a-gender-analysis-of-forced-malecircumcisions-during-kenya’s-post-election-violence/
5. www.thelancet.com “Circumcision in HIV-infected men and its effect on HIV transmission
to female partners in Rakai, Uganda: A randomised controlled trial.” Wawer MJ, et al. The
Lancet. 374(9685):229–237. July 18, 2009, doi:10.1016/S0140-6736(09)60998-3.
6. http://news.bbc.co.uk/2/hi/health/8272113.stm
7. http://news.bbc.co.uk/2/hi/8375297.stm
Chapter 6
Circumcision Psychopathology
George C. Denniston
Abstract Circumcision psychopathology is defined as a personality disorder characterized by a cluster of interpersonal, affective, lifestyle, and antisocial traits and
behaviors, including grandiosity, egocentricity, deceptiveness, shallow emotions,
lack of empathy or remorse, irresponsibility, impulsivity, and a strong tendency
to violate ethical norms. In this article, standard methods for the assessment of
circumcision psychopathy are outlined. Circumcision psychopathy is conceptually
similar to antisocial personality disorder (ASPD) from the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV). However, at the measurement level, the former places more emphasis on interpersonal and affective features
and their links to broad antisocial tendencies, while the latter emphasizes overt antisocial behaviors. Its association with antisocial personality disorder (ASPD) and its
implications for clinical and forensic issues, including risk assessment, crime and
violence are discussed. Circumcision psychopathy is associated with an increased
risk for antisocial behavior, deviant sexual impulses, and presents the mental health
and criminal justice systems with a formidable therapeutic challenge.
Keywords Male circumcision · Antisocial personality disorder · Psychopathology ·
Diagnostic and Statistical Manual of Mental Disorders · Antisocial
behavior · Deviant sexual impulses
Introduction
Circumcision psychopathy is a personality disorder common among medical and
religious circumcisers as well as advocates of circumcision defined by a cluster
of interpersonal, affective, lifestyle, and antisocial traits and behaviors, including grandiosity, egocentricity, deceptiveness, shallow emotions, lack of empathy
G.C. Denniston (B)
Doctors Opposing Circumcision (D.O.C.), Seattle, WA, USA
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or remorse, ruthlessness, determination, irresponsibility, impulsivity, cognitive dissonance, sexual deviance, and a strong tendency to violate ethical norms. This
disorder has a long history among circumcisers operating within specific religious
(Jewish and Muslim) groups and now, more recently among Western (specifically
United States) medical professionals since the imposition of mass circumcision on
the United States population in the middle of the twentieth century.
The ethical and legal principles and instruments that would prohibit circumcision include the Nuremberg Code of Ethics, the Hippocratic Oath, every one of
The American Medical Association’s Principles of Ethics, and the Good Medical
Practice Statement of the General Medical Council in the United Kingdom. Doctors
afflicted with circumcision psychopathy may be aware of these documents, but they
either consider them irrelevant to circumcision or a hindrance to be ignored and
suppressed.
Because circumcision psychopathy is associated with so much social, sexual, and
personal damage and distress, the basic and applied research endeavors are now supplemented by the provision of forums for victims to discuss their problems. Groups
such as NORM-UK, NORM (US), Doctors Opposing Circumcision (DOC), and the
National Organization of Circumcision Information Resource Centers (NOCIRC)
have created affiliated groups where victims of circumcision are free to discuss
their experience and seek counseling. Attempts to understand and deal with doctors afflicted by circumcision psychopathy, and to communicate research findings
to professionals and the public, may be impeded by confusion about what is meant
by the term. For this reason, we begin with a brief discussion of the construct of circumcision psychopathy, followed by a few comments about the conceptually related
anti-social personality disorder (ASPD), described in the DSM-IV.
Circumcision Psychopathy
Briefly, circumcision psychopathy is a personality disorder that includes a cluster of
interpersonal, affective, lifestyle, and antisocial traits and behaviors. On the interpersonal level, medical professionals with circumcision psychopathy are grandiose,
deceptive, dominant, superficial, and manipulative. Affectively, they lack guilt,
remorse or empathy with their victims. The interpersonal and affective features
are fundamentally tied to a deviant lifestyle that includes irresponsible, monomaniacal obsession with circumcision, ruthless determination to justify and impose
mass circumcision, and a tendency to ignore or violate ethical conventions and
mores. Typically, such offenders are circumcised males, though the disorder has
been observed in female doctors.
Causes of Circumcision Psychopathy
The common denominator linking all male offenders with circumcision psychopathy is that they themselves were subjected to circumcision in infancy.
Latent post-traumatic stress disorder and other long-term psychological problems
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stemming from infant circumcision have been well documented.1 This psychological harm may stem from the trauma of the surgery, which is usually performed without benefit of anesthetic. The harm may also result from the shocking realization,
later in life, that a significant part of the body was amputated.
Sufferers of circumcision psychopathy, however, appear to have evolved a psychological coping mechanism designed to protect the ego by justifying the loss of
the body part and, as with the Helsinki Syndrome, by identifying with the goals of
the perpetrators. Still, other sufferers of circumcision psychopathy appear to have
adopted the aggressive stance of “If I cannot have a foreskin, then I will make sure
that no one else can have one either.”
The second commonality linking all male sufferers of circumcision psychopathy
is that they have deliberately and assiduously maneuvered themselves into professional positions where they can unleash their impulses to perform circumcisions
or advocate for circumcision. Sufferers, therefore, are to be found among any professional group that is normally charged with performing circumcisions, such as
pediatricians, obstetricians, urologists, and family practitioners. Similarly, sufferers
without the impulse to perform circumcisions in a professional setting may manifest
their disorder by moving themselves into research positions where they can carry out
studies that appear to support mass involuntary circumcision. Currently, all of the
putative studies purporting that circumcision prevents AIDS, most of which come
from the pens of a small handful of researchers, provide very strong evidence of
being the product of sufferers of circumcision psychopathy, as will be explained
below.
Female sufferers of circumcision psychopathy are rare, but do exist. Typically,
they are motivated by misplaced loyalty to circumcised male family members, loyalty to the medical profession, or loyalty to a traditionally circumcising ethnic or
religious community, such as Jews or Muslims. Many female offenders are motivated to rationalize the circumcisions that they performed in the past or motivated
to rationalize and justify their personal responsibility for the decision to subject
their own male offspring to circumcision. One researcher was privately informed
by a female medical circumciser that she was motivated to perform circumcisions
because she wanted to punish males “where it counts” for perceived injustices done
to her and to other females throughout history. Psychopathy of this sort provides
evidence to support Freud’s theory that circumcision is a partial and a symbolic
castration.2
CPCL Assessment of Circumcision Psychopathy
The Circumcision Psychopathy Checklist (CPCL) is designed to measure the clinical construct of circumcision psychopathy; however, because of its demonstrated
ability to predict recidivism, it may be used in forensic assessments, either on its
own or, more appropriately, as part of a battery of variables relevant to forensic
psychology and psychiatry.
Briefly, the CPCL is a twenty-item clinical rating scale that uses case history
information, observation of the subject in public settings where he or she has
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advocated for circumcision to the lay public, careful observation of the subject’s
actions and reactions when debating circumcision with professional critics of
circumcision, analysis of the subject’s published writings on the subject of circumcision, and, finally, specific scoring criteria to rate each item on a 3-point scale
(0, 1, 2) according to the extent to which it applies to a given medical professional.
The items and the factors they comprise are listed in Table 6.1.
Table 6.1 Circumcision Psychopathology Checklist
F1
Interpersonal
1. Glibness—superficial charm used when dealing with the media, the public, and other
medical professionals
2. Grandiose sense of self-worth
3. Pathological lying—lying about medical and anatomical facts to the public, to patients,
and to parents of potential victims
4. Conning—manipulative
Affective
5. Lack of remorse or guilt
6. Shallow affect
7. Callous—lack of empathy
8. Failure to accept responsibility
9. Conscious disregard or disdain for medical ethical standards, which, if followed, would
prohibit circumcision
F2
Lifestyle
10. Unquenchable need to find justifications for personal circumcised status
11. Paranoia—frequently among Jewish offenders, ‘Holocaust paranoia’
12. Unquenchable need to defend ethnic identity, perceived to be under attack
13. Ruthlessness in dealing with opponents of circumcision
14. Irresponsibility—jeopardizing professional reputation through single-minded
circumcision advocacy
15. Monomaniacal obsession with circumcision—obsession with finding new rationales to
impose the surgery on others
Antisocial
16. Sexual deviance—pedophilic or homosexual arousal while performing, or fantasies
about performing, circumcisions
17. Sadistic impulse to control and/or destroy the sexual functions of other males
18. Disgust for and refusal to acknowledge normal penile anatomy and function
19. Disgust for individuals and ethnic groups with intact genitalia
20. Willingness to falsify or distort research data in order to promote circumcision
Total scores can range from 0 to 40 and reflect the degree to which the circumciser matches the prototypical psychopathic person. A CPCL cut-off score of
10 has proven useful for classifying people for research and applied purposes as
psychopathic. Analysis reveals that CPCL scores in the upper range appear to reflect
much the same level of circumcision psychopathy in North American male doctor
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offenders as they do in non-medical religious circumcisers. Nonetheless, we note
that there are ethnic and gender differences in the functioning of individual CPCL
items and in the external correlates of the CPCL and other measures of psychopathy.
The patterning and significance of these differences are the subject of much of the
current empirical research on circumcision psychopathy.
When conducting an assessment, it is important to use all information available to provide a complete picture of the person. In each case, the CPCL must be
used properly and in accordance with the highest ethical and professional standards.
Clinicians who use the CPCL must be prepared to outline the information used
to score the items and to explain and justify the manner in which they scored the
items.
There are no exclusion criteria for use of the CPCL. It can be administered
to offenders with various professional involvements in the circumcision industry.
Therefore, it is possible to have symptoms similar to psychopathy, as measured
by the CPCL scales, and other psychiatric disorders (for example, delusions of
grandeur in psychotic disorders, inflated self-importance in narcissistic personality
disorder, and grandiose self-worth in psychopathy).
A primary strength of the CPCL is its ability to provide empirical evidence
that not all doctors who perform circumcisions are necessarily afflicted with circumcision psychopathy. Many doctors who perform circumcisions do so merely
because they are innocently following orders and have no personal motivations
behind their actions. While the excuse of “just following orders” does not exculpate a medical professional from a charge of wrong doing, as demonstrated in the
Nuremberg Trials following World War II, it does elucidate the pressure placed
on doctors to conform and obey while ignoring the ethical implications of their
actions.
Factor Structure
As shown in Table 6.1, F1 reflected the interpersonal and affective components
of the disorder, whereas F2 was more closely allied with a socially deviant
lifestyle (the lifestyle and antisocial factors in Table 6.1). The psychopathological factors are significantly interrelated. The pattern of correlations among the
factors, as well as confirmatory factor analyses also confirm the presence of
two broad factors, identical with the original F1 and the other the same as the
original F2.
Because the CPCL factors are substantially correlated, it is important to examine the combined effects of elevations on both of these factors. Put in more clinical
terms, a syndrome of circumcision psychopathy is likely typified by a doctor who
chronically presents with elevated scores on both factors, not just one of these factors. Consistent with this idea, preliminary research by this author found that the
interaction of F1 and F2 was critical for predicting offenders’ ethical conduct in the
professional setting, predisposition toward performing circumcisions, and violent
and aggressive behavior toward opponents of circumcision.
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G.C. Denniston
Antisocial Personality Disorder
The DSM-IV states that Antisocial Personality Disorder (ASPD) “has also been
referred to as psychopathy, sociopathy, or dissocial personality disorder The
Disorders section for ASPD in DSM-IV clearly describes ASPD by personality
features that are an essential part of the circumcision psychopathy construct.3 The
association between ASPD and circumcision psychopathy is generally asymmetric: most people with ASPD are not psychopathic, whereas most of those who are
circumcision psychopathic meet the diagnostic criteria for ASPD.
Assessment of Risk
A detailed account of circumcision psychopathy as a risk for recidivism is beyond
the scope of this article. Recidivism in this context means the inability of the
offender to stop himself from seeking out more victims to circumcise. The predictive value of circumcision psychopathy applies not only to adult male offenders
but also to adult female offenders.
Although circumcision psychopathy appears to be more predictive of general circumcision behavior under the cover of a professional setting than sexual violence,
its relation with the latter may be underestimated because many sexually motivated
violent offences of this nature are rarely officially recorded by the criminal justice
system. Such offenses, however, have been reported in the underground fetishistic
and sadistic sexual pornographic literature in which doctors participate in covert
homosexual circumcision orgies.4 Not only are the offences of psychopathic circumcisers likely to be more violent than those of other sex offenders, they tend
to be more sadistic. In extreme cases, the—correlation between—psychopathy and
sadistic personality is very high.
One of the most potent combinations to emerge from research on circumcision offenders is circumcision psychopathy coupled with evidence of deviant
sexual arousal. Private communications between this author and nursing staff in
the maternity ward of an American hospital reported that circumcision recidivism
was strongly predicted by a combination of a high CPCL score and obvious sexual arousal among circumcisers while performing circumcisions on infant boys.
Deviant fantasies no doubt play an important role in facilitating this circumcision
psychopathy—deviance pattern.
Treatment
Unlike most other offenders, doctors with circumcision psychopathy appear to suffer little personal distress, see little wrong with their attitudes and behavior, and
never seek treatment. They appear to derive little benefit from exposure to objective
medical studies proving that circumcision is both ineffective at preventing or curing
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disease and that, in fact, it is harmful. They seem unable to accept the human rights
argument that males have an inherent right to keep intact all the body parts with
which they were born. This is hardly surprising, given that circumcision psychopathy is characterized by personality and behavioral propensities that are strongly
entrenched and presumably difficult to change.
Conclusions
Use of the CPCL to measure circumcision psychopathology in the most prominent
advocates of mass, involuntary circumcision has resulted in a substantial amount
of empirical evidence that circumcision psychopathy, as measured by the CPCL, is
a predictor of circumcision recidivism and advocacy of circumcision among medical professionals. Although circumcision psychopathy is not the only risk factor for
recidivism, i.e., circumcisions performed on multiple victims similar to the actions
of a serial killer, it is unusually pervasive and too important to ignore. Treatment
and management are difficult given the current societal tolerance for the activities
of circumcisers, however, new initiatives based on current theory and research on
circumcision psychopathy will serve to identify, isolate, and eventually disempower
those medical professionals suffering from the highest degree of circumcision psychopathology. The CPCL is a powerful new tool in the field of correctional medical
research that may help to reduce the societal and individual harm done by doctors
with circumcision psychopathy.
Notes
1. Rhinehart J. (1999) Neonatal circumcision reconsidered. Trans Anal J. 29(3):215–21.
2. Freud S. (1939) Moses and Monotheism. London: Hogarth Press and the Institute of PsychoAnalysis, p 192.
3. Ibid., p 647.
4. See the comments reported at: http://www.sexuallymutilatedchild.org/fetish-c.htm
Chapter 7
Physical Effects of Circumcision
John Warren
Abstract Male circumcision results in permanent changes in the appearance and
functions of the penis. These include artificial exposure of the glans, resulting in its
keratinization and altered appearance. Additionally, circumcision results in loss of
30–50% of the penile skin, loss of at least 10,000–20,000 specialized erotogenic
nerve endings, loss of reciprocal stimulation of foreskin and glans, and loss of
the natural coital gliding mechanism, etc. From the point of view of sensation and
function, the most important effect is caused by the tissue loss itself. The most sensitive part of the penis is removed, and the normal mechanisms of intercourse and
erogenous stimulation are disturbed.
Keywords Male circumcision · Harm · Complications · Penile anatomy and
physiology · Prepuce · Gliding mechanism
Introduction
The physical effects of male circumcision can be considered under the following
headings:
1.
2.
3.
4.
5.
6.
Cosmetic effects
Glans externalized and keratinized
Penile skin and mucosal loss of 33–50%
Loss of sensory nerve endings
Loss of reciprocal stimulation of foreskin and glans
Loss of the gliding mechanism
J. Warren (B)
Royal College of Physicians, London, UK; NORM-UK, Staffordshire, UK
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J. Warren
Cosmetic Effects
Circumcision results in an altered appearance of the penis, which, to all intents
and purposes, is permanent. While foreskin restoration may be carried out, it is
not straightforward and the results are not perfect. It is comparatively easy for an
intact man to be circumcised. Some men are perfectly content to grow up with a
circumcised penis, while others can be very disturbed by it. Among circumcised
men who have contacted NORM-UK for help, the appearance of their penis is often
one of their main complaints. They frequently report avoidance of allowing others,
particularly other men, to see them naked, and some, therefore, avoid sports.
Penis size: This is a subject about which men have strong emotions. The effect of
circumcision reduces flaccid penile length and width slightly, as the normal foreskin
often overhangs the glans in the non-erect state. Width is reduced because of the
loss of the double layer of skin covering the glans. The erect penis may also be
somewhat shortened, as there may be insufficient penile skin to permit full erection.
An Australian survey showed circumcised men, on average, to have erect penises
8 mm shorter than intact men (Talarico and Jasaitis, 1973; Richters et al., 1995).
Skin color: In intact European males, the glans ranges in color from pink to dark
purple, while in dark skinned men it ranges from pink to dark brown. Infant circumcision, carried out when the glans is adherent to the foreskin, results in scarring,
pitting, and discoloration of the surface of the glans and, over the years, increasing
keratinization is likely to lead to further loss of natural color (Fleiss, 1997).
Glans Externalized and Keratinized
The normal glans is an internal structure, only exposed briefly during urination,
washing, and sexual arousal. Its surface is moist, and is not keratinized. However,
circumcision converts the glans into an external organ. Immediately after the operation, it retains its exquisite sensitivity, and contact with clothing causes considerable
discomfort, but it soon becomes desensitized, probably as a result of the laying down
of a layer of keratin on the epithelium. A few circumcised men report persistent discomfort from contact with clothing throughout their lives. The epithelium takes on
the character of skin rather than mucous membrane. Not only is the appearance of
the glans altered, but also there is a dramatic loss of sensitivity.
Sorrells et al. (2007) mapped fine-touch pressure thresholds in the adult penis in
circumcised and uncircumcised men, comparing the two populations. With regard
to the sensitivity of the glans, they showed that the glans in the circumcised male is
less sensitive to fine-touch pressure than that of the uncircumcised (intact) male.
Bleustein et al. (2005) tested vibration, pressure, spatial perception, and temperature on the glans in the dorsal midline in circumcised and non-circumcised men,
and failed to show any significant difference in sensation on the glans between the
two groups after correcting for age, hypertension, and diabetes.
What is clear is that the glans is the least sensitive region of the penis, in any
case, and is only supplied with simple nerve endings, which sense deep pressure
and pain (Sorrells et al., 2007; Bleustein et al., 2005; Halata and Munger, 1986).
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Tissue Loss from Circumcision
It is the tissue loss that causes the most important functional effects of circumcision.
What is lost? Thirty to fifty percent of the penile skin, the area in an adult being
about 15 square inches (96 cm2 ), comprising nearly all of the inner and outer foreskin, is removed. The frenulum is sometimes removed. The inner foreskin includes
the ridged band, a zone of specialized mucosa encircling the distal end of the inner
foreskin, first described by Taylor and colleagues (1996).
They described the ridged band in this way:
When retracted, the inner surface of the prepuce displays two zones, ‘ridged’ and ‘smooth’.
The first, a transversely-ridged band of mucosa 10–15 mm wide, lies against the true skin
edge, forming the outer surface of the tip of the prepuce. In the dorsal midline, the ‘ridged
band’ lies above the level of the adjacent ‘smooth’ mucosa and merges smoothly, on either
side, with the frenulum of the prepuce. When magnified, the ridged mucosa has a pebbled
or coral-like appearance. Unretracted, the adult ‘ridged band’ usually lies flat against the
glans; retracted, the ‘ridged band’ is everted on the shaft of the penis. The remainder of
the preputial lining between the ‘ridged band’ and the glans is smooth and lax. There is
considerable variation in the degree of ridging: older subjects showed less and younger
subjects more marked ridging. Some ridging was seen in all the prepuces examined.
Taylor and colleagues further noted that the ridged band is intensely vascularized,
which is typical of components of the nervous system.
The tightly pleated concentric bands of the ridged band have been likened to the
elastic bands at the top of a sock. These expandable pleats arise from the frenulum
and encircle the inner lining of the foreskin. They allow the lips of the foreskin to
open and roll back, exposing the glans. The ridged mucosa also gives the foreskin
its characteristic taper (Fleiss and Hodges, 2002).
The importance of the ridged band lies in its innervation. When he described it,
Taylor, a pathologist working on histology, reported that it showed focal, spiky, or
more rounded and flatter ridges interspersed with sulci. Meissner’s corpuscles were
more plentiful in some subjects than others but, perhaps significantly, they were only
seen in the crests of the ridges, occasionally in small clumps that expanded the tips
of corial papillae. End-organs were not seen in sulci between ridges. Special stains
for nerve tissue showed the additional end-organs and myelinated nerve fibers in
the ridges. In contrast, histological examination of the smooth zone of the mucosa
showed no ridging and few Meissner’s corpuscles.
Meissner’s corpuscles are mechanoreceptors for detection of light touch. They
are distributed throughout the skin, but concentrated in areas that are particularly
sensitive, such as the fingertips, palms and soles, lips, tongue, face, and genitals.
It has been calculated that circumcision results in the loss of at least 10,000–
20,000 specialized erotogenic nerve endings (Winkelmann, 1959, 1956).
Also lost in circumcision is about half the smooth muscle sheath that invests the
penis, which is known as the dartos fascia and is temperature sensitive.
The frenulum, a highly erogenous V-shaped structure that tethers the underside
of the glans to the shaft, is frequently destroyed or damaged during circumcision.
Circumcision removes several feet of blood vessels, including the frenular artery.
This loss of the rich vascularity interrupts the normal flow to the shaft and glans,
damaging the natural blood flow of the penis (Netter, 1997).
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J. Warren
The mucosal surface of the foreskin produces plasma cells, part of the body’s
defense system. They secrete antibodies and antibacterial and antiviral proteins,
including lysozyme.
The list of structures lost includes lymphatic vessels, apocrine glands (producing
pheromones, scent signals), sebaceous glands, and Langerhans cells (another part
of the defense system).
Loss of Sensory Nerve Endings
As already described, circumcision removes the part of the penis most richly supplied with sensory nerve endings, the ridged band. In general, the inner mucosal
foreskin is more sensitive than the outer foreskin, which differs little from the shaft
skin. This loss is borne out by the results shown by Sorrells et al. If we look at the
figure showing fine-touch pressure thresholds, we notice that the lowest threshold is
found at position 3, which is the dorsal preputial orifice rim, while the next lowest
thresholds are found at 13 and 14, parts of the frenulum, and 4 and 5, which are the
mucocutaneous junction and ridged band, respectively. In the circumcised penis, the
lowest threshold is found at position 19, the ventral surface of the circumcision scar.
Loss of Reciprocal Stimulation of Foreskin and Glans
The mobile sheath of the intact penis allows the foreskin to glide back and forth
over the glans. As it does so, it repeatedly folds and unfolds itself. Inevitably, the
tactile nerve endings in the glans and, more especially, in the foreskin are strongly
stimulated by this action, whether the result of masturbation, foreplay, or penetrative intercourse. During intercourse, the ridged band is alternately stimulated by the
glans, when it is turned inwards, and by the vaginal wall, when it is turned outwards.
The smooth muscle in the foreskin ensures that it encloses the glans snugly.
Loss of the Gliding Mechanism
Bigelow drew attention to the mechanical function of the foreskin during intercourse
(Bigelow, 2002). This function provides more enjoyable intercourse for both partners. During sexual arousal, the vagina secretes lubricant fluid allowing penetration
to occur comfortably. Then, during intercourse, the intact penis glides in and out of
its own skin sheath with each thrust, reducing friction between the penile skin and
the vaginal wall, and allowing the vaginal secretions to remain on its surface, rather
than being drawn out as they tend to be by the thrusting of the circumcised penis,
which during erection may have no slack skin at all.
Masturbation is similarly affected. An intact man masturbates by manipulating
his foreskin back and forth over his glans. In a circumcised man, this is not possible,
and often a lubricant is needed to permit comfortable stimulation. Circumcision
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was originally brought into medical fashion in the nineteenth century because it
was thought to prevent or at least discourage masturbation. Masturbation was then
considered to be dangerous to health, though this has long since been disproved. In
fact, circumcision does not prevent masturbation in the least, but it probably makes
it less enjoyable, though this is hard to prove.
Conclusion
In considering the physical effects of circumcision, we have seen how there is a
permanent change in the appearance of the penis and the exposure of the glans,
resulting in its keratinization and altered appearance. From the point of view of sensation and function, the most important effect is caused by the tissue loss itself. The
most sensitive part of the penis is removed, and the normal mechanisms of intercourse and masturbation are disturbed. At the same time, we have learned about the
function of the male foreskin, a subject that has been neglected by medical scientists
in the past. We have not considered complications of the operation, but merely what
ensues when everything goes according to plan.
References
Bigelow J. (2002) The Joy of Uncircumcising! 2nd ed. Kearney, NE: Morris Publishing, p 17.
Bleustein CB et al. (2005) Effects of circumcision on male penile neurologic sensitivity. Urology.
65:773–777.
Fleiss PM. (1997) The case against circumcision. Mothering Mag Nat Fam Living. Winter:36–45.
Fleiss PM, Hodges FM. (2002) What Your Doctor May Not Tell You About Circumcision.
New York, NY: Warner Books, p 7.
Halata Z, Munger BL. (1986) The neuroanatomical basis for the protopathic sensibility of the
human glans penis. Brain Res. 371:205–230.
Netter FH. (1997) Atlas of Human Anatomy, 2nd ed. (Novartis 1997): plates 238, 239.
Richters J et al. (1995) Why do condoms break or slip off in use? An exploratory study. Int J STD
AIDS. 6(1):11–18.
Sorrells ML et al. (2007) Fine-touch pressure thresholds in the adult penis. BJU Int. 99:864–869.
Talarico RD, Jasaitis JE. (1973) Concealed penis: A complication of neonatal circumcision. J Urol.
110:732–733.
Taylor JR et al. (1996) The prepuce: Specialised mucosa of the penis and its loss to circumcision.
Br J Urol. 77:291–295.
Winkelmann RK. (1956) The cutaneous innervation of the human newborn prepuce. J Invest
Dermatol. 26:53–67.
Winkelmann RK. (1959) The erogenous zones: Their nerve supply and its significance. Proc Mayo
Clin. 34:39–47.
Chapter 8
Complications of Circumcision: A Urologist’s
Viewpoint
James L. Snyder
Abstract Background: Although circumcision is the commonest surgical procedure performed on male neonates, complications still arise from all methods used by
operators. Patients and Method: This is a retrospective case study of penile injuries
resulting from circumcision complications in neonates and young boys observed in
the author’s urological practice. Results: Injuries resulting from circumcision with
all devices include death, amputation of excessive skin, amputation of the glans
penis, fistula formation, infection, sepsis, meningitis, adhesions, skin bridges, gangrene, and loss of the entire penis. Conclusion: Grievous and crippling injuries and
even mortality can occur from routine neonatal circumcision. Adequate information
should be provided to new parents of male babies informing them about possible complications. Moreover, doctors should discourage circumcision and inform
parents about the many benefits of leaving the infant’s penis intact.
Keywords Urology · Circumcision · Complications · Penile injuries · Death ·
Amputation · Fistula · Sepsis · Meningitis · Adhesions · Skin bridges · Gangrene
I have been asked to discuss the complications of circumcision—specifically, the
complications of routine male infant circumcision, as I have witnessed it in the
United States, during my fairly typical experience as a medical student, intern, surgical resident in urology, and practitioner in urology. It is hoped that this narrative will
reveal some of the reasons that non-religious, non-therapeutic male circumcision
persists with some tenacity in the United States.
As a medical student in pediatric rotation, I was given about two hours of discussion on the benefits of circumcision. At the time, it was generally assumed that
circumcision was beneficial because it prevented cancer of the penis in the mature
male and prevented cancer of the cervix in his future wife. A corollary of this viewpoint was that, if or when cancer of the penis in a man circumcised at birth was
J.L. Snyder (B)
American Board of Urology, American College of Surgeons, Virginia Urological Society,
Clifton Forge, VA, USA
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J.L. Snyder
ever observed and reported in the medical literature, the rationale for routine newborn circumcision would cease to exist and that the procedure would cease to be
performed. Events would prove otherwise.
In the course of time, I was instructed in the performance of the typical newborn
circumcision and observed as I performed my first circumcision on a newborn. It
should be noted that there was no real choice about whether I would do circumcisions. The most common criticism of my circumcisions was that I left too much skin
on, which, I was informed, was not what parents wanted.
Eventually, in the tradition of, “See one, do one, teach one,” the day came that I
was told to go to the newborn nursery and do the circumcisions, unsupervised, on
the boys who has been born the previous night. When I arrived at the nursery, the
nurse was ready for me. She had denied the boys a feeding so that they wouldn’t
vomit during the circumcision and inhale their vomitus. The boys were lined up for
me, and I was instructed to go down the line and circumcise each one in turn. After
the circumcisions, I was given the charts to record what I had done. I was surprised
to notice that one boy had no written consent form in his chart. I asked the nurse
why this child with a Hispanic name had been presented for circumcision with no
consent. The response was a shrug and a comment that the circumcision would be
good for him.
In teaching hospitals that serve the poor and underinsured, and train physicians in
their various specialties, the custom was, and tends to be for the rest of a physician’s
career, that the obstetrician who delivers a male child would do the circumcision in
the delivery room in the absence of strong objections from an exhausted, sedated,
post-partum mother. If the circumcision had not been done at birth, it would be done
in the morning by the on-call pediatric resident who made rounds. At that time, and
perhaps even today, the requirements for informed consent were casually observed.
Usually, the admission clerk would present a stack of documents to a mother in
labor, among which was a vaguely worded paper with words including the word
“circumcision.” This mother was asked to sign these papers with no further discussion. The result was presumed to be “informed consent.” If the newborn nurse found
that someone had forgotten to have the mother sign a paper for the circumcision, she
would go to the mother after the circumcision was performed and have her sign it
after the fact. If parents objected that their son, against their wishes, had been circumcised, they would be subjected to a barrage of persuasion from every level of the
medical and nursing staff until they conformed. Only a handful of parents were so
bold as to seek legal advice and action against the hospital and trusted medical staff
who had so carefully and safely guided them through one of the most significant
moments of their lives.
Now we come to the current situation, in which doctors and hospitals still persist in customs from a more casual time, when doctors had almost unquestioned
authority to guide their patients’ care. However, new regulations are intruding themselves, particularly the notion of “informed consent,” which is required by the Joint
Commission on Healthcare Organizations, and by law in many jurisdictions. This
requires that the person who actually performs an invasive procedure come to the
patient, parent, or guardian, explaining a diagnosis with the benefits, alternatives,
8
Complications of Circumcision: A Urologist’s Viewpoint
83
and risks of the proposed procedure before performing it. This raises the problem of
how much information and what information satisfies this requirement, and how it
is to be documented. Unfortunately, parents are still given vague statements such as:
•
•
•
•
It will be good for the baby.
Just a little snip and it will be over.
You do want your baby to be circumcised, don’t you?
We’re going to do your baby’s circumcision today.
This sort of behavior still persists today because a largely unsuspecting public
still perceives circumcision as a benign and vaguely beneficial procedure. Rarely
are parents told of the risks of:
•
•
•
•
•
•
•
Death
Amputation of excessive skin,
Amputation of the glans penis,
Fistula formation,
Infection, sepsis, and meningitis,
Adhesions and skin bridges,
Gangrene and loss of the entire penis through a surgical misadventure (electrocautery instruments are to blame for more than one sex-change operation in small
children).
These complications are almost never mentioned. They are unusual, but they have
occurred in the experience of the present practitioner.
During my career, I have been called to the crib of two infants who were born
with a normal penis but became genital cripples as a result of a misguided circumcision. One was a neonate who had a Gomco clamp circumcision by a fully
trained obstetrician, the graduate of a major university hospital training program.
This child suffered loss of all the skin of the shaft of his penis. The foreskin was
curiously preserved. The shaft skin was discarded, and the child was transferred to
another hospital. The other was a seven-month-old child who had diaper rash of
his penis, perineum, and thighs. During his circumcision, an electrocautery device
was used to control bleeding, resulting in gangrene of the entire penis. The result
was a succession of painful procedures to construct a skin graft that resembled the
form of a penis. This child is now well into his twenties, and understandably very
unhappy.
Strangely, in my discussions with physicians who perform or advocate circumcision, the mention of these complications and of the undocumented but significant
number of deaths due or related to circumcision is not persuasive of the harm of
this procedure. Nor are these people impressed by the lack of informed consent to
perform a non-therapeutic, cosmetic procedure on a minor. Often the excuse is the
“possible benefits” alluded to in the current statements of the American Academy of
Pediatrics. These vague and unspecified benefits often reside in the imagination of
the person doing the circumcision and have not the force of an absolute indication
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J.L. Snyder
for routine circumcision of the newborn. My arguments against circumcision before
a medical audience have resulted in the most uncharacteristic disbelief and hostility,
with a line of otherwise well-intentioned persons at the microphone, each waiting
to repeat well-worn myths. I have spoken to the editor of a well-known medical
journal, who told me flatly that nothing opposing circumcision would be accepted
for publication in his journal. His successor also alleges the importance of doing
circumcisions to prevent phimosis, a normal condition in childhood.
So, where do we go from here? Persuasion of the medical profession has resulted,
perhaps, in a greater awareness of the controversy surrounding circumcision. Some
doctors now refuse to perform circumcisions. But, after all, those doctors will not be
the ones who come into the newborn nursery looking for circumcisions to perform
on their morning rounds. Only physicians who perform circumcisions have access
to parents to persuade them to allow their child to be circumcised. Others will not
have any opportunity to persuade for the benefit of the child that he be left intact.
Major medical organizations, while not yet admitting an absolute medical indication for routine circumcision of the newborn male, continue to teach, and to allow
their trainees to learn to perform routine newborn circumcisions. We have learned
elsewhere in this symposium to “follow the money.”
• It is possible, but expensive, to pursue lawsuits of these organizations.
• Information campaigns, such as those on the Internet, will reach those with a
sympathetic and inquiring mind.
• The future reorganization of the finance of US medical care, placing the financial
risk on those who deliver medical services, will drive out of practice those procedures that do not have an immediate and measurable benefit. Circumcision has
already responded to these pressures in Britain and New Zealand. The pressure
on the pocketbook proved to be one of the deciding factors, with the result of a
circumcision rate near zero in those societies.
• Finally, I would like to address the often-repeated justification for circumcision that the neighbors did not do it, and now they are having “trouble.” In this
case, trouble usually means that well-meaning parents are attempting to retract
a child’s foreskin for daily cleansing. The resulting discomfort to child and parents often leads to a visit to an equally ill-informed physician who confirms the
“trouble” to be a (physiologically) tight foreskin and recommends a circumcision. Proper teaching and understanding of the physiologic adherence between
the glans and prepuce—like the eyelids of newborn puppies and kittens—will
allow a generation of physicians and parents to emerge who know that it is not
necessary to retract a child’s foreskin to clean it or to insure that it is normal. They
will allow a child to naturally pull his foreskin forward, so that separation of the
physiologic attachment of the prepuce from the glans will occur in an orderly
fashion. We also know that one day, that same child will spontaneously retract
his foreskin in search of sexual pleasure, and the “trouble” will resolve without
intervention. This may be the end of the complications of circumcision.
Chapter 9
NOCIRC of Italy: Scientific Activities 2006–2009
Franco Viviani, S. Bobbo, S. Malaguti, and D. Paolini
Abstract As the majority of Italians are not circumcised, the knowledge of the various aspects of male circumcision (MC) is lacking. The waves of immigrants from
Muslim countries presented various problems concerning ritual MC, among them
the fact that an ambiguous legislation enabled fraudulent use of National Health
Services (NHS) funding, as ritual MCs were falsely labelled as being “therapeutic”
in order to have them performed for free under the NHS. To better understand MC
in Italy, during the last three years, different graduation theses supervised by the
author permitted the gathering of: (a) epidemiological data to update the first epidemiological survey on the topic, (b) the attitudes of 173 Italian urologists toward
MC, that were assessed by means of a questionnaire during a national medical
congress. A previous thesis allowed (c) the production of the questionnaire administered to these professionals and, finally, (d) interviews were carried out. They
were performed in the 15 health facilities supposed to carry out ritual MC, in order
to build a map of these facilities in Italy and to better understand the underlying
motivations and implications. Data confirm the fact that MC in Italy exists as a delicate, underground, and multifaceted problem. It appears that, “behind the scenes,”
not only unnecessary interventions are performed but also that legal violations are
common.
Keywords Male circumcision · Ritual circumcision
Introduction
Thanks to the effort of various researchers, different aspects of female circumcision
are at present quite known in Italy and still open to debate, not only to improve
legislation on the topic, but to find a more effective and respectful way to cope
F. Viviani (B)
Faculty of Psychology, University of Padua, Padua, Italy
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F. Viviani et al.
with the interethnic and bioethic problems rising with immigrants. Knowledge about
the various aspects of male circumcision (MC), however, is lacking. This is highlighted by media and observers only when life-threatening injuries occur following
ritual surgeries,1–5 when sentences for aggravated frauds toward the National Health
System (NHS) are delivered as ritual MCs, which are falsely labeled as “therapeutic” in order to have them performed for free under the NHS,6–12 and when
experimental designs to promote immigrants’ integration raise a lot of dust.13–17
Pediatricians and urologists discuss the origin and evolution of MC,18,19 and the
immediate- and post-circumcision complications,20–22 with papers that do not cover
important aspects such as, for example, the incidence of MC. They just cover topics
related to its historical significance, mostly ritual,23–27 and other aspects touched
on by the literature produced by NOCIRC (see: www.nocirc.org). For this reason,
in the last quadrennium, NOCIRC of Italy resolved to be active in this topic, and
only some years ago the first epidemiological survey on the incidence of the phenomenon was undertaken,28 to set the topic against its importance. In fact, recent
waves of immigrants from Muslim countries posed several issues, mostly related to
ritual MC. Important among them was the fact that an ambiguous legislation enabled
fraudulent use of NHS funding. Some NHS hospitals undertook experimental ritual MC projects, whose official aim was to improve immigrants’ integration. As
a reaction, professionals directly involved in MC, such as pediatricians and urologists, were divided with respect to this problem.16 Unfortunately, despite the great
sensation caused because of the severe and lethal consequences suffered by three
children after “homemade” surgical operations,2,3 the problem remains underrated.
The present paper reports the scientific activities performed in the last three years,
without mentioning the efforts made to blazon the problem in various meetings and
in the media.5,29
Materials and Methods
To better understand MC-related phenomena, four graduation theses, supervised
by the author, permitted the collection of: (a) epidemiological data to update the
first epidemiological survey on the phenomenon30 ; (b) the construction of a questionnaire permitting to undertake a descriptive research on the attitudes toward
MC (therapeutic, prophylactic, and ritual) of the professionals directly involved
in the topic.31 It contained general information on the professionals and openended, closed (with categorical responses), and ranking questions related to various
aspects of MC. Later on, (c) it was administered to 173 Italian urologists belonging to all the Italian regions, who were scrutinized during a national medical
congress.32 The average age of the professionals was 45.9 years (s.d. = 10.8;
min. 26, max. 70), and they were active, on average, from 18.4 years. To gain
further insights, they were subdivided into three macro-regions (southern, central, and northern Italy). Differences existing between public, private, and mixed
facilities were ascertained as well. Finally, (d) contacts were taken in 15 health
facilities where ritual MC was routinely executed (data were extracted from the
questionnaires), in order to build a map of the facilities performing ritual MC in Italy
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and to better understand the underlying motivations. Only two urologists answered
a semi-structured questionnaire prepared for the survey.33
Results
Epidemiology
Dismissal forms from Italian health facilities (years 2001–2003) gave an update
of previous data, gathered investigating the Diagnosis Related Groups (DRG) on
subjects lower and older than 18 years of age. From 1999 to 2003 MC interventions carried out in health facilities increased (+12.3%), but remained quite stable
from 2002 to 2003 (+1.4%). The observed trend (increment of MC performed in
day hospital vs. decrement of those carried out in regular hospitals) was maintained
(e.g. annual increment in day hospital = +19.3%). The two age-peaks in interventions, 5–14 and 25–44, remained stable. The previous trend,28 valid for the years
1999–2001 was thus confirmed.
The Opinions of Italian Urologists Toward MC
The professional typology of the interviewed Italian urologists is depicted in
Table 9.1.
Their opinions can be summarized as follows: 171 out of 172 interviewed urologists performed MC, mostly for therapeutic reasons (99.4%). Eleven percent of
them did prophylactic MC and 9.9% performed ritual circumcisions. Regarding
the therapeutic motivations for the intervention, 146 out of 173 urologists (84.4%)
declared “pathology,” 23 out of 173 (13.3%) prevention, 18 of them psychosexual
motivations (10.4%). Only 35.9% of the interviewed urologists declared to offer preintervention alternatives to their patients. Significant differences emerged among the
three macro-regions considered (χ 2 = 6.9; df = 2, p < 0.032), as they were offered
more often in the central (52.6%) and in the southern Italian regions (36.2%) with
respect to the northern ones (27.4%). The main MC post-intervention complications that could arise, according to 85.5% of the urologists, in order of importance,
are: hemorrhage, annular scars under the glans, psychological problems, infections,
progressive loss of glans sensitivity, glans malformations.
Table 9.1 Professional typology
Type
Frequencies
University
Public hospital
Self-employed professionals
Other
11
130
7
23
6.4%
76.0%
4.1%
13.5%
Total
171
100%
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F. Viviani et al.
Table 9.2 Judgments regarding MC practiced in the USA
Regions
Positive
Negative
Total
Southern
Central
Northern
28
11
41
52.8%
31.4%
62.1%
25
24
25
47.2%
68.6%
37.9%
53
35
66
Total
80
51.9%
74
48.1%
154
34.4%
22.7%
42.9%
χ 2 = 8.7; df = 2; p < 0.013.
When asked for an opinion about prophylactic MC practiced in the USA: 51.6%
of them were in favor, while 48.4 judged the practice negatively, with significant
differences between the Italian regions (Table 9.2).
As far as ritual MC is concerned, 63.6% of the professionals were opposed
because it was a practice contrary to their deontological code (36.9%) or because
they judged it an unnecessary mutilation (20.4%). Inappropriate (18.4%) and not
furnished (21.4%) responses to this question were high. Those in favor of ritual MC
declared to be such because of their “respect to religious beliefs” (72.1%) and to
avoid the negative effects of a refusal (3.3%). In this case, the improper (16.4%) and
not given responses (9.8%) were quite high as well. Table 9.3 depicts the differences
found by Italian regions.
It must be added that 53.0% of the urologists were opposed to ritual MC carried
out inside the NHS, of these, only 9.6% affirmed that this praxis was common in
the health facility to which they belonged, with significant differences among the
Italian regions (Table 9.4). Of those interviewed, 36.4% was asked to perform ritual
MC, mostly by parents of Muslim faith (85.7%).
The presence/absence of a Bioethics Committee in the facilities where urologists practiced gave significant differences among the macro-regions considered.
The presence declined from north to south (Table 9.5).
Differences among public, private, and mixed-health facilities revealed rates for
the day-hospital/ordinary regimen chosen for the intervention: higher in the mixed
facilities (33.3%), lower in the private facilities (27.3%), and very low in the public ones (9.0%) (χ 2 = 7.7; df = 2; p < 0.023). Even with the presence/absence
of a Bioethics Committee, revealed rates were significantly different (χ 2 = 7.9;
df = 2; p < 0.019) in 100% of the cases in the mixed facilities, 80.0% of the cases
Table 9.3 Ritual MC: sides taken by Italian urologists
Regions
In favor
Unfavorable
Southern
Central
Northern
17
20
22
29.8%
52.6%
33.3%
40
18
44
70.2%
47.4%
66.7%
57
38
66
Total
59
36.6%
102
63.4%
161
χ 2 = 5.6; df = 2; p not sign.
Total
35.4%
23.6%
41.0%
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Table 9.4 Performance of ritual MC in the facility where urologists worked
Regions
Yes
No
Total
Southern
Central
Northern
13
13
37
21.7%
33.3%
50.7%
47
26
36
78.3%
66.7%
49.3%
60
39
73
Total
63
36.6%
109
63.4%
172
34.9%
22.7%
42.4%
χ 2 = 12.2; df = 2; p < 0.002.
Table 9.5 Presence of a bioethics committee
Italy
Southern
Central
Northern
Total
Presence
Absence
Total
38
31
64
64.4%
79.5%
87.7%
21
8
9
35.6%
20.5%
12.3%
59
39
73
133
77.8%
38
22.2%
171
34.5%
22.8%
42.7%
χ 2 = 10.3; df = 2; p < 0.005.
in the public, versus 54.5% of the cases in the private health facilities. No significant differences emerged for the pre-intervention alternatives offered among the
facilities.
The Search for Facilities Performing Ritual MC
On the basis of the data gathered in the previous study, the 15 sites involved in ritual
MC were contacted. They were located mostly in the north (n = 9) and in the center
(n = 5), while in the south of Italy (n = 2) they declined. However, a good set of data
collection was almost impossible because of the fear of legal repercussions for the
professionals involved. This made the context hypocritical and reticent (many professionals actually claimed “conscientious objection”). Therefore, in this context,
and for the moment, it is only possible to sketch some major trends that emerged.
From the press, it was possible to ascertain that, from 2004 and 2008, in the northern
part of Italy, different experimental designs took place in order to limit ritual MCs
carried out in unsuitable sites, in situations disrespectful of current hygienic rules,
and to avoid a sort of “underground market” for MC. This caused several medical,
bioethics committees, and political stands to be taken about the problem. In Turin,
for example, only a minority of the doctors involved in the project were in favor of
MC, the others declared themselves to be conscientious objectors. Political controversies rose and the local bioethics committees generally admitted that, as ritual MC
intervention does not accomplish the function of safeguarding health—typical of the
NHS—it has not the ethical justifications to be inserted among the essential services
to be performed by the NHS.34,35 When interviewed, those responsible for the activities carried out in Turin, affirmed that the subduing motivations were exclusively
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economic, as it was more advantageous for the hospital to allot funds for ritual MC
than to face the damages caused by home- or country-of-origin-made ritual surgeries. However, when the 15 health units were contacted, responses were reticent
and contradictory: for example, an health unit in the center of Italy first declared
that ritual MCs were currently carried out in its facilities (officially declaring the
intervention was for phimosis), later on, when more details were asked, the previous declaration was completely denied. In another hospital, in the south of Italy,
clarification on the word “ritual” was asked. In general, the majority of the addressed
facilities (except for two) firmly denied performing ritual MC in their facilities (this
being clearly the opposite of what the urologists affirmed in their questionnaires).
At this point, to supplement the scene, several persons in charge of the Jewish and
Muslim communities were contacted. The previous declared that their ritual MC
(brit milah), to be fulfilled within the eight day of birth, needed the presence of
a rabbi and that it was usually carried out in private facilities. The latter declared
that, usually, Muslims do not apply to the NHS services because they prefer to circumcise their children in their home country, during vacations, as their tradition
does not require time limitations, as it does for Jews. Substantially, the responses
furnished by the only two professionals who it was possible to interview—in strict
anonymity—were similar. According to them, as the Italian law does not permit the
performance of ritual MC for free, even if some facilities do the operations (officially declaring them as being for phimosis or a sclerotic prepuce), it is impossible
to manage to trace them for obvious reasons.
Discussion and Conclusions
The update of epidemiologic data substantially confirmed known aspects of MC in
Italy in the NHS facilities. It is a practice performed mostly for therapeutic reasons, with interventions concentrated in the age ranges 5–14 and 25–44. In the first
case, interventions are carried out in ordinary regimen and they usually follow pediatric follow-ups routinely carried out in the schools. As the number of circumcised
appears to be slightly high with respect to the incidence of phimosis as pathology,
it cannot be excluded that cases of ritual MC (declared as congenital phimosis) are
performed in some facilities. In the second case, operations are carried out mostly
in day-hospital regimen and are due to secondary phimosis.
The responses furnished by the urologists show a substantial homogeneity for
their basic preparation on the topic of MC, the general therapeutic approach, the
admission regimen adopted, and the ignorance of the resolution of the National
Bioethics Committee.36 Quite non-homogeneous was their knowledge of the different forms of MC and, despite the motley responses given towards alternative to MC,
they appeared not to be in line with the current acquisitions of conservative nature
regarding the prepuce.37 It must be mentioned that only one professional claimed to
furnish non-medical alternatives. The differences that emerged in the three macroregions considered are due to the organizational and structural backwardness of the
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southern NHS, while the fact that, in the private facilities, the day-hospital regimen is less used, which is due to the higher cash audit earned applying the ordinary
regimen. The fact that the sample was equally halved in contrary/favorable to prophylactic MC practiced in the USA, in our opinion, is due to the absence of such
practice in Italy, therefore, the lack of interest and information. The finding that
22.0% of those who furnished a positive or negative opinion on the topic did not
explain their reasoning is significant. Similarly, it is notable that a high number of
incongruent and not-given responses to this question were found. Non-significant
differences emerged neither on the basis of the age of the subjects nor on their years
of practice. More opponents were found in the center of Italy, while those in favor
were more concentrated in the north (62.1%), probably for a more marked inclination to innovation (usually belonging to the USA). A curious undertone: the most
usual motivation for those who were in favor of the practice was the prevention of
penile cancer, a position clearly unsupported by strong epidemiologic data.38–40
Regarding ritual MC, 60% of the interviewed declared their opposition to it, with
a macro-areas repartition matching the diversification of the presence of Muslim
immigrants, who are settled mostly in the northern regions.41 It is possible that
the different sensitivity to ritual MC belongs to a different impact with such immigrants. The performance of ritual MC was required of more than one third of the
professionals, but their response should have been negative, as only 9.9% of them
admitted to having actively performed such surgery. The performance of this ritual
violates the Hippocratic oath (36.9%) and this leads one to formulate a culturallymediated defensive position (Italy is a country with a strong Catholic tradition, and
body integrity is a strong value).
The diffuse reticence to discuss and explore the aspects of ritual MC is mostly
due to religious motivations. According to Aldeeb,14 as the Holy Bible mentions
male but not female circumcision, this implies a substantial difference, even in the
public resonance of the problem. In addition, he notes that two prominent European
Catholic and Jewish representatives recently refused to express an opinion on female
circumcision because of the fear that this would open a debate of MC. Clearly, to
oppose ritual MC means to object to the sacred, a very difficult task in a country
that has been for centuries at the dual heel of the spiritual and temporal power of the
Catholic Church, that still exerts a great influence on politics. It is also difficult in a
democratic country in which one of the fundamentals is the principle of tolerance,
touching both the moral (the respect of the “other” beliefs) and the law (the admission of the existence of “other” manifestations with respect to the dominant culture,
in the frame of norms and sanctions). The core problem is a clear conflict between
the principle of inviolability of the human body and that of the intervention on the
body itself, in the name of the principle of belonging to a particular religious group.
Now, the problem rising from the conflict between principles can be solved only
by means of the compromise or by means of a scale of priority (in which it would
be possible—at least to discern—a “higher” principle that could solve the conflict
between principles). As long as ritual MC was confined to a restricted circle (the
Jews, a small minority group in Italy), it was not much considered, but when other
religious groups started vindicating rights, a subtle ethic conflict rose on religious
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F. Viviani et al.
basis. Other morals were superimposed: the laic one (etsi deus non daretur), the
liberal one (based on the respect and the defense—even all-out—of individual freedom and free enterprise, a principle whose limit is the others’ damage), and, finally,
when MC was medicalized, the utilitarian moral as well. To let our attention dwell
on this aspect could be useful. The medicalization of ritual MC was clearly conflicting because the introduction of a new possibility with respect to a practice till that
moment was carried out mostly for therapeutic reasons (therefore perfectly matching with the moral rules universally adopted by doctors), compelled a significant
part of the physicians to refuse it, even with vehemence (conscientious objection).
Now, epistemology teaches that science is able to enter into an agreement every
time that unforeseen situations appear on the horizon. Doctors are basing their practice on scientific findings, therefore, every time that a new possibility of intervention
breaks through the clouds, this changes the prevailing attitudes, the implicit and
explicit evaluations, and the normative compromises. At the end, even those who
adhered to an ethic code containing some obligations, try new ways in order to
avoid disagreeable consequences with respect to the practices for which it is possible to have recourse. In the sample of urologists, those who were in favor of the
medicalization of ritual MC, expressed the idea that the principle of solidarity is
stronger than that regarding the intangibility of the human body. In this case, a
scale of priority was introduced, together with a vaguely compromising moral: in
fact, their detractors affirm that the moral of principles was substituted by the moral
of compromise. The compromise—per se—is never enthusiastically accepted, as
it often raises the desire to set against it a strict rational procedure attenuating the
concession given.
Informal discussions with urologists inclined us to believe that the ethical
problems are substantially two: the dialectic of the “argumentations” and that of
“common sense.” In the first case, it is presupposed that ethics are tied with arguments and that this is the level that the contenders must disembroil. In effect, for
ritual MC, the starting point is the religious positions and those in charge to expound
them must resort to argumentations, whereas doctors should ascertain facts that are
relevant or could become relevant. The problem is that, according to our findings,
the facts are not clear for many doctors interviewed, as they see MC as a monolith
(i.e., many of them are unable to distinguish among the different MC typologies).
As a consequence, when they cannot appeal to facts, they usually face the problems assuming the lay position of “common sense.” This position, not dealing with
principles, leads to an appeal to a plausibility of solutions to be found “case by
case.” Clearly, this approach has strong limitations, as common sense shows a great
impotence towards new or odd problems. The trend that emerged regarding the prophylactic MC is analogous, as the furnished responses show a substantial lack of
reflection upon it. We noted a certain confusion between prophylactic and therapeutic. But what is therapeutic is directed by the main rule of consent and requires a
previous medical evaluation of the conditions able to justify an intervention, alas,
what is prophylactic does not require these premises. However, the responses of the
doctors interviewed can be justified by ignorance of the situation in the USA and
by the inertial force of a professional tradition based on the therapeutic tradition
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(and not the prophylactic or the ritual) that associate with the reluctance to leave
established schemes.
In conclusion, while it is not difficult to gather data on therapeutic, epidemiologic, and MC-related views in Italy, it is quite difficult to pierce the shroud of
reticence on ritual MC. This is because unnecessary interventions are performed and
because legal violations are common. Ritual MC in Italy exists as a delicate, underground and multifaceted problem. Clearly, new types of interventions—not only
debates—that are able to awaken the professionals and the public to the problem are
required.
Acknowledgments The author thanks Dr. S. Busatta, Dr. G.L. Costardi, Prof. G. Mantovani, Prof.
G. Martorana, Prof. P. Grassivaro Gallo, Dr. L. Catania, the Italian Urology Society, the participants
in the 79th Italian Congress of Italian Urologists, and all the doctors who, anonymously, added
insights to this paper.
Notes
1. Europe News. (2008) Nigerian man arrested in Italy for boy’s circumcision death. July 23rd,
2008.
2. La Repubblica, June 6th, 2008.
3. La Repubblica, July 22nd, 2008.
4. Marotta M, Marotta E. (2004) Solo infibulazione? La Gazzetta di Sondrio March 10th, 2004.
5. Viviani F. (2008) Circoncisioni fatte in casa, un rischio per i bambini. La Repubblica, June
7th, 2008, p 28.
6. Andretta E. (2000) Circoncisione, rispetto di una cultura. Il Gazzettino, Inserto salute, 13
Marzo 2000, p 14.
7. Il Mattino di Padova, May 9th, 2007.
8. Il Sole 24 Ore.com, July 22nd, 2008.
9. La Padania. (2000) Circoncisioni a carico del servizio sanitario. July 28th, 2000.
10. La Provincia Pavese, May 9th, 2007.
11. Manconi L, Boraschi A. (2006) Immigrazione. La ballata dei circoncisi. L’Unità, November
5th, 2006.
12. Miazzi L, Vanzan A. (2008) Circoncisione maschile: pratica religiosa o lesione?Diritto,
Immigrazione e Cittadinanza. Milan: Franco Angeli.
13. Accossato M. (2006) Via alla circoncisione rituale. Nuova bufera sul Sant’Anna. La
Stampa web, October 4th, 2006. http://www.lastampa.it/redazione/cmsSezioni/torino/2006/
200610articoli/11674girata.asp
14. Aldeeb S. (2004) Dibattito, circoncisione, infibulazione: mutilazione genitale “indolore”?
http://www.grillonews.it/modules.php?op=modload&name=News&file=article&sid
=1381
15. Domenici D. (2008) Salute: i pediatri italiani contro la circoncisione clandestina.
http://www.wikio.it/article/71822198
16. Il Corriere della Sera, October 15th, 2006 (http://archivio.corriere.it/archiveDocumentServelt.
jsp?url=/documenti>_globnet/corsera/2006/10/co_9_061013094.xml)
17. Stranieri in Italia. (2008) http://stranieriinitalia.it/attualita-circoncisione_gratis
18. Parigi GB. (2003) Destino del prepuzio tra Corano e DRG. Pediatr Med Chir. 25(2):96–100.
19. Zampieri N, Pianezzola D, Zampieri C. (2008) Male circumcision through the ages: The role
of tradition. Acta Pediatr. 97(9):1305–1307.
20. Beniamin F, Castagnetti M, Rigamonti W. (2008) Surgical management of penile amputation
in children. J Paediatr Surg. 43(10):1939–1943.
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21. Natali A, Rossetti MA. (2008) Complications of self-circumcision: A case report and
proposal. J Sex Med. 5(12):2970–2972.
22. Rossi E, Franchella A. (2006) Amputation neuroma following a circumcision: A case report.
Eur J Pediatr Surg. 16(4):288–290.
23. Doyle D. (2005) Ritual male circumcision: A brief history. J R Coll Phys Edinb. 35(3):
279–285.
24. Mattelaer JJ, Schipper RA, Das S. (2007) The circumcision of Jesus Christ. J Urol. 178(1):
31–34.
25. Meijer B, Butzelaar RM. (2000) Circumcision from a historical perspective. Ned Tijdschr
Geneeskd. 144(52):2504–2508.
26. Sari N, Büyükünal SN, Zülfikar B. (1996) Circumcision ceremonies at the Ottoman palace.
J Pediatr Surg. 31(7):920–924.
27. Waszak SJ. (1978) The historic significance of circumcision. Obstet Gynecol. 51(4):499–501.
28. Viviani F, Costardi GL, Capparotto L, Grassivaro Gallo P. (2006) Male circumcision in
Italy. In: Denniston GC, Grassivaro Gallo P, Hodges FM, Milos MF, Viviani F (eds.) Bodily
Integrity and the Politics of Circumcision. New York, NY: Springer, pp 141–147.
29. Viviani F. (2009) http://www.psicologisenzafrontiere.org/index.php?page=report-incontri-iiciclo-feb-mar-2009; http://www.psicologisenzafrontiere.org/index.php?page=intervista-aldott-franco-viviani; http://www.psicologisenzafrontiere.org/uploads/Considerazioni%20dina
tura%20bioetica.doc
30. Bobbo F. (2006/2007) La circoncisione maschile in Italia: aggiornamento dei dati epidemiologici. Graduation thesis, Faculty of Psychology, University of Padua.
31. Meneghello D. (2005) Elaborazione di un questionario sugli atteggiamenti degli urologi nei
confronti della circoncisione maschile in Italia. Graduation thesis, Faculty of Psychology,
University of Padua.
32. Malaguti S. (2006/2007) Gli urologi italiani di fronte alla circoncisione maschile. Graduation
thesis, Faculty of Psychology, University of Padua.
33. Paolini D. (2006–2007) La circoncisione maschile in Italia: contraddizioni e problemi etici.
Graduation thesis, Faculty of Psychology, University of Padua.
34. Nejrotti M. (2006) La circoncisione rituale è una pratica deontologicamente corretta?
Response of the OMCEO (Turin), personal communication.
35. OMCO Padova. (2005) Regional Consulting Committee for Bioethics.
36. Comitato Nazionale di Bioetica. (1998) La Circoncisione: Profili Bioetici. Governo Italiano.
Presidenza del Consiglio dei Ministri. Rome: September 25th, 1998.
37. Orsola A, Caffarati J, Garat JM. (2000) Conservative treatment of phimosis in children using
a topica steroid. Urology. 56(2):307–310.
38. Fleiss PM, Hodges FM. (1996) Neonatal circumcision does not protect against cancer. Br
Med J. 312:779–780.
39. Frisch M, Friis S, Kjear SK, Melbye M. (1995) Falling incidence of penis cancer in an
uncircumcised population (Denmark 1943–1990). Br Med J. 311:1471–1475.
40. Stancik I, Hölti W. (2003) Penile cancer: Review of the recent literature. Curr Opin Urol.
13(6):462–472.
41. Caritas/Migrantes. (2005) Immigrazione. Dossier Statistico 2005. Rome: IDOS.
Chapter 10
A Project About Male Circumcision
in the Veneto
M. Gloria de Bernardo
Abstract For the first time in Italy, a strong position has been taken against the
practice of male circumcision on therapeutic grounds, at the expense of public
health authorities, in a small town, Conegliano, Veneto. The hospital’s training service investigated the reasons for which the local medical authorities had decided
to reclassify a request for male circumcision, on therapeutic grounds, from a free
procedure to a paid one. For this reason, research was undertaken to show that,
in recent years, the request for male circumcision considerably increased among
Muslim families. It was impossible to understand the real reason for that because all
the families had made a request for therapeutic circumcision through their own doctor. By checking the number of these requests, it was noticed that, after the request
for male circumcision was reclassified from a free procedure to a paid one, these
requests diminished. We also know that some Muslim families used operators who
came from their same geographical area in Africa, but the results sometimes were
terrible. As reported by the press, one boy in Veneto and another in Puglia died
from hemorrhage, caused when the glans was cut off during circumcision. The echo
of such research has had consequences in other public health services, where the
possibility of creating a ticket-payment for circumcision began to be considered.
Keywords Male circumcision · Ritual circumcision
The legislation in Italy regarding the situation of male circumcision (MC) is ambiguous. In some regions, the practice of circumcision is excluded from the basic free
medical services (Livello Essenziale Assistenza), in others it is included if requested
on the basis of therapeutic need, and in others it is free in all cases.
Every local health authority, therefore, establishes very differing rules, thereby
further increasing the confusion around this problem, which has revealed itself to be
not only medical but also cultural and religious.
M.G. de Bernardo (B)
University of Verona, Verona, Italy; University of Padua, Padua, Italy
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M.G. de Bernardo
It is a fact that, with the increase in immigration, requests for circumcision have
increased from families for whom circumcision is a religious duty.
In July 2004, there was a parliamentary question as to why, in the local health
authority of Conegliano Veneto, in the province of Treviso (ULSS 7), a “Safe
Circumcision Project” had been launched, enabling circumcision to be performed
on request at a flat-rate payment of C34–50.
Both the Caritas charity and the social service were behind the project, trying to
avoid immigrant families ending up in the hands of back-street practitioners who
injured the children to be circumcised, sometimes even mortally.
On the other hand, other health authorities, such as that of Verona, carry out
the same procedure as out-patients on children between the ages of 0 and 6 years
old, and to adults making such a request, at a cost of C300. It is not only a question of medical resources, which the government cannot afford, but it has become
a cultural problem because ritual circumcision is incompatible with Italian culture,
especially now because, since 2006, there is legislation specifically forbidding all
bodily mutilations.
The Conegliano Veneto case has given rise to a series of requests from various
bodies that work and are directly concerned with the problems of immigrants in the
Veneto. All wish that circumcision be made available in hospital, even without any
therapeutic need being established, and at the cost of only the absolute minimum
national health service fee (ticket). The project in Conegliano has raised a problem that must be resolved as soon as possible, both in order to start educating the
African communities that are the poorest and least open to dialogue and in order to
harmonize the functional status of this surgical procedure in all local Italian Health
Authorities.
References
Agency for Regional Health Services (ASSR). (2004) Lea, monitoring trials. In: Pellegrini L,
Toniolo F. (eds.) ASSR, October 2004.
14th Legislature, Union Inspection Regulation Number 4-07152, published 27 July 2004, Session
n. 647, at the Ministry of Health.
Chapter 11
The First Survey on Genital Stretching in Italy
Pia Grassivaro Gallo, Annalisa Bertoletti, Ilenia Zanotti,
and Lucrezia Catania
Abstract In 2006 and 2007, the first survey of genital stretching (GS) in Italy was
implemented in order to evaluate the degree of knowledge of professionals involved
in immigration issues who may be faced with such ritual modifications in the future.
During the survey, some obstetrician/gynecologists pointed out that they had also
encountered the same morphology in Italian non-manipulated patients. We recorded
these cases as physiological stretching. In the survey, the data collection was done
by means of a questionnaire, administrated to 272 professionals, consisting of items
to measure the knowledge about these expansive modifications; moreover, among
the latter 272 professionals, 14 specialists were subjected to a detailed interview, and
they described 21 cases of stretching, both ritual and physiological. On the whole,
the phenomenon of GS is poorly known by Italian health operators: 93% of the
interviewees declared they knew little or nothing about it. The women with labial
hypertrophy identified in the survey included 20 Africans with ritual stretching and
about forty Western women with physiological stretching. The incidence in the latter
sample is hypothesized from 8 to 20%. In conclusion: physiological GS is ignored
by health professionals, even when it is stressed by the patients bearing this trait
with concomitant psychological discomfort, which may develop into real anxiety,
especially in teenagers. Ritually “modified” immigrant women, forced to cope with
a Western society of intact women, consider themselves “different” also because
of this morphological trait, with a consequent worsening of their feelings of discrimination and marginalization in diaspora, although they seldom ask for surgical
reduction of the elongated labia. Thus, labial hypertrophy has a different semantic
connotation in Africa and in Italy.
Keywords Expansive genital modifications · Genital stretching · Labia ·
Hypertrophy · Immigration
P. Grassivaro Gallo (B)
Working Group of FGM, University of Padua, Padua, Italy
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P. Grassivaro Gallo et al.
Introduction
The survey’s hypothesis was born by previous research done in Uganda (2002),
Malawi (2004), and in the Democratic Republic of Congo (2006), which attest to
the current existence of ritual genital stretching in these places of origin.
It is a female genital modification of the expansive type that WHO improperly
included among the female genital mutilation of the 4th type (1996).
We thought it right to first begin with a survey on the same genital morphology
in Italy, to evaluate the degree of knowledge and preparation of health operators
involved in immigration who may be faced with such ritual modifications without
being able to recognize and adequately tackle them on the psycho-medical level.
During the survey, some obstetricians pointed out the same morphology—
physiological genital stretching—in their patients.
We had not taken this event into account; therefore, we decided to extend the
survey to include the Italian women.
Method and Studied Subjects
A questionnaire was prepared to investigate the general knowledge about ritual GS
in African women and physiological GS in Italian patients.
The checked sample, the “occasional group,” consisted of 272 operators of both
sexes, involved at different levels with immigration socio-medical services, who
were examined in 2006.
The group had 46% operators working in hospital facilities and in different governmental health structures in Parma and in Bologna; 12% were female students of
the Faculty of Medicine (nursing section), 19% of health operators were attached to
the Obstetrical Clinic of Padua University, and about 11% of them were contacted
during some pertinent scientific events.
All in all, they are mostly female subjects (76.8%); operators’ calculated the
average age-length of professional activity is 14 years.
To complete the questionnaire’s information, some of the involved specialists
were interviewed in depth; on the whole, there were 14, “The Referents.” Selection
was based on meaningful information and/or relevant signals that appeared in
patients with GS; these were indicated as “Cases.”
The recognized 21 Cases of GS are children (little girls), teenagers, and women
with hypertrophic genital morphology, both congenital and manipulated types.
Referents
The sample group consisted of 14 operators from public health facilities, 6 males
and 8 females, aged from 24 to 67; with 15–35 years of professional activity (with
the exception of a young female student who reported her own physiological GS).
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These included a doctor from Chad, a Congolese pediatrician with knowledge about
ritual GS, a psychiatrist, an Italian missionary obstetrician in Congo with experience on genital intervention, and nine Italian doctors (six obstetricians and three
pediatricians, with GS experience).
Genital Stretching Cases
The 21 GS Cases are represented by children (little girls), teenagers, and women
examined in Italian health facilities, with hypertrophic genital morphology.
Five Italian children, four of them (6–10 years of age), present with a monolateral
physiological GS with hypertrophy on only one of the labia minora; two African
children, a 9 year-old Ghanaian child, and a 5-year-old Congolese child, who are
respectively described to have “open” external genitals and an enlarged hymen. Two
Italian teenagers had physiological GS monolaterally: one a 14-year-old, who was
emotionally disturbed because of the mistaken modification and a 19-year-old who,
on the contrary, had fully accepted her hypertrophic genitals. Eight women: five
Italians (24–55 years of age) with physiological GS, four of which have accepted
and one who has not accepted her labial hypertrophy; three African girls with ritual
GS, two of whom declare themselves satisfied with the modified morphology.
No information exists about the remaining four cases.
Results and Discussion
This preliminary survey carried out on GS must be considered the first approach to
the problem in order to open the way to more in-depth studies.
First of all, the survey will capture the interest of the international organizations
that are only concerned with the reductive aspects of FGM, completely disregarding
the expansive ones that are also changes implemented on the normal female genital
morphology.
As a secondary focus, not less important, as mentioned in the introduction, the
survey aims to provide updated information to those Italian socio-medical operators who are involved with immigration, in order to make them aware of this
morphology.
The preliminary result is not numerically significant, so here we thought it
appropriate to add some observations.
The phenomenon of genital stretching is still little known to the health operators
in Italy. In a total of approximately 300 interviewees, only one hundred of them
declare that they know about it, but, when investigated with more specific questions,
92% of them claim to know little or nothing.
Equally unknown is the culture that underlies this practice in Africa. The identification of the ritual expansive type of genital modification in immigrant patients
is the first difficulty expressed by the Ob/Gyns. Only 10% of professionals who
100
encountered ritual GS recognized it. The most common trend has been to treat such
variations as morphological diversity or unusual racial characteristics.
Patients with labial hypertrophy identified in this initial survey are a total of about
twenty African women with ritual GS and forty Western patients with physiological
GS. Of course, in the first case, it is a matter of culture, which means a ritual that
includes the manipulation to accomplish the genital modification. The manipulation
was not carried out in Italy, even if, in a previous survey on baganda Ugandan
women, it appeared in immigrants in Rome (Grassivaro Gallo and Villa, 2004).
For Italian obstetric patients having physiological GS, this is almost always
a character that manifests itself spontaneously with birth and/or increases with
growth. Therefore, we have indicated it with the term physiological GS to distinguish it from ritual forms present in African women.
For the latter, we can also provide a percentage guideline, as it happens in the
average obstetric patients in Italy, from 8 to 20%, according to what is reported by
the two Ob/Gyns of Parma and Florence, who took part in the survey.
Most subjects negatively experience physiological GS (60%), yet, this morphology is not taken into account by specialists, despite the psychological discomfort
sometimes reported by the Western patients, carriers of the hypertrophy. Immigrant
women who are ritually manipulated share such discomfort. When in the diaspora,
they are obliged to confront themselves with the western reality and feel “inadequate and different.” Consequently, their feeling of being excluded from the world
in which they live increases.
This genital manipulation is experienced positively in Africa, where it is endemic
and where it becomes an integral part of cultural identity, identity that we are facing
also in the diaspora. The manipulated immigrant only seldom requires or accepts
the surgical reduction of the elongated labia. In the African sample, 2 subjects out
of 16, and in Italy, 16 out of 40 subjects accepted surgery.
Among female immigrants, the elongation of the labia minora usually continues
to be regarded with the same purpose as it has in the homeland: to increase sexual
enjoyment, therefore, it is regarded as a sign of respect for the partner.
Indeed, as shown by studies done in the cultural context in which they originate
(Uganda 2002, Grassivaro Gallo and Villa, 2004, 2006; Malawi 2004, Grassivaro
Gallo and Moro, 2006; Congo 2006, Tshiala Mbuyin, 2005/2006; Grassivaro Gallo
et al., 2007), African women regard their manipulated genitalia as functional, if not
essential, to their individual growth and as the fundamental aspect of their belonging to the group and for their social identity. Western women, whose relationships
with their genital hypertrophy is a more subjective and private matter, the positive,
negative, or indifferent reaction is determined by their personal experiences and
individual responses, developed in their intimate relationships with partners.
Italian women carrying this trait usually manifest a related discomfort, which
becomes a real concern in some cases of teenagers who barely tolerate their diversity, while the Italian partners, not accustomed to this unusual shape, in the case
of promiscuous relations with immigrant women, consider it with frank disgust. In
relations with Italian women, they may consider it to be an over-growth, preventing
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penetration. Given the results, we believe that adequate psychosocial health information would help to better address the problem associated with these practices and
to better understand the woman and the way she deals with herself and with her
body.
References
Grassivaro Gallo P, Villa E. (2004) Longininfismo rituale tra le Baganda (Uganda). Rapporto
Preliminare, Rivista di Sessuologia. 28:17–22.
Grassivaro Gallo P, Villa E. (2006) Ritual labia Minora Elongation among the Baganda Women of
Uganda. Psychopathologie Africaine. 33:213–236.
Grassivaro Gallo P, Moro D. (2006) Modificazioni genitali femminili in Malawi. Primo resoconto di un’indagine sul campo. In: Grassivaro Gallo P, Manganoni M. (a cura di.) Pratiche
Tradizionali Nocive alla Salute delle Donne. Padova: Unipress, pp 87–102.
Grassivaro Gsllo P, Tshiala Mbuyi N, Mulopo Katende C. (2007) L’opinione maschile
sull’Elongation des pètites lévres RDC (Republic Democratic del Congo), Luglio,
Scienzaonline.com.
Tshiala Mbuyi N. (2005/2006) L’infermiere nel linguaggio del corpo: prima indagine sul longininfismo nella Repubblica Democratica del Congo. Tesi di Laurea in Scienze Infermieristiche.
Università di Padova.
WHO 1996 Female Genital Mutilation. (1996) Report of a WHO Technical Working Group.
Geneva: WHO, July 17–19, 1995.
Chapter 12
Knowledge and Opinions of North Italian Health
Operators About Female Genital Mutilation
Pia Grassivaro Gallo, Ilenia Zanotti, Annalisa Bertoletti, Lucrezia Catania,
and Miriam Manganoni
Abstract Since its creation, the Working Group on Female Genital Mutilation
(FGM) has looked at large-scale epidemiologic investigation as the best way to
monitor the evolution of FGM in Italy. Obstetricians and gynecologists have been
considered the most qualified subjects to be interviewed because they have the
first contact with the excised women of Africa. The first investigation, which was
made in 1993, found that 50% of professionals had at least one experience with
FGM patients (Grassivaro Gallo and Viviani, 1995, Female Genital Mutilation: A
Public Health Issue Also in Italy. Padua: Unipress); with the second investigation,
dated 1999, it was discovered that female gynecologists were more professionally
involved with this problem than their male colleagues (Grassivaro Gallo and Cortesi,
1999, Linee guida per il personale medico di fronte a casi di Mutilazione Genitale
Femminile (MGF), Quaderni di Ricerca, n. 5, Osservatorio Regionale Regione
Veneto (ORIV), Assessorato Politiche Flussi Migratori, Venice). We now introduce
the results of the third investigation. The national congresses of specific associations
have been the most valuable scientific occasions to collect the opinions of professionals, coming from all parts of the country; the most recent investigation is limited
to Northern Italy, but is strictly connected to a similar one in Tuscany. For this reason, the results of the two investigations give us information about the operators
working in the North Italian regions. The focus of the present investigation is to evaluate the knowledge and opinions on FGM of the socio-health workers of Northern
Italy (Zanotti et al., 2007, Conoscenza e Opinioni degli operatori socio-sanitari del
Nord-Italia sulle Mutilazioni Genitali Femminili (MGF) (Rapporto Preliminare).
Relazione all’83◦ Congresso Nazionale SIGO, Naples).
Keywords Female genital mutilation · Gynecologists · Obstetricians · Infibulation ·
Medical education
Working Group on FGM, University of Padua, Padua, Italy
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Subjects
The sample group consisted of 211 subjects of both sexes (78% males, 21% females;
average age 39.9; range 19–65 years), who were involved with different qualifications in health or social activities in immigration and were contacted in 2006 at
several scientific meetings.
The health workers include: 51.1% obstetricians or gynecologists; 7.7% consultants; 19.5% nurses; 6.3% subjects involved with immigration; 14.4% others.
Methods
By collecting the information, we preferred the use of a questionnaire for its
quickness and simplicity. The instrument that we used has been tuned with the collaboration of two institutions: the Research Center for Preventing and Curing FGM
of the Faculty of Medicine and the Department of Health Psychology, both of the
University of Florence (Abdulcadir and Catania, 2005).
The questionnaire is structured as a series of items based on five-levels, Likert
scale; 25 items were created to detect the knowledge level, and 14 items, were to
glean the opinions related to FGM.
After having analyzed the frequencies obtained by every item, we proceeded with
the statistical elaboration through the use of SPSS ver. 14.0 (Statistical Package for
the Social Sciences).
The first step was to analyze the T test, in order to investigate gender differences
among independent samples (males and females).
Then, on the basis of the answers given to the specific items, we investigated
the knowledge and the opinions related to FGM (qualitative variables); we used the
hierarchical analysis with the Ward clustering method, in order to investigate the
presence of subgroups within the sample. Through the external validation, we also
verified, in the last passage, whether there were important relationships between the
clusters and the external variables: for the quantitative variable (age, working years
of the subjects), the Student’s T test for independent samples has been applied; for
the qualitative variable (job title), the X2 test has been applied.
Results
After a first reading of the frequencies of the single variables, 85% of the subjects
believe they know what FGM is. This does not surprise us. Instead it surprises us
that 9% of the operators today do not know anything about it. In particular, from
the examination among these last 20 subjects, five obstetricians and six nurses were
included.
The professionals point out that direct experience with patients (29%) and
the mass media (26%) are the primary source of knowledge on FGM (see
Table 12.1).
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Table 12.1 How did you become acquainted with FGM?
Subjects
Medium
Nr
Percentagea
Professional training
Scientific literature
Direct experience with mutilated
patients/pregnant women
Referred from other health
figures
Mass-media
83
83
160
15.1
15.1
29.1
62
11.3
144
26.2
a We
obtained more than one answer per item.
They also state that they know the classification made by WHO related to the
different mutilation practices and the corresponding age at which the practice is
executed on little girls.
From the investigation emerges sufficient information about the details of these
practices (for example: short- and long-term consequences and socio-cultural motivations); the sample is mostly focused on only one value, with the exception of some
items that uncover some vague information.
The opinions and the general judgment about FGM are all based on a Western
viewpoint, and are focused only on negative aspects. According to these opinions,
these practices must be discouraged and abolished, since they have been considered
a violation of the female, an injury and a crime that is very harmful to women’s
health. Moreover, in their opinions, the circumcisers should be prosecuted because
they use violence against basic human rights and, although this practice is linked
to cultural traditions, it should not be absolutely respected. The whole sample is
strongly aligned to this Western vision.
Thus far, we have presented the results gleaned from the reading of the single
variables. Now, we will introduce the results obtained from a more sophisticated
statistical analysis.
As for knowledge about FGM, the analysis highlighted that the female group, in
respect to the male group, is much more inclined to think that:
• Hemorrhage is one of the short-term complications of mutilation
• FGM prevents the possibility of having an orgasm
In relation to the judgments on FGM, no other gender differences emerged.
The clusters analysis of the samples point out two groups that particularly stand
out from the others (Dendrogram); they are so defined:
• Cluster 1, composed of 84 subjects
• Cluster 2, composed of 76 subjects
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Specifically, some differences have been noticed as discriminants in the answers
related to the beliefs about FGM. In particular, the items that presented these
differences are:
•
•
•
•
•
•
•
•
FGM is practiced only in Muslim countries (item 1);
All FGM implies the mutilation of the clitoris (item 2);
FGM reduces sexual desire (item 5);
FGM is a religious imposition (item 8);
FGM causes problems with getting pregnant (item 9);
FGM reduces sexual excitement (item 15);
FGM prevents the possibility of having an orgasm (item 21);
The practice of FGM is circumscribed to poor and uneducated social groups
(item 24);
In these items, Cluster Number 1 is the one that reports a higher and more meaningful average of more probable statements than the answers obtained with Cluster
Number 2. In particular, if we examine the contents of these items, we notice that
five of them (items 1, 2, 8, 9, and 24) contain some “non-truths,” which have been
considered, thanks to a strengthened bibliography. The three items left (items 5, 15,
and 21) have been called into question for their contents only in some more recent
studies (Catania et al., 2004).
With this premise, we distinguish the subjects of Cluster Number 1 as people with
a low knowledge of FGM, whereas the people of Cluster Number 2 are subjects with
high knowledge of FGM.
This second group also reports a higher value on average, even in the answers of
items 12 and 13. These items both have a factual content, consequently the subjects
consider these statements as the most probable:
• FGM is done in order to preserve chastity (item 12).
• In the societies where FGM is practiced, an extended belief is that it increases
fertility (item 13).
In the end, through the external validity (done with variables that were different
from the ones used for the cluster creation), we analyzed for meaningful relationships between the clusters and the considered external variable. We obtained the
following results:
• No differences as discriminants emerged, neither between the two clusters nor in
respect to the age (T = 0.684; p = 0.495; p > 0.05) or the working years (T =
0.086; p = 0.931; p > 0.05).
• When considering the variable called “professional qualification,” the significance test was 0.054, slightly higher than p = 0.05. We can affirm that the last
variable considered relatively influences the level of knowledge of the sociohealth workers on FGM. From the contingency table, it emerges that, in regard
to the variable “professional qualification,” a very high percentage (80%) of the
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people working in the field of immigration belong to Cluster Number 2, which
has been labeled as a group with a high knowledge about FGM.
In regards to the items related to the judgments on FGM, no differences as
discriminants emerge on the subjects.
Comments and Conclusions
In relation to the goal that we wanted to reach, it seems that the analyzed sample of
221 subjects is sufficiently valid, since it is composed of doctors, specialists, nurses,
obstetrician/gynecologists, and workers in the field of immigration. They are all
professionals who have contact with the contexts where FGM is developed. Note
that Italy is the European country with the highest number of infibulated women.
Therefore, in our opinion, these results represent very well the present level of
knowledge about FGM, as far as the provinces of Emilia Romagna, Veneto, and
Lombardia are concerned, a big part of northern and central Italy.
During the previous years, other investigations of FGM have been made: an
investigation of 145 socio-health operators from Tuscany, which has been done with
the same questionnaire (Abdulcadir and Catania, 2005); two investigations made by
the Working Group on FGM of Padua, with six years between the studies, the first
one on 318 obstetrician/gynecologists (Grassivaro Gallo and Viviani, 1995) and the
second one on 114 gynecologists specializing in colposcopy (Grassivaro Gallo and
Cortesi, 1999). We will compare them to our analysis.
Thanks to their jobs, a high percentage of these subjects know the phenomenon
of FGM, precisely 95.5% in 1993; 97.2% in 2005; 85% in the present investigation.
With the high number of infibulated women there, the socio-health operators have
the concrete opportunity of being in contact with these patients.
These are the primary sources of knowledge that have been pointed out: direct
contact with patients and, above all, the mass media. For this reason, we could presume that healthcare professionals are proficient and competent with this problem.
In fact, however, they have a very superficial knowledge. Indeed, when asked for
more detailed particulars pertaining to this subject (for instance, “At what age FGM
is practiced?” or “What are the socio-cultural reasons for FGM?”), they seem to
have vague information on many aspects.
The reasons for this approximated knowledge seem to be the mass media, which
conveys stereotyped and ethnocentric information, and the superficiality of the relationship between socio-health operator and the mutilated patient. As for the first
point, the majority of interviewed subjects does not have a clear classification of
the different practices of genital mutilation, but often identify them with the most
known type—infibulation. Different sources of information about FGM mention
only infibulation (justly or not), which is surely the most severe mutilation practice
and the most known, as well, but it is not the only one. Moreover, these subjects,
both male and female, give to this practice only one interpretation—the Western one.
If we consider the data about the knowledge of FGM, a clear division on the
sample within two groups emerges—the “high knowledge” one and the “low
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knowledge” one. It seems that those responsible for this division are the staff that
work in the field of immigration because, given their answers to the items, they are
the ones with a high knowledge of the subject. It is important to note that the same
dichotomy has been highlighted in the investigation carried out in Tuscany, which
used the same questionnaire (Abdulcadir and Catania, 2005).
Once again, we believe that the mass media is indirectly responsible. Only specialists would be able to distinguish themselves from other professionals, after
deepening their knowledge about the subject, and this knowledge must be independent of the information supplied by newspapers and magazines, which are
characterized by very superficial news items.
Therefore, we think the leading reason that explains a part of the obtained results
is identified by the role that the mass media plays as a source of information,
which is then absorbed by the majority of readers and which is characterized by
uninformed opinions, biases, and half-truths.
In confirmation of our hypothesis, we made reference to a graduation thesis
written in Milan about the “Analysis of the articles regarding FGM published
in the last 20 years” (De Vita, 2004/2005). This thesis demonstrated the flimsiness, the mistakes, the half-truths, etc., that are repeatedly spread and absorbed
by an unsuspecting public thinking it will learn something but instead is shocked
by graphic images that are shown rather than detailed explanations and diffusion
maps of the phenomenon. The same images continue to be published in different
articles.
We comment again upon the obtained results in order to talk about the relationship among socio-health operators and excised patients. The operators know
superficially about the phenomenon of FGM, although they have daily and direct
contact with these patients. The majority of them listen to the information provided
by mass media, have learned about FGM through vocational training, but, at the
same time, do not seem to be completely informed and are still confused about
some points. It seems that information reaches the people, and there are also opportunities to broaden this information, but the people seem not to gain knowledge or
do not make use of it. It is as if they know that the problem exists, but it is put aside
and is considered superficially. We cannot say, for certain, that this fact is new, but
we can confirm its present existence.
The 6th National Congress, “The Immigrants in Lombardy,” organized by
ISMU –(Initiatives and Studies on Multi-Ethnicity) (Pasini, 2007), raised some very
important questions about the fact that obstetrician/gynecologists, when they have to
deal with FGM patients, often do not use these moments to gain information about
this subject. It seems that they cannot find enough time and the right way to have a
dialogue with these women in order to investigate this problem.
The difficulties come from both sides. They are caused by linguistic problems
or lack of time, but also because specialists may fear embarrassing their patient.
Obstacles are not merely linguistic, but also are psychological. Specialists do not
know how to face the subject with these women and they prefer to say nothing
about it for fear that they would make their patient feel “different.”
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Another problem that emerges is that the presence of FGM is not notated in
the mutilated patients’ case histories. This does not permit the transmission of this
information among medical personnel nor does it enable an educational process to
occur.
The last point we noticed is the negative view of this phenomenon, a biased
attitude, and the labeling of FGM as an inhuman practice. This attitude does not
increase understanding of the phenomenon (Bianchi, 2007).
In conclusion: in order to facilitate cultural understanding, the following could
be useful:
• A cultural mediator or a psychologist to make communication easier and set up
a dialogue also among healthcare professionals. From an investigation done in
Padua in 1998 (Grassivaro Gallo and Cortesi, 1999), it emerges that 78% of the
subjects say that the presence of a cultural mediator would be useful during a
gynecological visit.
• Frequent training courses for healthcare professionals. This training must be constant and continuous, so that the staff gains knowledge about these practices. In
fact, this phenomenon has become part of our country and it will involve Italy
more and more because of the progressive increase of immigration.
• Behavior guidelines can facilitate the socio-healthcare professionals’ job in order
to prepare them for certain behaviors and give them an enhanced awareness of
the complexity of the phenomenon.
As for this last point, as far as we know, the first draft of the government guidelines about FGM were published online in June 2007 (www.ministerosalute.it).
On the basis of the results obtained in our investigation, we thought it appropriate to present Minister L. Turco with some issues related to these guidelines
(www.scienzaonline.com, July 2007). None of our suggestions, however, have been
considered in the final draft of these guidelines (Linee, 2008).
References
Abdulcadir OH, Catania L. (2005) Mutilazioni dei genitali femminili: conoscenze e opinioni del
personale sanitario in Toscana. Atti della Soc Italiana di Ginecologia e Ostetricia, pp 1–2.
Bianchi S. (2007) Introduzione metodologica. In: Pasini N. (a cura di) Mutilazioni Genitali
Femminili: riflessioni teoriche e pratiche. Milan: Il caso della regione Lombardia, Fondazione
ISMU, pp 127–134.
Catania L, Baldaro-Verde J, Siringatti S, Casale S, Abdulcadir OH. (2004) Indagine preliminare
sulla sessualità di un gruppo di donne con mutilazioni dei genitali femminili in assenza di
complicanze a distanza. Rivista di Sessuologia. 28:26–34.
De Vita R. (2004/2005) MGF: ritualità sociale o barbarie? Tesi di laurea, Fac. di Scienze della
Comunicazione e dello Spettacolo. Univ. di Lingue e Comunicazione (IULM), AA Milano.
Grassivaro Gallo P, Viviani F. (1995) Female Genital Mutilation: A Public Health Issue Also in
Italy. Padua: Unipress.
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Grassivaro Gallo P, Cortesi C. (1999) Linee guida per il personale medico di fronte a casi di
Mutilazione Genitale Femminile (MGF), Quaderni di Ricerca, n. 5, Osservatorio Regionale
Regione Veneto (ORIV), Assessorato Politiche Flussi Migratori, Venice.
Linee G. (25 Mar 2008) Gazzetta Ufficiale della Repubblica Italiana http://ministerosalute.it/
saluteDonna/paginaInternaMenuSaluteDonna , www.Scienzaonline.com, Luglio, 2007, www.
ministerosalute.it
Pasini N. (a cura di) (2007) Mutilazioni Genitali Femminili: riflessioni teoriche e pratiche. Milan:
Il caso della regione Lombardia, Fondazione ISMU.
Chapter 13
Stretching of the Labia Minora and Other
Expansive Interventions of Female Genitals in
the Democratic Republic of the Congo (DRC)
Pia Grassivaro Gallo, Nancy Tshiala Mbuyi, and Annalisa Bertoletti
Abstract Ritual stretching, classified among the female genital mutilations by the
WHO in 1996, has been studied for the first time in the Democratic Republic
of Congo (DRC) by the Padua Working Group on FGM in 2006. Data gathering
took place indirectly from Italy by means of Italian and Congolese local referents,
through structured interviews with traditional operators as well as a focus group
of about ten intellectuals (in Kasai) and Italian health workers (in Kiwu). The data
have been completed, with answers from two questionnaires sent to affected women
and health workers of the Mbuji-Mayi Hospital in Kasai. The results enabled us to
outline cultural and naturalistic traits, social meanings, countrywide diffusion, and
time evolution of the ritual of labial elongation as it takes place in the two abovementioned regions of the DRC. Other forms of expansive genital modifications have
been identified, such as ritual defloration and the widening of the vaginal canal,
among very isolated populations in the Kiwu region.
Keywords Labia minora · Stretching · Democratic Republic of the Congo ·
Female genital mutilation · Padua Working Group on Female Genital Mutilation ·
Traditional operators · Ritual defloration · Vaginal canal
Introduction
Genital stretching (GS) (Longininfismo in Italian; èlongation des petites lèvres, in
French), the expansive modification of the albia minora (nimphae), is obtained by
the means of ritual manipulation. It is a common traditional intervention in the
African Great Lakes region, included within the DRC, as indicated previously (De
Rachewiltz, 1963; Kashamura, 1973).
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This morphology, in our opinion, is classified inappropriately by the WHO
(1996) under Female Genital Mutilation, Type 4. In fact, in these cases, there is
no sense of self-mutilation, but rather expansive manipulation of the genitalia.
In 2006, the Padua Working Group on FGM organized the first survey of
ritual genital stretching in the DRC; but due to the difficult political situation of
the country in carrying out its first national election, a direct survey in the field
was not advised. Instead, it operated indirectly, through in loco referrals, whether
Congolese or Italian, contacted from Italy by Italian and Congolese intermediaries
(among whom was the co-author of Luba ethnicity).
Survey Instruments
Interviews with adult subjects (women and/or men), Congolese and Italians present
in Congo, who, under examination, were aware of the ritual, were carried out
through a “track” processed in Padua.
The track is composed of 26 inherent items, including cultural aspects,
psychosocial importance, distribution within the territory, and evolution over time
of GS.
Moreover, there were two prepared questionnaires: the first, directed at women
who had undergone the ritual; the second, directed at sanitary operators (nurses,
obstetricians, doctors) who, throughout their professional activities, had come in
contact with women with manipulated genitals (often patients or women who had
just given birth).
Contacted Subjects
Altogether the “track” was proposed:
In Kasai:
• to the old Luba grandmother of the co-author (Fig. 13.1), interviewed by a cousin,
using the tshiluba dialect exclusively. (The mother of the candidate always
refused to speak, even by telephone, to her daughter about the ritual).
• to a group of intellectuals, all male, who responded (in French) through a “focus
group,” organized by a referred Congolese sociologist, contacted by a Luba
pediatrician, who practices in Italy and who made himself available for the
collaboration.
In Kivu:
• to an Italian psychiatrist who worked in Goma, in a center for mental hygiene
of missionaries of St. Saverio, who reported information yielded from two of his
nurses, of Bafulero and Bashi ethnicity, respectively.
• To a nun of St. Saverio, working as a missionary for 23 years in Kivu; an expert
of the Bukavu and Uvira region.
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Stretching of the Labia Minora and Other Expansive Interventions
Fig. 13.1 Grandmother
Njiba (86 years old)
(Kinshasa)
Fig. 13.2 Saint Sauveur Hospital (Mbuji-Mayi, in Kasai)
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The questionnaires, however, were sent to a Congolese obstetrician/gynecologist
who worked at the Mbenzola State Hospital of Mbuji-Mayi, in Kasai (Fig. 13.2).
Altogether, in this manner, information was collected from 52 women and 52 healthcare professionals (in maternity, pediatric, post-partum, and obstetric/gynecology
units) subgroups A and B, respectively—that reported on the culture of that territory.
Results
From the interviews and from conversations carried out through the “track” we
obtained information about the culture, the social meaning, the involved ethnicities, the role of the plants, and the evolution of the ritual of GS. Moreover, much
of this information has been confirmed through the questionnaires distributed to the
women and the healthcare professionals. This last data were processed exclusively
in terms of simple percentages and have given the following results.
Subgroup A
Of the 52 women interviewed, the majority (79%), belong to the Luba ethnic group.
They are adults with the mean age of 44.5 years; predominantly married (69%).
They were introduced to genital stretching within the atmosphere of daily, familiar life (17%) or through friendships (50%); at the age of pre-menstruation or
pre-puberty (75%); the manipulation was obtained through plant extracts (60%),
supported by objects/instruments of various typologies (40%).
The women confirmed the current vitality of the ritual (83%), from which one
grows in beauty (27%) and in consideration taken by the husband (78%); they have
the clear consciousness that its function is to “increase sexual pleasure” (92%). The
labial elongation does not cause substantial physical consequences (76%), except
for some women (19%).
Regarding the future of the daughters, the opinions of the mothers are divided and
almost equivalent—yes and no—(53 and 43%, respectively). They also added the
motivations for passing the traditions to their daughters that we enclose in the table.
They refer to a matrimonial stability, to the essence of femininity, to the increment
of sexual pleasure, and the possibility for women to conform in the same culture.
Other motivations advise against transferring the culture because it is obsolete;
the parents cannot speak, for the sake of modesty, conferring the task on elderly
people; it will be the partner, not the parents, who decides if the wife should be
manipulated because the ritual cannot be a pretext for initiating premarital sexual
relations.
Subgroup B
The majority (97%) of the 52 healthcare professionals are familiar with female
genital manipulation and they have recognized its spread in the regions of Kivu and
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Kasai. In addition, they are aware of its presence in the capitol (Map); especially in
the rural region (92%) compared to the urban environment (33%). It is work experience that has been favorable to many professionals (88%) in their encounters with
manipulation; they also indicate that the GS is not present in girls before age 13,
thus confirming the data obtained from the women.
Map: Genital stretching in Democratic Republic of Congo (present research)
The reasoning that supports the presence of the ritual in a more consistent matter (88%) is that of greater sexual satisfaction. Manipulated women are generally
accepted (42%) and are considered normal (94%), but often (42%) the hypertrophic
labia minora is not the subject of much interest on the behalf of the healthcare
professionals.
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The Ritual
We begin by emphasizing the manner in which the ritual in the DRC is not included
within any rite of passage ceremony, it simply accompanies the normal growth of
adolescents. That is, when the young girl begins to show signs of growing breasts
(age 12–16), family members believe that she should also have an elongated labia
minora.
In the development of the rite, we have recognized that some events follow others
chronologically, one after the other, but in some cases they can also be missing
materials, according to the availability of the environment or the foundation of the
ethnicity; the sequence seems to be confirmed for Kasai, as in the arid district of
Eastern Congo, in Kiwu.
These are the identified phases:
•
•
•
•
•
•
•
the decision of the family and the support of the elders;
the selection and preparation of plant extracts;
the application of the extracts on the genitals, to make them swollen and evident;
the manipulation: first intervention and subsequent learning;
stretching and maintaining the elongated labia minora;
the assurance of the elongation, using topical substances and potions;
the recuperation of the elongation after childbirth.
The ritual is imposed by the suggestion of a grandmother, an aunt, or a wise
woman in the village who can initiate the girl personally (Bafulero) or rather, entrust
it to another greater (Luba). It is suggested to the girl, having already begun, to
concern herself with the neophyte and to teach her what men desire to find in a
woman: “You cannot have nothing between your legs, otherwise you will not be
esteemed.” For the sake of modesty, it will not be the mother who will speak to the
adolescent.
Among the Bafulero, the girl was entrusted to an initiator, “old sage,” with whom
she would spend evenings and from whom she learned the technique of genital
manipulation and also “the movement of love,” that is, the action to be taken during
intercourse.
Therefore, the plant extracts are prepared in advance. In Kasai, a plant similar to
a rose, that grows naturally on the banks of waterways, is used. The flower is peeled
and the petals crushed to extract a stinging juice with which to massage the labia; or
alternatively the root of the tshifumba (that secretes a liquid similar to that of a wild
onion). During the ritual, the juice is stored in containers of wrapped Mangus tree
leaves.
The swelling of the labia by the already prepared, specific plant juices continues.
The self-manipulation (of the labia minora) follows. The older girl accompanies
the neophyte to an outdoor area (brousse), where they will not be disturbed; they
take a blanket, should it be needed, and they prepare a container made of Mangus
leaves, shaped like a funnel in which to store plant extracts. They sit facing each
other with their legs open. The initiator takes a root (of tshifumba), cuts it, wets the
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thumb and index fingers with the gelatin and begins to massage the labia minora.
Then they begin to pull it. It stops when the irritation takes over. They repeat the
action from time to time and so on. The first intervention can also be done reciprocally among neophytes to whom it has been explained how to act. Elders can also
intervene, touching the genital region to see the results of manipulation.
Among the Bashi and the Bafulero, however, the initiated females, sent outdoors and away from foreign eyes, sat in a circle and each person performed genital
manipulation. The latter situation seems not have changed over time (Kashamura,
1973).
Instead of roots, as already mentioned, a different plant, dilongu, a species of
rose, can be used. If the tshifumba leaves are used, they can serve two purposes.
From the leaves, a juice can be drawn that acts to soften the labia minora and foliar
veins can be drawn from the sticks. These sticks are cut down along the middle
and labia minora are inserted, one in each small stick, to prevent them from withdrawing. This way, each labia hangs down so that it will be lengthened in a way
that weights can eventually be attached. During the manipulation, the girl assumes
a particular position—that of a woman giving birth; sitting with knees flexed open
strongly towards the head, and feet turned inward.
Finally, the manipulated genitals are covered with coal dust (to which boiled
manioc flour can be added to help the elongation). Everything is covered with soft
pieces of plants (even tshifumba). The next day the application is removed and the
manipulation begins again.
A hot potion is prepared, finally, which serves the purpose of helping the GS (it
becomes effective, probably because it causes local vasodilation).
The GS continues until the labia minora reaches the length of 2–3 cm. or more;
at this point they do not withdraw anymore. The care of the GS is a constant task
for the woman, even after she is married, and she will resume manipulation after the
birth of a child and the subsequent reduction of the labia minora.
An in itinere examination of the length of the stretching is expected, and can
be implemented by the friends who accompany the neophyte (Luba) or the grandmother who invites her to come before them in private to assess the progress
(Bafulero). (In Rwanda—Utu e Tutsi—where GS is very much considered, it is carried on for longer, in consideration of a specific type of sexual intercourse, produced
by the vagina. That is at least what was reported in the past).
The manipulation is carried out at puberty when the tissues are still extensible.
If it is done later, they do not maintain the same elasticity; if it is done too early the
procedure is painful.
The manipulated girl keeps her reserve about her own condition that will be
known in time only by her new husband. No social presentation is held for the
initiated females.
Any girl who does not undergo GS is referred to by the term tshimbùla or tshimbumba, that is “one who has nothing;” a name given to a “goat that has no horns.”
There is also a song in which makonka is used as a term of mockery. The girl who
has been manipulated, however, is referred to as “wa tshichèkù,” ready woman, able,
who has prepared her body—literally—“flower garden.”
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The Role of Plants
The use of plants in rituals is very distinct in their specific, multiple, and differentiated functions. However, they are not always used in the proper way—
“The indiscriminate use of the herbs can cause ulcers,” an interviewed woman
said.
The functions supported by the plants at the ceremony are as follows:
• formation of edema in the genital region as a result of irritation caused by plant
extracts, often contained in a funnel made of curled mangus leaves;
• application of a plant extract that acts as a mordant on the skin of the genital
region and softens it;
• covering of the manipulated genital region in powder and pieces of plant marrow,
a facilitator of elongation;
• application of boiled flour in order to promote the elongation;
• use of slotted sticks, made from straw or foliar veins, where the labia are inserted
during stretching to prevent a return to the normal morphology;
• decoctions and teas, to be taken warm, that are favorable to the elongation,
through local vasodilation.
The ritual plants, classified from the botanic viewpoint (De Wit 1965) or
indicated only by their local name, are the following:
• Bauhinia tonningii Shumach (Family: Cesalpinaceae), in the local language
it is called tshifumba; has these uses: leaves are obtained from an extract
to soften the skin (it is used also to soften the leather in tanneries); ribbing
from foliar sticks are obtained to confirm the extension of the labia during
manipulation.
• Bridelia ferruginea, locally called shinkunku, is a “sacred” tree under which
ceremonies of groups are also carried out, for example, when men assemble
themselves before the hunt, to have a favorable outcome.
• Solanum delangeonsa Dunal (Family: Solanaceae), locally called nkulanyi. The
very pungent fruit was used to treat skin disease in goats. It is a ubiquitous plant
that has been indicated in the ritual of genital manipulation in Uganda and in
Malawi.
• Maniot (Family: Euphorbiaceae), the cassava.
A Ritual Defloration
In the eastern district, among the Bashi of South Kivu, there were reports of a very
particular form of female genital modification, different to the GS, which is a ritual
form of defloration. (The reference is not isolated in the DRC because even among
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the Thokwe, a ritual defloration is required during a girl’s preparation for marriage,
obtained by placing objects of increasing size into the vagina—sticks, eggs, horns,
etc.—until the hymen is eliminated. This ritual does not compromise pre-marital
virginity of women).
However, this refers specifically to another form of manipulation that is intended
to help maintain the elasticity of the membrane of the hymen and simultaneously achieve a progressive enlargement of the vaginal canal. This is done
to make the first penetration less painful and then to facilitate birth in the
future.
The procedure is carried out by the shangàsi, also called “mother mokubua,”
traditionally the father’s sister, that is, the oldest woman in the father’s family, the
person solely and indisputably responsible for the education of the offspring. It is
at the exact time of birth that the child undergoes the first procedure, checking the
elasticity of the hymen membrane and if necessary, immediately after, manipulation
begins in a gradual and constant manner. This is done to avoid having to consult a
doctor for the enlargement of the hymen and the vaginal canal when the membrane
is thickened with growth.
The shangàsi can continue the practice over time on her niece, at home or
elsewhere, taking her niece along with her, for example, during scholastic holidays. Everything is done in absolute confidentiality and often not even the father is
aware.
Specfically, the shangàsi inserts a finger at the opening of the vagina and
moves in a circular motion, gradually widening the narrow entry; it acts delicately on the elastic membrane of the hymen, in order to force the opening without
breaking it.
Such practice is more widespread among the tribes located in brousse and among
the most backward tribes; it tends to disappear in urban environments, where the
girls rebel against these customs and practices, as well as with other ritual practices,
adopted by the villages.
After this first procedure, the shangàsi oversees the social development of the
girl until marriage, continuing to exert her own authority over the girl even after.
She must make sure that the girl behaves in the manner expected of her to become
a good wife, responding appropriately to the tasks before her. In conclusion, she is
responsible for the growth, psychosocial, and sexual maturity of the grandchildren,
which will be removed from the mother immediately after birth.
On the other hand, the intervention on the genitals is reflected in an increase of
authority and of consideration for women, especially, where there are no traditional
educated workers who can educate the girls for whom they are responsible, through
more modern methods (education, setting an example, etc.).
Genital manipulation can be translated, lastly, for the shangàsi, as a personal
advantage, contributing to putting into motion the hormonal activity of the elderly
woman, from which she can draw sexual vigor.
We stress again that, when the child/adolescent in the diaspora is the bearer of
this ritual vaginal enlargement, during an inspection, she may seem to have been
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the victim of abuse but it is only through a closer look at the absence of concomitant signs of rupture and/or bleeding, usually caused by the forced penetration of a
male, it helps the professional to understand how the modification is the result of an
intentional act, performed by an expert.
Social Meaning
The motivation with which the girls were convinced to undergo the GS was
aesthetics; they needed to become more beautiful; a vulva that has not undergone
GS is considered ugly, not pleasing, therefore, it would not be possible to marry.
Women still have a clear awareness that genital modification serves to increase the
pleasure of intercourse for the woman as for the man. For the woman, the modified
labia become more irrigated by the blood and, therefore, are more sensitive as
erogenous zones (“The man is happier because the woman warms up first”). For the
man, who begins rubbing the labia minora, it increases the possibility of exercising
“petting” in the premises of mating. At this stage, they have their own reason for
being. The man likes to “feel” the woman under his fingers. The more meaty the
labia, the more attracted he feels to his partner. So much so that the women of the
past (ndumba, literally, “the manipulated prostitutes”) would put a lot more work
than current women in continuing the manipulation, to be able to subdue their own
men. For example, in the Lubumbashi region, the presence of the migrants could
make the availability of possible partners of women more competitive, the most
popular because they are “stretched.”
During the manipulation, the girl can have an orgasm but traditionally must
remain a virgin until marriage. The man of Kasai aspires to be the first for his woman
and be able to see the sheet stained with blood after the first night, so masturbation
is allowed and even encouraged in the practice of genital manipulation.
There are tribes, in particular the Rwandan (Utu and Tutsi) that develop these
practices much more than the others, the volume and length of the labia minora
reaching 5 or 6 cm. It seems that the manipulation in this case has been accentuated
and traditionally handed down to allow for sexual intercourse conducted outside
the vagina, by rubbing the penis on the labia minora so that they could respond
effectively to the sexual behavior adopted.
In women, these practices accompany the development of sexuality; for which
they are taught to give and feel pleasure (premise to reproduction), but at the same
time are obliged to control (that of remaining a virgin). It is added also that the
learning of manipulation is collective, for which they grow together in sexuality;
however, that must not be expressed completely except in marriage. This tradition
still exists in the DRC, mainly in rural areas.
In conclusion, in expansive genital modification, the woman becomes the active
protagonist in the relationship itself, not only a spectator, as in female genital modifications of reductive typology. So, if the husband (Luba) finds that his wife (of
another ethnic group) has not thought to prepare her body, he will go to a “wise
woman” so that she may initiate the wife to sexual manipulation.
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Geographic Distribution and Involved Ethnic Groups:
Evolution Over Time
Through analysis, we have identified the area of diffusion of GS in the DRC (Map),
especially present in the eastern region, limited by lakes, bordering the countries
where it is endemic (Uganda, Rwanda, Burundi, Zambia, etc.). The included regions
in Kivu comprise western and eastern Kasai and, in part, Katanga. As for the ethnic
groups involved, some were taken from bibliographical surveys, others were specified by the local contact during the interviews conducted. These include Bafulero
and Bashi in Kivu, any immigrants in the Congo in Rwanda, and ethnic Utu and
Tutsi. In the Kasai district, it occurs among the Tshokwe (performing also the defloration ritual, through the insertion of objects of increasing size into the vagina), the
Bindi, the Kete, the Tetela, the Sanga (in Katanga: the Ndembo, the Lulakat), the
Lulua. Basically it is always the Luba people.
The labial manipulation appears to be connected to the ethnic group, in Kasai, as
in Katanga and Zambia. In Lumumbashi in particular, the women had accentuated
elongation, through packs of dust produced from peels of plants. They feared that
the partners were attracted to immigrants of the nearest region, where the elongation
was highly regarded.
In the current evolution, the ritual was conserved predominantly in rural areas,
while in urban areas girls do not consider it necessary anymore, but rather as old
fashioned. Particularly in the capital, we were told that the abandonment of the
ritual may have occurred either because the mothers have a certain reserve to talk
about it to their daughters; or they are afraid to continue with the GS and have the
daughters have premarital contact with boys (“youth today are so uninhibited that it
is inappropriate to add this incentive”). The presence of the Christian religion and
the role that it may have as an inhibitor against a pagan practice that, therefore, is
sinful is not underestimated.
It is our opinion that, as in other African countries where genital interventions are
endemic, it will be predominantly the change of perspective of life in the women that
will be the driving force for the soft elimination of traditional practices that interfere
with their health, to bring women to a better state of mental well-being.
Comments and Conclusions
In previous surveys, conducted in 2002 in Uganda and in 2004 in Malawi, we have
shown that the physical damage related to the GS ritual is not severe, however, it
results in some non-negligible inconveniences in daily life (difficulty in walking fast,
requirement of a certain type of clothing, irritation and genital ulcers; discomfort
when remaining seated, etc.) and moreover, their importance is also more consistent
in migration (difficulty to maintain a stable relationship with western partners, intrusive and disturbing memories, low self-esteem, severe postpartum depression, etc.).
GS, however, is FGM (female genital mutilation of the 4th Type, according to
a classification given by WHO, 1996) and, as such, we believe its study should be
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deepened in order to understand the social and cultural environment in which the
procedure occurs and the high regard that it receives from the people that put it into
effect.
That said, we will not comment on the cultural results that we obtained, which
practically confirm those already noted in neighboring Uganda. Perhaps we can say
that the DRC is characterized by the complex structure of plants in rituals, which are
probably attributable to the presence of an equatorial, particularly lush vegetation
and a forest cover that stretches over more than half of its territory.
Here we would like to give priority to the original data that has emerged from
research, which we present below.
GS and Ethnicity
In the DRC, the Luba seems to be the ethnic reference of tradition. This is true both
for residents and for migrants in the territories within it. So, wherever the Luba are
present in high concentration, the women continue with GS.
We obtained similar results from the Baganda women in southern Uganda
(Grassivaro Gallo and Villa, 2004, 2005/2006; Grassivaro Gallo et al., 2006). This
polarization does not seem to apply in Malawi, if not by exclusion, where the yao
ethnic group of Muslim religion seems to have the only women who are intact
(Grassivaro Gallo and Moro, 2006).
In the DRC, genital elongation is present overall in contact with the eastern population that surrounds the Great Lakes, from which the tradition itself probably came
into the country. In particular, it is in the east where its social importance is accentuated, for reasons of competitiveness in the selection for marriage, of the presence
of immigrants from Rwanda and Burundi. The ritual is unknown in the west (Map).
GS is not the only genital modification present in the country; we have found
traces, particularly in isolated ethnic groups, of at least two other types: ritual
defloration and the enlargement of the vaginal canal. Such a plurality of genital procedures in one country has already been highlighted in Uganda, where expansive
and reductive modifications were included (Crozzolin, 2004/2005).
GS and Male Opinion
In the DRC, we have been fortunate enough to have information from males on the
ritual; normally, it is the women that are interviewed who express what they believe
to be the opinion of their partners in this regard.
The adolescents of Kasai practically grow up expecting to encounter a manipulated woman and, if this does not occur, it would be a great disappointment. From
their words, there comes a clearly positive appraisal of GS. This, for example, does
not occur for western adolescents. For them, the encounter with a manipulated
African woman is a source of contempt, mixed with a certain fear of an unusual
morphology that is culturally unknown.
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The information from the males virtually confirmed what the women said, in the
consideration of GS as a tool that encourages sexual activity.
From the information obtained, an unexpected element emerges (subsequently
confirmed by the women): the evaluation of pre-marital virginity. From research
done in Uganda and Malawi, we understood that the ritual of GS necessarily entailed
a defloration and was carried out with a clear incentive to sexual promiscuity. This
does not occur for the Luba people, where the adolescent learns the ritual with
the “theory” of the relationship that can only be implemented in the intimacy of
marriage.
Table 13.1 Luba women comment on the transfer of GS to the daughters
No because:
This culture is being erased
I do not see the need
Unimportant
No, does not apply to current customs
Because I cannot see the importance
As a matter of modesty
Modesty
Modesty unless another person does it for me
No, for modesty (initiation may be not be carried out by parents)
Modesty, she can be initiated by her friends
For modesty, but may be initiated by friends or grandparents
Modesty (initiation taught by the grandparents)
It must follow the desires of her husband
They follow the desire of her future husband
No, because the time in which we live does not allow it, the morals are corrupt
Yes because:
To have pleasure in the future sex life
To please her husband
That’s true femininity
This is a symbol of the woman
Every woman should have it
For the preservation of future marriage
For their future marital life
To conform to future marriage
For compliance in future marital sexuality
Because if this doesn’t exist there will be divorce
For sexual compliance (erotic zone)
Preparation for sexuality
For the daughter to be well prepared for future sex life
Yes, but not by me, for compliance in sexuality
To be like me
Because it’s good and should not be abandoned
Yes, but with the others who are not family
Yes, but through other people for sexual compliance
As my mother told me, I too must transmit it my daughters, it is considered as means of
stopping sexual promiscuity
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Passing of the Ritual and Urbanization
Even for the DRC, a disappearance of the ritual is occurring in the urban environment. The same young co-author of the Luba ethnic group, born and raised for the
first 20 years in Kinshasa, only learned about it in Padua at the time of selection
of the thesis. The modesty of the mother has always prevented the transmission of
information between them and has always been maintained that way, even when her
daughter asked for information over the telephone for her research. This sentiment
also appears clearly in the comments of the women interviewed (and presented in
the Table 13.1).
The passing of the ritual occurred, according to African indication, that it is noncoercive and virtually painless. In Kinshasa, it has simply gone into disuse. Whoever
considers it useful can still perform it, but is not more socially valued because of it.
Changing the destiny of the women who come to live in the city, the mothers simply do not consider it necessary to transfer the practice to their daughters anymore.
With the disappearance of the ritual, the function of instruction towards psychophysical maturity of the girl, which occurs traditionally by shangàsi, is entrusted to
another female family member, for example, a young aunt who makes herself
responsible for the future behavior of the adolescent.
In the analysis presented, there remains a point about which it was not possible
to survey, that is, how the Congolese behave in respect to the transfer of the ritual
“in diaspora,” for example, in Italy. The few subjects with whom we were able to
contact were not familiar with the practice. Therefore, we leave this point for future
research.
References
Crozzolin N. (AA 2004/2005) Il sincretismo nelle modificazioni genitali femminili in un gruppo
di sfollati. Uganda: un caso di studio. Tesi di laurea in Psicologia. Università di Padova.
De Rachewiltz BEN. (1963) Costumi sessuali in Africa dalla Preistoria a Oggi. Milano:
Longanesi e c.
De Wit HCD. (1965) Il mondo delle piante. Vol. I. Le Piante Superiori (II). Milano: Mondadori.
Grassivaro Gallo P, Villa E. (2004) Longininfismo rituale tra le Baganda (Rapporto Preliminare).
Rivista Italiana di Sessuologia. 28:17–22.
Grassivaro Gallo P, Villa E. (2005/2006) Ritual Labia Minora Elongation among the Baganda
Women of Uganda. Psychopathologie Africaine. 33:213–236.
Grassivaro Gallo P, Villa E, Pagani F. (2006) Graphic reproduction of genital stretching in
a group of Baganda girls. Their psychological experiences, Chap. 6. In: Denniston GC,
Grassivaro Gallo P, Hodges FM, Milos MF, Viviani F. (eds.) Bodily Integrity and the Politics
of Circumcision. Culture, Controversy, and Change. New York, NY: Springer, pp 65–84.
Grassivaro Gallo P, Moro D. (2006) Modificazioni Genitali Femminili in Malawi. Primo resoconto
di un’indagine sul campo. Chap. 6. In: Grassivaro Gallo P Manganoni M. (a cura di) Pratiche
Tradizionali Nocive Alla Salute Delle Donne. Padova: Unipress, pp 87–101.
Kashamura AF. (1973) Sexualitè et Culture. Essai sur les moeurs sexuelles et les cultures des
peuples des Grandes Lacs Africains. Paris: Payot.
WHO. (1996) Female genital mutilation. Report of a WHO Technical Working Group. Geneva:
WHO, 17–19 July, 1995.
Chapter 14
Preventing Infibulation: Mana Sultan
Abdurahman Isse at Merka, Somalia
Pia Grassivaro Gallo and Sandra Busatta
Abstract An interesting development of the project of eradication of infibulation
at Merka, Somalia, from 1993 to 2007 (The 9th International Symposium, Seattle
2006), implemented by Mana Abdurahman Isse, prematurely deceased, is the use
of singing and dance to reinforce a western-style approach to female health by
means of traditional methods of learning and sensitization. Although the CD on
which we base this presentation has a very poor technical quality, we consider it
an exceptional anthropological document on the happy combination of the traditional and the modern, which espouses local ways of emotionally communicating
very important notions through singing and dancing and more frigid school-like
teaching. We are going to apply the notions of British anthropologists, Victor
Turner and Maurice Bloch, about cultural performance to the visual document supplied by Mana Abdurahman Isse, a sultan’s daughter, and thus a charismatic figure
whose performance is particularly authoritative, in order to analyze how effective an
intervention can be that aims at the eradication of the infibulation that exploits culturally sanctioned means of communication. This culturally loaded intervention can
suggest to us new approaches to the prevention as well as the eradication of infibulation, with the help of native operators and cultural mediators, also in a diaspora
environment.
Keywords Female genital mutilation · Infibulation · Medical education · Ritual
circumcision
Mana Sultan Abdurahman Isse: A Charismatic Figure
for Your People
Mana Sultan (1953–2007) was one of the daughters of the last sultan of Merka,
Abdurahman Ali Isse, a legendary figure with about 400 wives, according to rumors,
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P. Grassivaro Gallo and S. Busatta
and an enlightened man who freed his Bantu slaves and educated his children.
Daughter of the first wife of the sultan, Mana was also a political person, who was
actively working to build up a constructive dialogue among the warring factions,
in particular between the government and the Islamic Courts. During the Nairobi
Conference in 2004, she succeeded in obtaining 12% of the representatives in the
provisional parliament who were women.
Mana was the force behind the creation of Ayuub, a refugee village founded in
1999 on the outskirts of Merka. Helped by an Italian NGO, Water For Life, Ayuub
had grown into a healthy model community of about 600 people, with more than
30 schools, promoting rural development projects all over the area of the Lower
Shebelli River. From 1996 to 2007, Mana dedicated a great deal of her efforts to
support the attenuation and elimination of infibulation, while maintaining the ritual
aspect, hence contributing to the campaign against excision as well as infibulation
among many Somali women in the district of Merka. Through projects such as
Gudnin Usub (New Rite), Mana tried to convince Somali women, as well as traditional and non-traditional health operators, to progress from the Sunna Gudnin,
i.e., clitoris incision, to the Gudnin Usub, which simply involves a puncture of the
clitoris, while preserving the ritual aspect of this female rite of passage, i.e., the cultural elements. This compromise had the aim of abolishing infibulation. Currently,
this alternative rite has been practiced on 3,000 girls in 32 villages of the Lower
Shebelli (Abdurahman Issa and Grassivaro Gallo, 2005; Grassivaro Gallo et al.,
2001, 2004).
Mana supported her campaign for the alternative rite through a number of initiatives, including sewing courses and traditional work groups where women could
speak informally about their experiences with infibulation. More formal meetings
(Friday Programs) were held every week, in the bush of Merka town, in open space
of the Timàn Càdde (White Hair). Meetings with some umulissa, the traditional
midwives, were also promoted. Mana and her helpers always strove to convince
women that infibulation is very dangerous for a woman’s health and that a good life
is possible without forcing daughters to suffer this terrible ordeal.
In the summer of 2007, we know that Mana organized and directed one of the
events: a performance by the umulissa, an elderly woman who enjoys command
of the audience. She is also known as a poetess and most of the performance
relies heavily on poetry and song. Before analyzing the constructed performance
itself, we will say some words about the cultural importance of poetry in a Somali
context.
Female Somali Poetry
Somalia’s poetic tradition differs markedly from the Western one. In 1982, Somali
scholar Said Sheikh Samantar remarked that even a casual observer could notice
the remarkable influence of poetry in Somali culture. In fact, Somali poetry has
been the country’s chief means of mass communication, substituting for history
books, broadcasting, and newspapers. Modern communication, such as radio, audio
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Preventing Infibulation: Mana Sultan Abdurahman Isse at Merka, Somalia
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cassettes, and transportation, have spread the art more efficiently from one area
to another. Poetry is an all-pervasive part of nearly everyone’s daily experience.
Historically, Somali bards, both men and women, have mobilized public opinion in
support of war or peace (Cerulli, 1964; Andrzejewski and Lewis, 1974; Jama, 1991;
Hultman, 1993; Orwin, 2001).
In Somalia, poetry is the currency of conversation and it is used as a platform for
everything from education and entertainment to politics and debate, disseminated
all over the country through the use of cassette tapes and players. With no pervasive
written language, Somali culture is indisputably oral, and the Somali population is
mostly made up of non-literate nomads. “As Islam provides a way of life and defines
a relationship with God, so poetry provides a way of speech and thought and defines
a relationship with the things of this world” (Lark, 1988).
Four criteria—scansion, melody, topic, and function—act in concert to differentiate one genre from another. As for the form, Somali verse is marked by alliteration
(xarafraac or kikaad) and an unwritten practice of meter (miisaan) (Samantar, 1982;
Orwin, 2001). Scholars group the various genres (more than fifty) into three basic
categories. First, classical poetry (gabay), which deals with politics and serious
issues, such as interclan relations, consists of texts composed in private and memorized verbatim for public performance. Second, work poetry (hees), which is specific
to particular tasks, such as herding camels or churning milk. Third, recreational or
dance poetry (cayaar), composed and recited simultaneously.
The poetic forms of expression allotted to women are the buraambur, which is
the highest of women’s literary genres, the hobeeyo or lullabay, the hoyal or work
song, and the sitaat or religious song.
Since the 1940s, the introduction of radio and audio cassettes has contributed
incalculably to the popularity and dissemination of poetry, which until then had
traveled solely on the nomad’s tongue. Today, from Mogadishu to the inner cities of
London and Toronto, Somali shops offer a wide assortment of cassettes and CDs,
adorned with images of the latest stars.
In more recent times, traditional gender roles, tribalism, female circumcision, and
especially the civil war, have been the subject of fiery poetic disputes. In poetry, the
use of violent diatribe is entirely acceptable, and poetic license provides the socially
marginal with a powerful tool to reclaim their honor and challenge the existing
power structure.
Somali women, in their own classical poetic genre called buraambur—its memorization and transmission has traditionally been restricted by social convention—is
no less socially and politically engaged than the men’s genres. Shifting social
norms, the result of war and exile, have now permitted many Somali women
to play increasingly active public roles, including the public recitation of their
poetry at political and cultural events. At the largest Somali peace initiative yet,
the Carta Peace Conference in Djibouti in 2000, women took center stage with
the performance of peace-promoting poetry and song. In many diaspora communities, women are spearheading the revival of the Somali cultural heritage and
actively participating in debates about the war and their status as refugees (Bavelaar,
2006).
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Given the discrimination against female poets, whose poems are not memorized
by professional male reciters because it is considered demeaning and insulting,
women do not receive exposure through the traditional network. Instead, their poems
have circulated through audiotapes and radio transmissions, as well as public performances to large audiences, made available in the refugee camps (Jama, 1991). While
the composition of a poem may vary widely, the content and the message always
appeal to ideas and experiences shared by the audience. Poetry remains a preferred
medium for the communication of sensitive social messages, while poetic license
allows people to address issues that may cause embarrassment when discussed in
ordinary conversation.
Poetry and Song or the Language of Traditional Authority
The idea and practice of performance have a particular import for oral expression (Finnegan, 1992) and one influential approach centers the idea of performance
around the concept of “social drama” (Turner, 1982, 1986). Social drama, Turner
says, is defined as a harmonic or disharmonic social process, arising in conflict
situations (1974, p 37, 1985, p 180). Social drama is defined by Turner (1985,
p 196), as “an eruption from the level surface of ongoing social life, with its
interactions, transactions, reciprocities, its customs making for regular, orderly
sequences of behavior.” Turner’s social drama theory has four phases of public
action: breach; crisis, redressive action, reintegration. In the liminality of the ritual, there is also room for the critical. Liminality inverts the reality external to
the ritual situation in order to produce alternatives for the everyday world. This
frequently gives an impression of chaos for the participants in the ritual. Acts
that are prohibited in normal day-to-day living are possible or sometimes even
ordained.
René Girard (1972) thought that the aim of rituals is to make contact with power
in order to control and channel it. Closer research into the liminal phase of rituals
(not only sacrificial rituals), however, shows that besides channeling, there is also a
free use of powers prohibited outside the ritual, not only to channel these powers,
but also to benefit the community with new beneficial dynamics. In this part of the
paper, we adapt Turner’s notion of social drama (1974) and his analysis of symbols
(1967) to the umulissa’s constructed performance.
Every social drama alters, albeit minimally, the structure of the related social
field. Hence, its “liminal” or “threshold” character transforms the social drama into
a limited area of transparency on the opaque surface of social life. As seen on a
DVD, umulissa starts immediately in medias res. Her oral performance, however,
can be divided into four parts, made up of recited verses in the opening, sung refrain,
spoken verses, sung verses and refrain, recited verses in the closing. On the other
hand, the poem/song is made up of a chant and counter chant, where the crude
description of the operation of the infibulation is alternated by exclamations, such
as “Mom, don’t do the pharaonic cutting to me!” or by the refrain, “Mothers are to be
blamed for it.” When the first description of the operation, which starts somewhat
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backwards with the girl’s tied legs, ends in a circular way with the girl sealed by
thorns, a song erupts: “We have refused it, we don’t want the pharaonic one. Parents
who still do it are to blame.” The song is then sung by the audience as a chorus, the
first time even clapping their hands (unfortunately, we cannot know whether it was
repeated with different audiences, because of the editing). A group of sung verses
follows, which forcefully sums up, for a second time, the girl’s ordeal, each verse
alternated with the refrain sung by the women’s chorus. A fourth part of recited
verses, interrupted only by the sung question, “Where did we get this practice?”
concludes abruptly, with force, “If you find someone doing it, advise her not to do
it.” Through recited verse and song, that is, through the formalization of language
typical of rituals, which we will deal with later, umulissa has created a space that,
if it cannot be properly called “liminal,” is at least “liminoid” in its characteristics
(Appendix 2).
The performer deals with two main arguments: health and religion. Using the
very strong metaphor of syphilis for clitoris, which is one of the traditional arguments in favor of the operation, umulissa counterattacks mentioning tetanus, to
which she adds other painful consequences during menstruation, urination, sexual intercourse, and childbirth. Yet, the religious argument is even stronger—the
child becomes the kid or the lamb on the butcher’s block, ready to be sacrificed.
In Somali culture, listeners enjoy poetry, not only for the message but also for the
way it is encoded (Orwin, 2001; Jama, 1991), while poetic license provides the
socially marginal with a powerful tool to reclaim their honor and challenge the existing power structure. This is such a case, where the sacrificed animal and the child
are both associated and opposed symbolically. On the one hand, they are opposed
because the former has its throat slit open, the latter has her genitals slit to be closed,
as in the very gory, but detailed descriptions by de Villeneuve (1937) and Lantier
(1972). On the other hand, the girl also will be slit open: “Infibulation replaces the
vulva with an almost solid wall of flesh that joins the thighs from the pubis nearly to
the anus, with the exception of a small orifice at the inferior portion of the vulva. . .
No matter how virile the husband, consummation of the marriage is nearly impossible because of the surgically created barrier. Another pastoral people, those of the
classic Greek myths and tragedies did not miss the symbolic relationship between
female throat and genitals” (Loraux, 1985).
Slitting the throat of an animal in the prescribed way (udhya, Arabic) is correct
because it conforms to the religious texts, but female circumcision is not. “It’s a sin,”
umulissa immediately points out. “The child girl is like an animal to be butchered.
The sacred books don’t order it done, neither Christianity nor Islam.” Mothers, who
should conform to tradition, on the contrary, are those to blame. Mothers are guilty
of putting their girls’ lives at risk. Another layer of symbolic meaning also lies in the
relationship between girls and sacrificed animals. At the Festival of Sacrifice (Eid
al-Adha, Ciidwayneey in the Somali language), after God tested Ibrahim’s faith, an
animal, not a human being, has its throat slit. Hence, the sacrifice of the girls should
not occur, according to the sacred texts. This is the theological argument umulissa
supports, which puts modern interpretations of Islamic law against customary law
and claims the former to be superior. Actually, in Ayuub and other villages, women
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have experimented with the Gudnin Usub, the New Rite of substitution of infibulation with a symbolic feast. Umulissa stresses her words and song by means of
sweeping arm movements, which ideally connect the audience with the girl in the
poster, and by a hint of swaying dance steps.
In his discussion on the “language” of traditional authority, Maurice Bloch (1989,
pp 19–45) remarks that formal speech-making, intoning spells, and singing are
but different steps in the same process of transformation from secular discursive
language. The same linguistic modification occurs in religious as well as political oratory: “In a highly formalized or ritualized political situation, there seems no
way whereby authority can be challenged except by a total refusal [of all political
conventions]. . . The ceremonial trappings of a highly formalized situation seems to
catch the actors so that they are unable to resist the demands made on them” (Bloch,
1989, p 24, original italics). Formalized language, that is, the language of traditional
authority, is impoverished language, a kind of restricted code, according to Bloch
(1989, p 28), who also notes that, in formalized speech, the features of articulation
“have been rendered arthritic, and so the possible answers are dramatically reduced
perhaps to one.” The propositional meaning potential of language is lost by formalization, but speech acquires an illocutionary or performative force. Intoning a poem
is but a further move in the process of formalization of speech, which is very close to
a third linguistic manifestation at the end of a continuum, song. “Song is, therefore,
nothing but the end of the process of transformation from ordinary language which
began with formalization” (Bloch, 1989, p 35). Singing a song involves an almost
total lack of creativity (although it does not completely rule it out). Yet, the fact
remains that the propositional force of all songs is less than that of spoken words in
an ordinary context, especially when songs are sung by groups of people in unison,
which characterizes so much of ritual. In a song, however, the illocutionary or performative force is at its most, because, as Bloch (1989, p 37, original italics) puts it,
“You cannot argue with a song.” As with speech, the formalization of body movements implies ever-growing control of sequences of movement and, when this has
occurred completely, we have dance (Bloch, 1989, p 38).
As a matter of fact, umulissa’s performance created a ritualized, non-ordinary
space in the school tent by means of the progression of formalization of speech
through poetry and song, as well as a hint of dance. The formalization of language
creates a quasi-ritual space, where the propositional meaning of the speech is weak
and its performative force is strong. Umulissa actually does not put forward a line
of argument, but creates a quasi-ritual context, where the pre-text is represented
by the poster. She elicits a typical response from the female audience by means
of the progressive formalization of her speech and repetition. As Bloch (1989,
p 42) points out, units in ritual do not follow each other logically, but sequentially.
A frozen statement cannot be expanded, it can only be made again and again, and by
means of repetition, it becomes understandable. Moreover, formalization not only
removes what is being said from a particular time and a particular place, but it is
also removed from the actual speaker, and it becomes a source of traditional authority. The Turnerian breach at the beginning of the performance is highlighted by
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the crisis described in the first verses intoned by umulissa, a tradition that is contested and felt as harmful by more and more people. The creation of a ritualized
space through poetry and song defies arguments to the contrary. The audience is
challenged through well-known, traditional cultural forms. The formalized speech
leaves only a yes/no option, that is, either utter acceptance or rejection. The female
audience replies to the challenging refrain by repeating it and clapping their hands.
Each verse in the third part of the performance is sung by umulissa and welcomed
by the audience/chorus repeating the refrain because they cannot argue with a song.
They can only accept it or not. Hence, the redressive action phase starts going back
to the intonation of the poem, which reintegrates the participants into the community reassuring them that, if they refuse pharaonic circumcision, they conform to
both the sacred texts and science.
Conclusion
The experiments with the Sunna Gudnin Project, as well as later attempts to attenuate female circumcision, such as the Gudnin Usub (New Rite) promoted by Mana
Sultan Abdurahman and her collaborators, have been successful in Ayuub and other
villages in the area of Merka. The DVD shows that, in order to succeed in attenuating or even eradicating FGM, it is extremely important that the intervention be
performed according to the socio-cultural norms of the population involved. Poetry
remains the preferred medium for the communication of sensitive social messages
in Somalia, while poetic license allows people to address issues that may cause
embarrassment when discussed in ordinary conversation. Umulissa’s performance,
while constructed in the edited videotape, accords with Somali cultural norms. In
this context, however, the contribution of a number of reformist shaykhs cannot
be underestimated. The DVD, moreover, shows that Mana found valid collaborators and followers to continue her work and, in addition, went a step further with
Gudnin Usub, possibly following today’s trend, which has mostly abandoned any
ritual during the operation, where it existed all over the area practicing FGM (Moen,
2008). This step forward, beyond Gudnin Usub, is bolder and points to the prevention of FGM, with Friday Programs. The women in the audience seem to accept this
proposal. Whether they will be able to carry it out is yet to be seen.
In conclusion, we would like to emphasize the diverse strategies against cutting practices, elaborated and applied by Mana in Merka, compared to those seen
recently in Italy.
The means used to accomplish the suspension of pharaonic circumcision and its
eventual eradication, which we have seen in Merka, are not coercive, rather they
exclusively employ psycho-social means, including colloquial speech, persuasion,
references to charismatic religious figures and/or local specialists (the umulissa), the
presentation of traumatic cases caused by pharaonic circumcisions that happened
within the same community, and women with their genitals intact that recount their
success in their matrimonial lives and in their work. These experiences, proposed
to women who are potential mothers of “at risk” daughters, do not impose another
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option different from pharaonic circumcision. The same women, who were participants of the initiative, were persuaded to put into effect the overcoming of the
tradition but were not obligated to do it through coercion.
Taking into consideration such directives, in fact, structure the initiative of
prevention against the tradition delineated by Mana and presented in the video-clip.
The umulissa puts into practice a very effective persuasion on the women present, in
reference to the life styles, the culture, and the mentality of that context. The DVD
employs traditional recitation and song and depicts an audience wearing the same
clothing worn by the women present, inspiring a sense of belonging and a sharing
of the same values and culture; it reinforces the message with Western references,
already familiar even to rural women.
The women that we see in the DVD could one day be present in the Somali
diaspora living in Italy. If they had not been reached in Somalia by the preventative
actions of Mana, we ask ourselves, how can the Italian government persuade them
to abandon infibulations?
It specifically has to do with the “Consolo,” Law, n. 7, January 9, 2006, published in the Gazzetta Ufficiale, n. 14, of January 18, 2006, on the “Disposition
concerning the prevention and the prohibition of the practices of Female Genital
Mutilation” and of the corresponding Guide Lines, delineated for the social-sanitary
figures and other professionals that operate in contact with the migrant community,
and emanated in performance of Article 4 of the same law; published in Gazzetta
Ufficiale della Repubblica Italiana, of November 25, 2008 (with the decree of the
Ministers of Health). Note, that it does not grant the right of asylum for excised
woman. This is a serious gap.
Since the “Consolo” is a penal law, it is structured necessarily in Article 9, written
in coercive language (Appendix 1), for which it is evident how diverse the specific
instruments previewed in Italy. Nevertheless, some representatives of the women’s
groups were consulted for the law “in fieri” and have taken part in the ministerial
commissions that have formulated the same guidelines. In substance, it is characterized principally by a fundamental punitivity and coerciveness, inadequate to address
a subject that in Merka, Somalia, is dealt with successfully using diverse methodologies. The law presents some proposed aspects, open to dialogue; but, for example,
we find that Article 7 is formulated too generally because it does not explicitly say
that, in the plans of formation and information directed to discourage genital cutting,
the associations of the African women in diaspora must be privileged. We strongly
fear that such initiatives will be managed by the Italian facilities that also are represented by competent personnel and, without a doubt, will be less credible in their
message of dissuasion of the excision practices because they are strangers to the
cultures of the target populations.
It is true that the Somali women in diaspora, partially integrated into Italian society, who perhaps live in a big metropolis, the way that Rome or Milan can be, are
different than those of Merka (present in the DVD), but it is probable that their
cultural roots have not been completely forgotten.
One Somali mediator, responsible for an NGO of Somali women in Milan, after
having seen the DVD, noted that Mana uses strategies of the village that cannot be
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utilized effectively in a Western metropolis. But now, why does the Association of
Somali Women in Italy not invent and propose original strategies in a manner that
can be adapted to the women in diaspora in our country?
We would hope to be refuted but we have no knowledge of any project by
the Somali women in Italy (Rigotti, 2007–2008; Ronchi, 2007/2008) that are even
vaguely similar in engagement, determination, and consistency in time as the project
put into effect by Mana in Merka.
Appendix 1
Consolo Law: Disposition concerning the prevention and the prohibition of the practices of female genital mutilation (we have highlighted in bold all coercive terms of
same articles of the law).
Article 1 (aim): omissis “. . . the law dictates the measures necessary in order to
prevent, to contrast and to repress the practices of female genital mutilation. . .”
Article 2 (occupation of promotion and coordination): omissis “. . . the
Presidency of the council of the ministers Department for the pars opportunity
acquires data and information on the activities carried out for prevention and
repression and on the contrast strategies programmed or realized in other States. . .”
Article 6 (Practices of mutilation of female genital organs): omissis “. . . Anyone
lacking therapeutic requirements, causing a mutilation of the female genital organs
is punished with imprisonment from 4 to 12 years. . . Whoever provokes injuries,
with the intention of disabling the sexual functions, to the genital female organs
different from those indicated to the illness in the body or the mind, is punished
with the imprisonment from 3 to 7 years. The punishment is increased by a third
when the practices are committed to damage a minor, that is if the act is committed
for means of profit. . .”
Article 8: omissis “. . . apply themselves to the entity, in whose structure the crime
is committed, the financial sanction from quotas of 300 to700 E and the punitive
sanctions expected in Article 9, subsection 2. . .”
Appendix 2
Translations from Somalian to English in the DVD.
First, her feet are tied, then they start cutting. . .. She’ll vomit and suffer pain
and have trouble to urinate. . ..When menstruating she’ll suffer. . .. After 7 days she
recovers. Then, other troubles occur. . .. Beware of damaging the girls. . .. They cut
the syphilis (clitoris) with the razor blade. . .. God, why did you make me?. . . When
she marries, her husband can’t open her. They use the knife. . .. Mom, don’t do the
pharaonic cutting to me!. . . The girl gets pregnant. She may get tetanus. . .. It’s a
sin. Mothers are to blame for it. The child girl is like an animal to be butchered. . ..
The sacred books don’t order to do it. . .. Neither Christianity nor Islam. . .. Men,
134
instead, do it not to get germs. . .. For those women already operated, God forgive
us! Don’t do it anymore!. . . Mothers are to blame for it. . .. The girl, she’s stitched
with thorns; mothers are guilty for it. . .. We have refused it. . .. We don’t want the
pharaonic one. . .. Parents who still do it, they are to blame. . .. The child/girl is
shaking (with fear). . .. Which law allows that?! Take a razor blade and sharpen it. . ..
Tie it on a piece of cloth. . .. Tetanus and other consequences, mothers are to blame
for it. . .. Answer me! Where is it written? In no book. . .. What did you reckon
of this picture?. . . Speak, I can see no one replying. . .. Think that this child girl
is on the butcher’s block. . .. Four are the injuries. . ..The woman feels no pleasure
in intercourse. . .. When she overcomes the pain, her menses arrives. . .. This razor
blade cuts everything from A to Z. . .. Where did we get this practice from?. . . When
the girl begins to grow, we say, “Let’s make her a Muslim.”. . ..Even Christians say
that circumcision is good for health, but they don’t become Muslim as a result!. . .
If you find someone doing it, advise her not to do it.
References
Abdurahman M, Grassivaro Gallo P. (1996/2005) Dieci anni del rito alternativo di Merka
(Somalia): da sunna gudnin a gudnin usub (il rito nuovo). Scienza Online no. 17, anno 2, 17
giugno 2005. http://scienzaonline.org/sessuologia/rito-alternativo-merka.html
Andrzejewski BV, Lewis IM. (1974) Somali Poetry: An Introduction. Oxford: Clarendon Press.
Bavelaar R. (2006) Somali Oral Verse in Exile. June 26, 2006, Wardheernews.com
http://wardheernews.com/Articles_06/june_06/27_Poetics_Rahma.html
Bloch M. (1989) Ritual, History and Power. London: Berg Publishers.
Cerulli E. (1964) Somalia: Scritti vari editi ed inediti, Vol. 3. La poesia dei Somali. La tribu dei
Somali. Lingua Somala in caretteri arabi ed altri saggi. Ministero Affari Esteri. Roma: Instituto
Poligrafica di Stato.
“Consolo” Law n. 7, January 9, 2007, http://gazzette.comune.jesi.an.it/2006/14/1.htm
de Villeneuve A. (1937) Etude sur une Coutume Somalie: les Femmes Cousues. J de la Société des
Africanistes. 7:15–32.
Finnegan R. (1992) Oral Traditions and Verbal Arts. A Guide to Research Practices. London:
Routledge.
Girard R. (1972) La Violence et le Sacre. Paris: Grasset (Eng. transl. London 1977).
Grassivaro Gallo P, Rabuffetti L, Sunna Gudnin VF. (2001) An alternative ritual to infibulation in merka, Somalia. In Denniston GC, Hodges FM, Milos MF. (eds.) Understanding
Circumcision: A Multidisciplinary Approach to a Multi-Dimensional Problem. New York, NY:
Kluwer Academic/Plenum Publishers.
Grassivaro Gallo P, Livio M, Viviani F. (2004) Changes in infibulation practices in East Africa:
Comments on a ritual alternative to infibulation in merka, Somalia. In: Denniston GC,
Hodges FM, Milos MF. (eds.) Flesh and Blood: Perspectives on the Problem of Circumcision
in Contemporary Society. New York, NY: Kluwer Academic/Plenum Publishers.
Guide Lines, March 25, 2008. http://ministerosalute.it/saluteDonna/paginaInternaMenuSalute
Donna
Hultman T. (1993) A Nation of Poets. ANALYSIS 3 Africa News Service (Durham), January 1993.
http://allafrica.com/stories/200101080500.html
Jama ZM. (1991) Fighting to be Heard: Somali Women’s Poetry. Afr Lang Cult. 4(1):43–53.
Lantier J. (1972) La Cité Magique. Paris: Fayard.
Lark EG. (November/December 1988) A Nation of Bards. Houston, TX: printed in Saudi Aremco
World, pp 32–36.
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Legge n. 7, January 9, 2006, “Disposizioni concernenti la prevenzione e il divieto delle
pratiche di mutilazione genitale femminile,” January 18, 2006, Gazzetta Ufficiale della
Repubblica Italiana, n. 14 http://gazzette.comune.jesi.an.it/2006/14/1.htm. cited in: Linee
Guida destinate alle figure sanitarie etc. (art. 4-Legge n. 7, 2006), March 25, 2008.
Gazzetta Ufficiale della Repubblica Italiana, n. 14, November 2008. http://ministerosalute.it/
saluteDonna/paginaInternaMenuSaluteDonna
Loraux N. (1985) Façon tragique de tuer une femme. Paris: Hachette.
Moen EW (2008). The Sexual Politics of Female Circumcision. Boulder, CO. Department of
Sociology http://www.etext.org/Politics/Progressive.Sociologists/authors/Moen.Elizabeth/Thesexual-politics-of-female-circumcision.EMoen
Orvin M. (2001) Islamic Religious Poetry in Africa. J Afr Cult Stud. 14:5–6.
Rigotti M. (Academic Year 2007/2008) La legislazione Italiana sulle MGF: osservazioni e commenti ricavati da alcune esperienze personali. Tesi di Laurea in Lettere e Filosofia, Corso di
laurea in Storia, Università di Padova.
Ronchi E. (Academic Year 2007/2008) Iniziative di prevenzione/eradicazione alle Mutilazioni
Genitali Femminili attuate da alcune associazioni di donne africane (in Africa e in Italia). Tesi
di Laurea in Psicologia, Università di Padova.
Samantar SS. (1982) Oral Poetry and Somali Nationalism: The Case of Sayyd Mohammad Abdille
Hassan. Cambridge: Cambridge University Press.
Turner VW. (1967) The Forest of Symbols: Aspects of Ndembu Ritual. Ithaca, NY: Cornell
University Press.
Turner VW. (1974) Dramas, Fields and Metaphors: Symbolic Action in Human Society. Ithaca,
NY: Cornell University Press.
Turner VW. (1982) From Ritual to Theater: Human Seriousness Play. New York, NY: Performing
Arts Journal Publications.
Turner VW. (1985) Liminality Kabbalah and the Media. New York, NY: Academic Press.
Turner VW. (1986) The Anthropology of Performance. New York, NY: PAJ Publications.
Chapter 15
Writing Rites Gone Wrong: Autobiography,
Testimonials, and Their Relevance to the Debate
Around Genital Alterations
Chantal Zabus
Abstract After briefly examining the discursive asymmetry in writings about excision (as I call it in my book Between Rites and Rights [Stanford UP, 2007]) and
circumcision, I discuss four moments in the literary history of autobiographies
around male circumcision—the seventeenth-century “confessions” from Conversos
in Spain and Portugal; two Kenyan ethnoautobiographies from the 1960s, Mugo
Gatheru’s Child of Two Worlds and Karari Najama’s Mau Mau From Within; Jacques
Derrida’s Circumfession introduce a necessary subjectivity and redress the wrongs
in what was originally a rite.
Keywords Male circumcision · Female genital mutilation · Ritual circumcision ·
Gender · Cognitive dissonance · Excision
Why such a big issue over a little bit of tissue? That tissue, whether of the foreskin or the clitoris, has a long history of being just that—long. Indeed, aside from
the idea of degree, which makes circumcision and excision shuttle between benign
and very severe, the foreskin and the clitoris happen to have similar reputations
as being disproportionately long. Across the Sudanic “excision belt,” spanning an
east–west axis from Yemen to Senegal, it is common to come across tales of the
clitoris being too long, in need of cutting, or endowed with the capacity to grow if
not excised or to grow back, if not excised properly. Likewise, the foreskin has been
thought to be too long and physicians often diagnose phimosis or foreskin constriction as a medical measure. The nineteenth-century medical label “phimosis” indeed
became attached to “any foreskin that appeared too long.” J. Cooper Forster, 1855
deemed it “a pathological condition arising from ‘nature having been too prolific
in the supply of skin at the extremity of the penis’” (pp 491–492; quoted in Glick,
p 153).
C. Zabus (B)
Universities of Paris XIII & III-Sorbonne Nouvelle, Paris, France; Institut Universitaire
de France, Paris, France
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C. Zabus
P. C. Remondino, in 1891, had vilified the foreskin, at tedious length, as a
maligned influence and moral “outlaw” (quoted in Comfort, 1967, pp 106–107). The
subsequent rise of circumcision as a preventive, and then routine, procedure, therefore, may be linked with the taboo around masturbation or “self-abuse,” to which
such a generous “supply of skin” would inexorably lead. Likewise, the clitoris has
been considered a long, tribadic appendage rivaling a man’s penis and threatening to
usurp its role as penetrator of females (Zabus, 2007, pp 19–35). In addition to masturbation, female same-sex desire is the threat looming behind the clitoral outlaw
appendage.
This history of both tissues is indeed long but I would like to address a much
shorter history, which is that of autobiography in relation to how these two bits of
tissue, when severed, seem to reveal different issues.
Discursive Asymmetry
In using “circumcision” and “excision,”1 I bear in mind their Latin etymology, circumcidere (“cut around,” “cut about”) and excidere (“cut out,” “hollow out”) to
refer to the procedures involved. The issue of excision, a.k.a., “female circumcision,” female genital mutilation (FGM), or female genital cutting (FGC), has
drummed up more attention in all fields—cultural and medical anthropology, human
rights, law, media, literature, and the arts—than male circumcision, if only for the
1975–1985 United Nations decade for women, which transformed the ancestral rite
into a human rights violation.
The implicit flaunting of African women’s excised or sutured bodies may explain
the success of the 2007 Engel film, A Walk to Beautiful, about five Ethiopian women
seeking treatment in Addis Ababa for obstetric fistulas as a result of infibulation,2
although the link between the ailment and infibulation is not clearly established. It
was awarded the Best Feature Documentary of 2007, besting studio-financed productions, like Sicko, Taxi to the Dark Side, Operation Homecoming, and Crazy
Love. One can hardly expect a film documentary about male circumcision to run
in New York and draw crowds with the same enthusiasm. Nor could one expect a
text to refer to the World of Foreskinlessness, the way Moses Isegawa’s Abyssinian
Chronicles (2000) mentions the Ogaden war raging in “the Horn of clitoris- and labialessness” (p 286). Indeed, the male circumcision issue is still shrouded in banality,
cloaked in obsolete justifications, despite notable efforts from numerous individuals
and associations.
Apart from the ongoing controversy in the United States around routine neonatal
circumcision, practiced currently on large segments of the American male population, there has not been a similar humanitarian impetus nor the same discursive
amplification around male circumcision as there has been around excision, despite
the work of, for instance, Sami Aldeeb Abu-Sahlieh (1999, 2001). On the one
hand, scholars and activists alike have been diffident about making a case for
symmetry between excision and circumcision, some of them presumably for fear
of being accused of anti-Semitism or for fear that excessive attention to male
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139
circumcision may distract from female genital alteration in Africa and elsewhere
(Glick, p 213). On the other hand, male writers who have denounced excision
or participated in its eradication, from Somali Nuruddin Farah’s From a Crooked
Rib (1970) to American, then Lagos-based Chuck Mike’s Ikikpo: A Sense of
Belonging (2000), have refrained from tackling the issue of male circumcision. The
same applies to the (male) movie industry, from Malian Oumar Sissoko’s Finzan
(1990) to the late Senegalese Sembène Ousmane’s Molaadé (2004). Ivorian-born,
Paris-based playwright and novelist, Koffi Kwahulé, has shown a lot of empathy
with the predicament of excised women in his play Bintou (1998). Yet, when he
told me in an interview I carried out with him in Paris in 2005, of the circumcision
he had elected to undergo when 13 years of age, he denied any symmetry (Zabus,
2005).
Conversely, besides Billy Ray Boyd’s TVS or “The Victims Speak” website and
others, which contain many harrowing testimonials, a website like Blouch, which
records stories from individuals having experienced forcible genital cutting, lists 49
MGC (male genital cutting) stories, mostly emanating from “Caucasian-European”
Americans with a Jewish background, but only two FGC stories from white NorthAmerican women, who were subjected to labiadectomy and/or clitoridectomy in
the 1950s, to remedy masturbation. None of these stories are from individuals
outside of Canada and the United States but they alert us to genital operations
similar to those practiced in non-Western countries but for apparently dissimilar
motives.
Tellingly, the general public is nowadays less familiar with these Euro-American
genital procedures than with excision in Africa and elsewhere. This may be due to
the fact that, in addition to media coverage, African women autobiographers, who
have experienced excision or infibulation in the flesh, have contributed to exposing
the physical and psychic damages of such operations to a worldwide readership.
Autobiography, that is, writing from the realm of the “myself,” thus introduces a
necessary subjectivity. An increasing number of scholars dealing with circumcision
have themselves been involved somewhat autobiographically in their own circumcision or that of their sons and relatives. In an interview I carried out with Sami
Aldeeb Abu-Sahlieh in Lausanne in 2002, he, as a Christian Palestinian, told me
that he had heard the shrill screaming of an infant in the process of being circumcised at a neighbor’s house in the Palestine of his childhood and this prompted him
to inquire about the raison d’être of circumcision, which he has probed in many
of his works, most notably in his seminal Male and Female Circumcision: Among
Jews, Christians and Muslims: Religious, Medical, Social and Legal Debate (2001).
Leonard Glick also speaks from memory in his Preface to Marked in Your Flesh
(2005) as a cultural anthropologist and a college professor with a medical degree
but also as the father of circumcised sons. He concludes: “[my] sons are now mature
men. Had I known at their births what I know now, they would never have been
circumcised” (p viii).
I would like to provide four moments in the history of discursive asymmetry around excision and circumcision, which help shed light on the way
we perceive both genital alterations at the turn of the present millennium: the
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C. Zabus
seventeenth-century “confessions” from Conversos in Spain and Portugal; Kenyan
Mugo Gatheru’s Child of Two Worlds (1964); the late French philosopher Jacques
Derrida’s Circumfession (1991); and French, Syrian-born Riad Sattouf’s comic
strip, My Circumcision (2004). Last but not least, I provide a coda with Somali
top-model-cum-UN ambassador Waris Dirie’s Desert Dawn (2002).
The Conversos: The Early “Confessions” of Cristobal Mendez
and Estevan de Ares de Fonseca
In the context of the thirteenth-century Christian “reconquest” of Spain, Jews were
forcibly converted to Catholicism during the Spanish Inquisition of 1478, instituted
by the monarchs Ferdinand and Isabella. For these male converts or Conversos
who emigrated outside of Spain, the first requirement for re-admission into the
Jewish community was circumcision. In the seventeenth-century, one such Spanish
Converso, Cristóbal Méndez, whose story Leonard Glick covers in his book, immigrated to Venice and accepted Judaism. He then returned to Spain to save relatives
and upon his return, he was apprehended and tried by the Inquisition, to whom he
“confessed” that, when pressed by a rabbi and an uncle, he underwent the operation. Mèndez recalled that the pain was “so great. . . that [he] was barely aware of
the benedictions. . .. After a recovery period, [he] was called up to the open ark to
recite the traditional blessing for deliverance from peril. [He] had become a Jew”
(quoted in Glick, p 79).
The second instance of autobiographical voicing of the experience of circumcision concerns a Portuguese Converso, Estevan de Ares de Fonseca, who was arrested
by the Spanish Inquisition for “Judaizing” and, in his 1635 trial, described his experience as a newcomer to Amsterdam and how the Jews of the Dutch city, upon his
refusal to circumcise, “excommunicated [him] in the synagogues, so that no Jew
would speak to or with [him].” After several days of ostracism, de Fonseca “finally
consented to be circumcised. And they circumcised [him] and gave [him] the name
of David” (Gilitz, 1996, p 235; Bodian, 1997).
Were these Conversos or Crypto-Jews rewarded in exchange for their confession? And were such rewards deemed worth (admittedly less than) “a pound of
flesh,” after the disturbing line from The Merchant of Venice? One notes that for
both Conversos, pressure, either from a relative or a religious authority, elicits a
confession, which gives a particular coercive dimension to autobiography or what
is, at any rate, a testimony.
The link between these Conversos and the African testimonials I here provide
may look rather tenuous at first but another edict by the King of Portugal in 1486
ordered the deportation of all the Jews who refused to convert to Christianity on
the coast of Guinea, West Africa. The Hebrew influence spread in North Africa and
then as far as Sudan and Ethiopia. This does not mean, however, that the origin
of all African circumcisions is Hebraic since circumcision on the African continent is also thought to date back to Pharaonic Egypt and the early cults of the
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phallus, themselves part of cosmogonic myths around the creation of the universe
(de Rachewiltz, 1993, p 169). As a case in point, Ra was thought to have engendered
himself through masturbation or even mutilating his own sexual organs. Indeed,
masturbation, thought to be infantile, often precedes circumcision in some African
societies (Zabus, 2009).
Kikuyu Irua
The phrase “female circumcision” makes most (cultural) sense in societies, such as
the Kikuyu one in Kenya, East Africa, where the term irua designates both circumcision and excision. As a purification rite, irua posits an original hermaphroditism
in the child in that excision aims at removing the allegedly vestigial masculinity
of the clitoris, the way in which circumcision removes the vestigial femininity of
the foreskin. Although the Jewish rite is always neonatal as opposed to the African
rite, both rites rejoin in their premise of the alleged androgyny of the child, who is
male-in-appearance until it is circumcised. Indeed, the Hebrew Yesod to refer to a
circumcised phallus, with its exposed corona or “crown,” reveals shekhinah or the
feminine emanation of Divine Being.
Despite its presupposed equivalency, however, the treatment irua has received
from Kenyan writers has been asymmetrical, as in Jomo Kenyatta’s famous treatise, Facing Mount Kenya (1938). This asymmetry between male and female irua
is also verifiable in the sanctioning of male circumcision in Protestant belief in the
1930s. Indeed, whereas young Kenyan male converts were encouraged to undergo
circumcision in Mission dispensaries, irua for girls was considered a brutal bodily mutilation. What is more, whereas in one Church Missionary Society station
(Kigari in Embu District), there was an attempt to introduce a Christian circumcision ceremony, at the other (Kabore in the Kikuyu section), not far off and at the
same time, Christians were asked to openly disavow female excision “on pain of
excommunication” (Murray, 1976, p 93). Excision, not circumcision, thus became
a mobilizing force during the anti-colonial or Mau-Mau insurgency in 1952–1956,
when Kenyan women had to choose between Christianity and Kikuyu identity. One
woman recounts: “If you were not circumcised [excised], they [the Mau Mau fighters] came for you at night, you [we]re taken to the forest [and] circumcised [read:
excised], and you [we]re roasted for what you have circumcised [the clitoris] and
you are told to eat it” (quoted in Thomas, 2000, p 141). By accepting the male rite
but not its female counterpart, the missionaries drove a symbolic rift between the
two practices, which Kenyan novelist Ngugi wa Thiong’o famously explores in The
River Between (1965), a novel which, incidentally, provides African American novelist Alice Walker with some plot elements for her novel, Possessing the Secret of
Joy (1992).
In his autobiography, Child of Two Worlds (1964), Kenyan Mugo Gatheru, who
augurs Karari Njama’s in Mau Mau from Within (1966), is eager to locate the irua
ceremony in the larger context of ancestral rites: “The Kikuyu do not circumcise at
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birth as do the Jews. They do it at puberty as do many other tribal peoples throughout
the world.” (p 56) Indeed, as already argued, circumcision as a puberty rite seems
to be quintessentially “African,” very much unlike Muslim circumcision or any religiously sanctioned practice, whereby a people seals a covenant with its god, as in
the Jewish rite (Hoffman, 1996).
Gatheru recounts his circumcision in 1940, which signals his belonging to the
riika ria forty or the “age-grade of 1940,” the age-grade and the circumcision date
being so important that they feature in Kenyan men’s e-mail addresses. His circumcision allowed him to participate in exclusive meetings, for which younger
men had to pay certain dues. In Kikuyu society at the time, boys undergo the
ceremony “between 15 and 19 years of age,” whereas girls are excised earlier
“so that they do not menstruate before the circumcision [excision]” (p 57) and,
therefore, avert thahu, that is, a type of ceremonial uncleanliness that demands
purification.
In the chapter, “Becoming a Kikuyu,” Mugo Gatheru describes how, at age
sixteen, he decided to undergo the ceremony. Yet, as is often the case, a young
man’s decision to get circumcised is predicated on the “harassment”—a word he
uses (p 57)—to which his peers subjected him. At the time of the actual ceremony, both girls and boys benefit from “helpers” but the boys are expected to
put up a show of bravura whereas the “girls must be supported by two aides
since they are considered delicate and may perhaps collapse if they are left alone
like boys” (p 57). This autobiographical narrative is very insistent on the “feeling
of fear” (repeated several times), which Mugo has to shed, along with behavior coded infantile or feminine, such as crying, before accessing full-fledged
manhood.
The Kikuyu, Embu, and Meru people of central Kenya prefer to leave “the ‘small
skin’ or ngwati hanging under [the] penis” after circumcision. But upon his uncle’s
insistence, Mugo is cut a second time, for were it not for that “second cut,” he would
have been identified as “a ‘primitive’ Kikuyu boy.” This recircumcision establishes
that he is “a grown-up Christian Kikuyu,” circumcised but without ngwati: “I was
a man. . .. I was now allowed to look down at the handiwork of the circumciser and
see what had been done to me. Blood was streaming” (pp 57–58). “Looking down”
signals the inexorable badge of passage. Likewise, among the Teda, the circumciser
tells the initiate: “Boy, look up,” and, after cutting the prepuce, “Man, look down”
(quoted in de Rachewiltz, p 181).
Kenya may look like a far-away place, only tenuously connected to the West,
but some of its genital practices, such as, among the semi-hamitic Nandi, the erotogenic transfer from the infantile clitoris to the mature vagina, were to inspire
Marie Bonaparte and Sigmund Freud’s theories of female sexuality, which still influence Westerners today (Zabus, 2007, pp 19–35). More to our purpose, the body,
which, in the Kenyan anthropological context of the 1940s, was neither object nor
subject and open to cultural inscription, is now inscribed in pain and in trauma.
Like later writings by women around their excision or infibulation, early accounts,
such as Gatheru’s, introduced an unprecedented emotionality and a necessary
subjectivity.
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Jacques Derrida’s Circumfession
As his book title indicates, Jacques Derrida, the French philosopher and father of the
“deconstruction” movement, was speaking around his circumcision, circumventing
the issue and, in the process, committing quite a few circumlocutionary acts, yet
speaking in the first person about the procedure that he underwent when he was an
8-day-old Jewish infant. In El Biar, Algeria, where Derrida was born in 1930, he
reports that one did not use the Hebrew word milah from berit milah (the alliance
through cutting or Covenant of the Cut [in Genesis 17:1–14 and Leviticus 12:1–5])
to refer to circumcision but rather “baptism,” a Pauline yet euphemistic word used
out of fear, but at the same time, a translation of sorts since Christian baptism was
an “alternative rite” to replace circumcision.3
Derrida’s philosophical corpus is so traversed by his own circumcision that he
goes as far as stating that desire for literature stems from circumcision, for it links
ink and blood: “I write with a sharpened blade, if it doesn’t bleed the book will
be a failure” (Derrida, 1993, p 130), thereby setting for himself “the impossible
task of writing by excision” (Siegumfeldt, 2005, p 32, my italics). Interestingly, the
Egyptian doctor, activist, and novelist Nawal El Saadawi also links excision with
the incisive act of writing-as-dissection (quoted in Bdran and Cooke, 1999, p 397).
Both El Saadawi and Derrida—Mashreq and Maghreb—have bound their words to
their wounds.
For Derrida, the circumcision ceremony is linked with the mother figure and,
more largely, the feminine, more so than with the mohel. Derrida returns to Moses’s
wife, Zipporah, the alleged first circumciser. Deemed one of the most obscure and
disquieting in the Torah, Zipporah’s gesture of circumcising her own son when
on her way to Egypt with Moses has been variously construed (Levenson, 1993,
p 50). Zipporah allegedly touched Moses’s feet (the Biblical euphemism for genitals, raglayim) with their son’s bloody foreskin to avert Yaweh’s anger at her
husband’s reluctance to confront Pharaoh (Robinson, 1986, pp 447–461). Because
Zipporah circumcised one of her sons in a redemptive but unexplained sacrifice,
Derrida assimilates Zipporah to his own mother, whom he implicitly accuses of
silent complicity with the mohel’s deed.
He claims to remember his circumcision, the “open wound” that he has been
flaunting like a badge since “the mohel’s succion” when he was 8 days old: “circumcision, cutting of the circumference; meziza, ‘suction of the blood,’ a practice
that was abolished in Paris in 1843” (p 115).4 If Derrida mentions mezizah with
so much harrowing trepidation, it is not so much because of the “mohel’s succion” but because of “the possibility that the mother sucked off the blood on the
child’s little penis” (Spivak, 1998, p 13). This feminine version of mezizah binds
Derrida, Zipporah, and his mother, Esther, in a perverse religio, adding incest to
injury. Likewise, many African women autobiographers writing about their excision have often accused the mother of being an “anti-mom,” the very opposite of
the caring, nurturing mother (Zabus, 2007, pp 163–202).
Derrida’s erasure of his father is significant insofar as circumcision is a “symbol of patrilinearity” and a “guarantee of abundantly fertile male lineages.”
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(Eilberg-Shwartz, quoted in Glick, 1992, p 245). The purpose of circumcision being
to symbolically release the male child from his mother’s impure blood or, in Saint
Augustine’s words in Marriage and Concupiscence II, “to erase the stain of the
original sin” (quoted in Steinberg, 1983, p 50), Derrida practices a reverse circumcision and rehabilitates his mother’s contaminating blood-milk-ink, the source of
his writing.
Riad Sattouf’s Anti-circumcision Strip
Discursive asymmetry between excision and circumcision can also be observed in
the realm of humor. Whereas there is even a genre that could be called “circumcision
humor,” there is no such humor around the female excision issue. Indeed, one could
not imagine a joke around the severed clitoris or the exciser, the way jokes circulate
around the rabbi or mohel. For instance, “why does the rabbi have such a good
income? Because he gets all the tips” (quoted in Glick, p 271). Along these lines,
the cover of Riad Sattouf’s comic strip book for children exhibits three boys peeing
side by side, with their backs turned to the reader, holding sticks that are supposed to
be symbolic extensions of their penises. While signaling the book’s glib but caustic
humor, it does not stifle the serious anti-circumcision message that the Paris-based
cartoonist of Syrian origin, Sattouf, wants to convey to the French and francophone
youth.
Born in a small village in Syria, the young Riad plays Conan the Barbarian
with his cousins and they swear by Crom, the God of the Cimmerians, Conan’s
tribe. While peeing side by side one day, one cousin remarks that, unlike them,
Riad has not turned the big wheel like Conan the Barbarian, which is a euphemistic
way of saying that he has not undergone the circumcision ritual. Accused of being
an enemy, that is, an Israeli, Riad is excluded from this group of self-appointed
“Cimmerians” and Conan-worshippers. You will remember that, once he is set free,
Conan, in the 1982 Milius film (played by Arnold Schwartzenegger), learns that the
warlord Thulsa Doom, who initially aimed to solve the riddle of steel, becomes the
head of a mysterious snake cult because, in Doom’s own words, “flesh is more
precious than steel.” The apt juxtaposition of steel and flesh provides Sattouf’s
youths with a powerful reasoning kit to comprehend circumcision while “turning
the big wheel” is presented as an inexorable rite of passage, necessary to achieve
manhood.
One day, Riad’s father tells him of his decision to have him circumcised and to
schedule the operation in three months’ time. After many fearful deliberations, the
boy agrees if his father offers him a plastic giant puppet, which looks like his idol,
Conan the Barbarian. As the day of circumcision approaches, Riad is haunted by
the pending loss of his prepuce. Two hours before the ceremony, men fill the living
room (women are excluded). He is then grabbed by four men who immobilize his
arms and legs. With a razor, the circumciser, who suddenly looks like Conan the
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Barbarian, cuts the prepuce. A spectacular squirt of blood spurts and spatters the
white handkerchief. Riad then stays in bed for several days with a bandaged penis.
Urinating is excruciatingly painful. As the wound is still bleeding after a month,
he goes to the village doctor who decrees that it has not been properly done. Riad
becomes introverted and regresses, playing with toys for smaller children. When
he brings up in an arduous conversation with his father the long-awaited gift of the
plastic action doll in exchange for his circumcision, his father dismisses him with
an insult.
After 2 months, the bandage is removed by the village doctor who jokingly
mimics cutting his penis with a pair of scissors. Riad can now pee but in three
streams, which gives an ironic twist to the book cover—the three boys peeing in
one stream. He, who was convinced that the Israeli were not circumcised, learns
that they are. More significantly, he learns that, without consciously articulating it,
these two monotheistic, Abrahamic belief-systems—Judaism and Islam—practice
male circumcision.
Syria, with its complex history—a centre of Islamic civilization from the seventh
century onward, a province of the Ottoman empire in 1516, a country mandated to
France in the First World War, then united with Egypt as the United Arab Republic
until 1961—practices Muslim (sunnite) circumcision. Sunnah is the Arabic term for
“tradition” or the “duty” of Muhammad the Prophet, based on the Qur’an and the
Ahadith, that is, the religious obligations or recommended practices emanating from
Muhammad’s teachings and deeds; sunnah is recommended (mustahhab) but not
obligatory (wajib). In the context of Riad Sattouf’s Syrian childhood, it has become
de-ritualized. There is no ceremony, religious or otherwise, Islam is not evoked
(at least not in the child’s recollection of the event), and there is no celebration
afterwards.
Riad Sattouf speaks from memory about an experience, which is traumatic enough to warrant an autobiographical narrative, as in Jacques Derrida’s
Circumfession. While emanating from two writers with, respectively, a Jewish and a
Muslim background, both circumfictions are imbued with a barely quenched anger
against the practice itself and the person who authorized the operation—the father
in Sattouf’s account, the mother in Derrida’s “confession”.
These autobiographies still constitute a tiny literary corpus, compared to the
growing body of autobiographies around excision. As of the late 1980s, these selfwritings, which built on earlier testimonies, such as Nawal El Saadawi’s in The
Hidden Face of Eve (1980), added nuance to the excision debate: Guinean Kesso
Barry in Kesso, princesse peuhle (1987); Somali Aman in Aman (1998); Waris
Dirie in her three autobiographies, Desert Flower (1998), Desert Dawn (2002), and
Desert Children (2005); Senegalese, Paris-based Khady (Koïta) in Mutilée (2005);
Somali, German-based Nura Abdi in Desert Tears (2005) and Fadumo Korn in Born
in the Big Rains (2006). In addition to these, Do They Hear You When You Cry?
(1998) by Togolese asylum seeker in the US, Fauziya Kassindja, helped propel the
issue of genital excision into the literature of exile and in the US media (Zabus,
2007, pp 221–233).
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Waris Dirie and Circumcision
As a Coda of sorts, I would now like to turn briefly to the Somali camel girl-turnedtop model and UN ambassador against “FGM” Waris Dirie’s Desert Flower (1998),
where Waris recalls her infibulation. From behind her mother’s legs, straddling her
body, Waris peers at the exciser, who spits on the blood that has dried on the jagged
edge of the broken razor blade. Then her mother blindfolds her, leaving her other
senses to record what she calls the “torture”: “The next thing I felt was my flesh,
my genitals, being cut away. I heard the sound of the dull blade sawing back and
forth through my skin. . .. I just sat there as if I were made of stone, telling myself
the more I moved around, the longer the torture would take. Unfortunately, my
legs began to quiver of their own accord, and shake uncontrollably, and I prayed,
Please, God, let it be over quickly. Soon it was, because I passed out” (Dirie, 1999,
pp 45–46).
One would expect Dirie’s recollections of the unspeakable to have deepened her
understanding of genital alterations. Yet, in her second autobiography, Desert Dawn
(2002), while relaying her experience of infibulation for the second time, Waris
Dirie recounts that she had her son circumcised as a 1-day-old infant in a US hospital, claiming that circumcision is very different from excision: “Despite my strong
feelings about FGM, I knew it was the right thing to do. My son has a beautiful
penis. It looks so good and so clean. The other day he told me he had to go to the
bathroom. I said, ‘You can do that alone, you are a big boy now,’ but he wanted
me to come and see him. His little penis was sticking up straight and clean. It was
lovely to look at!” (p 52). Notwithstanding a mother’s pride in her son’s genitals and
her marveling at the first throbbing of sexuality, we cannot help notice that Dirie is
juxtaposing Muslim notions of tahara (purity) with US medical justifications for
routine male circumcision.
Waris Dirie’s vignette about her son’s proud display of his erection also deserves
comment. Alphonso Lingis (1984) has somewhat eccentrically reformulated the
Freudian penisneid, or “penis-envy”: “[the child] perceives his mother desiring
him as a mutilated body craves the part detached, castrated, from it” (p 125).
Lingis’s reformulation becomes pregnant with new meaning, however, when the
mother as a metaphorically “mutilated body,” that is, a body devoid of the phallus, becomes a body that has been “mutilated” in the flesh through infibulation.
A new questioning therefore arises around Dirie’s pride in her son’s “beautiful,” “good” penis and her visual delight at seeing it “sticking up straight and
clean,” like a termite hill, which, in Somali lore, is a metaphor for the aroused
clitoris. Dirie may be unconsciously expressing nostalgia regarding the castration
of her talismanic clitoris and the impossibility of any clitoral erection. Behind this
vignette of phallic pride lingers, in filigree, the declitorization of the Somali girl
child.
Compared to the panoply of experiential writings around excision, there is a
tiny corpus about circumcision in the making but it is arguably disproportionate,
if we reckon that excision concerns some one hundred and fifty million women
whereas circumcision is practiced on five continents by about a billion Muslims,
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three hundred million Christians, sixteen million Jews, and an indeterminate number of “animists” and atheists. A discursive type of asymmetry has set in, not only in
first-person accounts but also in cultural anthropology, medicine, and law. It should
indeed be acknowledged that both circumcision and excision are irreversible genital alterations and that the issues over that little piece of tissue are basically the
same. Literature, more particularly, autobiography, is currently telling the wrongs in
the rite.
Notes
1.
2.
3.
4.
Zabus (2009).
Engel (2007).
Derrida (1993).
Derrida (1993, p. 115).
References
Aldeeb Abu-Sahleih S. (1999) Muslims’ genitalia in the hands of the clergy: Religious arguments
about male and female circumcision. In: Denniston GC, Hodges FM, Milos MF. (eds.) Male
and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice.
New York, NY: Kluwer Academic/Plenum Publishers, pp 131–171.
Aldeeb Abu-Sahleih S. (2001) Circoncision masculine, circoncision féminine: Débat religieux,
médical, social et juridique, Preface by Linda Weil-Curiel. Paris: L’Harmattan, Male and
Female Circumcision: Among Jews, Christians and Muslims: Religious, Medical, Social and
Legal Debate, Foreword by Marilyn Fayre Milos (Warren Center, PA: Shrangi-La Publications,
2001).
Bdran M Cooke M (eds.). (1999) Opening the Gates. A Century of Arab Feminist Writing. London:
Virago Press.
Bodian M. (1997) Hebrews of the Portuguese Nation: Conversos and Community in Early Modern
Amsterdam. Bloomington: Indiana UP.
Comfort A. (1967) The Anxiety Makers: Some Curious Preoccupations of the Medical Profession.
London: Nelson.
Cooper JF. (1855) A few remarks on the surgical diseases of children. Part I: congenital phimosis.
Med Times Gazette. November 17:491–492.
De Rachewiltz B. (1993) Eros noi. Mœurs sexuelles de l’Afrique noire de la préhistoire à nos jours.
Paris: Jean-Jacques Pauvert/Terrain vague.
Derrida J. (1993) Jacques Derrida: Circumfession: Fifty-Nine Periods and Periphrases. . . (January
1989–April 1990). Bennington. G (Trans.) Chicago, IL: University of Chicago Press.
Dirie W. (1999) with Cathleen Miller. Desert Flower. The Extraordinary Life of a Desert Nomad
(1998). London: Virago.
Dirie W. (2002) with Jeanne D’Haem. Desert Dawn. London: Virago.
Eilberg-Shwartz H. (1992) Why not the earlobe? Moment. 17:28–33, February.
Engel S (producer), Smith MO, Bucher A (director) (2007) A Walk to Beautiful, New York: Engle
Entertainment.
Gatheru M. (1964) Child of Two Worlds. London, Ibadan, Nairobi: Heinemann.
Gilitz DM. (1996) Secrecy and Deceit: The Religion of the Crypto-Jews. Philadelphia, PA: Jewish
Publication Society.
Glick LB. (2005) Marked in Your Flesh: Circumcision from Ancient Judea to Modern America.
Oxford/New York, NY: Oxford UP.
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Hoffman LA. (1996) Covenant of Blood: Circumcision and Gender in Rabbinic Judaism.
Chicago/London: University of Chicago Press.
Isewaga M. (2000) Abyssinian Chronicles. New York, NY/London: Alfred A. Knof/Picador.
Originally in Dutch, Abessijnse Kronieken. Amsterdam: De Bezige Bij, 1998.
Levenson JD. (1993) The Death and Resurrection of the Beloved Son: The Transformation of Child
Sacrifice in Judaism and Christianity. New Haven: Yale UP.
Murray J. (1976) The church missionary society and the ‘female circumcision’ issue in Kenya
1929–1932. J Relig Afr. 8(2):92–104.
Remondino PC. (1891) History of Circumcision from the Earliest Times to the Present.
Philadelphia: F.A. Davis.
Robinson BP. (1986) Zipporah to the rescue: A contextual study of exodus IV. Vetus Testamentum.
36(4):447–461.
Sattouf R. (2004) Ma Circoncision. Rosny-sous-Bois: Bréal Jeunesse.
Siegumfeldt I-B. (2005) Milah: A counter-obituary for Jacques Derrida. Substance. 34(1):32–34.
Spivak, GC. (1998) Three women’s texts and circumfession. In: Alfred H, Ernstpeter R. (eds.)
Postcolonialism and Autobiography: Michelle Cliff, David Dabydeen, Opal Palmer Adisa.
Amsterdam/Atlanta, GA: Rodopi.
Steinberg L. (1983) The Sexuality of Christ in Renaissance Art and in Modern Oblivion. New
York, NY: Pantheon.
Thomas L. (2000) ‘Ngaitana’ (I will circumcize myself): Lessons from colonial campaigns to ban
excision in Meru, Kenya. In: Shell-Duncan B, Hernlund Y. (eds.) Female “Circumcision” in
Africa: Culture, Controversy and Change. Boulder, CO: Lynne Reiner, pp 128–150.
Zabus C. (2005) A Propos de Bintou: excision et circoncision: Interview avec Kofi Kwahulé.
Africultures. 4235 (December 9, 2005) at www.africultures.com
Zabus C. (2007) Between Rites and Rights: Excision in Women’s Experiential Texts and Human
Contexts. Stanford, CA: Stanford University Press.
Zabus C (ed.). (2009) Fearful Symmetries: Essays and Testimonies Around Excision and
Circumcision. Amsterdam/Atlanta, GA: Rodopi.
Chapter 16
The Impact of Neonatal Circumcision:
Implications for Doctors of Men’s Experiences
in Regressive Therapy
Robert Clover Johnson
Abstract This paper asserts that, although most men circumcised as infants have
no conscious recollection of the trauma, the unexpected re-experiencing of the pain
and shock of circumcision by men in regressive therapies suggests that the experience is never forgotten by the unconscious mind, the source, as has been understood
since Freud, of most psychological problems. The history, aims, and methods of a
range of regressive therapies are briefly surveyed. Descriptions of men’s discovery
in regressive therapy of the profound impact circumcision has had on their lives are
described. The presenter outlines his own reexperiencing of circumcision in primal
and bioenergetic therapy over a 30-year span. Repatterning or corrective emotional
experience is explained as an effort to enable circumcised men to regain confidence
and self-assertion, characteristics damaged by the impact of the infant male’s helpless victimization during circumcision. Restoring is also mentioned as a necessary
palliative endeavor for victims (including doctors) of this practice.
Keywords Psychotherapy · Trauma · Unconscious mind · Regressive therapy ·
Foreskin restoration · Shock · Masturbation · Limbic system · Terror · Rate ·
Dissociation · Arthur Janov · Repatterning · Ridged band · Circumstraint ·
Erogenous nerves · Shame
Many observers of routine medical newborn male circumcision in America have
reported being alarmed by the agony of the baby and astonished that the doctors involved seem completely unaffected by the infant’s screams and clear signs
of shock (Romberg, 1985; Milos, 1989; O’Mara, 1993; Lewis, 2006). Although
the importance of focusing on the technical aspects of this surgery might partially
explain doctors’ indifference to baby boys’ protests, literature on reasons commonly
cited to justify neonatal circumcision suggests that acceptance of some or all of the
following beliefs may also play a role:
R.C. Johnson (B)
Gallaudet University Press, Washington, DC, USA
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(1) Having a foreskin greatly increases the likelihood of contracting HIV, cancer of the penis
(and of the cervix of a partner via intercourse), or other diseases, so its removal is important
for health and longevity.
(2) Parents, accustomed to circumcision as the norm in their society, often say “yes” when
asked if their sons should be circumcised, and doctors must comply with their wishes.
(3) A circumcised penis is just as sensitive and effective for sexual purposes as an
uncircumcised penis, so the amputation of the foreskin is no great loss.
(4) The procedure has moral benefits in that removal of the foreskin makes masturbation
and sexual excess more difficult.
(5) The infant mind is incapable of registering pain; or, alternatively, the pain experienced
will be forgotten, quickly, completely, and permanently, without causing trauma-related
complications.
Diehard beliefs that amputation of the foreskin prevents a range of serious diseases have been widely and seriously challenged (Weiss, 1964; Preston, 1970;
Wallerstein, 1980; Boyd, 1998; Sidler et al., 2008). The notion that doctors must
be beholden to the wishes of parents overlooks the fact that parents are often ill
prepared to make fully informed, wise judgments about whether or not their baby
should be circumcised. Such parents may rely on the doctor to help make the decision, even though the doctor stands to profit from performing the surgery and is quite
likely to be ill-informed himself about the damaging immediate and long-range
effects of circumcision (Goldman, 1997, pp. 29–56). The notion that circumcision
brings about no adverse sexual effects later in life has been discredited scientifically as well as anecdotally (Taylor et al., 1996; O’Hara, 2002; Sorrells et al.,
2007). Although circumcision does make masturbation and sexual excess more difficult and less pleasurable, the “moral” issues mentioned seem oddly anachronistic
in most modern, cosmopolitan cultures. It is therefore important to remember that
the primary reason for excising the richly innervated, erogenous tissue of the foreskin has historically been to reduce sexual excitability, thus diminishing instances
of masturbation and/or promiscuity (Kellogg, 1888; Maimonides, [tr.] 1963).
Those issues, though extremely important, are somewhat outside the scope of this
paper, which focuses on the discovery by many men in various forms of regressive
psychotherapy that the intense genital pain and terror suffered during circumcision
have never been forgotten by the unconscious mind, the source—as has been understood since Freud—of most psychological problems. These men’s unanticipated
re-experiencing of that trauma and subsequent awareness of the trauma’s negative
impact on their lives suggest that, whether consciously remembered or not, circumcision can have lasting, damaging effects on men’s emotional and psychological, as
well as sexual, development.
In this paper, based on experiences described in the literature as well as on my
own experiences during regressive therapy, I will argue that revisiting infant circumcision and expressing rage at or fight/flight reactions against the perpetrators in
a regressed state, combined with efforts to create an ersatz foreskin, can have therapeutic psychological and sexual benefits for circumcised men. I will mention some
hazards associated with re-experiencing circumcision in regressive therapy and
caveats related to using this approach for resolving circumcision-related emotional
and sexual issues. Implications for circumcising doctors will also be discussed.
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The Impact of Neonatal Circumcision
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Memory in Infancy
Since few people have conscious memories of experiences that occurred before the
ages of two or three, some readers of the following paper may be skeptical of reports
that men in various forms of regressive therapy have remembered or re-experienced
aspects of their infant circumcisions. Arthur Janov, author of The Primal Scream
(1970) and inventor of Primal Therapy, has written that he similarly was doubtful
when many of his clients in the late 1960s began having experiences that looked
and reportedly felt like “re-living” their births. When Janov asked neurologists if
brain science at that time could substantiate such claims, they replied that they were
also doubtful because the hippocampus and prefrontal cortex, known to be primary
support systems for the formation of conscious memories, were not sufficiently
developed in prenates or newborns to formulate detailed records of experience
(Janov, 1983, 2007).
Since then, however, the dynamic field of neuroscience has made many discoveries that seem to explain and support the validity of neonatal memories being
experienced in regressive therapy. The principal corroborative discovery is that certain parts of the “lower” human brain—most notably the twin amygdala in the limbic
system—have the function of recording experiences of intense pain and such emotions as terror and rage, associating these feelings with specific external stimuli.
Neuroscientists now theorize that the amygdala evolved among mammals as a warning system capable of provoking fight or flight reactions to stimuli associated with
previous experiences of harm. These memories tend to be more visceral and reactive
emotionally than the explicit conscious memories we generally experience in a more
emotionally detached way, as if watching movies in our minds. Also, memories as
recorded in the amygdala appear not to depend on the level of neurological maturity required for the creation of most conscious memories. Contrary to the long-held
notion that “babies do not feel pain” (still a frequently cited excuse for performing
surgery on babies with no or minimal anesthesia), it appears that extremely painful
(i.e. traumatic) experiences are not only felt but are stored in all their intensity within
the amygdala (Schore, 1994; Phelps and Anderson, 1997; Siegel, 1999).
Although the emotional and sensory memories stored in the amygdala are usually
kept out of the reach of consciousness through the protective mechanism of “dissociation” or amnesia, these unconscious memories can nevertheless have a profound,
lifelong effect on an individual, damaging his or her ability to respond in an optimally healthful way to sexual and other stimuli. Regressive therapies generally aim
to create a safe, supportive setting in which individuals suffering from an overload
of repressed or dissociated pain can gain enough access to the traumas involved to be
able to diminish their damaging impact. Various techniques, including bioenergetic
exercises, hypnosis, massage, breathwork, and focused exploration of the emotions
underlying anxiety may be used to help clients break through the conscious mind’s
habit of recycling familiar, comfortable thoughts that promote avoidance of pain and
detachment from the suffering they wish to alleviate. Persistence in regressive therapy can help clients re-experience enough traumatic or highly charged unconscious,
emotional material to assimilate and come to terms with the experiential sources of
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their anxieties. The fact that individuals pursuing regressive therapy for many years
often re-experience birth or neonatal circumcision traumas testifies to the validity of
the following observation by David Chamberlain (1989):
Instead of responding to [baby] cries as authentic communication, birth professionals have
proceeded to cause pain with the conviction that the pain is merely reflexive and that owing
to the immaturity of the infant brain, the pain could not really matter. From the perspective
of present knowledge, these key nineteenth century beliefs are only myths, but tragically,
they are mega myths still influencing mainstream psychology and obstetrics today.
Regressive Psychotherapy
Regressive psychotherapy is a broad term referring to a variety of therapeutic practices that help individuals discover and come to terms with the traumatic origins of
inhibitions, anxieties, depression, projected rage, obsessive-compulsive disorders,
substance abuse, suicidal impulses, and other tendencies. In spite of quicker, less
painful, more popular approaches that describe such leanings as symptoms of chemical imbalances best treated with medications or as results of self-defeating thought
patterns that need to be replaced with more constructive ideas, a number of psychological disciplines have moved in the direction of exploring and releasing deeply
repressed pain and gradually integrating the memory and significance of this pain
into consciousness. These include Reichian Therapy (Reich, 1949), Bioenergetic
Analysis (Lowen, 1967, 1975), Primal Therapy (Janov, 1991), Primal Integration
(Rowan, 2000), Deep Feeling Therapy (Vereshack, 2001), Hypnotherapy (Hartman
and Zimberoff, 2004), Re-evaluation Co-counseling (Jackins, 1970), Holotropic
Breathwork (Holmes et al., 1996), EMDR (Shapiro and Forrest, 1997), Somatic
Experiencing (Levine, 1999), and others.
This development was presaged by Freud and Breuer who discovered in the
1890s that hysteric symptoms appeared to be associated with early traumas and
could be significantly relieved if patients were helped to re-experience painful, formerly repressed memories and react to them with a cathartic discharge of suppressed
feeling. Freud later shied away from accepting as real many of the memories of child
abuse and other traumas brought forth by his patients.1 He concluded that these
individuals were recalling their own troubling childhood fantasies, which should be
approached critically through a combination of free association and analysis in what
is now often called “the talking cure.” It should be added that although Freud thereby
created a framework through which patients could be “talked out of” accepting as
literally true some of their emerging memories of abuse as infants or young children,
he saw literal rather than fanciful significance in the belief sometimes expressed by
circumcised men that they had been in some way emasculated very early in life
(Freud, 1916–1917/[tr.] 1933). Perhaps the reason for this was that—for anyone
aware of normal male anatomy—the evidence of a physical trauma is unmistakable
on the circumcised penis.
Freud’s disciple, Wilhelm Reich, and many other psychologists later rejected
his verbal-analytical approach and returned to the idea that neurotic symptoms in
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general were results of genuine early traumas and could not be alleviated without re-experiencing the pain, even if not a complete multi-sensory replay, of those
events. Regressive re-experiencing of repressed painful memories is described by
Arthur Janov, the creator of Primal Therapy, as the essential component of psychological healing (Janov, 1991). Some life-threatening or extremely painful traumas
can be so agonizing to re-live, however, that most regressive therapists recommend
experiencing small doses intermittently so the client can assimilate the memories
gradually while also pursuing countervailing, life-affirming expressions of self.
Many regressive therapies, in fact, emphasize the exploration of new patterns of
reaction to trauma, such as bioenergetic discharge, primal integration, sublime
release of shame, repatterning, somatic redecision, corrective emotional experience,
survival (fight/flight) discharge, etc. Some of these new experiences may consist
of expressing feelings that were deliberately inhibited during the original traumatic
event (or events).
Tom Golden (1999), a psychotherapist who uses a variety of regressive techniques to help men deal with grief and other issues, discusses in a website how
many of his clients have unexpectedly re-experienced aspects of circumcision:
I began to see that one of the experiences that was not uncommon for men to “re-experience”
within a cluster of old traumas was the pain and trauma related to being circumcised. When
I first noticed this I was amazed and shocked. . . I hadn’t thought of the experience of circumcision as being anything but a routine medical procedure. The men who re-lived these
things were usually just as startled. They were expecting other issues to surface and were
surprised to see circumcision as one of them. We were. . . shocked at the intensity of the
related pain. I started looking into the medical aspects and was completely blown away
to find that doctors didn’t use any anesthetic. . . the assumption being that babies don’t
feel pain.
In his article, “Neonatal Circumcision Reconsidered,” John Rhinehart (1999)
describes several case histories of men who discovered in the course of regressive
therapy that circumcision had set in motion various lifelong, self-defeating patterns.
These men entered therapy because of such tendencies as avoidance of intimate relationships, feelings of inferiority to other men, fear of authority figures (or doctors),
shyness or panic attacks in unfamiliar circumstances, and other related feelings. In
the course of regressive explorations of the origins of these tendencies, these men
were astonished to find themselves re-experiencing their own neonatal circumcisions. Some of Rhinehart’s clients reported distinct sensations of being cut in the
genitals. All described feeling overpowered, helpless, and victimized. Rhinehart
reports that, once his clients became deeply aware of the impact circumcision had
on their lives, he was able to help them “repattern” their emotional responses to this
event and to the challenges of adult life, exchanging feelings of helplessness in the
face of overwhelming force, personal violation, and intense pain for new feelings of
self-worth, self-confidence, and self-determination.
How is such repatterning accomplished? Another term that amounts to the same
thing is “corrective emotional experience,” this wording was introduced by Franz
Alexander, a disciple of Freud who left Europe during World War II and spent
most of his career in Chicago. In the abstract of an article on corrective emotional
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experience, hypnotherapists Hartman and Zimberoff (2004) summarize how regressive recall of traumatic experiences can lead to healing:
Healing unresolved traumas from early life requires accessing the events that produced
the trauma, re-experiencing them cathartically in the original ego state, and reframing the
meaning of the experience through corrective emotional experiences. We identify [numerous] types of corrective experiences and suggest that they all fit into one of three categories:
(1) building ego strength through release of shame and reclaiming worthiness; (2) building agency through release of helplessness and reclaiming personal power; and (3) building
authenticity through release of dissociation and identification and reclaiming self-reflective
identity.
In what follows, I will use terms from the Hartman-Zimberoff abstract to outline
a narrative describing my own process of discovering and endeavoring to “heal” the
trauma of circumcision.
Re-experiencing the Trauma
In my experience, the discovery that circumcision had something to do with anxieties related to intimacy that had bothered me since my teens did not become clear
until I was 60 years of age. A year earlier, I had reached a point in my marriage in
which I faced the fact that, in spite of decades of self-coaching in an effort to sustain a healthy and sophisticated attitude toward sex, all of my intimate relationships
had required a struggle to subdue an inexplicable fear that often interfered with or
stopped sexual excitement. I had dealt with this feeling 30 years earlier in an intense
group therapy experience built around Reichian, Primal, and Bioenergetic Analysis
concepts. At that time, I participated in exercises aimed at releasing muscular tensions that Reich and the co-creator of Bioenergetic Analysis, Alexander Lowen,
described as chronic reactions to trauma that had the effect of simultaneously keeping painful memories out of consciousness and inhibiting the free flow of emotional
and sexual energy (Reich, 1949; Lowen, 1967, 1975).
Leaning backwards over a rolled-up towel strapped to a kitchen stool (a device
called “The Rack” by Bioenergetic Analysis therapists [see Fig. 16.1, an exercise
Fig. 16.1 “The Rack” used
for emotional release (Lowen,
1967)
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Fig. 16.2 Tantrum (Lowen,
1975)
that forcibly relaxed the ordinarily tense muscles in the solar plexus region, released
feelings of fear, much yelling and crying, but no clear indicators of the exact nature
of the experience my body/mind was remembering. Shortly after that experience,
I was permitted to pursue an unanticipated and, until then, deeply repressed inclination to have a full-blown, wordless temper tantrum (see Fig. 16.2). This tantrum,
which took place on a king-sized mattress, my fists, feet, and head moving like
pistons, my voice emitting high-pitched baby cries, seemed to be my reaction to
some terrible physical offense experienced when I was a baby. Once I was finished,
feeling enormous relief and a surge of joy, neither my therapists nor I could guess
what these seemingly related episodes were all about except that I must have been
terrified of something in infancy and appeared to need to react to that event with
explosive rage.
Though I knew I was far from having resolved the painful emotional issues that
led to that radical therapy experience, my next 30 years were devoted to the pursuit
of a conventional life: getting married, getting a good job, having and raising a child,
etc. But after my daughter went to college, the old feelings of unease and fear associated with intimacy recaptured my attention. I knew from years of experience with
traditional psychotherapy that antidepressant medications and talk therapy did little
to unearth or resolve deeply repressed, painful memories. I decided I must return
to regressive therapy to find and—if possible—quell the sources of my anxiety. For
various reasons, I chose to do this work on my own. I used some techniques recalled
from my earlier experience, but also made use of suggestions discovered in certain
printed and online documents, especially the work of Paul Vereshack, a Canadian
practitioner of Deep Feeling Therapy, who offers detailed practical advice online
(free) and in print (Vereshack, 2001).
As most individuals pursuing regressive therapy would attest, it is difficult to
find physical or interpersonal circumstances in which it feels safe or appropriate to
release the powerful feelings associated with early traumatic memories. Not wishing to disturb my wife or neighbors, I most often primalled2 at home when those
people were away. (Some primallers play recorded music to obscure sounds of crying; others cry or yell into pillows. Some soundproof a room in their homes or are
lucky enough to find an understanding therapist with soundproof facilities. Many
join groups of primallers at retreats in remote locations.)
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At home, alone, lying on my back on a mattress, I began by focusing on tensions
I sometimes experienced in response to intimate situations, then allowed deeper,
related feelings to surface. Exploring the emotions associated with these tensions
transported me eventually to painful, extremely early experiences. Beneath my adult
persona with its pretense of calm self-assurance, I discovered first a toddler, then an
infant, crying in pain for his mother. It might seem that such an experience would be
embarrassing, but great relief is usually felt when profound feelings—repressed but
continually asserting themselves with troubling, enigmatic effects—finally emerge
in sessions of weeping or rage. For me, the effort led to my first prolonged, conscious
immersion in what I believe was my state of mind and feeling as an infant and
toddler, endlessly seeking comfort and healing from a weary, overwhelmed mother.
After several months of exploring mother-related emotions, I began to sense that
underlying my cries for her help was some terrifying earlier experience increasingly nudging the edges of consciousness, my long-repressed reactions to that event
pressing for release. My father once told a friend of his, in my presence, about an
occasion in which he gave me “hell” when I was a baby upon discovering that I
had done something inappropriate on the living room floor. I couldn’t remember
this event (which still remains buried in my unconscious), but sensing that something frightening like my father’s brief and vague description had indeed occurred
and following Vereshack’s theory that in regressive therapy we position ourselves,
move, and vocalize in ways that—through trial and error—feel increasingly “congruent” with a painful memory ready to surface, I lay on my back, regressed to my
now-familiar, whining-for-mother state, then—imagining her complete absence—
kicked and flailed defensively as someone or something very powerful began to
wrestle with my arms and legs. While struggling to push the strong being away, I
suddenly felt sharp, very distinct cutting pains progressing from right to left over
the shaft of my penis.
I immediately stopped the regression, at once shocked by the unexpected body
memory of being cut in a very sensitive, private part and energized by the realization
that I had finally identified the trauma I’d endured on the “rack” and subsequently
had a tantrum about 30 years earlier. The word “circumcision” came to mind immediately; a surgery certainly performed by a doctor, not my father. Whatever “hell”
my father had given me, as far as my unconscious mind was concerned, clearly
paled by comparison with this earlier experience. But like Golden, I had never
sought to learn about circumcision, thinking of it (as I assume most American
men must) as simply a routine medical procedure performed on baby boys for
important reasons understood by doctors—analogous, I’d unthinkingly supposed,
to severing the umbilical cord. The surprise of discovering that circumcision had
been an excruciating, terrifying experience and that the repressed memory of it,
combined with the physical harm it caused, might have played a damaging role
throughout my life aroused a strong intellectual curiosity that sent me quickly to a
computer.
I did an Internet search for the word “circumcision,” half-hoping I would find a
reasonable explanation as to why this surgery had been performed and how (if at all)
I had benefited from it. I was willing to “take my medicine,” in other words, if it were
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generally agreed and easy to understand how beneficial it is for personal happiness
to have one’s foreskin removed in infancy. What I learned instead—from countless
reliable websites and eventually from many books and articles on the subject—was
that no reputable medical organization in the world currently recommends routine
infant circumcision as a prophylactic against disease. I learned that circumcision
causes the keratinization and desensitization of the glans, a part of the male body that
is normally moist and protected by the foreskin (as the tongue is by cheeks and eyes
by eyelids) from the daily abrasions that cause it to lose sensitivity. I learned that
the foreskin I lost during circumcision contained some three-fourths of my erogenous nerves (most notably the “ridged band” at the aperture), and that this highly
sensitive tissue plays important mechanical as well as sensual functions during normal intercourse. The amputation of my foreskin, in other words, had deprived me of
certain joyous and joy-giving aspects of sexual experience well-known by the vast
majority of men who are not circumcised.
I learned that highly influential doctors such as John Harvey Kellogg (who also
invented cornflakes) promoted universal circumcision of newborn boys largely to
stamp out masturbation, an activity that more than a century ago was erroneously
believed to cause insanity and many diseases. I learned that Kellogg, who trained
thousands of doctors concerning circumcision techniques—directly or in books—
was extremely squeamish about sexual intercourse and was not dissuaded from
his determination to stamp out masturbation by the realization that circumcision
would also hamper or prevent sex as nature intended it. I learned, in other words,
that my circumcision was one aspect of a larger effort in America and elsewhere
to reduce the pleasure in one of life’s most enjoyable and important experiences
and to instill feelings of shame and dread about sex into the minds of men.3 More
importantly, I learned that, in spite of this wealth of information suggesting that
the practice of circumcision should have been outlawed decades ago, approximately
3,000 routine infant circumcisions of baby boys are still performed daily in the
United States alone.
When a particular trauma has clearly had a major damaging effect on an individual, most regressive therapies advise clients to relive the traumatic experience
in digestible portions often enough to “see it for what it is,” to objectify it, and
eventually to allow the individual to dilute the impact this formerly repressed memory has had on his or her ability to enjoy new experiences free of the trauma’s
dire influence.4 A major difficulty in endeavoring to heal the psychological wound
of circumcision, however, is the simple fact that the wound is physical as well as
emotional. The impact of circumcision has been to terrify an infant, to subject him
to excruciating pain that is not brief, to alter his sexual nature, to reduce his sexual
capabilities, and to inject feelings of shame, fear, and self-doubt into his personality.
In my case, the discovery of the psychological damage of circumcision coincided
with my first keen awareness of the physical and sensory damage this practice had
inflicted on me. In America, we call this a “double whammy.” The overall effect
of this knowledge, combined with continual regressive immersions in the now very
accessible memory of circumcision, was that I experienced about a year of seldom
interrupted suffering, followed by a general sense of sadness, resignation to my
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own diminished state, and determination to do what I could to end this practice by
persuading doctors and parents of its many harms.
During that time and to varying degrees ever since, the agony of circumcision
became largely unrepressed for me. In the many primals I had subsequent to that
first one, I felt I had opened Pandora’s Box, re-experiencing again and again the pain
I first experienced during and after circumcision, relinquishing all possibility of ever
completely shutting those feelings away. Part of the price I paid for gaining intimate
knowledge of an experience my repressive mechanisms had striven for 60 years to
protect me from was that, even when I was not explicitly primaling, I often felt
keenly as if I had just been circumcised, my penis the site of intense phantom pain.
In addition to re-experiencing circumcision as a traumatic memory, my mind
raced as I dealt with feelings of betrayal by the people responsible for my well being
during infancy. Why would anyone do such a thing to an innocent baby? Could
the doctor who circumcised me in 1945 possibly still be living? (Not likely.) What
would I say to him if I were to confront him? More important and puzzling to me
personally was the question: What role did my parents play regarding my circumcision? Since both had died by the time of my discovery, there was no way to directly
ask them how the decision was made or how they felt about the decision, so my mind
has jumped from clue to clue in search of the never-to-be-fully-known story. The
only details I had learned about my birth from my parents included that my mother
was anesthetized when I was born at 3:45 a.m. and slept for many hours thereafter.
She had never forgiven my father for “being away on a business trip” at the time;
and neither parent met me face-to-face until my father finally arrived at the hospital
sometime that afternoon and a “search” was undertaken in the maternity ward.
I have learned that American doctors were not required by law to ask parents’
permission to circumcise in 1945, so I have imagined that the deed was already done
by that afternoon meeting, but since my older brother was circumcised in 1941, it
seems that my parents must have known that I was likely to undergo the same procedure unless they took steps to prevent it. Could it be that my father, who was not
circumcised, wished to be away so he would not be blamed for whatever happened?
He had been a first-born son. Could it be that the thought of giving a second-born
son an advantage over his own first-born son was unendurable, prompting him to flee
rather than intervene on my behalf? I’ll never know. I often imagine and re-imagine
how these events might have unfolded and how confusion, blame, recriminations,
and guilt all led ultimately to the complete silence concerning my circumcision
that is so typical and so very American a way of dealing with irremediable family
traumas.
Since the storylines I have spun in my mind cannot be verified, they must be relegated to the realm of fiction, but what is pertinent here is that once a man becomes
aware that his circumcision was painful and debilitating and someone else’s choice,
innocence is permanently lost. Cynicism and an anguished sense of having been a
helpless victim may erase for a long time all hope of any sanguine resolution to this
personal tragedy.
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Discovering Power
Several months after my first distinct circumcision-related primal, it occurred to
me that something about my actions during that regression may have made it seem
safe or conceivably beneficial for my unconscious mind to release the unmistakable,
identifying signal of genital cutting sensations. My physical and mental attitude at
that point must have been remarkably similar to that of a newborn baby boy about
to be circumcised—except that I was allowing myself to defend my body with my
arms and legs, actions that would have been attempted but prevented by restraints
during the original event. Although it is seldom described as such, the Circumstraint
used in routine infant circumcision provides a striking example of forcibly inhibited
defensive reactions to this trauma. The limbs of baby boys are strapped down to
prevent them from using their hands, knees, or feet, or their ability to assume a
self-protective “cannonball” or “roly-poly” posture to interfere with or thwart the
violence being perpetrated (see Fig. 16.3). Defeating the baby’s only defense mechanisms in this way adds to the repressed memory of genital pain, a profound sense
of helplessness, and ineffectuality. My unimpeded, baby-like, defensive actions during that regression appear to have been the key that unlocked the somatic memory
of my life’s worst experience (see Fig. 16.4).
Fig. 16.3 Forced inhibition
of defensive reactions
(Goldman, 1997, p. 96)
Fig. 16.4 Release of
repressed anger and defensive
reactions to circumcision
decades after the original,
forced inhibition. (Modified
from Lowen, 1975)
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Now, with the benefit of three years’ hindsight, I can also see that the defensive
actions of my arms and legs during that regression constituted a first step toward dismantling a timid, defeated attitude that had plagued me throughout life, in spite of
the calm, confident manner I had developed as a façade to obscure those feelings. To
use a term from Transactional Analysis, the feeling of inevitable defeat associated
with circumcision may become the entire “lifescript” of a man. However, allowing a grown man in the course of a regression to this buried memory to express
his infant self’s rage with the power of his adult male body, can contribute to the
rewriting of this script and the emergence of a new pattern of feeling, outlook, and
behavior.
Hartman and Zimberoff point out that “There is sublime release of shame when
one is able to experience in the original regressed ego state overcoming what was
inhibited, forbidden, or impossible in the past experience, and expressing it in the
present situation” (p 9). By revisiting the source of their chronic, defeated attitudes
toward experience and discovering within themselves a new, self-affirming response
to the initially agonizing experience, victims of early trauma are able to gain a new
sense of power and effectiveness.
A word should be said here about the circumstances in which anger can help
heal trauma. Many men habitually express anger or aggression as a way of asserting
their masculinity and may do so reflexively when hurt—partly to hide from themselves or others their feelings of being a victim or “loser.” This is one form of what
psychologists call “dissociation.” When we imagine the feelings most men would
naturally have if they faced the facts of what was done to their genitals in infancy,
it becomes immediately clear why most men, including circumcised doctors, are in
denial about anything “bad” ever having happened down there. They are, in other
words, dissociated from their authentic selves. I would go so far as to assert that on
some level such men have always been aware that something is wrong—something
is missing. In the most blatant sense, of course, what is missing for circumcised
men is their foreskins. In a deeper sense, however, what is missing is awareness
of any feelings whatever about missing a foreskin. When Hartman and Zimberoff
speak of “building authenticity through release of dissociation and identification
and reclaiming self-reflective identity” they are pointing out that regressive therapy,
though admittedly painful in many respects, is extremely beneficial in that it can
introduce people to their true selves. Circumcised men, for instance, can discover
that they were “robbed” as infants. This discovery, combined with experiencing the
sorrow and grief that go along with it and the expression of reactions “in the original regressed ego state” to the violence perpetrated on their genitals are essential
aspects of healing the trauma.
It may be true that many men, upon realizing that they lost part of their sexual birthright as a result of surgery by some known or anonymous doctor, can gain
momentary satisfaction by expressing rage toward the individual or the medical profession at large that they now perceive as having betrayed them. This anger can have
great benefit if it leads to the release—as it often does—of tears of grief. This grief,
in turn, once deeply felt and identified with, can eventually enable the authentic
individual to pursue regressive therapy and discover the benefits of expressing the
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anger that was repressed at the time of violation. Hartman and Zimberoff state that
releasing this repressed anger “fosters an empowering cognitive-emotional shift.”
They cite Van Velsor and Cox (2001) who describe how the expression of repressed
anger toward a rapist by a female rape victim can lead to healing. For the purposes
of this paper, I will exchange “she” for “he” and “her” for “his” in the following
quote without changing the basic meaning:
When the client experiences the healthy unleashing of repressed anger toward [his]
perpetrators. . . [he] claims a boundary, or a piece of personal entitlement to certain rights
involving safety and protection, personal integrity, emotional reality, and the outward
expression thereof, and reinstitutes feelings of personal efficacy and power.
This is not to say, however, that adult, objective rage, properly channeled, should
never be used in the campaign against circumcision. Rage against a system collectively ignorant of the consequences of its routines can be legitimately channeled
into peaceful anti-circumcision gatherings, editorials, and demonstrations. Systemwide revolts also can be useful, such as the refusal of nurses to participate in
circumcisions in a particular hospital.5
To the victims of this practice, many of whom are themselves medical interns or
doctors, I would urge that you seek psychological healing by returning to the state
that formed your personality . . . the innocent state of being a newborn baby boy
with a foreskin. Recalling then how it felt to be bound, clamped, and circumcised,
express your rage as you wish you could have then. Lift your knees until the leg
restraints snap! Push away the doctor who approaches you with misleading smiles,
scalpels, and a Gomco clamp! Assert your right to be left alone! Say “Leave me
alone!” if that helps, but above all, keep those sharp instruments away from your
body. Protect yourself! Be victorious! Even if this be fantasy only, exult in this
moment of triumph over those intent on damaging you! Trust that you are right and
they are wrong!
Not everyone is able to access what Goldman (1997) describes as the “hidden
trauma” of circumcision, but if anyone reading this—including a male doctor—
feels the need to heal his own circumcision-related trauma and is unsure how to
proceed, I advise starting by reading some of the therapy-related documents and
Internet resources listed at the end of this article.
Restoring a Foreskin
There is an additional way that victims of circumcision can regain some of the
capability denied them by this surgical procedure: restoring a foreskin. An excellent resource on this subject is a book by Jim Bigelow (1992), called The Joy of
Uncircumcising! Exploring Circumcision: History, Myths, Psychology, Restoration,
Sexual Pleasure, and Human Rights. This volume discusses the history of circumcision and practices that can facilitate restoration of foreskin. Today, thousands of
men around the globe are using one or another technique proven to cause new
skin cells to develop in the remaining shaft skin of their circumcised penises. The
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process is slow, but patience and diligence can enable a person to develop a foreskin that will cover the glans, protecting it from further abrasion, enabling it to shed
keratinized cells and restore its sensitivity. A restored foreskin lacks the erogenous
nerves of the original, lost foreskin, but it greatly facilitates intercourse and, according to many reports, greatly increases sexual pleasure for both the restored man and
his partner. In light of the fact that Bigelow’s volume is no longer new, it would
also be wise to consult websites for one of the many national branches of NORM
(National Organization of Restoring Men) that usually contain contact information
for individuals who can provide information over the phone, in emails, or through
group or individual meetings. These websites also generally contain links to countless articles, books, and online discussions concerning circumcision and restoring.
The papers by Ron Low and Wayne Griffiths in this volume also provide useful
historical and current information on restoring devices.
I should add that, in my opinion, the best way to overcome a significant amount
of the damage of circumcision is to combine regressive therapy with restoration.
The more aware a person becomes of the psychological trauma, the more keenly he
will be aware of the physical and sexual loss. Restoring augments the psychological
healing process with a physical process that may help a person to gain new
confidence in the sexual equipment, even if circumcision has dealt a heavy blow.
Words of Caution
In case my story inspires anyone to pursue some form of regressive therapy in hopes
of resolving emotional issues associated with circumcision, I should add a few cautionary comments. In my view, no amount of re-experiencing, catharsis, corrective
emotional experience, or restoring can entirely remove from circumcision its inherently tragic nature. Even if a person were to become one of the few who are able
to access feelings experienced in infancy, let alone those feelings associated with
circumcision itself, please don’t expect any powerful connection to those feelings to
miraculously provide long-term happiness or to quickly eliminate all the problems
this surgery has caused. All I can guarantee for those determined to pursue regressive therapy is that this endeavor has the capacity to present, over time, a completely
new, more accurate grasp of personal history. If a person happens to be circumcised,
the probability is that somewhere in the unconscious mind is the repressed memory of that event. Painful and saddening though it almost certainly would be to
re-experience that particular memory (or some other, unanticipated traumatic memory), doing so can be extremely rewarding for truth-seekers, whether or not the
truths that emerge bring happiness. Also, many will testify that the cognitive dissonance resulting from the continual sabotage of efforts to enjoy life and love brought
on by repressed, unfelt pain begins to resolve itself once a person starts having connected regressions. Feeling and owning those long-dissociated pains can eventually
enable the conscious mind to make peace with the unconscious mind, leaving one
the sadder but wiser, and freer to chart one’s own future.
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Advice for Doctors
If you are convinced that circumcising a baby boy’s penis does no harm, please think
again. Read carefully the Taylor et al., study on the anatomy of the foreskin (1996)
and the Sorrels et al., study (2007) comparing the sexual sensitivity of the intact
versus the circumcised penis. Also, find on the Internet a video of a medical circumcision (e.g., http://www.youtube.com/watch?v=AwBCElbVkuY&feature=related).
Watch it carefully, but listen to the sounds produced by the baby. Imagine that you
are the baby rather than the surgeon. This exercise, if pursued objectively, should
help provide a new perspective.
I would like to quote from a personal communication from Gabriela Monasterio,
a practitioner of deep feeling therapy in Mexico, who believes that unresolved inner
pain is what prevents individuals from feeling the natural joy of being alive. In the
following response to a video of a routine medical circumcision of a newborn male,
Monasterio offers some additional possible explanations for a circumcising doctor’s
apparent indifference to the baby boy’s suffering:
Watching this video of a baby boy being circumcised, I wondered how on earth this doctor
or anyone who witnessed the circumcision could be deaf to the sound of the baby’s cries
and the evident fact that he was in shock. The doctor continued to describe the process as if
he were talking about a cooking recipe. I feel that this kind of reaction reveals an emotional
numbness and deafness in the doctor that can only come from denying and stuffing up his
own pain. . . and possibly from a deep “acting out” of that denied pain evident in the fact
that he could circumcise that poor baby as if he were just following instructions in a manual.
Torturing babies through circumcision is plain torture and we are not here to sugarcoat,
justify, or hide this fact. The younger the victims are the worse they are harmed. Facing
this truth is the only way we can change what needs to be changed. All that is needed is
that we change the way we treat children. If we would stop needlessly torturing them, we
could undoubtedly change the world in profound ways. If children grow up accepted as
they are, they will become humane and compassionate. If they are not, then humankind will
be condemned to repeat its mistakes over and over, till we destroy ourselves (Monasterio,
2007, personal communication).
Fully realizing that doctors perform miracles of healing daily through the
removal of malignant tumors and the mending of broken bodies, my final word
of advice is simply that physicians remember the first part of the Hippocratic Oath
taken upon entering this profession: “. . .never do harm to anyone.” If there is nothing malignant or broken about a newborn boy’s foreskin, what could be simpler and
more wonderful than to let it be? If, on the other hand, you choose to circumcise a
baby’s healthy foreskin, please remember: he will never forget and likely will never
forgive the harm you have needlessly done.
Notes
1. It has been argued that Freud moved in this direction because of intense criticism by shocked
Victorian readers of reports suggesting that childhood sexual abuse may have led to hysterical
symptoms of many of his patients. In the 1990s, some regressive therapists caused a scandal
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3.
4.
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by planting suggestions regarding the possibility of such abuse in their patients’ minds.
Responsible regressive therapists are scrupulous about avoiding such suggestions.
For simplicity’s sake, I choose to use the word “primal” in this paper to refer to all forms
of regressive re-experiencing, not just those that occur specifically within Primal Therapy or
Primal Integration contexts.
A well-known Kellogg quote supports my assertion: “The operation [circumcision] should be
performed by a surgeon without administering an anesthetic, as the brief pain attending the
operation will have a salutary effect upon the mind, especially if it be connected with the idea
of punishment” (Kellogg, 1888).
Peter Levine, the inventor of Somatic Experiencing, reduces the re-experiencing component
of regression to tiny “titration” drops of recollection—just enough to provoke a rebounding
reaction that can “shake off” the trauma. Levine goes so far as to advise against “reliving the
trauma,” asserting that awareness of its symptoms should be sufficient to enable the traumatized
individual to shake it off (Levine, 1999).
Golden (1999) supplies the following statement by nurses at an American hospital who refused
to participate in neonatal circumcisions: “Our medical position was that neonatal circumcision
was unjustifiable. Our ethical position was that it violated a newborn’s right to a whole, intact
body. As patient advocates and nurse-educators working in maternal-child health, we believed
that we had a professional duty to dispel myths and offer parents factual information about
circumcision, and that we had a duty not to participate in a procedure that surgically altered the
normal genitalia of unconsenting minors.”
References
Bigelow J. (1992) The Joy of Uncircumcising: Exploring Circumcision: History, Myths,
Psychology, Restoration, Sexual Pleasure, and Human Rights. Lindenhurst, IL: Hourglass Book
Publishers.
Boyd B. (1998) Circumcision Exposed: Rethinking a Medical and Cultural Tradition. Freedom,
CA: The Crossing Press.
Chamberlain D. (1989) Babies remember pain. Pre- Peri-Nat Psychol J. 3(4):297–310.
Freud S. (1916–1917/1933) New introductory lectures on psychoanalysis (Lecture XXXII),
“Anxiety and Instinctual Life.” In: Strachey J (ed. & Translator) The Standard Edition of the
Complete Psychological Works of Sigmund Freud, Vol. 22. London: Hogarth Press, pp 81–95
(Original work published 1916–1917).
Golden T. (1999) Do men “remember” the trauma of circumcision? Posted on MENWEB
(www.menweb.org/circtom.html).
Goldman R. (1997) Circumcision: The Hidden Trauma; How an American Cultural Practice
Affects Infants and Ultimately Us All. Boston, MA: Vanguard Publications.
Hartman D, Zimberoff D. (2004) Corrective emotional experience in the therapeutic process. J
Heart Cent Ther. 7(2):3–84.
Holmes S, Morris R, Clance P, Putney R. (1996) Holotropic Breathwork: An experiential approach
to psychotherapy. Psychother Theory Res Pract Train. 33(1):114–120.
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Chapter 17
Circumcision Memory
Thomas W. Hennen
Abstract A doctor circumcised me six days after my birth. I vowed just before
passing out in extreme pain, cold, rage, and exhaustion that “I will not forget” what
happened to me that day. Then, 52 years later, I chanced to regain those long-buried
memories. This account describes regaining the memories and, through the memories, my perceptions of my world from birth to ten days. The remarkable memories
consist of richly detailed visual images, spoken words and sentences, tactile sensations, extreme pain, intense anger, rage, fear, puzzlement, and sadness. I address
the memories from the viewpoint of the child I was, living the memories, and of
the adult I am, examining and interpreting the memories in context. The first person
account is honestly presented, and is not fiction. Predictably, some will not want
to believe this account because it challenges their beliefs of what a newborn infant
thinks and experiences.
Keywords Memories · Rage · Fear · Anger · Pain · Nightmares · Shock · Foreskin ·
Mutilation · Disfigurement · Deception · Betrayal
Introduction
On July 1, 1997, at the age of 51, I had the unusual and unsettling experience of
beginning to recover long-buried memories of my first ten days of life outside the
womb. These recollections included graphic memories of my own birth and circumcision. Be forewarned that what follows is not fiction: it is real. Today, I am a
63-year-old lifelong bachelor. Although educated, I am not an academic by profession. I have no formal medical training or religious instruction. This account has
been through many drafts and was not originally intended for publication. In the
T.W. Hennen (B)
Washington and California Bar Associations, Attorney Before the US Patent & Trademark Office,
Des Moines, WA, USA
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beginning, I sought only to document what I recalled. Admittedly, my account is
anecdotal rather than scientific, and is more data than it is thesis. If this account has
a thesis, it is that infants possess a level of awareness far beyond anything normally
reported in the medical literature, and that pointless and unwarranted circumcision
damages the child far more than legal authorities and medical personnel have been
willing to acknowledge.
All of my life, I have known I had been born in November 1945, at Tacoma
General Hospital, a fairly typical American metropolitan hospital in Tacoma,
Washington, USA. As a baby, I remembered the pain of my experience there but,
after a year or two, those memories became buried under countless other more recent
memories. Still, the buried memories continued to negatively affect my life.
When I was about ten, and had long since lost access to the early memories, my
mother told me explicitly that, soon after I was born, the doctor had “cut a little flap
of skin off the end” of my penis. She tried to reassure me that I didn’t need the flap
of skin. She said this as though she believed the doctor had performed a valuable
service, and I am sure he had convinced her that he did. I was shocked beyond words
to think that my own mother would allow this to happen and not protect me, but my
mother, it appeared, had requested it be done.
I asked earnestly why she would do such a thing, and she responded that the
doctor had recommended it be done to me while an infant because otherwise I would
grow up and soon be “too big to handle,” and they would never be able to do it
then. The doctor made no medical arguments, or at least none my mother could
repeat to me; the unsupported assumption being that there was any reason to do
this at all. There wasn’t. That was all she would say to me. Further questions were
rebuffed, even though I desperately needed to ask many more. In her defense, I
don’t think she had any other answers to give. Looking at these arguments today,
their complete lack of logic is self-evident. Many years later, my mother admitted
to me that she had been very young, from a rural upbringing, really didn’t know
anything about these matters, and placed (or misplaced) far too much trust in the
doctors.
Nightmares Passing as Dreams
My experience in the hospital had affected me deeply and I believe was the genesis
of many irrational fears that have plagued me for years. Irrational fears included my
extreme shyness and inhibitions, my lifelong lack of trust in others, and my initial
fear of barbers, dentists, doctors, or anyone else with shiny metal instruments and a
white coat.
My mother told me that, while I was a very small child, I would often have trouble
sleeping and would toss and turn constantly; I would get little rest. This matches my
recollection of having bad dreams of the circumcision at that age. The pediatrician’s
solution was to suggest my mother have me sleep with a stuffed toy animal, but that
did not help. My problem was not loneliness, it was medically inflicted terror with
no redeeming purpose, but no one cared about that.
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One hospital memory, in particular, served to inspire many nightmares. The
memory concerned a strange, dark-colored wooden worktable that I believe was
a chemistry lab bench that I saw from time to time as I was carried around the
hospital. I remember a nurse once tripping and falling down near such a bench and
another nurse helping her back up.
The dream this memory inspired usually began by me going through a door and
finding myself in a small room dominated by just such a chemistry lab bench. In
my dream, a nurse would walk on one side of the chemistry lab bench between the
bench and the wall on a wooden lattice or grid that kept her feet about six inches
off the floor. There was very little room to move past that chemistry lab bench but
the nurses were all drawn to it. I dreamed that nurses were tripping and falling
down on the wooden grid work that was unstable and lurched from time to time as
they stepped on it. In my dream, the wooden grid was sometimes floating on water.
Once nurses fell down, they disappeared down into the floor drain. In one common
variation of this dream that recurred many times, the room also held a boiler that
was heating up and was about to explode. I had this dream or variations of it too
many times to count in my childhood and adolescence and continued to have this
dream well into adulthood.
These and other dreams, some involving steam locomotives trying to kill me,
haunted my sleep for years. I could have finished the rest of my life never knowing
what was bothering me, but for a bit of technology, and one very fortunate choice
on July 1, 1997.
The Account Begins
I was not under the influence of any intoxicating substances the night the memories began to return. I did not drink any alcohol that night, nor take any drugs of
any kind. I was fascinated by computers and, in June 1996, had acquired a new,
faster Windows 95 computer to supplement my older 1985 computer. Then, on
July 1, 1997, in the early evening just after dinner, the thought occurred to me
that I now had Internet capability and for the last year had been largely ignoring it. I decided to take some time that evening just to see what I could find on
the Internet, not looking for anything in particular and with everything being fair
game.
I began simply enough looking at various sites, and then clicking links that
looked interesting. I went from one subject to another in rapid succession without
following any particular theme. Then, as I was beginning to get bored, the thought
occurred that I could even explore the pornographic sites I had heard people talk
about if I could only find one, and this was a good opportunity to try. It was while
clicking on a link on one such site that I was taken to a site on male circumcision.
Then, when I clicked on a link, I saw a color photographic image of a circumcision being performed on an infant. It was not a pretty image; the bloody infant was
screaming in terror; the photo hit very close to home.
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Suddenly, I felt something very strange happening physically in my head. It
literally felt like how I imagined having a stroke might feel. I felt no pain, and
experienced no other stroke symptoms, but I felt a part of my brain suddenly
flooded with a fast flowing, very warm liquid. I presumed the flow was blood. I
could feel the sudden flow of liquid as though an artery had burst deep in my
brain. I could feel the turbulence of the flow and could tell the flow rate was
high.
The flow, at first, seemed uncontrolled, as a burst artery would be. Not knowing what was happening and thinking I might have been injured; I felt for signs
of blood in my hair, but found none. My whole head quickly overheated and I
began to feel flushed and uncomfortable. I felt this only in my head. I felt the
turbulent flow of liquid probably for less than a minute, and the overheating probably only 3–5 min. I had never before felt a sensation quite like this and have not
felt one since. This was not simply a red-face or embarrassment; it was something very different and much more; this was some kind of autonomous arterial
event that I could neither understand nor control. There were no other physical
symptoms, but it felt as though something had caused an artery to dilate and
quickly allow a great deal of blood to flow to a particular part of my brain. Then
after several seconds it seemed to slow down, the flow rate returning closer to
normal.
As these sensations came on, I was quickly overcome by an inconsolable rage.
It was anger so intense it completely dominated my consciousness. Nothing had
happened to make me angry. It was a remembered anger, reincarnated from the
point I had passed out on the table 51-and- a-half years earlier. I sat motionless in
my chair in stunned silence and slowly began to remember. The first memory to
return was the memory of the extreme pain I suffered during the most painful part
of my circumcision. Initially, the searing pain was all I remembered, but so vividly,
I literally thought for a brief moment I was being circumcised again and quickly
glanced down for reassurance. I wasn’t.
Then, I remembered a little more, but in a somewhat jumbled order that was difficult to put in a proper chronology. I knew instantly what it was I was remembering
and I struggled to get it right. I also knew how fragile memory could be and decided
it was important that I immediately try to record these memories and so began to
write down what I remembered. I continued to be so consumed with rage during
the initial writing that the first several drafts of my writing were so angry they were
almost incoherent, like the ravings of a lunatic. It has taken me fully 11 years of
working intermittently to filter out most but probably not all of the anger from this
writing.
Remembering was not easy and required great concentration. I was able to work
from memories already recovered toward related memories not yet recovered. I went
through several more drafts of my documentation until in about late 2002 I thought I
had completed my task, but I soon discovered I was wrong. It wasn’t until, in 2008,
the effort to write this account completed my recollections and, for the first time, I
was able to tell the complete account.
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Estimated Time Line
In reconstructing the time line for the events described, I have relied on knowledge
of my birth date, and the fact that I was in the hospital for ten days after birth as my
mother told me was customary in 1945.
The Memories Assert Themselves
The memories I have accessed consist of short episodes of consciousness, of words
spoken, of visual images of people, of places, of things, of warmth, of cold, of
my own thoughts and of fear, anger, rage and extreme pain made all the more
memorable by my intense emotional reaction to the pain, the fear, and the anger.
Interspersed between these memories are long periods of sleep, apparently a favorite
pastime of newborns. Everything reported here that I remember from 1945 is as I
genuinely remembered between 1997 and 2008.
Zero Hour, Wednesday, November 28, 1945, Time from Birth
Records: 4:30 A.M.
My Birth
My natural state was sleep. My memories begin about two hours prior to my actual
birth with the initial wrenching movement that broke me lose from my position in
my mother’s womb and carried me a short distance from the womb on my way to
the world. I initially awoke when I felt I had been bumped loose from the position I
had been occupying for so long. With each contraction I sensed that I moved a short
distance. The forces seemed violent, sudden, unpredictable, out of my control, and
unnecessarily strong yet gentle at the same time, and of relatively short duration,
followed by a relaxing calm. I felt no pain.
Before birth, my eyes were tightly closed and I could see nothing. Starting at the
time shortly after the initial contractions, and for a prolonged time, including during
the height of the birth forces, my field of vision (with eyes shut) did fill with patterns
of light and dark a couple of times. I was at first frightened and worried that I was
leaving the only world I knew for an unknown world and I didn’t know if I could
survive the change or not. With few exceptions, I seemed to have little conscious
sense of my physical body, only of my mind. Often the onset of birth forces was
accompanied by muffled, unintelligible words from someone outside (presumably
the doctor). Each time the forces on me subsided, I tried to return physically to
where I had been, to where I knew I could survive, so I could go back to life as
usual and sleep. But I had no traction and could not go back. I thought I had done
something wrong to cause the contractions to start and didn’t know if I was about
to die.
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I also remember in particular during birth two episodes of external force that I
felt on my neck vertebrae. Up to that point, I didn’t know I had a neck. On two
distinct occasions, my head was forcefully twisted to the limit of its motion, and
then it was twisted a little further. The pain in my neck vertebrae was severe. At the
time, I was sure my neck was very close to snapping and would snap at any moment
if the force did not subside, but I was powerless to protect myself. I can only hope
that by now doctors have learned better than to use this dangerous technique.
Shortly thereafter, with the aid of someone’s hands, I emerged and was then outside, feeling wet and cold and slightly uncomfortable. I recall shortly after arriving
being handled one way then another, then held vertically by my ankles and being
slapped on the butt, one time. I recall I didn’t like being held upside down, or being
hit, nor did I see the need for it. At this point, I caught a glimpse of the doctor. He
was dressed in blue or green surgical clothing, but wore a mask. My birth certificate
says he was Dr. David H. Johnson. In a fleeting glimpse, I thought I saw a gray beard
or other facial hair under and at the right edge (my left) of the mask. The doctor who
circumcised me a few days later did not have a beard, as I recall.
I sensed the welcome warmth of the large surgical light illuminating the table,
its bright light affecting my sensitive retinas through my tightly closed eyelids. The
nurses didn’t understand I needed warmth and left me for a time on the cold metal
table. I didn’t know where my mother went. She had to be there at first, but once I
was on the table, they couldn’t get her out of there fast enough, apparently. I looked
for her and expected to be reunited with her but I was never given to her that I recall.
The message this sent to me was that the hospital people thought I was not important
enough to be allowed to be near my mother, or perhaps my mother didn’t want me
and somehow it was my fault. This did not make me feel good.
At one point, a nurse pulled on my leg, right or left I don’t know which, but
probably right. Then I felt an intense sharp stabbing, burning pain in my heel (the
obligatory blood sample). That pain was intense, but fortunately was of short duration and did no permanent, irreversible damage so far as I know. The biggest effect
it had was to make my otherwise pleasant arrival unpleasant and to frighten me and
make me wary of people. Before taking the blood sample, the nurse foot printed
me. At least that didn’t hurt, but tickled a little when she applied the ink to my
feet with a roller, and felt sloppy when she pressed each foot against a sheet of
paper. This paper became my Tacoma General Hospital Record of Birth that I
still have with my important papers. I eventually went to sleep, thus ending this
memory.
Day Two, Thursday, Time Unknown
The First Nursery I Remember
My next earliest recallable memory is of waking up on my back in a bassinet in a
dimly lit nursery, wrapped up tightly and trying to sleep. The lights were dim and
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there were no windows. I think this was deliberate to shield the newborn’s eyes from
bright lights as the newborn transitioned from life in the womb to life in the world.
I was wrapped so tightly I could not move. I was very warm, too warm really, and
constrained by the tight wrap. Most of my time was spent sleeping in a bassinet
that had high sides, and that did not afford me much of a view except of the ceiling. I heard two or three nurses moving around, talking to each other, and talking to
some of the infants. One of the nurses then peered over the side of my bassinet and
talked to me. The nurses frightened me. I didn’t know who they were or what they
wanted, and I wanted to avoid them. I think I would only have felt comfortable with
my mother, but she and I were deliberately kept apart in the hospital, as was standard hospital practice in 1945, almost as if I was to be put up for adoption. I really
didn’t know if it was morning or night. I would guess it was early evening when I
awoke.
Day Three, Friday, About 10:00 P.M.
The Nurse Takes Me on Her Break
I do remember a few times, one probably late on the evening of my third day, when a
nurse wearing a starched white uniform (probably an RN, not a nurse’s aide) picked
me up from my bassinet. I sensed the time from the darkness and low level of activity
in the nursery and hallway, and the hushed voices. This nurse was older, probably
35–45 with dark black hair and a white nurse’s cap. We stood there and the nurse
talked with the other people. I was very sleepy, but the nurse and her friends seemed
wide-awake.
I was scared when the nurse picked me up (almost in panic) because I didn’t
know who the nurse was, or where the nurse was taking me, or why, or what she
expected of me, or what would happen. Also, my mother was not there to protect
me. I knew very well how vulnerable I was. The sounds of the people’s voices
talking seemed very loud to me, but after I had heard them talking for a short
while, the sound volume became more “normal” as my brain adjusted the volume
lower.
My Early Thoughts at Being Taken from My Bassinet
I felt safe in my bassinet, even though my mother was not there. As the nurse carried
me down the hall, several thoughts began to run through my mind. “Where is my
mother? Where could she be? What will these people do to me if she is not here
to protect me? Are you taking me to meet her?” These had to be some of the first
actual thoughts using English words that I ever had.
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Day Four, Saturday, Early Afternoon
The Boston (Baby) Marathon
I now think it was Saturday, but at the time it was just another day to me. A young
student nurse, probably about 18 or 19 years old, came to me and picked me up from
my bassinet to take me for a walk. We walked out of the nursery and down the hall
to an open area with a high ceiling. I think now this was the lobby just inside the
main public entrance to the hospital, the same place I had gone the night before. It
was probably shortly after 12:00 noon or so, because I could see blue sky through
a high window in what I believe was the west wall. It was warm indoors, and there
were a few other people walking up and down the hallway. We walked up and down
that hall about four to six times as if running some sort of baby marathon course.
My Introduction to Numbers
We walked past many closed offices, probably doctors’ offices, having golden varnish colored wood grain doors with black numbers painted on them. I saw the
numbers mostly as mysterious symbols, not as numbers, but suspected they had
some significance in identifying the doors.
Day Five, Sunday, About 7:30 P.M.
Tommie’s Big Adventure
I believe it was about 7:30 P.M. the next night, my fifth day in the world, Sunday,
when something wonderful happened. I shared a memorable adventure with a nurse.
I’m fairly certain it was against the rules for nurses to take a baby outside the hospital, even if they remained on the grounds, and likely it was illegal as well; it certainly
would be illegal today.
In the interest of brevity, rather than report the details of this next memory, I will
simply summarize it. A nurse decided to take me from the nursery for a walk down
the hall, and in the process one thing lead to another and before I knew it, she had
taken me outside through one of the many side by side metal framed glass doors
of the main entrance and onto the grass “to show me rain.” Unfortunately, it was
no longer raining so we came back inside. This abortive attempt inspired others to
organize a full-scale expedition that included my nurse, and about ten of the other
nurses. We were to go outside for a walk on the grounds at about 10:00 at night.
We exited through the janitor’s workroom through a fireproof door near the hospital
incinerator, and walked all over the lawn for about 20 minutes before returning. We
avoided detection by the supervisor and entered through the same fireproof door
through which we exited.
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Day Six, D-Day, Monday, About 7:00 A.M.
A Rude Awakening Early One Morning
I remember early the next morning, which was my sixth day in the world, Monday,
I was in the hospital nursery. I was sleeping in a bassinet, wrapped in a blanket of
some kind. I was very warm and comfortable, and was perspiring heavily from the
warmth. I was very sleepy. It felt so good to sleep. I would guess now as an adult it
was probably just before 8:00 A.M.
All of a sudden there was noise and bustling activity in the nursery as the nurses
had begun their morning wakeup routine. After a designated time, probably 8:00
A.M., the nurses stopped trying to be quiet and began speaking loudly to each other,
deliberately trying to wake up the babies. I yawned and opened my eyes.
My Journey Through the Hospital
Another nurse said something, as if some event involving me was listed on a schedule they needed to follow. After several minutes, my nurse handed me to another
nurse who then carried me through a doorway out of the nursery and down a hallway. The doorway had two swinging doors, each with a round glass window at about
an adult’s eye level.
The Portable Surgical Light Question
People were getting organized and there was some discussion whether they could
proceed with their plan because of an equipment problem. Against the wall was
a portable surgical light that doctors use to light the operating field. I saw it as I
was carried into the room. The nurses questioned whether their plan could proceed
because they thought the portable surgical light was not working. One of the nurses
said it had not worked earlier and she didn’t know if it had been fixed or not. A
little later, one of the other nurses confirmed that the light had been fixed and did
work properly or that they had arranged to borrow another identical portable surgical
light. The decision was made to go ahead because everything was ready. Other than
what I have said here, I had no idea what they were talking about. We then must
have moved to a second room.
The Entourage Arrives
After some delay, the door opened and I heard a man come into the room. He was
wearing a brown suit, a white shirt, and a dark tie. The others treated him with great
respect. He said something to the nurses I did not understand, probably something
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like “Are we all ready?” And a nurse responded something like “Yes” and may
have said his name. They exchanged some pleasantries. I don’t remember precisely
what they said. As I recall, there was a time problem, the doctor was in a hurry,
probably trying to keep to a schedule, or the nurses were behind schedule, and it
was the nurses’ job to make sure everything was ready. Since I only saw my birth
obstetrician one time, and he was wearing surgical clothing when I saw him, I could
not say if this man in the brown suit was the same person or not.
Close Encounters, First Contact
Finally, the doctor turned to me, put his face very close to mine, and said something
to me (really he spoke at me, not to me). At some point during this encounter, I
smelled the doctor’s bad breath. I almost threw up. I smelled something strong and
very bad smelling, probably a mix of coffee and cigarettes, though I had no idea
at the time what caused the stench. When he put his face close to mine to speak to
me, he spit little drops of saliva at me that hit my face, and he breathed his awful
breath on me. I did not like that. I quote him almost verbatim when he said “Hello
there, Buddy Boy. Don’t worry about a thing. We’re going to take good care of you.
You’ve got nothing to worry about. We will fix your problem. You’re going to be
fine after we take care of it.” He used almost if not exactly these words, and certainly
that was the tone and substance of what he said to me.
Of course, at the time, I did not know how I could respond. I was listening close
for any clue as to what he had in mind. When I heard the word “problem,” and that
he would “take care of it,” I became quite concerned, got a bad feeling in the pit
of my stomach, and wished for some way I could contradict him, and explain why
he was wrong, but of course, there was nothing I could do to communicate my disagreement. I had no way to tell this doctor he was full of crap. What I remember
especially was his use of the generic name “Buddy Boy” for male infants. When
I finally arrived at my new home, coincidentally I soon was given the nickname
“Bud.” Each time I heard that name, it made me think of doctors hurting me, and
at first it made me worry I was soon to be subjected to some other terrible, disfiguring procedure for someone else’s amusement. Fortunately, I never was after I came
home, but I never liked that nickname.
I genuinely believe he meant no harm, but in fact, I think he just didn’t appreciate
the extensive level of damage his ignorance, ego, and greed were causing by inflicting an unnecessary and disfiguring medical procedure when nothing was wrong. I
think he did not particularly care about me as a person, other than as a biological
specimen. I think he was primarily performing for the nurses who interested him.
The portable surgical light, if it was the same one I had already seen, had been
moved from the first room and was still in the stowed position, not set up for use.
One nurse asked how you set the light up and the other nurse demonstrated how that
was done. I remember the doctor sitting in a desk chair, like a stenographer’s chair,
at the desk several feet in front of me as I lay on the table.
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Time to Go Now
When the doctor had finished doing whatever it was he was doing, he got up from
the desk, the people spoke as if making some kind of arrangements, and we all
walked down the hall through several doors. My nurse was carrying me. People
began putting their coats on and assembling as if preparing to go somewhere. We
then went outside and some people began getting into automobiles while others
walked. My nurse was going to walk, but since my nurse was carrying me, and
since one of the people had recently purchased an automobile, the automobile owner
insisted she and a few others ride with him. My nurse and I got into the automobile
along with several other people, some men, some women. The front seatback folded
forward on the passenger side to allow us to enter the back seat. My nurse and I
sat in the center of the rear seat with other passengers on either side. One thing I
remember from that ride was the constant pitching forward and backward as the
driver shifted the transmission gears.
Driving to Our Destination
Again, to make a long story short, I will briefly summarize what happened next. We
drove probably less than a quarter of a mile to a building where, after waiting for
someone to bring a key, we entered. We rode an elevator to about the fourth or fifth
floor, exited, and went into a room off a hall. Others were there in what seemed to
be a library and conference room. There the people conducted about a 30-minute
lecture on some medical topic. We then left and returned to a different part of the
hospital.
We exited the car and climbed up stairs, walked across a porch, and into the
building. We waited a few minutes in the main hallway for someone to find the key
to the room off that hallway to the right. I can remember seeing down the hallway
a pair of swinging doors with round portholes near the top of each one and when
they opened, I saw a black man in a rubber apron and elbow length rubber gloves.
Someone arrived with a key and opened the door. They carried me inside. This room
was cold and dark, had tables and counters that looked fairly old, and looked like it
received little use.
At first they couldn’t find the light switch, someone cussed, but someone finally
switched on the light as more people arrived. Thinking about it as an adult, I suspect
the point of what they were doing was finding a room where they could do the
circumcision without taking up a costly operating room, a room where no one would
see what they were going to do, and where no one would interfere.
Things Start Getting Serious
The nurses were beginning to don surgical masks and gowns, and I could tell something was about to happen. The doctor was still dressed in his shirt, tie, and suit.
Then the doctor left the room through a door a nurse held open for him. I was curious
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where he went. He left through a wooden door. I looked through the doorway as the
door opened and can remember seeing blue ceramic tiles on the wall through the
open door. One nurse said the doctor has something to do and we have to wait now
until the doctor returns, and that he wouldn’t be gone long.
My adult guess is that he had to leave to change his clothes, perhaps shower, and
scrub up for “surgery.” He really took it seriously. When he returned, he was dressed
head to toe in a deep blue surgical gown with a matching surgical cap on his head
covering his hair, and he wore a surgical mask. The nurses anticipated that I might
be uneasy at not seeing his face and not recognizing the doctor and so made a point
of introducing him to me and telling me he was the same person only dressed up. I
did recognize him, and thought the nurses’ explanation was unnecessary.
Time to Put the Horsie into his Harness
As everyone was busy doing their part of this procedure, one nurse, an RN I would
guess from her all-white uniform and cap, and her more professional demeanor, had
appeared in the room. The RN removed my diaper, and said to me as she picked me
up under my arms, “Now its time to put the horsie into his harness.” She used exactly
these words, no more and no less. She said it as though I was a horse about to be put
in a harness, and I think it was supposed to be cute. I did not really know anything
about horses or harnesses and so didn’t know what to think about her comment.
I remember she picked me up under my arms and dangled my legs down into
some form of a device not unlike a ship’s life preserver (or horse collar?). She then
fastened elastic straps or other retention devices below to restrain me. I was propped
up in an uncomfortable sitting and slightly reclining position that would have been
impossible without the restraining device.
The Visual Barrier
The nurses built a barrier in front of me by placing a dark blue cardboard box of
paper product (probably Kotex brand sanitary napkins) that was about ten inches
square and about two or three inches thick, on its side on the surface of the “life
preserver” device directly in front of my face, and then placed a second box on top
of the first box, and then I believe a third. They placed a blanket over the boxes to
make sure I could not witness their work.
I believe the doctor took a seat on a low stool or chair in front of me. I could
not see him. Then as the room lights seemed to go down, the portable surgical light
was quickly set up, turned on, and positioned to shine on the area where the doctor
would be working. It was at this point I felt the welcome warmth from the portable
surgical light on my abdomen as the nurses adjusted the angle of the light.
The Torture Begins with Manual Separation of the Foreskin
The doctor must have given a signal that he was ready to begin. At this point, the
doctor or nurse swabbed my genital area with what must have been an iodine-based
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disinfectant. I do know there was absolutely no anesthetic. I then felt what I thought
must be the doctor’s hand in a rubber glove touch my penis. He began a slow examination. Then, he somehow quickly grabbed my penis tightly and pulled or twisted
on the foreskin, perhaps using a tool, or perhaps not, but in a few quick jerking or
twisting motions, tore it loose where it was naturally attached to the glans penis. I
was again frightened at this point. What he was doing made me feel I was being
permanently injured. There was a fairly severe level of pain, discomfort, and surprise, but once the foreskin was loose, the pain subsided somewhat. I don’t know if
the foreskin or tip bled at this point, but the foreskin certainly did later as its arteries
were severed.
He continued working until he could stroke the foreskin back to fully expose the
tip and shaft. I don’t think he applied any artificial lubricant. I felt cool air on the
tip as it slipped forward through the foreskin to become fully exposed for the first
time, as he squeezed the penis shaft and pulled and tugged on the foreskin. The
tip must have been moist, and the moisture began evaporating into the air, cooling
it. I felt the smooth texture of the latex glove and could distinguish between touch
by his hand, and touch by metal instruments. I didn’t know what he was doing, or
why he was doing it, but assumed this was merely an examination that would soon
be over, not the permanently mutilating, and disfiguring surgery that it turned out
to be.
The Metal Clamp
Soon I felt something else touching my foreskin. It was something that was cold,
probably metal, and that did not feel good. I could not see it or tell what it was, but
it was uncomfortable. It hurt when it pinched my foreskin as it was attached. It must
have been a clamping device of some kind and seemed to be made of light gage
sheet metal, perhaps spring steel. I felt the doctor pull on this metal clamping device
until my foreskin was stretched tight and my penis itself was stretched and very
uncomfortable. It is possible my foreskin was stretched to form a tunnel extending
beyond the tip. I had the feeling that if I moved in the wrong direction, I might
actually pull my penis off, and so tried to remain still. This frightened me further.
Despite this mistreatment, the pain and discomfort was moderate to severe, but not
extreme. I was thinking that, when this “examination” was over, I would eventually
recover and be back the way I was, unharmed. I was wrong again. Harm, it seems,
was the whole point.
The Touch of a Scalpel
Everyone in the darkened room became silent. Then, with the blanket and boxes
blocking my view, and not being able to see anyone’s face or anything else, and
feeling restrained, helpless, all alone, and abandoned in the darkness, I felt on my
penis the most extreme searing, burning pain. It was greater pain than any other I
have ever experienced. It seared me as if to the core of my soul, without warning,
without reason, without explanation, without compassion, without understanding,
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and while I was bound and helpless to struggle, against my will, without my
permission or consent. I felt a burning arc of pain stream from the bottom of my
penis around the right side to the top surface punctuated by a series of separate
individual crescendos of pain as each nerve was severed in rapid succession as the
scalpel plowed through my most sensitive tissues.
Accompanying this extreme, searing, burning pain was the extreme but dull ache
of cut skin. I did not cry out. My breathing stopped momentarily. My whole body
tensed in shock and surprise. My head looked up and to the right or left in disbelief.
My eyes opened wide and I lost my focus on what I could see in the room as my
mind focused tightly on my foreskin and I tried to deal with the unexpected burning, searing pain that overwhelmed me. This was the memory that had first broken
through to my conscious mind on July 1, 1997. It was the memory that I think has
been subconsciously poisoning me psychologically all my life.
Because I stoically bore the pain and didn’t at first cry out, I am sure I confirmed their belief that this procedure was indeed painless, justifying withholding
all anesthetic. It wasn’t painless. My first reaction was to think the doctor had made
a terrible mistake since I had been given no warning that such a thing might happen,
nor any reason why it should. Upon seeing my reaction to the first cut, one of the
nurses, watching with rapt attention, said “Ha, there we go, I don’t think he likes
it much. What’s the matter, baby? Don’t you like it?” Again these were her exact
words. The nurses continued to occasionally make insensitive, clinical comments to
the doctor as the mutilation and disfigurement proceeded, though I don’t remember
what they said. I think this was really a demonstration for the nurses, many of whom
may have been student nurses.
I did not want this to happen and I was terrified to think what they might be doing
to me or what they might do next. They did not explain. They lied. They deceived
me with their silence as much as with their words. They did not ask. They just took
advantage of an innocent child. My whole body tensed from the pain and shock and
tried to escape, but there was no escape. This was not my fault. I was a victim of
their cunning, their stupidity, and their greed.
I could feel not only my pain, but also the doctor’s instruments and rubber gloves.
I could visualize and actually feel the foreskin being removed from my penis, carefully, efficiently, one small piece at a time, with metal tools. It was being removed
permanently; it would not grow back. I could also feel the blood from the tiny severed arteries pulsing and flowing over my penis and belly, making them slippery
and wet, and the nurse trying to keep the blood under control by blotting it up with
a wiper of some sort, pressing against my abdomen, making me more nauseous.
The pieces of foreskin were being stripped away from the tip one small piece at a
time, never to touch it again. I tried to move to cancel the doctor’s motion, but it
didn’t work. I could not pull free, held in place by the “life preserver.” I absolutely
did not want this amputation and disfigurement but was powerless to stop it. The
message I was left with was that I was only a worthless infant whose body was
theirs to mutilate at their whim. I had no value. There was no telling what other
mutilations might come next. That message was received loud and clear and I can
only believe it profoundly affected my later psychological development in many
negative ways.
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Surgical Technique
I did not actually see any of the surgery, and I am not an expert on anatomy, but I
think I can describe what must have happened based on my sense of touch and my
lifelong ability to visualize. I was placed in some sort of body restraining device
that looked like a life preserver. My foreskin had been manually separated from its
natural attachment to the glans, and then a light gage metal clamp of some kind was
attached to the foreskin and used to pull it past my tip and away from my body. The
pulling force on the clamp was so strong, that my penis felt stretched in a roughly
horizontal direction and was very uncomfortable. I felt like, if I wasn’t careful about
how I moved, my penis was going to be pulled off.
The first cut of the foreskin was made with a scalpel and began near the bottom
right side of my horizontally stretched penis. The cut seemed to sweep circumferentially upward on my right side in a plane perpendicular to the length of my penis
from a point near the bottom to a point near the top of the shaft. This cut allowed
the right half of foreskin to remain attached at the sides to the uncut left half while
severing the nerves at the base of the foreskin. I believe that destruction of nerve
function is the primary goal of circumcision as practiced routinely on newborns,
and the removal of skin is simply an associated necessity.
Once the first semicircular cut was made, there was a brief pause while the doctor
put the scalpel down and picked up the other instruments. Then, the doctor began
to use tweezers and surgical scissors to cut the loosened foreskin on my right side.
With this first incision, the tension that had been applied by the clamping device
was relaxed on the right side, but was still present to some degree on the left. The
reduction in tension also meant that now the penis was not quite as stretched as it
had been. The doctor used the tweezers to grip the loosened foreskin and hold it
steady. The doctor used surgical scissors to trim off the skin in what seemed like
one very small triangular piece at a time. The right half of my foreskin was removed
in what seemed like about six or more separate triangular pieces. I can’t be sure of
the exact number or shape and it could have been much more than six pieces. I could
feel each small piece of skin being cut and removed separately.
I could tell he was fairly experienced using his hands and dissecting tools on
biological specimens. This realization that, even though I did not like what he was
doing, at least he was skilled and doing it well calmed some of my fear that he
might accidentally injure me further. I found my reassurance in knowing he seemed
focused only on my foreskin and had not yet attempted to open my belly or remove
either of my legs, even if the medical reason to do so equaled the reason to circumcise. It did nothing to change how I felt about what was happening to me, however,
nor did it dull the pain.
I think his technique was unusual and that was why he had explained his technique to the nurses earlier at the study group meeting. I think he was demonstrating
that, when he severs the nerves with the first scalpel cut, he could then use scissors
to make many small cuts to the skin without causing me more pain. The many small
cuts may have been his way of fitting the remaining skin to the penis so as not to
remove too much. At any rate, I think his ego was heavily invested in whatever he
was seeking to accomplish and I think he relished having an audience.
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After he had removed most of the skin on my right side, his scissor cuts were
getting close to where the skin was still served by functioning nerves from the left
side. He seemed to know when to stop, though the last few cuts began to become
very painful again and I flinched. He apologized to me, but he did not apologize for
the mutilation. I noticed that, as he removed more of the skin, there was less skin to
grab with the tweezers and his job was getting more difficult. Finally, he decided he
had removed as much as he could without causing me excessive additional pain and
risking blowing the whole point of his performance, and he stopped.
The “Intermission”
At about this point, after the first half of foreskin had been removed, there was a
delay for some reason. My memory is not very clear about the reason for the delay,
but I think the nurses expected a pause and said something about it. Perhaps this
pause was to allow the doctor time to rest and refocus. Perhaps it was to allow me
time to recover by spreading the trauma out over a longer period of time. Perhaps it
was to allow the bleeding to slow down. I don’t know which.
The Second Scalpel Cut
After this short break, he returned, and everyone again moved in close to me. At this
point, I had almost forgotten there might be a second cut, thinking that since the first
part was over and done with, I hoped there wouldn’t be another cut. I was wrong.
Soon after the doctor had returned and resumed his work, I felt him readjust the
clamp pulling on my foreskin to tighten it on the remaining left side, and then the
same excruciating, burning, searing pain, the crescendos of pain as each remaining
nerve was severed, and the cutting from the bottom but this time on the left side,
sweeping up to the top. Then there was the tweezers, grabbing the partially severed
foreskin, and the cutting with scissors. By this time, the tension on my penis was
completely relieved and it was no longer being stretched.
Apparently, the second cut did not quite join the first cut at the top or bottom
but was intended merely to sever the nerves; else the left half of the foreskin would
have merely fallen off, spoiling the doctor’s fun. By then, I knew the routine. Next,
he used tweezers and scissors to remove small triangular pieces of foreskin and to
put a final trim on the skin.
Blood Runs Freely
I felt the moist tip being exposed to the cool air as the pieces of healthy, warm, protective foreskin were cut away. I felt the blood running on my penis, dripping, and
being smeared on my abdomen. I felt nothing contacting the tip, as had previously
been the case with the warm, snug foreskin. I felt the nurse wiping up the blood,
smearing it around on my belly with an absorbent cloth. The feeling of blood and
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the pressure on my abdomen from the wiping scared and sickened me further. My
emotional reaction was severe because I knew very well the disfiguring mutilation
was unnecessary and wrong. I knew it at the time, at six days of age, but could not
communicate to stop it. I will forever be disappointed in the doctor that he could
not (or would not) see the unnecessary nature of the mutilation. I had trusted these
people, but realized they had betrayed that trust and were now dissecting me, alive,
for no reason anyone has ever been able to explain to me.
The Merciful End to Torture
When my ordeal was over, the nurse in the white RN uniform removed the blanket
and boxes blocking my view so I could see again, and unfastened me from the
restraining device to which I had been shackled. She lifted me up and laid me on
my back on the table. Shortly thereafter she disappeared, leaving it to the other two
nurses to clean up. One was a young nurse, perhaps a nurse’s aid, about 18 or 20
years old, perhaps younger. The other one was much older, and very thin, with a
gaunt and heavily wrinkled face. She was probably about 45–50 years old or more,
looked much older, and probably was a heavy cigarette smoker. I think now the
older nurse was as much a janitor as she was a nurse. I thought at the time the older
nurse was ugly and mean tempered, and not someone I wanted to have around me.
I was glad the one nearest to me was the younger one.
Immediately afterward, the doctor disappeared from the room as the nurses
worked straightening everything up and preparing the room for its next use. The
doctor soon returned fully dressed in his brown suit and said something to me I
didn’t completely understand, but that I remembered. As I was lying there in agony
from the severed skin, he said, “There you go, Buddy. No need to thank me. I was
glad to help you out. Now you’ll be fine and you can thank me later for the wonderful thing I did for you.” These were close to exactly the words he used. I noticed
he didn’t say “Buddy Boy” this time, only “Buddy.” He forgot the name he gave
me and that was just one more impersonal insult to top off the day. I think it was
important to him to convince himself he was doing something good. I think somewhere in the back of his fuzzy thinking, he might have suspected the truth, but had
suppressed it. It was good I didn’t have to thank him.
Make Him Stop Crying! Pick Him Up!
I cried continuously at this point. It was the only way I could communicate my pain
with these people and have any hope they might do something about it. I think I
also needed to communicate to them that I had been genuinely injured, pointlessly,
and I knew that they were responsible. The older nurse was busy cleaning up the
blood-soaked linen and putting things away. She ignored my cries as long as she
could, until she could take no more. She shouted rudely and sharply to the young
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nurse, “Make him stop crying or I’ll come over there and give him something to
cry about! Pick him up! Pick him up!” Again, these were her exact words, delivered
in a very angry, menacing tone. I stopped crying, momentarily, out of fear, but I
wish now I hadn’t. I wish I had begun screaming. I think that much if not all of the
psychological damage I experienced resulted from being injured in this way for no
reason, feeling extreme pain, and being surrounded by people who thought I had no
pain and who wouldn’t listen to my cries. I continued to cry from the unremitting
pain, the surgical shock, the ache of severed nerves and skin, the nausea, the blood
loss, the fear, and the anger.
My Vow to Remember and to Obtain Justice
I sensed the nurses wanted me to forget about what had happened. I think they
said as much. Before I lost consciousness, however, I vowed to myself that if these
people thought these events were something I would forget about, and that was how
they were going to get away with them, they were wrong. I would make an extreme
effort to remember what they did to me that day so that someday I might obtain
justice. What justice was, or how I would do that was still a mystery to me. I do
remember thinking in precisely these English words the thought “I will not forget
this!” This thought kept running through my mind, over and over. This is not the
adult interpretation of my feelings; this was literally the thought in English words
that went through my small head, time and again, as I lay there in agony on my sixth
day. I think this intentional effort to form a permanent memory is probably why I
was successful so many years later in recovering this memory.
Merciful Sleep: The End of that Day for Me
I did finally stop crying as exhaustion overcame me. Before I lost consciousness,
I remember feeling sick to my stomach. My penis burned and I felt the dull but
severe ache of cut or torn skin. The fact that my penis ached so much and that the
nurses ignored my cries only contributed to my rage. This was not the gentle sleep
of a baby, but was the result of the extreme physical and emotional stress I was put
under, coupled with the significant blood loss and effort of screaming and crying,
mostly to no avail. At the point I blacked out, no one had dressed my wound or
wrapped me in a blanket to keep me warm. Apparently it was more important to
clean up the room than to tend to the injured infant.
It is here my memory of that event that day ended, as my mind went black and I
went to sleep. The terror, anger, rage, deception, betrayal, and pain of that memory
were as much as my young mind could handle. My brain immediately buried that
memory in the deepest recess it could find. When I next awoke, I did not remember
the event clearly, but remembered enough to know I should be scared. The next time
this anger surfaced was over 51 years later.
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Day Seven or Eight, Tuesday or Wednesday, About 10:00 A.M.
My Reawakening
I do remember the next time I was awake. I awoke in a bassinet in a brightly sunlit nursery room. It seemed like late-morning, probably about 11 A.M. or 12 Noon;
though I can’t be sure it wasn’t later. The morning rush hour of the nurses was over,
and a calm bustle had settled in. I know it wasn’t the same day as the circumcision
because if it were it would have been late afternoon or night. The room was very
warm and I was very groggy from sleep (remember, I was not given anesthetic), felt
very warm, and a little nauseous.
Power Lawn Mower
I recall hearing a sound like a power lawn mower, with the clatter rising and falling
as it came close to the building and then moved away. A nurse shut the windows to
reduce the noise.
One nurse heard a car screech its tires and began a lecture about unsafe drivers
and the damage they can do. One of the other nurses said to another nurse that she
wished the talkative one would shut up. I agreed.
The Intense Itch
I remember, some unknown amount of time later that day, being carried from my
bassinet in a wicker bassinet insert and placed on my back on a low coffee table
or surface of some kind in a hospital public area just outside a ward of beds. I was
wearing a loose fitting diaper. Lying on my back, the diaper was pinned at the waist
and formed a large gap off my belly at the top in front. I remember that my penis,
where my foreskin had been, itched intensely.
I tried to look down my belly to see what was causing the itch. With some effort
on my part to control my hand, my hand touched the end of my penis and I felt
something that seemed dead and that had no feeling. I was immediately frightened
that my penis was dying and falling apart. I touched the dead material to try to stop
the itch and found to my surprise I could grab it and pull it. I could not see what I
was doing and thought I might be tearing more of my dead penis away. Removing it
did stop the itch immediately, however, and so I continued. No nurse ever checked
on what I was doing. With the removal of the foreskin, they seemed to lose interest
in me. When the nurse did return, she didn’t even seem to notice I had removed the
dead material.
This thought that I was pulling off pieces of dead penis, probably coupled with
the pulling of the foreskin clamp during the circumcision, became the subject of yet
another dream that I had many times through my childhood and adulthood in which
my penis would come loose and could not be reattached.
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A Gauze Strip Saturated with Vaseline Brand Petroleum Jelly
The dead material seemed adhered with some sort of sticky salve. It turned out
that the dead material was gauze (probably the dressing to protect the wound). It
was saturated with a sticky salve (probably Vaseline-brand petroleum jelly). It was
probably intended to prevent urine from making its way to the incision and causing
pain and diaper rash there before the incision healed. It was some kind of wellpracticed nurse’s trick.
With the gauze removed, I could see the edges of the cut skin and bits of bloody
scab at the incision line on my penis. The wound seemed recent, but dry, partially
healed and somewhat shrunk. There was no fresh bleeding. Seeing the condition
of the incision made me think that much time had passed since this condition
had been inflicted. I think the physical healing must have been well underway,
causing me to believe it was at least 48 hours after I had been cut, and perhaps
longer.
A Visit from My Mother and Time to Get Ready to Go Home;
Wednesday About 11:30 A.M.
I heard the nurse come and go a few times. She began talking to me, saying in
an excited voice that I would be going home in a few days, and she wanted to
bring my mother to see me. It is revealing that, even though they wanted to show
me to my mother, they could not simply carry me in to her, but had to arrange a
surreptitious rendezvous in the common area outside the ward, so as not to make the
other mothers want their babies, too. Also, it seemed to be hospital policy to prevent
mothers bonding with their babies on hospital premises. What were those people
thinking? What frightened them so much?
After about half an hour, I saw my mother for the first time. She was wearing
a pale green robe that was open in front with white pajamas or hospital clothes
underneath. She bent down to look. She did not pick me up or touch me but spoke
to the nurse for a while and then left. She did not speak to me and acknowledged
my presence only to the nurse. If only she had picked me up and held me, I would
have felt safe for the first time. I have come to learn in later years that she probably
didn’t want to risk hurting me and so chose not to touch me, but I didn’t know this
then. The world, indeed, was a cold place for me.
I don’t currently remember leaving the hospital, or of arriving home the first
time, but I do remember the excitement in the nurse’s voice about getting me ready
to go home. I didn’t know anything about “home” or why I should be excited and
not terrified. I remember thinking at the time the nurse was being unnecessarily
enthusiastic and she was embarrassing me. As my mother left me to go back to her
room, my recollections of hospital life ended.
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Epilogue
Since completing and documenting the bulk of my recollections, I certainly understand better than I did before what happened to me. I still am affected by my
experiences and probably always will be, though I may never know the full extent
of damage or what might have been. The anger will always be there but at least the
mystery is gone. One improvement I have noticed is that now I sleep more soundly
than I have most of my life. I dream pleasant dreams almost every night. This is
very unusual for me, but a welcome change.
My hope is that anyone who has read this far has found my account interesting,
and has perhaps gained some useful insight into the mind and awareness of a newborn. I hope further that anyone contemplating circumcision for someone other than
themselves will have second thoughts and stop, realizing that no one has the right
to sexually mutilate another person’s body and that medical indications for circumcision are rare. We owe special consideration to those, such as infants and children,
who cannot protect themselves, but who, if mutilated when young, will grow in
time to be mutilated adults. Laws protect adults. Why don’t the same laws protect
children? Why do we continue to sacrifice our children on the altar of the medical
gods.
Chapter 18
Foreskin Restoration 1980–2008
R. Wayne Griffiths, J. David Bigelow, and James Loewen
Abstract The goal of foreskin restoration is to cover the glans penis to some extent
with a double sheath of retractable tissue. Many men who contact NORM (the
National Organization of Restoring Men) want full coverage of the glans, plus overhang, even when fully erect. A realistic goal is important, however, since satisfaction
or disappointment is clearly related to expectation. For a tightly cut man, “success”
may be just enough loose tissue so that erections are no longer painful. For others, it may be possible to achieve full coverage during erection. Currently, there are
both surgical and non-surgical methods to re-cover the glans. The results, however,
of most surgical procedures have proven disappointing. This presentation discusses
both methods; however, the emphasis is upon various non-surgical tissue expansion
techniques and devices. While the moveable sheath that covers the penile shaft is
commonly called “skin,” its structure is far more complex. Therefore, expansion of
the shaft tissue is more challenging than expanding ordinary skin.
Keywords Foreskin restoration · Glans · Foreskin · Non-surgical tissue expansion ·
Moveable sheath · Dartos muscle · Peripenic muscle · Raphe · Corpus cavernosa ·
Corpus spongiosum · Tunica albuginea · Nerve supply · Ridged band · Meissner’s
corpuscles · Viagra · Surgical reconstruction · Scrotal tissue · Mitosis
Natural Structure
Before recounting the history and methods of foreskin restoration, I would like to
discuss the structure of the shaft tissue and the effects of tissue expansion upon that
structure. I will then describe the most common devices used for tissue expansion.
Parenthetically, I will mention surgical reconstruction. I will also show some devices
used as protection for the circumcised penis.
R.W. Griffiths (B)
National Organization of Restoring Men, Concord, CA, USA
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R.W. Griffiths et al.
To understand the process and practical issues associated with restoration, we
need to take a detailed look at the structure of the penile shaft tissue. The corpus
cavernosa is bound by fascia, which determines the diameter of an erection. As
we discuss various aspects of penile structure and foreskin, it is important to bear
in mind that the shaft covering is a complicated structure, not just skin (derma) as
most people seem to believe.
The dartos muscle starts at the perineum, envelops the scrotum, and, as it reaches
the shaft, it is sometimes referred to as the peripenic muscle; albeit it is the same
muscle. The dartos smooth muscle lies about 1 or 2 mm beneath the outer layers of
the shaft tissue, which is skin. Between the dartos muscle and the skin are elastic
fibers. The dartos muscle is quite separate from the skin layers, except on the ventral
side where they join at the region of the median raphé (Fig. 1).1
The muscle fiber bundles are very slender and made of few cells, but they appear
in every direction: transversely, longitudinally, and obliquely. At the prepuce, a great
many of the fibers course in the long axis of the organ. They are loosely packed and
filled with lax fibrous tissue. One researcher suggests that the dartos muscle fibers
run circularly, forming a sheet of muscle of equal thickness for the entire length;
however, the muscle lines the inner mucosal layer and doubles as the outer sheath
tissue, forming the double layer of the foreskin.2
The layers of the penile shaft covering, from the outside inward, include the epidermis, dermi, and the superficial fascia (loose connective tissue that is connected
to the dermis and enables the extraordinary mobility of the penile skin), which is
also intimately connected to the dartos fascia layer (peripenic muscle), and to most
superficial veins.
The next inward structure is the fascia penis, which is condensed connective
tissue; it surrounds both the corpora cavernosa and corpora spongiosum. Each
corpus cavernosum penis is surrounded by the tunica albuginea, very dense connective tissue and almost pure collagen, providing strength against over-inflation
(in the manner of reinforced garden hose). This factor determines maximum penile
size.3
The ridged band and frenular delta are the most specialized parts of the penis.
They contain more nerve endings than any other part of the penile organ. There are
Fig. 1 Dartos muscle (see endnote 1)
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Fig. 2 Ridged band (see
endnote 5)
Fig. 3 Ridged band and
frenular delta (John A.
Erickson, photographer)
17.9 bundles/mm ventrally, 8.6 bundles/mm laterally, and 6.2 bundles/mm dorsally.
As each bundle contains tens of axons, the nerve supply to the prepuce is obviously
very substantial (Figs. 2 and 3).4
The majority of the medical community in the USA is apparently unaware of
or disregards the fact that this specialized mucosal tissue even exists. They are
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also apparently ignorant of the quantity of Meissner’s corpuscles which, when
stretched and rubbed over the corona of the glans, trigger fine touch sensations during sexual activity.5,6 Circumcision removes this erogenous tissue, which cannot be
replaced (although questions have been raised about the possibility of cloning a new
prepuce). In my opinion, the medical community in the USA would not even consider this issue, and, if they did, it would no doubt be at the bottom of the list of
their priorities. Also, the pro-circumcision advocates would not be helped in their
cause. One restorer was told by his healthcare professional that the medical community prescribes Viagra-type medicines as an apology for circumcision. The medical
community often uses terms, such as “redundant” and “excess” to describe the foreskin; however, a second set of adjectives that intact men know to truly define the
foreskin include: “profuse, lavish, bountiful, luxuriant, exuberant.”
Surgical Methods of Reconstruction
In order to fully cover the history of restoration, we need to at least mention surgical reconstruction—the chronology of which dates back to biblical times and also
includes attempts during WWII to camouflage Jewish circumcision. Although a few
modern-day procedures (beginning in approximately 1980) have been reasonably
successful, most attempts have not had the desired results. A few types of reconstruction are (1) a skin graft from thigh or buttocks, (2) scrotal implant, or (3) Z- or
Y-V plasties.
Skin graft methods place hairless tissue from elsewhere on the body, unlike
penile/scrotal tissue, into a circumferential cut made around the penile shaft. Both
the structure of the grafted tissue and muscle, if any, do not perform in the same
manner as the very elastic penile shaft tissue.
The transplanted tissue usually has a very different condition, texture, and is quite
inflexible and smooth. One man commented that his reconstruction looks great, but
has no feeling and is quite numb. He added that his sexual activity has not been
enhanced.
A scrotal implant graft is a multiple-stage reconstruction, involving circumferentially cutting the shaft tissue at the circumcision scar. A tunnel is created in the front
side of the scrotum between two incisions, and the penile shaft is threaded through
the tunnel, and stitched at both ends.
After about six months, when healed, the penis is surgically removed with the
new scrotal tissue cut on either side and wrapped around the shaft and sewn on the
ventral side. There is then another healing period. At that point, it is typically necessary to reduce the “overhang” and to enlarge the orifice of the new foreskin. One
restorer, who had this procedure done in the mid 1980s, had a “wonderfully” long
foreskin; however, it was non-retractable. Later, the plastic surgeon cut a ventral slit
to facilitate retraction, leaving a dorsal flap over his glans of considerable length
(approximately three inches).
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Non-surgical Methods of Restoration
Contrary to surgical methods, tissue expansion uses the current tissue expansion
method of producing new tissue. In the case of foreskin restoration, it avoids surgery,
nerve loss, or disasters that are more common with surgical methods. The works by
Takei et al.,7,8 indicate that cyclical periods of tension are quite successful and a
preferred method of producing additional new tissue. This method is well suited to
the many and varied functions of the penis.
Parenthetically, some men have felt that penile pumping would achieve the
desired results of tissue expansion; however, the new cells that form after pumping
remain in a bloated state and continue to reproduce bloated cells for life. A couple
of men who have pumped for many years have a penis that looks like a bloated
sausage. In addition, the penis is soft and spongy to the touch.
A Logical and Successful Restoration Regimen
New cells are produced by the process of mitosis, that is, cell division. It has
also been shown that excessive tension does more damage than moderate tension.
Excessive tension causes scar tissue to form, which takes longer to “heal” and
hinders flexibility.9
Since the shaft tissue is both muscle and skin, the model for foreskin restoration
is a body-building regimen. In such a regimen, one works on the upper body one
day and the lower body the next; this allows each set of muscles to have a day of
rest to generate new cells and then to be coaxed again the following day to grow
more cells. The same principle is true for the penile shaft tissue, which consists of
tensioning for a determined number of hours during the day and then letting it rest
at night.
Consequently, one must realize that there is no fast or instant restoration. One
must work into his daily habits a regimen that will suit his lifestyle and work habits.
One colleague has noted that one is “fooling” the penile tissue into “thinking that it
has to grow to cover the longest penis in the world.”
A suggested regimen (which has worked quite successfully for many restorers)
is to apply weights or an elastic tether in the process of getting ready to start one’s
day. One wears them from four to eight hours and then removes them later in the
afternoon or evening. Actually, it is suggested that one start his restoration regimen
with a manual tensioning method to get accustomed to a daily regimen. By so doing,
one forms a daily habit of tensioning. During this initial period, one has time to consider the type of device that would suit his lifestyle best before making a purchase
or designing a homemade device.
It is important that cautions be observed and followed: Don’t cause or endure
pain. Don’t be overzealous. Don’t cause constriction of blood flow, which includes
pain and/or color changes. It is important to make pressure tests to check blood
flow.10 Further, as part of the restoration regimen, no matter what device is being
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used, there must be frequent release of the tension against the sheath tissue and/or
pressure against the glans so as to allow for free blood circulation.
The restorer will want to keep the glans covered as soon as it becomes more
sensitive and the nerves become more responsive. When one achieves some longer
tissue, a retainer can be used for the remainder of the evening and night. This will
keep the glans covered and protected from rubbing against clothing. It will also help
retain the sub-preputial fluids, where they will start the process of dekeratinization
(sloughing off of the layers of calloused tissue). The retainer might be a tape ring,
crisscross taping, an O ring, or narrow Velcro strap. Such a nighttime rest period
will allow the shaft tissue (derma and muscle) to produce additional cells.
Some restorers have advocated excessive tension for 24 hours, 7 days a week.
This type of regimen does not work well, as most of us have other things to do,
which involve our genitals, such as urination, sex, bathing, and rest. As noted above,
damage and much longer healing time is required with such a stringent regimen, and
constant tension is not necessary to achieve restoration. Experience has also shown
that restoration does not happen faster with such a regimen. Some of the tissue and
muscle may be torn by such excessive tension and, if so, scar tissue is formed in the
muscle fibers; flexibility and mobility are thus reduced.
Every male has just one penis and needs to become aware of its structure and
its care. Please be careful and be aware of what your own body is telling you about
your efforts to restore.
There are many devices that have been invented since NORM was founded in
1989. In past centuries, the Pondus Judeaus and thongs were used to lengthen
the foreskin or to keep the glans covered. The first modern-day recorded attempt
occurred in the early 1980s. It involved implanting a small platinum ring in the
remaining shaft tissue, which held the tissue in front of the glans. It was hoped that,
eventually, the shaft tissue would lengthen to cover the glans when the ring was
removed. The tension proved to be insufficient to lengthen the tissue, and, further,
calcification formed a ridge where the ring was implanted.
A great many devices have been designed since that early effort. A select few
of the current devices have been chosen for discussion, along with an evaluation
of the results that each one produces. Various devices produce somewhat different
results; all devices will produce new tissue and, thereby, produce a “foreskin.” Many
current procedures require the application of tape to the shaft tissue; however, fixed
tape does not allow the tissue covered by the tape any tension or growth. Therefore,
the less tissue covered by tape or the device, the more sheath tissue is tensioned
and coaxed to grow additional cells. As a consequence, the degree to which tape is
used in the various procedures should be taken into consideration when choosing a
restoration method.
Restoration Devices
The following is a brief description of the selected devices in the approximate order
in which they were invented and made available to the public. Only a few devices
have actually been patented: the PUD, Vac-U-Trac, and the Tug Ahoy. Most others
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are being produced and made available without restriction. At present, NORM is
aware of at least 17 devices available, and a more thorough count, no doubt, would
yield several more.
The FOREBALLS was devised in 1987. The first version was made by “barrel”
taping two balls together as is shown in The Joy of Uncircumcising, by Jim Bigelow,
PhD, as a homemade device. With ideas from fellow restorers at NORM meetings in
San Francisco in the early 1990s, the tape was replaced by a rod welded between the
two balls. At one of the meetings, someone suggested the name “FOREBALLS.”
The PUD (Penile Uncircumcising Device) was patented by American Body
Crafters’ Roland Clark. The device was made in several sizes/weights. Wide tape
is required to secure the device to the shaft tissue. Because of the circumference of
the device, it holds the new foreskin in a somewhat tube shape. The American Body
Crafter web site touts it as, “The most sophisticated foreskin restoration product to
date.”
The BUFF (Brothers United for Future Foreskins) method was available privately
from a source in Arizona. It featured the use of tape strips to secure the foreskin in
front of the glans. It was soon discovered that a source of additional tension was
needed to produce further results. The use of silicone cones to provide the needed
tension was one of the first methods developed. It was published in Mark Waring’s
1988 pamphlet, Foreskin Restoration (uncircumcision).
After several months of utilizing the information from BUFF and Waring’s pamphlet, Tim Hammond and R. Wayne Griffiths felt the need for a support group.
Together, we founded NORM in February 1990. Shortly after its founding, the
NORM group was asked to try on various sizes and shapes of the Second Skin
Cones, which we did at a meeting in Concord, CA. The cones were a bit bulky,
and we made several recommendations for better shapes and sizes. When the cones
were produced, in both weighted and non-weighted forms, men who used them
complained that the meatus was pushed into the urinary opening and that long-term
use was often uncomfortable.
D. Evans, of Arizona, devised the T-Tape System. The T-tape method uses fixed
tape to secure the shaft tissue and provides tension with an elastic strap. In this
method, the tape is applied around the shaft tissue of an erect penis (to allow for
nocturnal erections) and holds the tissue in both directions, extended circumferential
as well as longitudinal. D. Evans also made a small number of videos, not only of the
device, but also of a NORM meeting, as well as other documents about the benefits
of restoration. However, he soon went out of business, and others have since made
available the instructions and T-tapes.
The RECAP-EZ was devised by Arthur Gibson of Texas. It is a combination
device that allows the restorer to vary his regimen. The variations are all based on the
cone-and-cup structure, which is a tapeless device system. One of the varieties has a
scrotal retainer to hold the scrotum in place against the body and allow the cone/cup
to tension only the shaft tissue. Due to their bulkiness, most of the RECAP-EZ
devices need to be worn at home.
The DTR, Dual Tension Restorer, uses pressure against the glans to provide tension; however, the strength and size of the rubber band determines the exact tension.
NORM holds that using pressure against the glans to achieve tension is not the best
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procedure. The glans is being crushed, thereby, compressing nerve endings and cutting off circulation. One must be sure to relieve such pressure/tension often in order
to provide relief from the compression and allow for blood circulation.11
The CATIIQ—(Constant Applied Tension II Quick), devised in 2002, is another
variation on the pressure-against-the-glans system. It uses a rod with a collet/ferrule
that applies whatever tension one puts on the glans.
TUG AHOY is made by a physician in southern California, which he touts as
the “gold standard of foreskin restoration.” The cup is made from half of a flexible
toy-store “egg.” The other half is used as the cone, with a bent coated wire attached
to an elastic strap for tensioning.
The TLC TUGGER is a very sophisticated tapeless tensioning device made with
various sizes of cups and cones to fit the individual shape and size of the glans penis.
It is made of food grade silicone and uses an elastic band for tension.
THE NATURAL RESTORER is a weighted device of stainless steel with a long
rod. A lock screw on the rod governs tension. It is a device that, again, puts pressure
on the glans for most of the tension.
MYSKINCLAMP is a complex device. The cup puts pressure on the glans and
the cone holds the sheath tissue. There is a sturdy spring that has to be adjusted and
locked in place with a setscrew on the rod. Should the setscrew loosen, however,
the spring would expand to the fullest, and that could possibly cause tearing and
pain.
Homemade Devices
There are many inventive homemade devices made from the use of pill tubes, 35 mm
canisters, and plastic pipe couplers, which are discussed further.
One device is made with a baby bottle nipple fitted over a cup with a rod through
it to hold a ring. It uses an elastic strap for tension. It has the advantage of pulling
away from the glans.
Paul’s Foreskin Restoration Kit supplies materials and instructions to make a
cup-and-cone tensioning device.
Tube devices are made using a pill tube, a PVC pipe coupler, a 35 mm canister,
etc. to place over the glans. The sheath tissue is taped to the outside of the tube. It
does not have to be removed for urination. While the device does lengthen the new
tissue; it also widens it. Therefore, the lengthening tissue will not readily close down
over the glans like a normal foreskin. Men have contacted me to get information on
surgical closure because they have used such devices/methods that have not given
closure to the aperture of the new foreskin. Although such surgical procedures are
presented in The Joy of Uncircumcising, later experience with such surgical touchups has not proven successful. They are no longer recommended.
O rings have been used in various ways as nighttime retainers or several in a
sequence on the foreskin to put tension on the tissue. If the rings are narrow and too
small, circulation will be cut off quite quickly and the rings must be removed.
ANGUS’ O RINGS are a variation on the use of O rings with a urination tube.
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Foam cones are made in various lengths and widths to be compressed over the
glans. The shaft tissue is then taped in place so that the foam expands to put tension
on the shaft tissue.12 Such cones, however, expand the tissue in both diameter and
length.
Tape straps with weights or with an elastic band are made in any number of
variations.
Single Ball Bearings. Some men have used a single stainless steel ball placed in
front of the glans, and the shaft tissue is pulled over it. A Velcro strap or cross tape
system is used to hold the bearing in place as a weight to tension the shaft tissue.
Velcro straps or tape rings are usually used as a retainer to keep the glans covered
when not tensioning. It is similar to the O rings used for the same purpose.
Non-restoring Covers
There are a number of products that have been offered since the beginning of this
era of restoration, such as:
MANHOOD is a rayon sheath that was designed to cover the circumcised penis
and to protect it from abrasion and cold especially for bike riders. It was designed
by and is available from the maker in Canada.
SENSLIP is a latex tube with ridges and is attached to the penis with a fold in it
to simulate a functioning foreskin. It is somewhat complicated to apply. The concern
is that the glans, mucosal tissue, and shaft tissue are covered with a foreign product
rather than natural tissue. The manufacturer says that it is porous and should be used
mainly for sexual intercourse. The problem, however, is that, if left in place too long,
it produces an anaerobic condition that is not conducive to healthy tissue.
Natural Phimosis Treatment
NORM has been the central clearinghouse for information about both restoration
and how intact men can lengthen their foreskin, as well as providing help for men
with phimosis. For the latter, the following devices are available:
GLANSIE, from Japan, is a speculum (an instrument for examination of canals)
with narrow tips that can be inserted into a phimotic foreskin. It puts tension in a
lateral direction to gently open the foreskin so that it will allow retraction over the
glans. With time, new cells are formed and the opening widens.
PLATIGO AFS BALLOON, from Australia, is a device using small balloons to
put tension on the foreskin to widen the opening. With time, new cells grow in the
foreskin tissue.
This homemade phimosis treatment device is merely an old-fashioned spring
clothespin that has had the finger ends tapered. When used, it is opened and
coins or washers are inserted into the opening. As necessary, these coins/washers
are removed to open the tapered end to provide tension on the opening of the
foreskin.
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Fig. 4 Restored foreskin
(James Loewen,
photographer)
Results
As can been seen, the restorer in Fig. 4, after using tissue expansion for about a year
and a half, has full coverage of the glans, with an overhang of about three quarters
of an inch. When the body is warm, the foreskin opens and can be easily retracted.
It is also noted that, after 20 years of being covered, the foreskin has reduced in
its thickness and works quite naturally. It protects the glans.
Notes
1. Jefferson G. (1916) The Peripenic muscle; some observations on the anatomy of phimosis.
Surg Gynecol Obstet (Chicago). 23(2):177–178.
2. Ibid.
3. McGrath K. (2001) The frenular delta, a new preputial structure. In: Denniston GC, Hodges
FM, Milos MF. (eds.) Understanding Circumcision: A Multi-Disciplinary Approach to a
Multi-Dimensional Problem. New York, NY: Kluwer Academic/Plenum Publishers.
4. Ibid.
5. Taylor JR, Lockwood AP, Taylor AJ. (1996) The prepuce: Specialized mucosa of the penis
and its loss to circumcision. Br J Urol. 77:291–295, February.
6. Taylor JR. Private correspondence.
7. Takei T, Mills I, Arai K, Sumpio BE. (1998) Jul.: Molecular basis for tissue expansion:
Clinical implications for the surgeon. Plast Reconstr Surg. 102(1):247–258.
8. Takei T, et al. (1997) Oct.: Effect of strain on human keratinocytes in vitro. J Cell Physiol.
173(1):64–72.
9. Ibid.
10. Bigelow J. (2002) The Joy of Uncircumcising! Exploring Circumcision: History, Myths,
Psychology, Restoration, Sexual Pleasure and Human Rights, 2nd ed., p 14143.
11. Ibid., pp 172–173.
12. Ibid., pp 174–177.
Chapter 19
Restoration: The Foreskin and the American
Dream
Ron Low
Abstract The author first heard about intactivism in the “Letters to the Editor”
section of a national monthly magazine in 1986, at age 24. A decade later, a seed was
planted by something he heard on the radio, and now he markets foreskin restoration
devices, with over 10,000 clients served. Being a “professional” intactivist has given
him some unique opportunities. He explains why he counts himself among the lucky
few—with a life’s work in perfect harmony with his passions.
Keywords Foreskin · Penis · Uncircumcising · Jim Bigelow · Glans · Tapeless
tugger · Intactivism · Devices · TLC tugger · Circumcision · National Organization
of Restoring Men (NORM) · Howard Stern
My Journey Begins
When I was an 11-year-old boy, I pedaled up to a group of male friends involved
in a lively discussion: “. . . Plotzstein is!” said one. “Is what?” I asked. They were
discussing who among us was circumcised. Until that moment, I had never imagined
there were kids around with anatomical gifts I didn’t have, but Plotzstein’s Irishheritaged tormentors were intact, probably the only normal boys in my grade. We
never got around to my turn to be tormented because a mom stepped outside to
render our conversation more polite. Later, I asked my own mom about it, and I got
the standard description of an inconsequential flap of skin, without which I would
be happier and cleaner.
Over the years, I gradually realized the vast majority of my peers were like me. I
personally never noticed any problems from my lack of a foreskin. I never even fretted that my dad’s penis was different. Even though we saw each other nude plenty
R. Low (B)
Northwestern University, Kellogg Graduate School of Management, Chicago, IL, USA
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R. Low
of times, I just hadn’t noticed Dad was intact. By the time I was 24, I had enjoyed
plenty of opportunities to make sure my anatomy measured up to the expectations
of the opposite sex, and foreskin absolutely had never been mentioned.
Then one day in 1986, I was browsing my roommate’s Mensa Bulletin magazine. The letters to the editor included several notes about some article I never saw
from the prior month. The first two letters sounded like my mom could have written them; foreskin is a dirty flap, intact men get diseases, cutting infants is easier
than having adults endure major surgery, etc. But, then came one from an intact guy
saying the only problems he’d ever had were too much sensitivity and women handling him roughly, but that he’d overcome both with practice and communication.
Then, one from a circumcised man; he explained all about what he thought he was
missing and what his partners were missing, how most of the world was intact, and
why only an adult should be allowed to elect his own cosmetic pleasure-reducing
surgery.
I realized in that moment that my mom had no idea what she was talking about
when it came to a penis. She even had told me: “Your father had no end of trouble
until they did his.” Her language was so vague, I thought she was describing his
circumcision; I didn’t find out for another couple of decades that Dad, to this day, is
still intact. My parents divorced when I was a kid, so Dad wasn’t handy to discuss
it with when I read the Mensa letters, even if I had been inclined to bring it up. Now
I knew. There were enough guys on either side of the issue in that magazine (and
in the following month’s issue) that there was no way it made sense to decide this
on behalf of an infant when he could just as easily weigh the evidence for himself
when he matured.
I was a silent intactivist for a decade after that. I didn’t know anyone expecting a
baby boy to bring it up with, but I would have said to let him decide for himself, if
the subject had come up. I didn’t know restoration existed, so there was no point in
interjecting purely bad news about lost sensitivity into discussions with my fellow
circumcised young men.
Then came Jim Bigelow and his book, The Joy of Uncircumcising! I heard Jim
being interviewed about his book in 1995 on Chicago radio, and he said in no uncertain terms that sex was a lot better since he had restored his foreskin. The DJ was
as intrigued as I was, but after the interview was over, the DJ said: “I suppose
that guy made sense, but I’m not going to hang a weight on it.” The DJ’s sidekick chimed in: “And couldn’t he just wear a. . . a little hat?” I am now selling the
little hat.
Knowing that sex could be better was not enough yet to move me to start restoring. I didn’t want to “hang a weight on it” either, and besides I didn’t then recall the
title of that book about restoring. Plus the taping-my-penis part didn’t sound like
too much fun. And sex was fine, I thought; I was able to give my wife, Alice, as
much satisfaction as she could stand. But in 2000, Alice surprised me for Fathers
Day. We spent the night in a romance hotel. My wonderful wife had worked out all
the details. It should have been a fantasy come true. And it was for her, but I was
unable to climax until the next morning.
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Restoration: The Foreskin and the American Dream
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Restoration
After the Fathers Day 2000 sex romp didn’t live up to my expectations, I wanted
to ascribe a cause. I decided I lacked sensitivity due to my exposed glans. I began
using copious amounts of lotion on my genitals to help me become more supple.
Soon enough, I got an infected hair follicle on my scrotum, which I told my doctor
might be due to all the lotion I was using to get more “supple and sensitive.” He
said I had better stick with “tough and leathery,” never mentioning the possibility of
restoring. I’m sure he didn’t know about it.
By Christmas, I decided I definitely would restore, and started researching methods on the Internet. I really didn’t want to use tape, but the tapeless methods
didn’t make sense to me. There wasn’t enough evidence online to convince me
they weren’t an elaborate hoax. And the money for a tapeless device wasn’t trivial
either.
I decided I could try a simple tape method called the Pill Tube (aka, the Canister)
based on a web write-up by Australian Bill Sides and, if it showed promise, I might
invest in a fancy device. I still recall muting the TV on the evening of April 1, 2001,
and explaining to my wife how I was missing something, and summarizing what I
had learned about how to get it back with medical tape and elastic straps.
She said: “That’s ridiculous. Is this an April Fool’s joke?” No, I told her, I was
serious and that I would need her patience and support because I might have tape
on my penis when she wished to employ it. We would need to be a little less spontaneous and more planned in the bedroom. Alice quickly caught on to warning me
about when to get untaped, and I was soon taping my penis every morning after my
shower before work, and not usually untaping myself until the following morning’s
shower.
Two months of this taping was enough. I ordered a tapeless device online and
waited. It never came. Had his device shown up in my mailbox, I would have
started using it and might never have bothered making my own. But, I got most
of my money back from PayPal and went back online to discover that a man named
Dave Leary had published a “how-to” for crafting a silicone tapeless tugging device
at home. I made myself a tapeless tugger, which would become the prototype for
today’s TLC Tugger. After months of tinkering with it, I wrote to Dave to discuss
some improvements on his concept and he gave me his blessing to offer ready-made
devices to restorers.
Once I started to see measurable gains in slack skin, I was convinced non-surgical
restoration would really let me get a whole foreskin’s worth of slack skin back.
I started hanging out in the online forums (none of the ones that were around
then survive to this day). My new passion was becoming more than a hobby, it
was an obsession. Every night, I would get to bed an hour or two after my wife
because I found it so rewarding to help the beginning restorers online with their
questions and concerns. I was so delighted with my own progress that I published
my explicit monthly status photos and some methodology guides online in hopes
they would help and inspire others. I knew that every man who discovered restoring
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R. Low
and improved his sexual experience would most likely also join us to help shout
down those who would advocate cutting an infant.
At that time, my intactivism prompted me to write to the VP of Human Resources
at my day job and tell him how much money we could save if we dropped coverage for routine circumcision from our health plan. He did not appreciate being
told how to do his job and also that his culture’s covenant was needless cosmetic
surgery. My boss called me in to yell at me for not working this cost-savings scheme
through proper channels. Since my job was Industrial Engineer, anything that saved
the company money was legitimately my area, so the dust eventually settled.
But then the 9/11 attacks came. Sales volume dropped and the company needed
to cut costs. The same VP of Human Resources directed each department on how
many people they would have to cut. My department was just my boss and me. We
were told we would have a 50% reduction. I suppose my salary was a little more
money saved than what they were spending on routine infant circumcision.
You Can Get It on Ebay
I got another engineering job in 2002 at a toothbrush factory. My family had gotten
by in the meantime by selling things on eBay. We got quite creative, for example,
by reproducing our kids’ watercolors as lovely calendars and greeting cards.
By March of 2003, I had decided that wearing a tapeless retaining cone to hold
the shaft skin over the glans was the easiest thing any circumcised man could do to
get a persuasive taste of what he was missing. I had visions of millions of circumcised men picking up a cone at the local drugstore and using this simple painless
trick to realize the harm of infant circumcision. I didn’t know how to make or sell
cones by the millions, but I could make a few. To test the market, I made an eBay
listing and offered cones for a few weeks in an online auction. I announced the availability of the cones in the online forums. Five men found the listing and bought a
cone. Then I had to figure out how to make them.
I told the five cone buyers I would give them free shipping if they would allow me
a few weeks to work out how to make a better product with greater efficiency. The
one-at-a-time method involved crude hand-made paper forms, which were destroyed
with each casting. I needed something durable and geometrically perfect. I used
computer drafting software to design a 2-part plastic mold, and I e-mailed my design
to a lab that grows 3D plastic shapes in a process called stereolithography.
In a week, I received my new mold in the mail, without having met the man who
made it. I feel so lucky to live in an age when the Internet was available to help me
research my problem, discover the solution, find the first customers who shared my
need, and find the mold maker and a supplier of food-grade silicone so I could go
into a new business; all without leaving my house.
I coined the name “Your-Skin” Cone for the retainer, because it rhymed with
“foreskin.” Then a few months later, I figured out how to efficiently make a Tugger
to go with it. I called it the Conical Tapeless Tugger, or CT Tugger for short. I
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announced the CT Tugger in the forums, and soon I was selling a few every week.
Lucky for me, a user wrote to suggest I call my device the Tape-Less Conical
Tugger, or TLC Tugger, because it had more of a ring to it. In June of 2003, I
registered my web site, TLC Tugger.com.
I still had my day job as an industrial engineer, and I told a couple of co-workers
about restoring and how I was making and selling these devices as a sideline. I
was already staying up late to offer help in the forums, and now my evenings were
consumed with cooking the devices in my family’s kitchen. Within some months,
I really had to become an expert at exploiting every free minute. I would leave the
house with a supply of devices and postage stamps, plus pre-printed mailing labels
coded with what a customer had ordered. I’d prepare the tugging straps and mailing
boxes at every red light while driving to work. Then, at lunch, I’d sit in my car and
pack the orders, dropping them in the postal box next to the sandwich shop where
I ordered the same thing every day. They would make my sandwich when they saw
me pull up, so I never had to wait.
My wife, Alice, soon noticed that I was buying myself things on eBay; music
CDs, Michael Jordan sneakers, rock-and-roll t-shirts. She asked what was up and
I told her these devices were bringing in real money and I deserved some treats
because I was working so hard. She said we would have to organize this like a real
business and pay taxes and stuff. At that time, she was an MBA/accountant with
a job that required only 20 h/week, so she could also be a “full-time” mom. We
incorporated TLCTugger.com, Inc., in 2004, as equal partners, and Alice took care
of the “business” end of the business, while the kids helped with sub-assemblies.
Growth
We had our web site and our eBay listings, and the men who needed help with
restoring kept finding us. I continued to enjoy participating in the online support
process, even for men using methods we didn’t sell. Since we had a corporation
and could write off expenses, I started thinking of ways to promote intactivism that
could be legitimate business expenses.
We offered free foreskin-friendly bumper stickers at our web site:
•
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•
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•
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“A Foreskin is NOT a birth defect”
“Breastfeeding for all, Circumcision for none”
“Bring home your WHOLE baby, say NO to circumcision”
“Circumcised? You have no idea what you’re missing”
“Circumcision? HIS body, HIS decision”
“Circumcision? ‘No’—Moroni 8:8”
“Circumcision = Sexual Lobotomy”
“Feel the love—End circumcision”
“Foreskin feels REALLY good”
“Foreskin—Not just the wrapper, it’s the candy”
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R. Low
“God makes no mistakes—say NO to circumcision”
“If God wanted me to have a foreskin, I would have been born with one”
“I make milk—What’s YOUR superpower?”
“Restore your foreskin—TLCTugger.com”
“10 out of 10 babies oppose circumcision”
“THOU SHALT NOT STEAL—that includes foreskins, HIS body, HIS decision”
“YOU may go sit in the toilet until I’m done nursing”
Some of these slogans are about breastfeeding, another of the issues I’m
passionate about. I got to dust off some other old hobbies. Now that I had a business
to promote, I could invest time and energy into producing pro-intact Internet radio
segments. Radio is where I really thought I was headed back during college. Now
that the industry’s imploding, I’m glad to call it just a hobby. I’ve also always loved
music, song writing, and home recording, so now TLC Tugger sponsors an annual
foreskin-related song-parody contest. I get to seed each year’s entries with some
works of my own, while not competing for my own cash prizes, of course.
These soft-sell promotional efforts have made us just conspicuous enough to
snare some free high-profile promotional opportunities. We’ve appeared in two documentaries. We’ve been interviewed by Chicago radio stations. We’ve been written
up in three big-city newspapers, and Details and Time magazines. The Chicago
Tribune said for “circumcised men who feel they might be missing something, Ron
Low is their savior.” While I thought that job was taken, as long as they spell the
web address correctly, they can say what they want.
In 2006, I tried out for an inventor’s reality show called Everyday Edisons. I had
a nicely polished spiel for the first round judges who were specialists in various
aspects of marketing new products. Within the 90-second time limit, I told them
how circumcision was unnecessary, pleasure-reducing, cosmetic surgery, which had
befallen 80 million US men and another 80 million outside the US, all for nonreligious reasons. What I needed the show to help me with was the graphics and
communications expertise to take my little Your-Skin Cone from a niche mail-order
item in use by several thousand men worldwide, to a family–friendly commodity
available at Wal-Mart.
They loved it! I was green lighted by the first-round panel and sent to the green
room to await videotaping of my audition in front of the actual TV judges. I sat
in that green room knowing it was still a long shot. Sure, I had gotten further than
99.5% of the thousands of people who showed up that day, but this was just one
city’s audition. The producers designed the auditions so they would have dozens of
finalists to draw from and assemble a slate of just a dozen show participants for the
season.
With all the confidence I could muster, I sat in that green room going over my
next speech in my head. There was an adorable little girl sitting across the room
with her mom. They had invented some new board game. Another green-lighted
guy had brought a whole couch to show off his ingenious tray table that pops up
from beneath it. The door opened.
“Ron Low?” said a guy in a suit. “Bring your stuff.”
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Odd, I thought. Why was I getting to go before these others who were waiting
before me? We walked out together.
“I’m Josh, one of the show producers. Congratulations on being green lighted.
That shows your idea had real promise. Listen, the production company doesn’t
have the last word here. The network also has lawyers on site today to review the
ideas. I’m sorry to tell you the network’s lawyer says your idea is not going to be
part of the show. There’s nothing to discuss, we’re bound to their authority. So, I
just want to say thanks for coming out and best of luck with your invention.”
At this point, I noticed we had been strolling the halls of WTTW Studios straight
for the exit. In just under a minute, my hopes had been dashed, and I was neatly
shuffled out the door.
Living with Integrity
Despite setbacks like Everyday Edisons, somehow TLC Tugger keeps getting just
enough publicity to maintain a 20% annual growth rate. In March of 2008, I did
some math and decided my family could live on just what the Tugger business was
bringing in if we were willing to scale some things back a bit. We really had to
change something because I wasn’t sleeping. I was getting four solid hours on a
good night. The alarm always went off at 6:30 to get me to the car in time to drop
my gifted daughter off at high school.
One of the co-workers I had told about my sideline was Angel, the production
manager. I had confided in him back in 2005, when we were peers on a project
together. By 2007, Angel had been promoted to Director of Engineering, my boss.
Like a true humanitarian, he privately declared that he wouldn’t hold the moonlighting I had revealed under different circumstances against me, as long as it didn’t
affect the quality of my work. By allowing me to keep my day job and continue to
work TLC Tugger on the side, including occasional days off, which he knew were
for things like TLC-related radio interviews, Angel really taught me the definition
of compassion.
In late 2007, when my day-job performance came up at the office, I promised
Angel that I would hire someone to help with TLC stuff. Indeed, we found a brilliant high-school student, Dan, who now does a lot of the assembly and handles
the free bumper-sticker orders. It turns out, Dan has lived in Israel and speaks perfect Hebrew and Russian, so he also helps with some of the international customer
service.
Early 2008 marked my fourth consecutive annual physical, where I had to again
apologize to my doctor for showing up dog tired from lack of sleep. I again got the
“de-stress your life” lecture, which I could mouth along with him from memory.
I told Angel that I was going to have to choose TLC Tugger, and leave the toothbrush company eventually. He agreed to let me transition out gently. I agreed to go
home and tell Alice. Yes, I quit my job without clearing it with my wife. We had
discussed it on and off, but it just seemed like she would never be ready, so I took a
huge leap.
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I think what imbued me with the guts to leave, apart from the stream of customers
that never seemed to stop finding us, was a “living with integrity” seminar to which
my pre-9/11 job had sent me. If that seems like a funny place to learn to keep secrets
from your spouse, let me explain.
The American Dream
In 1996, the beverage can company I worked for must have wanted us to stop stealing paper clips, or to just work harder, or something. They spent a boatload of money
on a man-and-wife team who offered a seminar called “Living with Integrity.” They
sent us all to the 2-day extravaganza on a rotating basis. The show turned out to have
very little to do with working as selflessly as Mother Theresa or being as honest as
George Washington. They played on a very specific definition of integrity. They
showed examples of people whose work lives integrated closely with their core personal values. I don’t know if the company expected us to change our core personal
values to align with the company’s mission, or what. I left the seminar resolved to
find a way to pay my way through this world by pursuing my passion, if only I could
figure out what that was.
My co-worker Phil seemed to be changed by it as well. He asked me shortly after
the seminars: “Ron, do you feel you have a ‘life’s work?’ Is shaving costs for the can
business something you’ll brag to your grandkids about?” Of course, he had made
his point. He really clinched the message when he quit his job and started medical
school at age 31. He is a graduate of University of Chicago today and practices
medicine. My own foray into life with integrity has been very fruitful. TLC Tugger
now carries product offerings for all the primary restoring methodologies.
•
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Taping: TLC Canister and ReJuveness tape
Retaining: Your-Skin Cone
Packing: TLC Packer, TLC-X
Tugging: TLC Tugger, TLC-X, and ComforTug straps
Weights: TLC Stackers
Covering: SenSlip prosthetic foreskin undergarment.
In the near future, we hope to offer a device to help men with phimosis to
comfortably stretch the preputial sphincter so they can avoid circumcision or other
surgery.
We have so many clients, we can easily research the nature and make-up of the
restoring community. In 2008, we conducted a preliminary survey (only 40 respondents that were limited to our newest customers) and learned some things. We found
25% self-identified as gay. This question has been asked quite often, so it was nice
to finally have a ballpark figure. The survey produced 0% identifying as Black or
African-American. This certainly highlights a conspicuous failure on our part, and
we have work to do to figure out how better to serve all communities and ethnic
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groups. Then, 19% said they would like face-to-face restoring support but had never
attended a NORM (National Organization of Restoring Men) meeting, so we’ve
been doing all we can to facilitate the formation of local chapters. Our full-scale
survey will refine these numbers and answer some additional questions this year.
We have enough users at our sponsored-user forum that we can quickly find
subjects to volunteer for research into comparing foreskin restoration methods and
regimens. We hope to soon finally answer the question, Is tugging half of the time as
effective for quick results as tugging 24/7? We can address further questions every
six months from now on. This will be an important contribution to restoring.
When I quit my job, I wasn’t really sure if, any day, the number of men needing
our help would shrivel to nothing. I also didn’t know at the time what the US FDA
(Food and Drug Administration) thought about restoring. I was afraid to ask. An
eBay user forced my hand. This guy saw our auction listings and wrote to ask me
if our “penis stretchers” were FDA approved, because he thought they looked dangerous. I explained that our products really worked, were not dangerous and, unlike
other penis stretchers, they helped victims of a senseless mutilation. He managed to
waste a lot of my time with repetitive and circular questions, which I worked hard
to answer carefully because I hoped he would leave the FDA out of this. He didn’t.
I heard from the FDA. They wrote to say there was a complaint, so they had to
open a file, investigate, and “close the file.” That sounded like “close our business”
to me, so I proceeded very cautiously. It turns out, the FDA people were very nice
and were on my side. I told them that our devices really worked but that we had no
formal studies to prove it. I explained how restoring involves tissue expansion by
application of gentle tension.
The FDA said, if I wanted to claim that my devices caused faster cell division
or the growth of new skin, then I would definitely be classified as a medical device
purveyor. I said: “Yep, that’s me.” They advised me about what would be involved—
annual inspections of my production facilities at $5,000 per year, plus a device
approval process that could take years, eventually cost hundreds of thousands of
dollars, and still possibly fail. And the opportunities to continue offering devices
while approval was pending would be very restrictive.
We had a sort of bargaining session, where the FDA said I could call my devices
stretchers and boast only of stretching skin (the way penis stretchers stretch the
penile shaft), and then I could be ignored by the FDA (the way penis stretchers
are). I said restorers know they grow new skin and don’t just stretch it. The very
kind FDA representatives mentioned the hundreds of thousands of dollars again.
We finally came to an understanding. I get to keep calling my devices Tuggers, and
now I describe their effects as “restoring slack skin.” The FDA is OK with that,
so now we are better than FDA-approved, we’re FDA-ignored, and I have a letter
saying so.
Now that I can hold my head up high and tout the benefits of restoring slack skin
from every mountaintop, there is no stopping me. In 2008, I started looking for more
ways to reach out to new audiences. TLC Tugger sponsored a prize for International
Mister Leather and we started sponsoring Chicago-NORM’s annual intactivist entry
in Chicago’s Pride Parade.
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Then, in August of 2008, the ultimate opportunity arose; one that only a guy
like me—with no “day” job—could seize. Howard Stern, who I call the world’s
loudest pro-intact celebrity, announced that he would have an on-air “Prettiest Penis
Contest” in honor of George Takei, the famous actor from Star Trek. George is
intact, and he’s also gay. Howard’s show was eager to have a bachelor party for him
in celebration of his then-legal planned marriage in California. Anyone who could
get to the Sirius Satellite Radio/Howard TV studios in New York on a Wednesday
morning was welcome to enter the contest for a $500 prize.
When I called, I was sure they would have more entrants than they could handle,
so I tried to distinguish myself: “You should also know I’ve restored my foreskin
using constant gentle tension over several years” I told their producer. “Oooh, you’re
a. . . real. . . Sicko, aren’t you?” he replied. I explained that I thought what I was
doing was a perfectly sane reaction to undo a senseless amputation, and I assured
him I would have no trouble getting from Chicago to New York in 5 days, and
offered to bring my honor-student daughters along to vouch that I was no Sicko.
“That’s OK. You’re in.” he said.
When I entered the studio, Howard proved he is the master interviewer, simultaneously witty and sensitive.
Howard:
Ron:
Robin (female newscaster):
Ron:
George:
Howard:
Ron:
Howard:
Ron:
Howard:
George:
Ron:
Robin:
George:
Howard:
Ron:
Howard:
Ron:
Ron, what brings you here today? You want the title,
eh?
I have the prettiest penis and you’re going to see it.
How do you know you have the prettiest penis?
Well, I think it’s the only one that’s going to look like
a renaissance painting.
A renaissance painting!
Who has told you that you have a beautiful penis?
Are you into girls or men?
My wife loves my penis.
And she says you have a great looking penis. Alright,
let George see it. This will be great for him and he
loves it. This is certainly a gay bachelor par. . .
(drops his trunks)
. . .WOW! What’s going on with that thing? There’s
something ATTACHED to your penis.
Yes, what is that?
This here is a foreskin restoration tugger.
Oh, no.
Foreskin restoration. Oh, you’re circumcised?
You’re one of those guys who was circumcised and
you’re trying to get your foreskin back.
I was circumcised at birth; certainly not by choice.
Right.
And so, for four years, I wore a device similar to this
one.
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Robin:
Ron:
Howard:
Ron:
Howard:
George:
Ron:
Robin:
Howard:
George:
Ron:
Howard:
Ron:
Howard:
Robin:
George:
Ron:
Howard:
Ron:
Howard:
George:
Howard:
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(laughs)
Sometimes you wear it strapped to your knee to
pull down. At night, you wear it strapped up over
your shoulder to pull up, and it just basically applies
constant gentle tension.
Are you getting your foreskin back?
Let’s have a look.
All right.
Oh, that comes off, does it?
(removes Tugger)
Ugh.
Well, there it is! It actually does work, doesn’t it?
And has that been helping the penis itself?
I’ll tell you what. Foreskin feels REALLY good.
Until you’ve experienced it slinking around, it’s just
impossible to even describe. It’s like, you can picture
the skin tube as it rolls over on itself, it’s making like
a 180 turn. . .
It was THAT important to you to get your foreskin
back?
Oh, it feels so good. And the glans and the skin just
below the glans are now covered and protected all the
time, so it’s reverted to being more moist and supple,
and I just can’t even tell you how much better sex is.
Well, Robin, there you go. Here is a man who has
restored his penis to its natural state.
There’s a lesson for you.
And the process gives a good feeling all the time?
Yeah, having something attached to your penis does
kind of give you an awareness of your penis all day,
and so. . .
How long did it take before your foreskin came back?
You can grow about an inch of new skin a year, and I
needed four inches, so it took me four years.
Four years you’ve been doing this! Well congratulations to you. What an accomplishment!
Good for you. Helping Mother Nature.
Yes, I’m glad to see you taking your time, and putting
it into something useful! (Everyone laughs)
I didn’t win the prettiest penis contest, which is a shame because that might
have won me an invite to the post-show wrap-up show, with more questions about
restoration. As it was, I reached Howard Stern’s loyal radio and TV audience of over
7 million. I know the next time circumcision comes up on his show (he often rails
against it) he will have restoration on his mind.
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I don’t need to be declared the prettiest penis to know I’ve accomplished something. I hear it every day from the men I help. I get the feedback I need in letters like
this one, from a Your-Skin Cone user:
First of all, I wish to thank you for making a fine product. I have been using your Restoration
Cone for just over a month, and already I am seeing & feeling significant differences in my
penis.
I am married, and my wife & I are trying to start a family. Before, my penis was so raw &
desensitized, it was almost impossible for me to receive enough stimulation to achieve
orgasm. In addition, my wife would complain that sex with me would always take so long, &
dry her out, making her vagina incredibly sore. Now after a month, things have changed.
Sex is much more enjoyable, & we may even be able to conceive naturally. You’ve really
helped me out.
Thank you again so much for your product. It has changed my life.
Everyone needs to find out in what way they can leave the world a better place
than they found it. If you’re Howard Stern, you can earn hundreds of millions of
dollars for leaving millions entertained. If you’re like me, you get to pay your way
through life by improving one penis at a time, while helping boost the odds that the
next boy born won’t ever need restoration services.
I’m really living the American Dream. I don’t know if there’s a popular
phrase like Australian Dream, Canadian Dream, or English Dream. But I think the
American Dream is about finding that way to make your living by providing something people need; doing something you can be proud of. To be able to do this,
hand-in-hand with your loving family, well, I think any common phrase would be
too trite to describe this kind of satisfaction.
Chapter 20
Genital Autonomy: The Way Forward
David Smith
Abstract Genital mutilation has always been a cure for the latest fashionable disease. From curing club foot and epilepsy to ensuring a faithful wife, it has been
the universal remedy. Now is the time to break down the barriers, alter perceptions,
and broaden the knowledge of the subject to every thinking human in the civilized
world. This talk will explore ways of widening the debate to make genital mutilation
as acceptable to discuss in polite society as HIV/AIDS has now attained.
Keywords Genital mutilation · Genital integrity · Genital autonomy · World
Health Organization (WHO) · NORM-UK · FORWARD · Female genital mutilation
(FGM) · Commissioner of Children
In 2006 at Seattle, the winds of change were beginning to be felt on the whole subject of both male and female genital cutting. At that event, the Ninth International
Symposium on Circumcision, Genital Integrity, and Human Rights, the initial concepts for the way forward were formulated. In the intervening two years, much has
been achieved and some progress has been made towards a brighter future. This
symposium is a staging post on the way to a better-informed society and it is essential that the momentum created both here at Keele University, during the last three
days, and with the initial launch of Genital Autonomy is maintained and enhanced.
To coincide with this symposium, we chose to hold a press conference, in London,
to publicize the official unification of the two aspects of our organizations, male and
female, and to launch a new genital autonomy symbol. We were gratified that the
press turned up and took notice of the new vision for the groups and we anticipate
that this will be the beginning of a significant change in thinking worldwide on the
issues of genital cutting and this should be the start of the new way forward. For
D. Smith (B)
NORM-UK, Staffordshire, UK
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D. Smith
those of you not able to be present in London, with us, I would like to read to you
the press statement released to the world’s media:
Genders Unite for Genital Autonomy
London, 3 September 2008
NORM-UK, the organization concerned with the male foreskin, and FORWARD,
the organization concerned with female genital mutilation (FGM), will unite at the
Genital Integrity 2008 symposium on September 4th to launch a new campaign
promoting the right of all men and women to say no to unnecessary genital surgery.
In the face of a large-scale World Health Organization (WHO) promotion of male
circumcision as a means to reduce risk of HIV infection in Africa, the new campaign
seeks to redress the balance by making the public aware of the strongly conflicting
evidence around the effects of circumcision, and the mixed evidence about its value
in HIV prevention, and by promoting the fundamental concept of informed choice
in medical treatment.
“Subjecting young children to a painful, damaging and humiliating circumcision in an
attempt to prevent HIV infection from sexual contact is not only profoundly unethical, it
is an insane waste of money. These boys will not be sexually active for many years, by
which time properly proven and more reliable prevention strategies may be available,” said
John Warren, chairman of NORM-UK. “Boys must be left to make their own decision when
they are old enough to understand the full implications.”
“When the issue of female genital mutilation was still sensitive and highly politicized,
FORWARD played a leading role in putting the issue on the international agenda, breaking down the walls of silence,” said Naana Otoo-Oyortey MBE, Executive Director of
FORWARD. “It is time to recognize that the right to genital autonomy belongs to all children, regardless of race, culture or gender.” Unnecessary genital surgery on babies is said to
be cheaper and easier than on adults. All abuse of babies is easier. They are powerless and
history will judge us by how we protect the powerless, said Paul Mason, children’s commissioner for Tasmania, Australia; a keynote speaker at the Genital Integrity 2008 Symposium
at Keele University. “Do we say to children that they have no say in this because statistically
when they grow up and practice unsafe sex they might be better off? I say let the children
decide for themselves—all in good time.”
This is a powerful statement, which has been made by an eminent man who is not
only in a position of authority but is prepared to speak out publicly internationally,
as we have all had the privilege of hearing today.
Paul Mason has come all the way from Tasmania not only to be with us and share
with the symposium his words of wisdom, but he has also taken the opportunity
to support and to speak out here in Britain on these issues. When approached, he
was most willing and enthusiastic in his support. This is a refreshing change from
the attitude of his British equivalent, Sir Al Ainsley-Green who, on being asked to
attend and speak at this symposium, declined due to a prior engagement. Initially,
I thought this was an excuse but, in fact, he is at a conference in Dublin, where
Paul Mason went to meet him—in essence to attack the lion in his den and give
him the ear bashing he deserves, which I know he most probably has. You will
probably be interested to hear the response we received from Sir Al when, after
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numerous email and snail mail exchanges, we finally got a response to bring to this
symposium—perhaps not the words we were expecting or hoping for, he wrote:
Thank you for your note and request for a meeting.
The Children’s Commissioner is charged with promoting the views and interests of children and young people in England. We have a limited budget and resources, which means
that regrettably we are not able to comment on every issue affecting children and young
people.
We simply do not have the capacity to cover every area. For this reason, we are unable
to comment officially on your symposium or arrange to meet to discuss the topic.
We all face an uphill battle as you will realize from the British Children’s
Commissioner’s comments, but that is nothing in comparison with the constant battle we
wage with the very organization that should be helping our cause to prevent cruelty to children, the NSPCC (National Society for the Prevention of Cruelty to Children) the largest
organization of its kind in the world. They have the audacity to run a campaign called Full
Stop; the by-line for which is: Cruelty to children must stop—full stop.
After ten years of constant attempts at negotiations, countless emails, endless letters, and hours of wasted time on the telephone, we have finally managed to obtain
an actual meeting with them, yet, they still refused to send a speaker or even a delegate from the head office in London to attend this conference, although a delegate
from a minor regional office did eventually agree to attend this symposium for two
days—perhaps this is the first chink in the door against which we have been pushing
for so many long years, Let us hope that, with constant pressure and further diligent
effort, we can break down this intractable barrier once and for all for the betterment
of all children.
On a more hopeful and positive note, it is interesting that, in London, some attention is now being paid to genital cutting of both sexes and the Metropolitan Police
and the London safeguarding boards are now actively examining cases where evidence of the use of these practices has occurred. Perhaps before long prosecutions
will be made and reported widely in the press making our activities easier, but we
must be ready and be able to take advantage of the inevitable waves that such public exposure to the procedures will create. The way forward is to be prepared, to
have our statements and spokespeople prepared to face the media with positive and
reasoned responses when the sadly inevitable tragedy occurs and the true horrors
become part of the media frenzy.
Perhaps one of the areas that needs to be addressed urgently and where some
progress can be made in the relatively near future is engaging with and influencing
the current educational system in Great Britain. Sex education for boys is sadly
lacking—there is still a reluctance to discuss the topic and more often than not the
tone reverts to—read the chapter on the reproductive system of the rabbit—not the
most useful or helpful advice! Is it surprising, therefore, that 80% of our enquiries
come from boys who have no basic information on the function and working of the
foreskin, even to the extent of not realizing that it should retract and that is a normal
aspect of its function.
This lack of basic information must be addressed; it is essential to get the details
out to these young men who face a fearful and worrying time and potentially lifealtering consequences as a direct result of the lack of male sex education in our
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schools today. This information should also be given to every young girl—they are
just as likely to be the one of influence and the decision makers of the future—not
only can they help their partners but they will keep their future children intact. It is
essential that, as an international organization, we start to make waves in this area
and beat a path to the Education and Health Ministers’ door to spread the word and,
most importantly, to protect our future generations.
Where problems occur, the most frequent recourse is to circumcision as a first
course of treatment, and it is disconcerting that this is actively supported by the
National Institute for Clinical Excellence (NICE). NICE is a powerful government
organization in Britain that dictates policy on everything from what drugs may be
used to which bedpans can be purchased. They are all-powerful but will not tackle
the subject of male circumcision. They openly state they will not consider anything
that will not save the NHS a million pounds annually. NORM–UK has submitted
a carefully researched paper to them, detailing how restricting the practice of circumcision to those that are medically essential would actually provide significant
savings in excess of six million pounds—it is a no-brainer, the essence of which
they refuse to examine and embrace.
With due reverence to doctors, I feel it important to make reference to the salutary fact that many of the nation’s doctors are both ill-informed about our subject
and have no inclination to both adapt to changing attitudes or accept the evidence
presented through new research and a change in medical thinking. This, in part,
must be attributable to the regrettable practice of financial rewards given to those
medics who still persist in circumcision for the betterment of their own pocket. This
will be a harder mountain to climb and eventually eradicate, but it is one that must
be tackled. The best weapon in our armament will be the threat of legal action. The
first case brought will focus their minds and assist our cause considerably. Let us
hope that someone, in the very near future, is brave enough to bring that prosecution
and open the floodgates to other potential actions. Before this will be successful, it
is essential that the diagnostic codes used to disguise circumcision be changed so
that they can no longer masquerade as therapeutic operations.
Symposia like this are an ideal platform to disseminate information and to assist
in the eradication of both erroneous and what we all know is frequently inaccurate information. A classic example of this can be illustrated in the attitudes of the
media doctors whose advice is read by millions daily in the more reputable press.
It is a well-known fact that two of the most prominent, Thomas Stutterford, in the
Times, and Miriam Stoppard, of the Mirror, are pro-circumcision and frequently
give what we would all believe is wrong advice to anxious readers in need of more
sensible help. Both were invited to attend this symposium, but Stutterford ignored
all communications and has similarly ignored all attempts to give him information
on our subject. Miriam Stoppard assured the organizers that the date was firmly in
her diary and high hopes were raised that she might attend, even for a single day,
so that we could enlighten her. Since then, as you probably already have guessed,
she has ignored all attempts to contact or communicate with her. Both attitudes are
unacceptable and cause a problem that we must attempt to break down. It is a wellknown fact the population will always believe what they read in the press or see on
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television, not what is blatantly obvious truth. The way forward, however, is unpalatable to the recipient, to bombard with literature, letters, and information until,
through a war of attrition, we win them over and get the message across. This is
something everyone here can assist with. Write to the editors, contact the media,
and put the record right. If each and every one is vigilant and you follow your
convictions, this situation can and should be reversed.
The joint collaborations that have been fostered though the organization of this
conference have brought into focus areas of mutual interest that should be developed together. The amalgamation of the female and male campaigns will be a more
forceful voice and prevent those, who, in the past, have attempted to divide the
two and by doing so weaken the arguments against the practices of both male and
female cutting. The most obvious areas of joint working must include efforts to fund
collaborative research projects. Similarly, it will be important to work with the communities who practice genital cutting of either sex, at a grassroots level. It will be
essential to start speaking and working with the diverse communities whose cultures
we need to influence and educate.
The quantum-step change in thinking and actions on genital cutting will be
enhanced and brought to the attention of a wider public not only by the new symbol but with the launch of a website—Genital Autonomy—which, hopefully, will
awaken the world to the problems about which we are actively campaigning and
endeavoring to make the subject acceptable in polite society in the same way in
which the very word AIDS has gone from the greatest taboo to a subject discussed
even around the most polite and formal dinner table. This is where we need to be in
the future and preferably making significant inroads into that status by the time of
the 2010 symposium. It is up to every one of us to make a difference, to challenge
the preconceptions of the public, to wear our badges with pride, and to not be afraid
to put our heads over the parapet, as you will realize from the numbers of similarly
minded people, not only in this room but those you know on both sides of the Pond
who actively support both organizations—NOCIRC and NORM-UK. Without communicating with those who are too afraid to ask but are desperate for help and, more
importantly, information, the message of the possibilities for assistance and support
will never reach the wider population. The way forward is for everyone to take our
message out into the communities where it will do the most good.
Two hundred years ago, campaigns were equally important in changing the perceptions of society and radically altering the whole subsequent course of history.
This is well illustrated in the movement for the Abolition of Slavery and the production of the first campaigning lapel pin by Josiah Wedgwood. That emotive depiction
of a kneeling manacled slave became universally recognized and admired. What
was possible in the eighteenth century surely can be improved upon in the twentyfirst century. We should emulate one of the great pioneers of Staffordshire and wear
our Genital Autonomy symbol with pride and stand up for what is right, just, and
humane.
Chapter 21
Circumcision
George Wald
Abstract At the 7th International Symposium on Circumcision, Genital Integrity,
and Human Rights, held at Georgetown University in Washington, DC, Van Lewis
presented a paper about the amazing work of George Wald (1906–1997), who, in
1967, won the Nobel Prize for his discovery of Vitamin A in the retina of the
eye and how it works with light to produce vision. Not only was he a world-class
research scientist, Time magazine declared him one of America’s Ten Best Teachers.
A child of immigrant New York Jewish parents, beloved Harvard biology professor,
and well-known twentieth century activist for peace and justice, George Wald also
worked to defend the right of all children, male and female, to genital integrity. Here,
thanks to Van Lewis and George Denniston—both students of George Wald—and to
his wife for giving us permission to publish this never-before-published paper. This
is what Dr. Wald had to say about penile reduction surgery, euphemistically called
circumcision.
Keywords Myelin sheath · Initiation rite · Maimonides · Jews · Moses · Zipporah ·
Hygiene · Cancer · Adhesions · Phimosis · Anesthetic · Glans penis ·
Foreskin · Reform Judaism · Covenant · Violence
George Wald (1975)
Every year in early February, after my last lecture at Harvard, I go off into the
back country for a while, to put myself together. Last February it was to Mexico, to
visit two remote Indian tribes in the Sierra Madre. On the way I stopped off for a
lecture at Florida State University in Tallahassee. It was a big public lecture, with a
discussion afterward, and a reception.
G. Wald (B)
Professor of Biology, Harvard University, Cambridge, MA, USA
G. Wald (1906–1997), Nobel Prize recipient, 1967.
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Toward the end, a young man came up, bearded, lots of hair, open shirt, jeans.1
He introduced his wife and his mother, a stately woman, carrying the young couple’s
7-month-old infant. “When are you leaving Tallahassee?” he asked. I told him on a
seven o’clock flight to Atlanta next morning, to catch the Mexico City plane. “Can I
drive you to the airport?” “Yes, thanks,” I said thoughtlessly, “if your car will run.”
“We have three,” he said, “and one of them is sure to run.”
So at six next morning he came for me and we set out for the airport. A little way
along he said, “Have you thought much about circumcision?”
“No,” I said, a little surprised, “I haven’t thought about it at all.”
“Well, I’ve thought about it a lot,” he said, “I’ve been thinking about it for years.
I think it’s a terrible thing to do to a male infant that’s just gone through the struggle
of being born, that’s just left the warmth and security of the womb to come out into
a cold and strange world, to greet him with the knife, with a mutilation. I’ve never
been able to forgive my mother for having that done to me.” (Note: his mother—a
recurrent theme)
“A few years ago,” he went on, “I realized that to make further progress in my
thinking I’d have to go public. So I prepared some carefully lettered signs; and since
it was a windy day I asked my younger brother to come along and help carry them. I
told my father what we planned to do.” “Well son,” he said, “you know I’ve backed
you in almost everything, but I think I’ll pass this one up.”
“We drove to the entrance to a big general hospital on a main road, and began to
picket. One of the signs read, CIRCUMCISION IS A SEX CRIME. Another read:
SEX CRIMINALS FOR HIRE? INQUIRE WITHIN.”
Almost every car that drove past would slow up to read our signs. Then something
interesting developed. There was a difference in the way men and women reacted.
Some of the men were with us. They would lean out, wave, and say things like, ‘You
tell them, kid!’ and ‘Right on!’
“But the women were furious. They shook their fists at us, and some of them
stopped to curse us out. You’d be surprised at the language they used.”
“After awhile the police came and took us in for disorderly conduct. We spent
the afternoon in jail, posted bond, and went home.”
By that time we had reached the airport. My plane was late, so we sat down and
went on talking. Up until then I had been listening, interested, a little amused, not
involved. Suddenly he said something that shook me.
“It seems to me,” he said, “that the foreskin is the female element in a male. It’s
warm flesh enclosing the penis; a kind of male vagina.”
“My god!” I said, “That’s wonderful! Because we’ve always been told that the
clitoris is the male element in a female!” And I told him about the Dogon.
The Primitive Event: An Initiation Rite
The Dogon are a West African people living in Mali south of the great bend in the
Niger River. I became interested in them long ago, through their very distinctive
wood sculpture. I had hopes to visit them last April; but just before setting out was
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warned that April is the worst month of the year in that region: temperatures near
110◦ and torrential rains that might make the roads impassable. So I had to give
it up.
The Dogon have an extraordinary creation myth. The primal god, Amma, made
the Earth from clay in the shape of a woman lying on her back. Then Amma, being
lonely, wanted to copulate with her. Her vagina was an ant hill; but beside it was her
clitoris, a termite mound. (These characterizations became clearer to me when I ran
across a photograph of a field with termite mounds. They are not broad, rounded
eminences like ant hills, but tall, slender, phallic columns.)
As Amma approached the Earth to copulate with her, the male element, the
termite mound, rose against him. So first he had to destroy it.
Suddenly everything fell into place. The Dogon, like many other African peoples,
not in early infancy but at or near puberty, as an initiation rite, circumcise the boys,
and excise the girls: the clitoris is cut away, in some tribes along with the labia
minora. Up to puberty every Dogon child is thought to be to a degree bisexual, a
gynandromorph; and that is acceptable, since it has as yet no serious sexual role to
fulfill. But then, in preparation for adulthood, the boys are made altogether male by
removing the foreskin, their female member; and the girls are made wholly female
by excising the clitoris.
One does not have to improvise this interpretation. The tribal traditions state it
plainly. So, speaking of the creation of man: “each human being from the first was
endowed with two souls of different sex. In the man the female soul was located in
the prepuce; in the woman the male soul was in the clitoris. . . The dual soul is a
danger; a man should be male, a woman female. Circumcision and excision are the
remedy.”2
I have no doubt that this is the dominant primitive meaning of circumcision and
excision: that, androgynous to a degree in infancy, children have their sex roles
established unequivocally at or near puberty by removing the foreskin from boys
and the clitoris from girls.
These practices are ancient and widespread. They have arisen on every continent.
“The bodies of Egyptians exhumed from the earliest prehistoric cemeteries, back
of 4000 B.C., have disclosed the evidence of circumcision whenever the body is
sufficiently well preserved to make the observation possible. The actual performance
of the operation by the Egyptian surgeon is depicted in an Egyptian tomb relief of
the twenty-seventh or twenty-eighth centuries B.C. in the cemetery of Memphis.”3
This great Egyptologist believed that the ancient Hebrews, led by Moses, “born in
Egypt and bearing an Egyptian name” (Mose = child of, as in the Pharaonic names
Ahmose, Thutmose), borrowed from the Egyptians at once the Pharaoh Ikhnaton’s
monotheism, the rite of circumcision, and the ban on eating pork. Yet among the
ancient Egyptians also, circumcision was a puberty rite, performed at ages 6–14.
It is curious that up to relatively modern times, circumcision never set the Jews
off from most of the people about them. The custom prevailed not only among
the ancient Egyptians, but the Semitic peoples among whom the Jews continued to
dwell: Moabites, Edomites, Ammonites, Phoenicians. Circumcision tended much
more to divide Semites from non-Semites than Jews from others. To the ancient
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Jews the epitome of the uncircumcised were the Philistines, a non-Semitic sea people, probably from Crete; until the ninth century B.C. they encountered also the
Assyrians, Semites yet uncircumcised.
With the coming of the Prophet, circumcision became universal among Moslems,
accompanied in some groups by female excision. It is practiced ritually by numerous people of central and west Africa including the Ethiopians; many Australian
aborigines; Malays, Fijians and Samoans; and Indian tribes in North and South
America. (I have a fine pre-Columbian stirrup-bottle from the Vicus area in Peru,
the spout of which has the form of an erect, circumcised penis.)
The most usual status of circumcision among all these peoples is as an initiation
rite, performed at or near puberty, often in direct preparation for mating or marriage. There is some reason to believe that it may have begun that way among the
ancient Hebrews. In the Ethiopian (“Coptic”) Christian Church, though boys are circumcised in early infancy, girls are excised at or close to puberty. So far as I know,
no other people circumcise as early as the Jews—on the eighth day—except for
present-day Americans, who owing to the exigencies of hospital practice, are likely
to have their infants circumcised on the third or fourth day.4
Running through all modern discussions of circumcision is the thought that it
began, and still operates as an aspect of preventive medicine. Adults who need to be
circumcised because of some penile disorder have always uncleanness to blame for
their trouble. John Morrison, an Australian physician, observes that in Australia ritual circumcision is practiced only by those tribes that live under desert conditions, in
which the combination of sand, wind and shortage of water for washing would have
made circumcision frequently necessary later in life, had it not been performed in
childhood. He suggests that similar environments may have prevailed wherever else
in the world this custom has arisen (Medical Journal of Australia, 1967, p. 125).5
It may well be true that millennia of painful experiences had a part in developing circumcision as a ritualized health measure. That cannot be the whole story,
however, or probably even a dominant motif. For one thing it does not touch the
parallel practice of female excision, which no one has tried to defend on medical
grounds. Nor does it apply to a great variety of other mutilations of the external genitalia practiced by native peoples. But most important of all, such surgery performed
under primitive conditions must always have presented a serious hazard. Even under
relatively impeccable conditions in a modern hospital, circumcision occasionally
causes complications. Done with rude tools in the bush or in the desert, it must
often have led to infection, maiming, at times the death of the subject. It is hard
to assess what net medical advantage, if any, circumcision might offer under such
conditions.
It seems to me much to the point that the ancient Jews, far from looking upon
circumcision as a health measure, regarded it as a dangerous operation. Thus it was
decided early that a Jewish infant whose brother had died as a result of circumcision was to be spared this ritual. In the ceremony of circumcision, the special
chair said to be reserved for Elijah is left in place for three days, because these are
days of danger for the child. Moses Maimonides, the twelfth century rabbi of Cairo
and court physician to Saladin, put the matter plainly: “No one should circumcise
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himself or his son for any other reason than pure faith; for circumcision is not like
an incision on the leg or branding on the arm, but a very difficult operation.”6 To
regard the Jewish rite of circumcision as primitive prophylaxis is a modern interpolation of medical hindsight on a par with the notion that the ban on eating pork was
to prevent trichinosis.
As was to be expected, the rite of circumcision has also excited great psychoanalytic interest. Sigmund Freud took it to represent the symbolic castration of
sons by jealous fathers.7 There is little anthropological evidence to support this
view. It implies a primitive awareness of the male role in procreation that was
generally lacking, as well as an interest in castration that so far as we know developed only in relatively sophisticated peoples and in quite other associations. Bruno
Bettelheim has suggested an ingenious alternative: that circumcision may represent
an attempt on the part of males symbolically to mimic characteristically female roles
in reproduction including bleeding at puberty.8
I find it a relief to turn from such baroque interpretations to the simple reasonableness of the traditional view already expressed: that, usually in the form of a
puberty ceremony, circumcision is to render boys wholly male, and excision to make
girls wholly female. This is, I think, the most widespread view among the peoples
themselves who have practiced these rites. I think that this is as close as we shall
ever come to rationalizing them.
Also I find the concept of the innate bisexuality of the human body not only
attractive but well founded anatomically and embryologically. In the human fetus
the external genitalia are identical in both sexes until the end of the third month.
Then they begin to differentiate. The rudiment that forms the penis with its foreskin
in the male becomes the clitoris with its sheath in the female. The folds that become
the labia majora in the female become the scrotal sac in males. (There is no male
counterpart to the vagina.) Men keep throughout life their vestigial nipples that can
be developed into breasts, though never to lactate, by treatment with estrogen. (Have
any native people ever excised the male nipples at puberty?)
The human body is gynandromorphic in origin, remains so to a degree until
puberty, and retains vestiges of this condition throughout life. Anatomically, male
and female are variations on the same central theme. That is the reality; what
concerns us here are the mutilations practiced to deform that intrinsic reality.
These are amazing in their extent and variety. All peoples everywhere have displayed an obsessive preoccupation with the external genitalia (as also with the
mouth: witness moustaches, painting the mouth, lip plugs, covering the mouth or
veiling the lower part of the face. Eating and reproduction are the two great primal drives). The genitalia tend to be hidden, often when nothing else is hidden.
Conversely, males may flaunt them as in the sixteenth century European codpieces;
or the gourd sheaths with which Dani tribesmen in west New Guinea hold their
members erect and greatly exaggerate their length (R. Gardner and K.G. Heider:
Gardens of War, Random House, New York, 1968).
Some of the mutilations are cosmetic: the male members are made more attractive by scarifying them and distorting them with swellings and protuberances. In
some African tribes the labia minora are purposely lengthened so as to be visible
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externally. Some mutilations have to do with enforcing virginity: Some of the
African Arabs practice infibulation: the entrance to the vagina is sewn partly closed
so that copulation is impossible until this obstruction is removed. One male mutilation is most remarkable: Some of the Australian tribes that practice circumcision
follow it later with so-called sub-incision: The penis is slit below for its entire length,
laying open the urethral canal, so that thereafter the man must squat while urinating, like a woman. The member is still capable of erection and copulation; but I
should think must be less effective for delivering sperm to the cervix. Could this be
a primitive device to limit conception? Or a particularly striking manifestation of
Bruno Bettelheim’s mother-envy?
It is against this background of endlessly bizarre practices and grotesque explanations that I single out as most reasonable and meaningful the view of circumcision
as a puberty rite, along with the parallel excision in girls. Before puberty a degree
of gynandromorphy is tolerated in both sexes; but at puberty, when sex begins really
to matter, as an initiation into adulthood and preparation for marriage and parenthood, these ceremonial mutilations turn boys into pure males, and girls wholly into
females.
The Jewish Rite
The Jewish rite of circumcision is something else again, being confined to males and
performed in earliest infancy. Yet vestiges remain of its possible source in a puberty
rite; so for example the 8-day-old infant is hailed as “chatan”—a bridegroom.
The Biblical injunction to circumcise first appears in the weightiest possible
form, sealing the covenant between God and Abraham, father of nations: “And God
said to Abraham. . .. This is my covenant, which you shall keep, between me and you
and your descendants after you: Every male among you shall be circumcised. . .. He
that is 8 days old among you shall be circumcised . . . both he that is born in your
house and he that is bought with your money. . . So shall my covenant be in your
flesh an everlasting covenant. Any uncircumcised male . . . shall be cut off from his
people: he has broken my covenant.” (Gen. 17:9–14).
Abraham was then ninety-nine. God had no sooner finished speaking than
Abraham had himself circumcised, he and his 13-year-old son Ishmael—so a
pubescent boy. Also all his male slaves. Did the slaves thereby become Jews? My
rabbinic friend, a deep student of such matters, says “Almost.” They became, so to
speak, second-class Jews. Any who were freed thereafter were accepted as full Jews.
On the other hand, slaves who evaded circumcision had to be sold to Gentiles.
Circumcision is one of the holiest and most universal of Jewish rites, and yet it
has its limits. One might think the command to circumcise so absolute as to permit
no equivocation. It is astonishing to realize that on the contrary any son of a Jewish
mother is fully a Jew, circumcised or not. A Jew whose brother has died as the
result of circumcision is excused from this obligation. The Bible contains some
other interesting vagaries.
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Belated circumcision: When Joshua led the Israelites over the Jordan to claim the
Promised Land, God enjoined him among the ceremonies of investiture to “Make
flint knives and circumcise the people of Israel.” For though all the Jews who came
out of Egypt had been circumcised, that was not true of any born during the 40 years
of wandering in the wilderness. So it was done then to all of the males in the nation,
some of them 40 years old, at the Hill of the Foreskins. They laid over in camp until
healed before moving on (Joshua 5:2–8).
Circumcision as a military tactic: When on his wanderings Jacob with his
household came to the city-state of Sechem in Canaan, his daughter Dinah went
to visit with the women of the city. The prince of Sechem seized and raped her;
but also fell in love with her and wanted to marry her. But Jacob’s sons were outraged by the indignity done their family, and wanted revenge. The king interceded
for his son, and proposed that Jacob stay at Sechem and that their people intermarry. Jacob’s sons replied, not until all the Sechemite men were circumcised. They
agreed, and all underwent the rite. “On the third day, when they were sore, two of
Jacob’s sons, Simeon and Levi, Dinah’s brothers, took their swords and came upon
the city unawares, and killed all the males.” Then they took everything for their own,
including the women and children; and brought back Dinah. Jacob reproached them
for this deed, but only because it was impolitic (Gen. 34). Yet he seems to have kept
it in mind, for on his deathbed he cursed their ferocity and cruelty, and he left them
alone landless among all his sons (Gen. 49:5–7).
Circumcision for battle trophies: Saul offered his daughter Michal as wife to
David because she loved him, but also because Saul, jealous of David’s popularity,
planned by a ruse to have the Philistines rid him of a potential rival. So when David
modestly demurred, pleading his insignificance and poverty, Saul sent back word
that all he asked as a bride price was one hundred Philistine foreskins. That made
David happy. He brought the king two hundred foreskins, and married the princess
(I Samuel 18:20–27).
Was Moses circumcised? An altogether astonishing passage occurs in Exodus
4:24–26. It will be recalled that Moses, having killed an Egyptian who had mistreated a Hebrew, fled to Sinai and there married Zipporah, daughter of Jethro, a
priest of Midian. While Moses was shepherding his father-in-law’s flock, God spoke
to him out of the burning bush, and ordered him to return to Egypt. Moses was reluctant to do so, but God insisted; and finally Moses gave in. He gathered up his family
and started back to Egypt. Now the amazing passage: “At a night encampment on
the way, the Lord met him and sought to kill him. Then Zipporah took a flint and
cut off her son’s foreskin,” and smeared the blood on Moses’s genitalia (my translation says “touched his legs with it,” but that is a circumlocution) saying, “You are
truly a bridegroom of blood to me!” And when the Lord let him alone she added,
“A bridegroom of blood because of the circumcision.”
What this seems to mean is that, growing up in Pharaoh’s palace as the ward
of an Egyptian princess, Moses had not been circumcised, nor were his sons born
in Midian. Zipporah’s quick action saved his life; God was deceived by the blood
upon Moses into thinking him circumcised. The Midianites were Semites, but not
Jews. Zipporah was not Jewish, hence neither were her children. But she had done
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the right thing; and I like to think that her exultant cry meant, “Now I am fully your
Jewish wife. I have circumcised our son, and have saved your life with his blood.”
(There is of course a difficulty. Since circumcision was a much more ancient
Egyptian than a Jewish rite, Moses should have been circumcised as an Egyptian,
if not a Jew. Perhaps this was not done in order to disguise his Jewishness, to
make him seem to the Egyptian nobles a more acceptable kind of foreigner. We are
never told whether, after Zipporah made Moses appear to have been circumcised,
he actually was.)
The unique feature of circumcision among the Jews, relative to all the peoples
about them who seem to have practiced it as a puberty rite, is its displacement
to earliest infancy. No other people have practiced ritual circumcision on infants
so young; and those who approach it, the Moslems and Ethiopians, probably did
so in imitation of the Jewish custom. Ironically, the Jews are now outdone in this
regard by American gentiles—and some Jews—who, having to leave the hospital
3–5 days after a child is born, have non-ritual circumcisions performed as early as
the second day.
Why Did the Jews Circumcise So Early in Infancy?
Moses Maimonides, the twelfth century codifier of the Talmud, gives “three
good reasons:” (1) If it were postponed, the grown boy might not submit to it.
(2) The young infant does not feel much pain, “because the skin is tender and the
imagination weak;” and (3) the father, who is responsible for carrying out this commandment, hardly knows the infant as yet, whereas later his love for his son might
tempt him to spare the boy this mutilation.9
This explanation, for all its practical good sense, I believe is trying to rationalize
an ancient practice that must have arisen for other, deeper and more arcane reasons,
more closely connected with our earlier discussion.
Male and Female in the Jewish Tradition
Let us begin with the ancient belief that the foreskin is the female element in a male.
I should like first to suggest that the displacement of circumcision to the eighth day
of life, as also the failure to provide any parallel rite for females, were aspects of the
obdurately male orientation of Judaism. Then, having dealt with that, I will come
back a way.
The Jews alone among the Mediterranean peoples worshipped one, militantly
male God. This position needed constant defending, both the mono- and the
androtheism. It was with good reason that God cautioned Moses, “You shall have
no other gods but me . . . for I, the Lord your God am a jealous God” (Exodus 20:
3, 5). Throughout the Mediterranean region the worship of the Great Mother flourished and constantly intruded: Ashtoreth (Astarte), whom Solomon was persuaded
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to worship in his old age (I Kings 11:5); Asherah, mother of the gods, whose worship, attended by both male and female temple prostitutes for the use of the male
communicants, persisted for centuries, even invading the Temple in Jerusalem until
Josiah, the great reformer, ordered the priests to remove from the Temple “all the
vessels made for Baal, for Asherah, and for all the host of heaven . . . and he brought
out the Asherah from the house of the Lord. . . And he broke down the houses of
the male cult prostitutes which were in the house of the Lord. . .” (II Kings 23:4–7).
Not only was the Jewish God male; all about were powerful goddess cults. As Freud
put it, Judaism is a Father religion, just as Christianity is a Son religion.10 The only
relief from this exclusively male Judeo-Christian theology is in the Roman Catholic
cult of Mary.
The preoccupation with maleness extends to humankind. Not only was the first
human being a male; as the feminist Mary Daly remarks with some bitterness, he
preempted the first childbirth under sedation in giving birth to Eve.11 All this ancestral couple’s early children were males. Females were an afterthought. After Seth
was born when Adam was 130 years old, we are told that Adam lived another 800
years “and had other sons and daughters” (Genesis 5:3–4).
The literal-minded wonder where Adam’s firstborn Cain and his sons in turn
found their wives. Where indeed? That was not a pressing problem to the ancient
Jews. Once the men were there, women would turn up as needed.
I once was told the story of a revivalist preacher who in the course of a sermon used the phrase, “There will be wailing and gnashing of teeth!” “How about
me?” asked an old woman sitting up front, “I ain’t got no teeth!” “Teeth?” said the
preacher, “Teeth will be provided!”
That’s how it was with women in Genesis—they were provided!
Could it have been this obsession with maleness that persuaded the ancient
Hebrews to make their sons wholly male from earliest infancy by circumcising them
on the eighth day? And in the same spirit to do nothing about their daughters, then
or later? The Bar-mitzvah for the sons at age thirteen, and nothing for the daughters? One of the ordinances that God gave Moses on the mountain begins: “When a
man sells his daughter as a slave. . .” (Exodus 21:7). Men did not sell their sons. In
the daily morning prayer, now well over 2,000 years old, Jewish men say: “Blessed
art thou, Lord our God, King of the Universe, who hast not made me a woman.”
Women say: “. . . who hast made me according to thy will.” Exultation for the men,
resignation for the women. In the Judaic scheme the thing to be is male, wholly
male, right from the start; and one way to achieve that is by early circumcision.
This seems to be a plausible hypothesis; it is not intended to be more, nor can
it be. But in defending it I have gone too far. I want now to draw back from it
somewhat, for the reality is both more complicated and more interesting. For what
I have called the obsessive male-orientation of the Mosaic tradition concealed, and
perhaps for that very reason tried to overwhelm, a fundamental ambiguity, a taint of
the female, not only in Adam, but reflecting back upon God himself.
In the oldest Biblical account of human creation—said to have been written in the
ninth century B.C., though presumably the oral tradition goes back much further—
“the Lord God formed man from the dust of the Earth” (Genesis 2:7). In Hebrew this
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is to derive man, Adam, from Adamah, the Earth, a feminine form. It is an idea held
by innumerable peoples from time immemorial. We keep it still, in our expression
Mother Earth.
Two other accounts of human creation are assigned by Biblical scholars to the
later Priestly version, written in the fifth century B.C. In both of them man and
woman are created together, as in the words: “And God created man in his own
image; in the image of God created he him; male and female created he them”
(Genesis 1:27). Genesis 5:2 begins with almost the same words and then goes on:
“. . . and blessed them, and called their name Adam, in the day when they were
created.”
In both these statements there is the same curious switch of number, from “him”
to “them”. The Hebrew is that way too. How get from “him” to “them”? How have
a “them” named “Adam”?
Does it mean that the first human creature was bisexual? And hence that God,
since he shared the same image, is at once male and female?
The rabbis who made the Talmud found this a worrisome problem, troubling
enough to dispose of early and put behind them. Some ingenuity was expended
upon it. Moses Maimonides summed up in the twelfth century as the opinion of
“our sages”—the usual expression for a preferred interpretation—that “Adam and
Eve were at first created as one being, having their backs united. They were then
separated, and one half was removed and brought before Adam as Eve.”12 My
rabbinical mentor tells me that this kind of idea—both of a bisexual God and a
bisexual first human being made in his image, was in the mainstream of Jewish mystical (Kabbalistic) thought until dismissed in the last century under the influence of
German rationalism as sacrilegious or absurd.
So Judaism at its source is not as unequivocally male-oriented as at first appeared.
There is room in the tradition for God the Parent as well as God the Father; and Eve
may not have been born out of Adam, but born with him and sundered from him,
the better to “Be fruitful, and multiply, and replenish the Earth. . .” (Genesis 1:28).
And infant circumcision? This makes it seem more an act of male assertiveness,
perhaps all the more aggressive because the theological ground was a bit shaky. A
wholly male priesthood may have insisted very early on masculinizing not only the
godhead, but every other aspect of Judaism. It may have been part of that effort to
render all males wholly male from earliest infancy by removing the foreskin as a
female contaminant.
This view of the matter is somewhat reinforced when coupled with the otherwise strange prescription in Deuteronomy 23:1: “He whose testicles are crushed or
whose male member is cut off shall not enter the assembly of the Lord.” One can
understand that such mutilations might make a Jew unfit to marry, but why should
they exclude him from the rituals? Is it that circumcision was regarded as confirming
and purifying his maleness, whereas these more drastic mutilations would destroy
it, and hence would bar him, as women were barred, from direct participation in
religious observances?
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Is Circumcision a Health Measure?
I have already given reasons for questioning the origins of circumcision as primitive preventive medicine. In recent times this practice has been taken up widely
as a supposed “health measure” by gentiles particularly in the English-speaking
United States, Canada and Australia, less in Europe. Many Jews also, religious and
otherwise, now defend this practice on grounds of health.
Within the last few years many physicians have gone over to the view that infant
circumcision, having begun as religious ritual, now survives in Western societies
as little more than medical ritual. In that sense it is often grouped with another
ritualized operation, tonsillectomy.
A few distinctions are needed. Both these operations have a limited role in therapy, in treating specific disorders. What is now being questioned increasingly is their
routine performance as prophylaxis, as aspects of preventive medicine.
Tonsillectomy, like circumcision, has an ancient history going back some 2,500
years.13 Both operations—excepting circumcision done for religious reasons—have
a curious class character. Not only are they restricted largely to developed nations,
but within them mainly to the well to do. They are aspects of middle class privilege,
evidences of affluence and social status, demonstrations of the special care that middle class parents lavish on their young. Not only do the parents frequently initiate
these procedures; they may be performed more for them than for their children, to
show that they are as solicitous as the Joneses. A statistic bears out this connection:
in England circumcised boys are seven times more likely to have tonsillectomies in
early childhood than uncircumcised boys.14
Though routine tonsillectomy is rapidly declining in this country, an American
pediatrician could still say in 1969: “It is probably the commonest surgical operation
performed today in Western civilization.”15 A physician in good position to know
assures me that this is still true. And tonsillectomy is something one can do for
daughters as well as sons! Even when the physician is neutral or negative toward
these procedures, the parents may still request them. And the physicians’ attitudes—
as some of them readily grant—may be colored by the recognition that these rapid,
relatively innocuous procedures pay rather handsomely. A circumcision takes about
10 min, and a dozen may be run off any morning. One of our best Boston hospitals
at present charges $40 for the use of the room and nurse; and the physician bills his
private patients $30–$50 for the operation. It adds up.
One of the reasons frequently given for infantile circumcision is that it “will avoid
trouble later.” The medical statistics of such later troubles among the uncircumcised
also have a strong class orientation. Not only are the sons of the poor less likely to
be circumcised, but their lack of circumcision is much more likely to cause later difficulties. The conditions of their lives and the kinds of things they do and are done
to them are much more likely to foster uncleanliness of the male member, the only
condition that childhood circumcision ameliorates. The statistics of penile pathology among uncircumcised men are overwhelmingly weighted toward workers,
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peasants, and soldiers. What should be blamed upon poverty and squalor is heedlessly ascribed instead to lack of circumcision. As one physician says, “Venereal
disease is more prevalent in lower socioeconomic groups and these are the groups
that are most likely to be uncircumcised. They are also the groups in which there is a
poor standard of personal hygiene. The lower socioeconomic groups are also those
with a higher incidence of tuberculosis; but one could be excused for doubting that
the retention of the prepuce renders one more susceptible to tuberculosis.”16
One of the most striking things said in support of childhood circumcision is that
it practically rules out the development of cancer of the penis. That may be true in
the United States; but a study of Javanese men, who are circumcised ritually, found
among 78 cases of carcinoma, 7 carcinomas of the penis. Conversely, though almost
all of Sweden’s 3.7 million males are uncircumcised, in 1960 only 15 cases were
found of cancer of the penis or scrotum. It seems clear that penile cancer is very
rare in uncircumcised men with high standards of cleanliness as in Sweden; and
that circumcision offers little protection where personal hygiene is not as prevalent.
“If the uncircumcised man has a foreskin which he can retract and which he keeps
clean, the risk of this cancer is removed.”17
There was a recent flurry in the medical literature owing to the allegation that cancer of the cervix is more prevalent in the wives of uncircumcised men. The initial
observation was that Jewish women have lower rates of cervical cancer than gentile
women. However gentile women with circumcised husbands seem to develop cervical cancers as frequently as gentile women whose husbands are not circumcised.18
In fact cancer of the cervix seems to follow the same class pattern as penile disorders of all types including penile cancer: “Factors shown to be associated with
a high risk of developing cervical cancer include low socioeconomic status, early
marriage, multiple marriages, extramarital relations, coitus at an early age, frequent
coitus, non-use of contraceptives, syphilis and multiparity.”19 There is no solid basis
for believing that circumcision in itself has anything to do with the incidence of
cervical cancer.
To keep the penis properly clean in the adult demands retracting the foreskin.
Many mothers are alarmed because their infants’ foreskins cannot be drawn back.
But in fact this is the normal condition in young infants. The foreskin can only
rarely be retracted at birth, and ordinarily becomes retractable only at 2–3 years of
age. In a careful English study the prepuce was found to be completely retractable
in only 4% of newborn boys. In only 54% the tip of the glans (the head of the penis)
could just be seen, while in 42% it was completely hidden. Even at 6 months the
foreskin could be retracted in only 20% of the infants, whereas at 1, 2 and 3 years
this figure rose to 50, 80, and 90%.20 With increasing age the condition improves
further. A study in Danish schoolboys, few of whom are circumcised, showed that
the foreskin could not be retracted (phimosis) in 8% of 6–7 year olds, but only 1%
of 16–17 year olds.21 Clearly the way to deal with unretractable foreskins in boys is
not to circumcise, but to wait.
Another common complaint is that the foreskin adheres to the glans. Again this
seems to be normal in young boys. In Danish schoolboys Oster found the incidence of such “adhesions” to diminish without treatment from 63% in 6–7 year
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olds to 3% in 16–17 year olds. No adhesions were found among ninety-five 17
year olds. Normally the skin of glans and foreskin, which may be fused in infants,
separates spontaneously during childhood, a process that may take to age 17 to
complete.22
It is also normal for a cheesy sebaceous material called smegma to collect
between foreskin and glans. This causes no trouble in young children with unretractable foreskins, since they form little smegma. Oster found smegma in only 1%
of 6–7 year olds, increasing at about puberty, and rising to 8% in 16–17 year olds.
One can conclude that there is little trouble to expect in the uncircumcised that
would not be prevented by simple cleanliness, by older boys and men occasionally
drawing back the foreskin and washing gently. As one physician has remarked, the
problem is little different from washing behind the ears, yet no one has suggested
amputating the ears.
Finally, it should be understood that circumcision, like any other surgical procedure, can cause trouble. It produces an appreciable incidence of complications:
immediate, such as hemorrhage,23 infection and loss of skin;24 and delayed, such
as ulcerations and blocking of the urinary opening. More serious complications are
fortunately rare, but they occur.
I cite only for its intrinsic interest, not to frighten expectant parents, the wellknown case of a 7-month-old boy, one of a pair of identical twins, who was being
circumcised by electrocautery. The current was too strong and burned the penis
so badly that it was wholly ablated, flush with the abdomen. The desperate parents finally agreed to have this little boy transformed into a girl, through surgery
and hormone treatment.25 It is unlikely that so drastic a mischance will happen
again soon.26
A particularly well-considered essay by the pediatrician E. Noel Preston concludes: “Routine circumcision of the newborn is an unnecessary procedure. It
provides questionable benefits and is associated with a small but definite incidence
of complications and hazards. . . Circumcision of the newborn is a procedure that
should no longer be considered routine.”27 Another physician, W.K.C. Morgan,
ends an essay in the same journal with the words: “The teaching of the Koran
and Bible, the mistaken beliefs of many in the medical profession, the intuition of
woman (note: woman), and above all folklore, tradition and health insurance agencies support this ritual. Nevertheless let us remember that 98 times out of 100 there
is no valid indication for this mutilation other than religion.”28
It is only fair to note that each such statement in the medical literature inspires
letters from other physicians, both of agreement and rebuttal. Having read both sides
of the argument carefully, I come out convinced that there can be little wrong with
keeping the foreskin that the habit of washing won’t fix. Given a good chance that
the genital area will be kept reasonably clean, regarding infant circumcision as a
“health measure” is only to rationalize what is in fact a distressing mutilation of
young infants.
But that is only one of a galaxy of such rationalizations. Specifically for those
parents with whom this practice is not traditional and so must decide whether or not
to circumcise, that decision involves motivations and repressions that rarely surface,
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perhaps for the very reason that they lie so deep and are potentially so painful. But
that brings us back to where this essay began.
The Mothers
“I’ve never been able to forgive my mother for having that done to me,” said my
young friend in Tallahassee. His mother, not his father. Throughout the current
medical discussion of circumcision, it’s all mothers; not a word about fathers.
For it’s the mothers who decide, in the hospital, talking with their obstetricians, their pediatricians, about their babies, still wholly their responsibility. Not
the Jewish mothers. There no decision is needed, circumcision is taken for granted,
and the fathers are ritually responsible. No Jewish boy would dream of blaming his
mother for having him circumcised.
Why do gentile mothers have their infant sons circumcised?
It is strange that one of the commonest reasons they offer is that the penis looks
better circumcised. I think that strange because those same mothers are horrified
by all kinds of other mutilations practiced by peoples they regard as barbaric, for
just such cosmetic reasons: tattooing, scarification, lengthening of the ear lobes—or
in some African tribes, of the labia minora—lip plugs, and the like. Why do they
condone this mutilation? Why do they think it cosmetic? In part for the curious
reason that by now—for here in the US we are in the second and third generation of
white middle class circumcision—many mothers have never seen an uncircumcised
penis. It would seem strange to them; they are afraid that their little boys would feel
strange having one.
That is ironic, for Michaelangelo’s David, the epitome of young male beauty,
whose pictures adorn innumerable school textbooks—Michaelangelo’s David is
uncircumcised. Ostensibly Jewish, yet uncircumcisied. What was in Michelangelo’s
mind, making David so big, as big as Goliath; making him so old, no stripling as
in the story; making him nude, a sinful state in Biblical times? Was that last just to
show that he was uncircumcised?
Other changes are rung on this sentiment. A young woman about to have her first
child said to me that if it was a boy she would want him circumcised “so that he
would look like his father.” And innumerable mothers have their sons circumcised
so that they will look like other boys, so that they won’t be embarrassed later when
undressing with others “in the locker room.”
But there are deeper issues, somewhat harder to come at since they involve in
part what are still powerful social taboos.
Some years ago the English neurologist Henry Head and his co-workers showed
that the glans of the penis lacks the receptors of fine sensory discrimination—light
touch, small gradations of warmth or cold—what Head called the epicritic sensations. The glans conveys only protopathic sensations: of deep pressure, extreme heat
or cold, and pain. That is, the glans responds only to coarse stimuli, yet with sensations that possess what Head spoke of as great “affective tone,” whether exquisite
pleasure or acute discomfort. The foreskin, however, like most other skin, has all
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the apparatus of fine as well as coarse sensory discrimination; and removing it takes
away a considerable area of delicately responsive sensory surface.
The foreskin also provides a protective sheath for the glans, keeping its skin
moist and tender. Its removal exposes the glans to the constant abrasion of clothing
and keeps the skin dry. Hence the skin of the glans grows tough and coarse, with
a further loss of sensitivity. Through both these effects, circumcision results in an
appreciable loss of sensitivity and responsiveness of the male member.
There is also a mechanical consideration. “During the act of coitus the uncircumcised phallus penetrates smoothly and without friction, the prepuce gradually
retracting as the organ advances”29 An English physician likens penetration by the
circumcised organ to thrusting the foot into a sock held open at the top, whereas for
its intact counterpart it is like slipping the foot into a sock that has been rolled up.30
Western women are horrified to hear of the practice in other parts of the world of
female excision, clitoridectomy, particularly now that it is commonly believed that
the clitoris is the main, if not the only source of female pleasure in coitus. Women
are indignant that so much more damaging a practice should be taken to be in any
way parallel to circumcision. We should realize however that what is done to males
by circumcision involves a similar loss of sexual responsivity.
Having first encountered such considerations in the current medical literature,
I was surprised to learn that this was familiar ground to the ancient rabbis. The
great twelfth century Talmudists Judah Halevi, Judah of Barcelona and Moses
Maimonides all agreed that the main object of circumcision was to encourage sexual
restraint by lowering the sensitivity of the male organ and hence sexual pleasure.
Thus Maimonides: “Circumcision simply counteracts excessive lust; for there is
no doubt that circumcision weakens the power of sexual excitement, and sometimes lessens the natural enjoyment. . .. Our Sages (Bereshit Rabba, c. 80) say it
distinctly: It is hard for a woman with whom an uncircumcised man had sexual intercourse to separate from him. This is, I believe, the best reason for the commandment
concerning circumcision.”31
One encounters also the contrary view, that circumcision involves a sexual advantage, directly for women, indirectly for men in making them more pleasing to
women. The loss of sensitivity of the male organ can be viewed as a gain, since
it increases staying power, the capacity to prolong the sex act. Also I have heard
American woman express a preference for the circumcised organ on the grounds
that it is neater, less messy and more available. Perhaps for these among other reasons, circumcision is reported to be spreading rapidly in parts of the Congo and
Sudan in which it has only recently been introduced and has no ritual significance,
because the women insist upon it in their sexual partners.
It is almost as though some women saw in the foreskin a competing vagina.
And indeed Bryk reports an encounter just after an African circumcision rite, that
almost says as much: “His girl comes . . . they talk all through the night. Early in the
morning she gives him her hand and in parting says: ‘I’ll return tonight and then I’ll
give you my vagina. My dear man. Now I love you truly.’”32
Looking back over the last paragraphs, I see emerging some degree of opposition between man-talk, whether by ancient rabbis or modern physicians, and
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woman-talk, much of it still unrecorded, and the little there is of it still largely
filtered through males. It seems to bring out a male impression that circumcision
decreases sexual pleasure in men that must compete with a female preference for
this condition.
It is hard to estimate how much such considerations weigh when mothers decide
to circumcise their infants. Whatever their reasons, the mothers do opt for this operation, at present almost universally in our country33 —those who can afford it—yet
sometimes with misgivings, knowing that they are handing over their babies for
what may seem advisable, yet is surely unnecessary surgery.
What makes this decision easier is the widespread conviction that it doesn’t hurt,
that the infant feels no pain. The physician is likely to assure the mother that it
doesn’t hurt; and she thinks—and sometimes he thinks—that he knows. Here we
encounter what I believe in fact to be a deeply planted and passionately defended
rationalization.
As a biologist I have had to live with that kind of rationalization all my scientific
life. We biologists in the course of experimenting sometimes have to decide whether
to do things to animals that would hurt people if done to them. The question is
whether those operations hurt the animals.
Biologists differ in their opinions about this. One must understand that there is
no way whatever of finding out. There is no way—not even conceivably—of knowing what another animal feels. There is indeed no way to know what another person
feels. The person can tell you; but then you only know what he has said, perhaps
inaccurately, perhaps even to deceive you. There is no way at all to check up. A
person’s or animal’s sensations are forever their own, forever locked within a private world of consciousness that science cannot penetrate—if indeed one concedes
consciousness to another person or animal, since one can know only one’s own.
We can do no more than recognize what we take to be signals of pain in certain
patterns of behavior—writhing, struggling, squirming, yelping, moaning, and in the
case of human beings capable of it, speech—yet with no assurance that the pain
is felt.
Many biologists, having done some violence to an animal and observed such
behavioral signals, prefer to dismiss them as “reflex,” particularly when dealing with
a “lower” animal—in invertebrate such as a lobster, or a cold-blooded vertebrate
such as a frog or a fish. Such attitudes are not confined to biologists. Few of us
hesitate to throw a live lobster into a pot of boiling water, in which it writhes and
struggles for a while before dying; or to thread a worm on a hook, however much it
writhes; or with that bait to hook a fish, and then work or cut out the barbed hook.
Do those animals feel what we are doing to them, do they feel pain? There is no way
of knowing; one assumes whatever one likes.
As for me, working in the laboratory, I decided long ago that if I did anything to
an animal that would hurt if done to me, and the animal reacted much as I would
react—except for speech—that I would rather assume that the animal felt pain than
that it didn’t. Hence I don’t do such things to animals. Once, not knowing any better,
I did something awful to a lobster—though perhaps not as awful as boiling one
alive—and I shall never forget how it writhed as it died. So now the only operation I
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perform on an intact, unanesthetized animal is to kill it; and I take a lot of trouble to
see that I kill instantly, with one stroke, an animal handled gently up to that moment.
So I wonder about those babies. Why does anyone think that circumcision doesn’t
hurt them? Well, they can’t say it hurts, not yet having learned to speak; and they
don’t seem to remember it later. But then, few persons remember much that happened before they were two or three, and just about no one remembers anything
before that; yet who has lived with babies and believes that they are not perfectly
aware of all kinds of experiences that they won’t remember later?
There is a third, supposedly scientific reason for thinking that very young infants
do not feel pain. We are told that the nerve fibers of newborn infants have not yet
acquired the myelin sheaths that will later insulate them from one another and help
them to conduct excitation more rapidly. It has been suggested that for this reason
newborn infants may not feel pain. But as it happens, the sensation of pain, unlike
other skin senses, continues throughout life to be conducted, at least in part, by very
fine nerve fibers that lack myelin sheaths. So none of these arguments makes much
sense.34
I called an old friend, an obstetrician who long ago had taken care of my wife—
and circumcised our son. “How do you do the operation?” I asked him. “Do you
use a local anesthetic?” “Oh no!” he said. “Then doesn’t it hurt?” I asked. “Well,”
he said, falling back upon a common physician-to-patient euphemism, “there’s no
doubt that the baby is uncomfortable.” “Doesn’t it squirm and struggle?” I asked.
“Well,” he said, “it can’t!” -and then to my surprise, “As a matter of fact it’s rather
gruesome. We fasten the baby down in a form that holds him so that he can’t move
during the operation. But it takes only about five minutes.” “Five minutes!” I said.
“That sounds pretty long to me. I thought it only took a few seconds.” “Would you
like to see one done?” he asked. “Sure,” I said. So we made a date.
A few mornings later I went to the hospital at the time he had mentioned. When
I asked for him at the desk, I was told that he had been delayed. Would I wait over
there? When I went over there, I found a young couple, the mother holding a lovely
baby boy. “So you’re waiting for Dr. ___, too!” she said with a bright smile; and
with that I realized that her baby was going to be the patient.
We had about 20 minutes to wait, and chatted together, all happy and relaxed.
The parents were very proud of their beautiful son. He had been a little premature,
the mother explained, and so had to wait awhile before being circumcised. Now he
was six weeks old and doing fine, as I could see. He had already more than doubled
his birth weight.
Just then, a middle-aged nurse came up to us and asked for the baby. She began
to walk off with it. The mother, still all smiles, started along with her; but the nurse
stopped and said, kindly but firmly, “Please wait here.” The mother looked distressed. “I thought I could go along!” she cried. “Oh, no!” said the nurse, “but we’ll
be back in about ten minutes.” And she went off with the baby.
That mother’s face was a study. She sat down again, but now bolt upright, very
tense, her face rigid, her eyes straight ahead. Her husband on the other hand was
completely relaxed, even making a show of it, chuckling, patting her on her shoulder,
telling her jovially that there was nothing to worry about. “Be a man!” he seemed to
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be saying to her; but she wasn’t. She was a very worried woman. I wondered how
many mothers had been through that before.
Then I was called, and found the doctor in a little surgery. The nurse was still
holding the baby, who was quiet and relaxed; and I put on a sterile gown and cap.
Then the infant was laid on a plastic form with a depression the shape of a child.
His wrists and ankles were clipped into cuffs that held them gently but firmly. With
that he began to cry bitterly; the restraint seemed to bother him at least as much as
anything that happened later.
The surgeon laid a sterile sheet over the child’s middle, with a circular opening
exposing the genitals. As already said, the foreskin of such a young infant is usually too tight to be retractable, and often is attached to the glans. So after gently
freeing the foreskin all around with a probe, the doctor slit it dorsally with scissors, so that it could be slipped back. There was a little bleeding. Then the shaft
of the penis was inserted into the thimble-shaped end of a stainless steel rod, and
the slit foreskin pulled forward over the outside of the rod. A circular steel ring
was clamped tightly about the foreskin, crushing a narrow band of it between the
clamp and the steel rod, just below where the foreskin would be severed. The physician explained that crushing the tissues in this way would cut the bleeding, help
the cut ends of the foreskin to heal properly, and numb the nerves. The clamp was
left on for five minutes. Then the foreskin was cut through all around, just above
the clamp, and slipped off. The steel tool was removed, and the penis wrapped in a
Vaseline-gauze dressing. The baby’s wrists and ankles were freed, and the operation
was over.
“Are you for it or against it?” the surgeon asked me afterward. “I suppose you’re
neutral.” “I’m against it,” I said. “So am I,” he replied.
Yet nothing about this operation seemed to me horrifying. Clearly the infant was
distressed, but seemingly as much by the restraint as anything else. There was no
marked response to what I would have judged to be the most painful episodes—the
moments of crushing and cutting of tissues. After the first bout of crying on being
fastened down, it seemed to me more as though the infant were trying to withdraw
into himself. To my astonishment, at one point right in the middle of the operation
he seemed to be falling asleep!35
Someone later showed me an interview with the psychiatrist Wilhelm Reich, in
which he said: “Circumcision is one of the worst treatments of children. And what
happens to them? They can’t talk to you. They just cry. What they do is shrink. They
contract, get away into the inside, away from that ugly world.”36
And of course the operation is not the end of it. Barring complications, the circumcised infant is in for 3–5 days of soreness, his glans swollen, inflamed, and blue
owing to the disturbed blood circulation.
And the mother? Under the usual conditions of a hospital delivery and circumcision, she hardly knows her baby yet. He is brought in to her periodically to nurse;
but he is still in the hospital’s care, not hers. She agrees to have him circumcised,
or perhaps requests it, quite impersonally. It is a social decision, and remote. She
doesn’t know, and no one tells her, when or how it will be done. It all happens far
off somewhere, between two feedings.
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And yet. . . The infant comes back to her somewhat changed, fretful, withdrawn.
One mother said to me, “His crying sounded different to me afterward.” He has been
hurt; a violence has been done to him. Many a mother wonders a little, worries a
little, then puts it out of her thoughts. After all, everyone else does it, all her friends.
And it was done for his sake, for his health, for his peace of mind later when he
undresses in that locker room.
And yet. . . Suppose it was done for no good reason? Suppose all that was accomplished was the painful mutilation of a helpless infant? The very suggestion is an
affront, an attack where the mother is most vulnerable. I shall probably not be forgiven this essay. And to have that attack come from sons! No wonder that those
mothers in Tallahassee were upset with my young friend.
The Outcome
I have come a long journey since Tallahassee. It is not yet over; I wonder whether
it will ever be. There is a lot more to explore. Yet I should like to say where this
encounter finds me now.
As I write this essay, we are working in the laboratory on the skins of frogs.
We use just a small patch of skin in each experiment. The other day the thought
occurred to me—I wouldn’t dream of cutting that snippet of skin from a live frog.
You couldn’t bring me to do it. As it is, we kill the frog, take a piece of skin to
work with, then come back later for another piece. It would probably make a better
experiment to take a patch of skin from a live frog, and leave the rest on him until
we wanted more.
But I couldn’t do that. It would seem to me cruel. Yet frogs can’t talk. Does it
feel pain? Does it remember? I don’t know; and there is no way that I can find out.
It’s just like those babies.
It’s curious—and revealing—how few persons think about circumcision, or
indeed about anything involving the genitalia, even their own. What do they even
look like? Are they pretty much alike from person to person, or do they vary a little,
or a lot? One hardly knows. At one point in writing this essay I looked through the
shelves in our Biological Laboratory Library, through books on the senses, on neurophysiology and neuroanatomy, some of them medical textbooks. I was looking for
what new information there might be on sensory responses from the glans penis and
foreskin. Neither of those words was in the index of any of those books.
I hadn’t thought at all about circumcision until that conversation in Tallahassee;
but now that I have thought about it—it’s just as with the frogs. I could not bring
myself to have another infant of mine circumcised.
There is a complication, for I am a Jew, circumcised as is my son. A nonobserving Jew, a non-believer in anything supernatural, yet deeply involved, a Bible
reader—of both Testaments—and very much a Jew. For me there are special barriers
against deciding not to circumcise; for it is hard to break with a tradition that one’s
ancestors have observed for thousands of years, however else one feels.
236
G. Wald
So I have looked into what it means for a Jew not to be circumcised. I find the
position a little surprising.
For one thing, the son of a Jewish mother is wholly a Jew, regardless of circumcision. He can practice his Judaism in any form and to any extent he likes. He may
take part in all observances, private and public. A Jewish father is obliged to have
his son circumcised; but at thirteen that obligation passes to the son. Not to carry out
that obligation is a transgression; the uncircumcised Jew is fully a Jew, but transgressing. Incidentally, Reform Judaism asks circumcision only for born Jews, not
for those converted to Judaism.
A second discovery will surprise many Jews: the usual hospital circumcision does
not fulfill the ritual requirement. It is only an operation, where what is needed is a
consecration—a handing over by the Jewish father of his son, to enter the covenant
of Abraham, sealed with the shedding of the son’s blood. A hospital circumcision
does nothing in this regard. A Jewish child who has already undergone such surgery
would still need this ceremony and a token drawing of blood to fulfill the ritual
requirement.
An added surprise for me has been to realize the relative relaxation with which
great talmudists of past centuries viewed circumcision. I have already mentioned
that Maimonides, the twelfth century codifier of the Talmud, considered the main
point of circumcision to be, by weakening the organ of generation, to foster sexual restraint—an opinion with which other great rabbis of his time concurred.37
Maimonides also allowed for the possibility that a grown boy might refuse to be circumcised, or a father for love of his son might neglect to have it done. After all, said
Maimonides, it is “a very difficult operation.” My rabbinic mentors agree that in former times and in other places Jews may have felt more relaxed about circumcision
than do orthodox Jews now, perhaps goaded by the existence of reform Judaism,
and the disastrous aftermath of a century of relaxed standards in central Europe.
It seems to me that a final consideration might bear upon this problem. Child
sacrifice (to “Moloch”) was a common rite among the ancient peoples of the Near
East, and the Jews were forbidden it in the harshest terms (Leviticus 20:1–2). When
God laid claim to all firstborn males, he specified that though those of the domestic
animals were to be sacrificed, children were to be redeemed. As Moses, having been
instructed by God, explained to the people: “I sacrifice to the Lord all the males that
first open the womb; but all the first-born of my sons I redeem” (Exodus 13:15). And
one of the ordinances that God gave to Moses along with the Ten Commandments
states: “The firstborn of your sons you shall give to me. You shall do likewise with
your oxen and your sheep: 7 days it shall be with its dam; on the eighth day you
shall give it to me.” (Exodus 22:29).
That command, to sacrifice the male firstborn of a domestic animal, taking it
from its mother when it is eight days old, makes one wonder whether the prescribed circumcision of sons on the eighth day was once a form of redemption, the
token sacrifice of the foreskin to substitute for sacrifice of the child. In any case the
principle of redemption runs through these commandments, not only the obligatory
redemption of sons, but “every firstling of an ass you shall redeem with a lamb. . .”
(Exodus 13:13).
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237
It is with the greatest hesitation, since I have no right and know so little, that I
should like to suggest to my fellow Jews that perhaps the time has come to redeem
the foreskin itself, rather than sacrifice it. Surely some substitute might be found for
this rite, perhaps even involving a token drawing of blood from an older child, that
would be preferable to this assault upon and mutilation of a newborn infant.
Since by now I would not circumcise even a Jewish infant, I would not dream of
doing this to a gentile child. I would know no medical reason to deprive my sons
of their foreskins, being confident that they would share with me habits of cleanliness that would make that unnecessary. If I had my children in grinding poverty
and squalor, that might make a difference. I might then even want to have them circumcised, and perhaps would fail, for the usual reason that I could not pay. As with
so many other things, those who might need circumcision are least likely to get it,
and those who get it are least likely to need it. But even were I poor, if I had cleanly
habits and some chance of passing them on to my sons, I would not circumcise them.
For it is a barbarous thing to meet a newly born infant with the knife, with a
deliberate mutilation. And the part that is removed is not negligible; it has clear and
valuable functions to perform. Not circumcising a boy will not only spare him a
brutal violence as he enters life; it will promise him a richer existence. And that not
only because the possession of a foreskin will increase his genital sensitivity and
make possible more satisfactory and pleasurable sexual activity, but also because
of the consideration with which this essay began: that the foreskin is the female
element in the male.
To be sure, that is only a primitive insight, and has no standing in science. Yet
that is hardly a criticism. What we consider to be male or female is largely cultural
in any case; many of our conventional notions in this regard are now in flux and
being challenged. This one has more basis in reality than most. Also unlike many
unscientific interpretations of reality that are misleading and dehumanizing, this one
can sustain, enrich and illuminate. It offers some redress where it is most needed,
in a world increasingly devastated and threatened with destruction by a rampant
machismo, a mindless exercise of organized aggressive maleness.
Every schoolchild knows that femaleness is determined genetically by the possession of two sex or X chromosomes (XX), and maleness by one together with a
relatively empty Y chromosome (XY). Very rarely a male is born with an extra Y
chromosome, so XYY. A few years ago, on somewhat questionable grounds, this
condition was reported to be correlated with violent behavior.
Recently a research project was set up at the Harvard Medical School, to type
the chromosomes of a large number of infants and so find a group, which is XYY.
The idea was then to tell the parents and follow the behavior of the children, to
see whether any special tendencies toward violence emerged. Some other research
workers at Harvard Medical School objected strongly to this project, feeling that
the study itself might prejudice the children’s behavior and relationship with their
parents. A bitter controversy followed, that ended with the director of the project
terminating it.
While this dispute was at its height, Dr. Michael Mage of the National Cancer
Institute wrote a letter to Science magazine to say that all that concern with the
238
G. Wald
XYY syndrome provides a fine example of the way research workers in medicine
pick strangely peripheral, esoteric topics to study. Our real concern, said Dr. Mage,
should be with the XY syndrome, which afflicts half of humanity including himself, and is known to be strongly correlated with war and other forms of criminal
violence.
Just so. Maleness is our problem, excessive maleness. The circumcised organ is
only the beginning of it, and kept hidden. What are displayed, like so much male
plumage, are the penis surrogates and aggrandizements: the guns; the cars, named
for predatory beasts, driven to and from work as though they were PT boats; the
flaunting of power and status; the devastation of the earth and the cultivation of a
technology of death and destruction beyond any former imagining, all in the pursuit
of an obsessive accumulation of wealth far beyond any possibility of use—all the
brutal, gaudy, pretentious and infinitely dangerous panoply of male aggression that
now envelops and threatens our lives.
This is no time to circumcise males. They need all the female element they
can get.
For every child is born into the world with much of one sex and a little of the
other. The mistake is by a mutilation to take that little of the other sex away. It
should be left as nature evolved it, as in the child, so that all our lives we can go on
being much of one sex, and always a little of the other.
Notes
1. Ed. Note: This was Van Lewis, who had been a student of Wald’s at Harvard.
2. Griaule M. (1965) Conversations with Ogotemmeli. Oxford University Press, Oxford,
pp 22–23.
3. Breasted JH. (1946) The Dawn of Conscience. New York, NY: Scribner, p 353.
4. Ed. Note: An American textbook on obstetrics documents a case where the obstetrician circumcises the breech infant while waiting for the head to be born: Schaffer AJ, Avery MJ.
(1977) Diseases of the Newborn, 4th ed. Philadelphia, PA: Saunders, p 420.
5. Note: Urine provides a sterile medium for washing under the foreskin that does not demand
retracting it. On the contrary it can be pulled forward and held closed so that the child urinates
into it, ballooning it, until released.
6. Guide for the Perplexed, M. Friedlander trans. (1904) London: Routledge and Kegan Paul,
p 378.
7. Freud S. (1938) Totem and Taboo. New York, NY: Random House.
8. Symbolic Wounds. (1954) Puberty Rites and the Envious Male. Glencoe, IL: Free Press,
p 112.
9. Guide for the Perplexed M. (1904) Friedlander Translation. London: Routledge and Kegan
Paul, pp 378–379.
10. Moses and Monotheism. (1939) New York, NY: Alfred A Knopf, p 215.
11. Beyond God the Father. (1973) Boston, MA: Beacon Press, p 195.
12. Guide for the Perplexed M. (1904) Friedlander Translation, 2nd ed. London: Routledge and
Kegan Paul, p 216.
13. McNeill RA. (1960) History of tonsillectomy: Two millennia of trauma, hemorrhage and
controversy. Ulster Med J. 29:59–63.
14. Illingsworth RS. (1960) Is removal of tonsils and adenoids necessary? Proc Roy Soc Med
Lond. 54:393–395.
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239
15. Bolande RP. (1969) Ritualistic surgery—circumcision and tonsillectomy. N Engl J Med.
280:591–596.
16. Morgan WKC. (1965) The rape of the phallus. J Am Med Assn. 194:309–311.
17. Preston EN. (1970) Whither the foreskin? J Am Med Assn. 213:1853–1858.
18. Boyd JT, Doll R. (1964) Study of the etiology of carcinoma of the cervix uteri. Br J Cancer.
18:419–428.
19. Editorial. (1964) Circumcision and cervical cancer. Br Med J. 2:397–398.
20. Gairdner D. (1949) The fate of the foreskin. Br Med J. 2:1433.
21. Oster J. (1968) Further fate of the foreskin. Arch Dis Childhood. 43:200.
22. Oster, ibid.
23. A 9 pound infant has only 12 oz. of blood. Loss of 20% (only 2.4 oz.) can lead to shock, heart
failure and death.
24. Ed. Note: Loss of skin puts the complication rate at 100%.
25. Money J, Ehrhardt AA. (1972) Man and Woman, Boy and Girl. Baltimore, MD: Johns
Hopkins University Press, pp 118–123.
26. Ed. Note: An article in 1989 documents four cases. (Gearhart JR, Rock JA. (1989) Total
ablation of the penis after circumcision with electrocautery: A method of management and
long-term followup. J Urol. 142:799–801).
27. Preston EN. (1970) J Am Med Assn. 213:1858.
28. Morgan WKC. (1965) J Am Med Assn. 193:224.
29. Morgan WKC. (1965) J Am Med Assn. 193:223–224.
30. Whiddon D. (1953) Lancet. 2:337.
31. Guide for the Perplexed M. (1904) Friedlander Translation. London: Routledge and Kegan
Paul, p 378.
32. Bryk F. (1928) Neger-Eros. Berlin: Marcus and Weber, p 59; cited in Bettelheim B: Symbolic
Wounds, p 163.
33. Ed. Note: Thirty-five years later, the rate is down close to 50%, and in some parts of the
country, much lower.
34. Ed. Note: Wald was ahead of his time. In 1987, Anand and Hickey wrote an article in the N
Engl J Med (317:1321–1329) that documented cortisol levels with circumcision as high or
higher than those in adults with great pain, and now it is generally recognized that infants
suffer under the knife.
35. Ed. Note: The crushing has now been documented as excruciating pain, and the infant has
just gone into a coma.
36. Reich W. (1967) Reich Speaks of Freud. New York, NY: Farrar, Straus and Giroux, p 29.
37. cf. Philo of Alexandria: The same view, a millennium earlier.
Appendix
Resources
Organizations
Association Contre la Mutilation des Enfants (A.M.E.). Didier Diers and Xavier
Valle, Boite Postale 220, 92108 Boulogne Cedex, France.
Attorneys for the Rights of the Child, J. Steven Svoboda, JD, 2961 Ashby Avenue,
Berkeley, CA 94705 USA. Tel: 510-464-5430. www.arclaw.org
Circumcision Information Australia. www.circinfo.org
Circumcision Resource Center. Ronald Goldman, PhD. PO Box 232, Boston,
Massachusetts, 02133 USA. Tel: 617-523-0088. www.circumcision.org
Doctors Opposing Circumcision (D.O.C.). George Denniston, MD, MPH,
President; John Geisheker, JD, Executive Director. www.doctorsopposingcircum
cision.org
Equality Now. Jessica Neuwirth, President. 250 West 57th Street, New York, NY
10107. Tel: 212-586-0906. Fax: 212-586-1611. www.equalitynow.org
Foundation for Women’s Health Research and Development (FORWARD). Naana
Otoo-Ovortey, MBE, Executive Director, 765-767 Harrow Road, London NW10
5NY, UK. Tel: +44 (0)20-8960-4000. www.forwarduk.org.uk
Inter-African Committee. Berhane Ros-Work, President. 147 rue de Lausanne, CH1202 Geneva, Switzerland. Tel: 22-731-2420. Fax: 22-738-1823.
International Centre for Reproductive Health. Els Leye, FGM Project
Coordinator. Ghent University, De Pintelaan 185 P3, 9000 Ghent, Belgium.
Tel: +32-9 240.35.64. Fax: +32-9 240.38.67.
International Coalition for Genital Integrity. Dan Bollinger. Tel: 765-427-7012.
www.icgi.org
Israeli Association Against Genital Mutilation. Avshalom Zoossmann-Diskin, PO
Box 56178, Tel-Aviv 61561 Israel. www.britmilah.org
Intact America, Georganne Chapin, Executive Director, PO Box 8516, Tarrytown,
NY 10591, USA. 914-372-2331. www.IntactAmerica.org
London Black Women’s Health Action Project. Shamis Dirir. Cornwall Avenue
Community Centre, First Floor, 1 Cornwall Avenue. ondon E2 0HW United
Kingdom. Tel: 181-980-3503. Fax: 181-980-6314.
G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9,
241
242
Appendix
Medical Ethics Network. John Sawkey, PO Box 578, Yorkton, Saskatchewan, S3N
2W7. Tel: 306-744-2436. med-fraud.org
National Organization of Circumcision Information Resource Centers (NOCIRC)
[International Headquarters] Marilyn Fayre Milos, RN, Executive Director. PO
Box 2512, San Anselmo, CA 94979-2512. USA. Tel: 415-488-9883. Fax: 415488-9660. www.nocirc.org
National Organization to Halt the Abuse and Routine Mutilation of Males
(NOHARMM). www.noharmm.org
National Organization of Restoring Men (NORM) International Headquarters. R.
Wayne Griffiths, MS, MEd, 3505 Northwood Drive, Suite 209, Concord, CA
94520-4506 USA. Tel: 510-827-4066. Fax: 510-827-4119. www.norm.org
NORM-UK. John P. Warren, MB. Chairman, David Smith, Manager. PO Box
71. Stone, Staffordshire, ST15 0SF, United Kingdom. Tel/Fax: 01785-814-044.
www.norm-uk.co.uk
QuranicPath.com. Kamil Hussain, [email protected], Mary-Rose
Booker, RN. www.cirp.org/nrc
Rainb♀. Nahid Toubia, MD. 915 Broadway, Suite 1109, New York, NY, 10010-7108
USA. Tel: 212-477-3318. Fax: 212-477-4154.
Terres des Femmes. Petra Schnull, Gritt Richter, Claudia Piccolantonio.
Kreuzbergring 10, D-37075 Gttingen, Germany.
Websites
Alliance for Transforming the Lives of Children. www.atlc.org/
Association Contre la Mutilation des Enfants (French). pages.pratique.fr/~ame1/
Attorneys for the Rights of the Child. www.arclaw.org/
Birth Psychology. www.birthpsychology.com/birthscene/circ.html/
BoysToo.com (Official Website of NOCIRC of North Dakota). www.boystoo.com/
Circumcision and HIV. www.circumcisionandHIV.com/
Circumcision Information and Resource Pages. www.cirp.org/
Circumcision Information Resource Center (Montreal, Canada). www.infocirc.org/
index-e.htm/
Circumcision Resource Center (Boston, Massachusetts). www.circumcision.org/
D.O.C. (Doctors Opposing Circumcision). www.doctorsopposingcircumcision.org/
Female Genital Mutilation Research Home Page. www.fgmnetwork.org/
In Memory of the Sexually Mutilated Child (John A. Erickson). www.Sexually
MutilatedChild.org/
Intact America. www.IntactAmerica.org/
The Intactivism Pages. www.circumstitions.com/
International Coalition for Genital Integrity. www.icgi.org/
Intersex Society of North America Home Page. www.isna.org/, www.dsdguidelines.
org/
Jews Against Circumcision. www.JewsAgainstCircumcision.org
Appendix
243
National Organization of Circumcision Information Resource Centers. www.nocirc.
org/
Muslims Against Circumcision. www.QuranicPath.com/
National Organization to Halt the Abuse and Routine Mutilation of Males.
www.noharmm.org/
National Organization of Restoring Men (NORM). www.norm.org/
NORM-UK (Great Britain). www.norm-uk.org/
Nurses for the Rights of the Child. www.cirp.org/nrc/
Students for Genital Integrity. www.studentsforgenitalintegrity.org/
Books
Aldeeb Abu-Sahlieh SA. (2000) Male and Female Circumcision Among Jews,
Christians and Muslims: Religious Debate. Beirut: Riad El-Rayyes Books.
Aldeeb Abu-Sahlieh SA. (2001) Circoncision Masculine – Circonsion Femine:
Debat Religieux, Medical, Social et Juridique. Paris: L’Harmattan.
Bigelow J. (1995) The Joy of Uncircumcising! 2nd ed. Aptos, CA: Hourglass [ISBN
0-934061-22-x].
Boyle EH. (2002) Female Genital Cutting: Cultural Conflict in the Global
Community. Baltimore, MD: The Johns Hopkins University Press.
Darby R. (2005) A Surgical Temptation: The Demonization of the Foreskin & the
Rise of Circumcision in Britain. Chicago, IL: The University of Chicago Press.
Denniston GC, Milos MF. (eds.) Sexual Mutilations: A Human Tragedy. New York
and London: Plenum Publishing Corporation.
Denniston GC, Hodges FM, Milos MF. (eds.) (1999) Male and Female
Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice.
New York, NY: Kluwer Academic/Plenum Publishers.
Denniston GC, Hodges FM, Milos MF. (eds.) (2001) Understanding Circumcision:
A Multi-Disciplinary Approach to a Multi-Dimensional Problem. New York, NY:
Denniston GC, Hodges FM, Milos MF. (eds.) (2004) Flesh and Blood: Perspectives
on the Problem of Circumcision in Contemporary Society. New York, NY:
Denniston GC, Gallo PG, Hodges FM, Milos MF, Viviani F. (2006) Bodily Integrity
and the Politics of Circumcision: Culture, Controversy, and Change. New York,
NY: Springer.
Denniston GC, Hodges MF, Milos MF. (eds.) (2009) Circumcision and Human
Rights. New York, NY: Springer.
Dorkenoo E. (1996) Cutting the Rose: Female Genital Mutilation: The Practice and
Its Prevention. London: Paul & Co Pub Consortium.
Fleiss PM, Hodges FM. (2001) What Your Doctor May Not Tell You About
Circumcision. New York, NY: Warner Books.
244
Appendix
Gallo PG, Viviani F. (eds.) (1995) Female Genital Mutilation: A Public Health
Issue Also in Italy. Proceedings of the 1994 International Symposium on Female
Genital Mutilation, May 3rd, 1994, Padua, Italy. Padua: UNIPRESS.
Glick LB. (2005) Marked in Your Flesh: Circumcision from Ancient Judea to
Modern America. New York, NY: Oxford University Press.
Goldman R. (1996) Circumcision: The Hidden Trauma. Boston, MA: Vanguard.
Goldman R. (1997) Questioning Circumcision: A Jewish Perspective. Boston, MA:
Vanguard.
Gollaher DL. (2000). Circumcision: A History of the World’s Most Controversial
Surgery. New York, NY: Basic Books.
Gruenbaum E. (2000) The Female Circumcision Controversy. Philadelphia, PA:
University of Pennsylvania Press.
Jallow BG. (2004) Dying for My Daughter. Louisville, KY: Wasteland Press.
Korn F. (2006) Born in the Big Rains. University of New York: Feminist Press.
Lightfoot-Klein H. (1989) Prisoners of Ritual: An Odyssey into Female Genital
Circumcision in Africa. New York: Harrington Park Press.
Lightfoot-Klein H. (2007) Children’s Genitals Under the Knife: Social Imperatives,
Secrecy and Shame. Charleston, SC: BookSurge Publishing.
O’Mara P. (ed.) (1993) Circumcision: The Rest of the Story. Santa Fe, NM:
Mothering.
Omoifo C. (2007) Saving Bekyah: Confronting Female Circumcision, Sexuality,
and Womanhood. East Orange, NJ: Sun Rose Publishers.
Rahman A, Toubia N. (2000) Female Genital Mutilation: A Guide to Laws and
Policies Worldwide. London: Zed Books.
Ritter TJ, Denniston GC. (2002) Doctors Re-examine Circumcision. 3rd ed. Seattle,
WA: Third Mellinnium Publishing [Available from Amazon.com.].
Robinett P. The Rape of Innocence. Eugene, OR: Aesculapius Press.
Skaine R. (2005) Female Genital Mutilation: Legal, Cultural and Medical Issues.
Jefferson, NC: McFarland & Company, Inc., Publishers.
Somerville M. (2000) The Ethical Canary: Science, Society and the Human Spirit.
Toronto, ON: Penguin Books.
Wallerstein E. (1980) Circumcision: An American Health Fallacy. New York, NY:
Springer.
Weiner K, Moon A. (eds.) (1995) Jewish Women Speak Out: Expanding the
Boundaries of Psychology. Seattle, WA: Canopy Press.
Videotapes/Films
Circumcision? Intact Facts. 18-min. VHS. $44.05. Injoy Productions, 1435
Yarmouth, Suite 102-B, Boulder, CO 80304. Tel: 800-326-2082.
Cut: Slicing Through the Myths of Circumcision. Eliyahu Ungar-Sargon. 70-min.
DVD. $24.95 plus $4.95 S&H. www.CutTheFilm.com.
Cut: Slicing Through the Myths of Circumcision. Eliyahu Ungar-Sargon. DVD.
$24.95 plus $4.95 S&H. www.CutTheFilm.com
Appendix
245
Facing Circumcision: Eight Physicians Tell Their Stories and Reveal the Ethical
Dilemmas of Physicians who Circumcise Newborns. Nurses for the Rights
of the Child. 20 minutes. VHS. 1998. Nurses for the Rights of the Child.
369 Montezuma #354, Santa Fe, New Mexico, 87501. 505-989-7377. www.
cirp.org/nrc/
Fire Eyes. Soraya Mire. 60 minutes. sale: 16 mm $2,000, video $445, rental: 16 mm
$300, video $85. Filmakers Library, Inc., 124 East 40th Street, New York, Y
10016 (212-808-4980).
It’s a Boy! Victor Schonfeld. 41 minutes. VHS. $295 institutions, $195 individuals,
$65 rental. Filmmakers Library, 124 East 40th Street, New York, NY 10016. el:
212:808-4980. Fax: 212-808-4983.
Mother, Why Was I Circumcised? Program for Dutch public broadcast. VPRO, see
www.macdocman.com.
NOCIRC PSA and Educational DVD, 20 minutes. $5. NOCIRC, POB 2512, San
Anselmo, CA 94979-2512. The Prepuce by Steve Scott www.doctorsopposingcir
cumcision.org/video/prepuce.html
Restoration in Focus: instructional video. 200 min. VHS-PAL tape. www.
foreskinrestoration.info.
Tahara. Sara Rashad. 18-min. NTSC VHS. $30 ($200 for institutions, schools,
libraries). Order at www.taharafilm.com
The 8th Day. 53 min. VHS. $30ppd in US, $50ppd outside US. Keren Markuze,
POB 361425, Los Angeles, CA 90036. Tel: 323-936-6802.
Whose Body, Whose Rights? Lawrence Dillon and Tim Hammond. 1996. 56 minutes. VHS. Home Sales: Video-Finders, 1-800-343-4727. Educational Sales:
$195, Rental $70, Catalogue no. 38342, University of California Extension,
Center for Media and Independent Learning, 2000 Center Street, Fourth Floor,
Berkeley, CA 94704, 510-642-0460
Newsletters
Attorneys for the Rights of the Child Newsletter. Albert Fields, Editor. ARC, 2961
Ashby Avenue, Berkeley, CA 94705, USA.
Awaken. Faiza Jama Mohamed, Editor. Equality Now, 250 W 57th St #1527, New
York, NY 10107, USA.
NOCIRC Annual Newsletter. Marilyn Fayre Milos, RN, Editor. NOCIRC. POB
2512. San Anselmo, CA 94979-2512, USA.
NOCIRC of Michigan Informant, Norm Cohen, Editor. POB 333, Birmingham, MI
48012, USA.
NORM NEWS. David Smith, Editor. NORM-UK, POB 71, Stone, Staffordshire
ST15 0SF, England.
Index
A
Abraham, 222, 236
Abuse, 40, 57, 120, 138, 152, 212
Adam, 225–226
Adhesions, 25, 83, 228–229
Adolescent autonomy, 22, 26–27
Africa, 4, 9, 49–58, 62–64, 66, 99–100,
139–141, 212, 220
African-American population, 55
Africans, 3, 5–8, 52–53, 55, 57, 62–66,
96, 98–100, 111, 121–122, 124, 132,
138–143, 206, 218–219, 221–222,
230–231
Ahmose, 219
AIDS, 8, 52, 61–66, 69, 215
Aldeeb Abu-Sahlieh, Sami A., 6, 138–139
Alderson, Priscilla, 31
Alexander, Franz, 153–154
American Academy of Pediatrics, 83
American Jewish Committee, 20
American Jewish Congress, 20
Amish, 28
Ammonites, 219
Amputation, 2, 7, 64, 83, 150, 157,
180, 208
Amsterdam, 140
Amygdala, 151
And the Band Played On, 65
Anti-Defamation League, 20
Antisocial Personality Disorder (ASPD),
68, 72
Asherah, 225
Australasian College of Physicians, 42, 46
Australia, 33, 39–40, 43–44, 46, 197, 212,
220, 227
Australian aborigines, 220
Autonomy, 18, 22, 26–27, 32, 46, 211–215
Ayuub, 126, 129, 131
B
Beneficence, 46
Berit milah, 143
Best interests, 4, 16–17, 19, 21, 23, 26, 32, 40,
42, 45–46
Bettelheim, Bruno, 2, 221–222
Bible, 91, 222, 229, 235
Bigelow, Jim, 78, 161–162, 189–198, 200
Bioenergetic analysis, 152, 154
Bioethics, 65, 86, 88–90
Boddy, Janice, 5
Bodily integrity, 16–18, 22, 32–33, 43
Boldt v. Boldt, 3–4, 17–18, 21
Bologna, 98
Boston, 174, 227
Brain, 151–152, 170, 173, 184
Breuer, Joseph, 152
British Journal of Urology International, 33
British Medical Association, 16
Bryk, Felix, 231
Burkina Faso, 52
Bush circumcisions, 63
C
Cain, 225
Cameroon, 52–53
Canaan, 223
Canada, 139, 197, 227
Cancer, 7, 19, 25, 42, 81, 91, 150, 228, 237
Catholicism, 140
Centers for Disease Control (CDC), 8–9
Chad, 99
Chamberlain, David, 152
Chapin, Georganne, 61
China, 55
Cholera, 50, 56
Christian Church, 220
Christianity, 28–29, 129, 140–141, 225
247
248
Christians, 22, 24, 28, 121, 139–143, 147,
220, 225
Christian Science, 28
Chromosomes, 237
Circumcision, 15–33, 39–46, 49–58, 67–73,
75–79, 81–84, 95–96, 144–147, 149–163,
167–187, 217–238
Circumcision psychopathy, 67–73
Circumcision Psychopathy Checklist (CPCL),
69–73
Circumfession, 140, 143–145
Clinical efficacy, 49–58
Clinical trials, 49–51, 54, 56
Clinton, Bill, 65
Clitoridectomy, 139, 231
Clitoris, 2, 7, 106, 126, 129, 137–138,
141–142, 144, 146, 218–219, 221, 231
Colb, Sherry, 16–17
Comfort, Alex, 138
Common law, 27, 39–41, 43, 45
Competence, 21–24, 27, 31–32
Complications, 42, 63, 79, 81–84, 86–87, 105,
150, 220, 229, 234–235
Conan the Barbarian, 144
Conant, Marcus, 65
Condoms, 8, 52, 56, 62–63, 66
Congo, 52, 55, 98–100, 111–124, 231
Congo Kinshasa, 52, 55
Congolese, 99, 112, 114, 124
Conversos, 140–141
Corona, 141, 192
Côte d’Ivoire, 52
Court of Appeal, 3, 16–18, 20, 23, 31–32
Covenant, 3, 142–143, 202, 222, 236
Cultural/culture, 1–2, 4–10, 17–18, 23, 32–33,
40, 42, 45, 64, 66, 91, 95–96, 99–100, 105,
107, 109, 112, 114, 122–123, 126–127,
129, 131–132, 138–139, 141–142, 147,
150, 212, 215, 237
Customs, 2, 42, 64, 82, 119, 123, 128,
219–220, 224
D
Danish, 228
Darby, Robert, 57
Dartos fascia, 77, 190
Dartos muscle, 190
David, Smith, 211–215
Death, 66, 83, 220, 223, 238
Deep feeling therapy, 152, 155, 163
Democratic Republic of Congo, 98, 111–124
Demographic impact, 49–52, 54–57
Derrida, Jacques, 140, 143–145
Index
Deuteronomy, 226
Dinah, 223
Dirie, Waris, 140, 145–147
Djibouti, 127
Doctors Opposing Circumcision (DOC), 20,
57, 65, 68
Dogon, 218–219
Dorkenoo, Efua, 8
Dwyer, James, 28–29
E
Earth, 163, 219, 225–226, 238
Ecological studies, 55
Edomites, 219
Egypt, 2, 140, 143, 145, 219, 223
Egyptians, 5, 143, 219, 223–224
Electrocautery, 83, 229
Elijah, 220
El Saadawi, Nawal, 143, 145
Embu, 141–142
EMDR, 152
English law, 17–19, 22, 27
English Law Commission, 27
Epidemiology, 87
Ethics, 1–3, 16, 32, 46, 61, 68,
91–92
Ethiopia, 52, 140
Europe, 51, 55, 153, 227, 236
Eve, 145, 225–226
Excision, 5–6, 10, 27, 126, 132, 137–139,
141–147, 219–222, 231
Exodus, 223–225, 236
F
Female genital cutting (FGC), 2–3, 5, 6–9,
63–64, 138–139, 211
Female genital mutilation (FGM), 4–5, 41,
98–99, 103–109, 112, 121, 131–132, 138,
146, 212
Fijians, 220
Fistula, 83, 138
Florence, 100, 104
Food and Drug Administration (FDA), 207
Foreskin, 2, 7, 9, 25, 69, 75–79, 83–84,
137–138, 141, 143, 150, 157, 160–163,
178–182, 185, 189–198, 199–210,
212–213, 218–219, 221, 223–224, 226,
228–231, 234–237
Foreskin restoration, 76, 189–198, 207–208
Foreskin retraction, 192, 197
FORWARD, 8, 18, 84, 130–131, 177, 179,
211–215, 234
Freedom of religion, 3, 19, 30
Frenular delta, 190–191
Index
Frenulum, 77–78
Freud, Sigmund, 69, 142, 146, 150, 152–153,
221, 225
G
Gangrene, 83
Gates Foundation, 61, 64–65
Genital amputation, 64
Genital autonomy, 211–215
Genital cutting, 2–3, 5–6, 8–10, 33, 40, 42,
63–64, 132, 138–139, 159, 211, 213, 215
Genital modifications, 2, 9, 98–100, 118,
120, 122
Genital stretching (GS), 97–101, 111–112,
114–115, 117–118, 120–123
Gentiles, 222, 224, 227–228,
230, 237
Ghana, 52
Gilbert, Howard, 30
Glans, 75–79, 83–84, 87, 157, 162, 179, 181,
192, 194–198, 201–202, 209, 228–231,
234–235
Glick, Leonard, 137, 139–140, 144
Gliding mechanism, 75, 78–79
God, 64, 127, 129, 144, 146, 187, 204, 218,
222–226, 236
Golden, Tom, 153, 156
Grassivaro Gallo, Pia, 97–101, 103–109,
111–124, 125–133
Guinea, 140, 221
Gynecologists, 104, 107–108, 114
Gynecology, 114
H
Halevi, Judah, 231
Hartman, D., 152, 154, 160–161
Harvard, 65, 217, 237
Harvard Medical School, 237
Head, Henry, 230
Hebrews, 140–141, 143, 205, 219–220, 223,
225–226
Hellsten, Sirkuu, 5, 9
Hepatitis, 9
Hermaphroditism, 141
Hippocratic Oath, 68, 91, 163
HIV, 7–8, 42, 49–58, 61–66,
150, 212
HIV prevalence, 52–55, 63
Human rights, 1, 3–5, 28, 39–41, 73, 105, 138,
161, 211
Human rights violations, 3, 138
Hutu, 64
Hymen, 99, 119
249
I
Immigrants, 6, 86, 91, 96, 99–100, 108,
121–122
Immigration, 96, 98–99, 104, 107–109
Indians, 217, 220
Infection, 8, 19, 25, 42, 50, 56, 62–63, 66, 83,
87, 212, 220, 229
Infibulation, 107, 125–133, 138–139, 142,
146, 222
Informed consent, 4, 6, 44, 46, 65, 82–83
Initiation rite, 9, 62, 218–222
Ishmael, 222
Islam, 45, 55, 126–127, 129, 145
Israel, 205, 223
Israelites, 223
Italy, 85–93, 95, 97–101, 107, 109, 112, 124,
131–133
J
Jackson County Circuit Court, 18, 21
Janov, Arthur, 151–153
Japan, 55–56, 197
Jehovah’s Witness, 24, 28
Jethro, 223
Jewish rite, 141–142, 221–224
Jews, 69, 90–91, 139–140, 142, 147, 219–220,
222–227, 235–237
Jong, Erica, 10
Jordan, 203, 223
Joshua, 223
Joy of Uncircumcising!, The, 161,
195–196, 200
Judah of Barcelona, 231
Judah Halevi, 231
Judaism, 19, 28–29, 140, 145, 224–226, 236
Justice, 5, 17, 32, 46, 72, 184
K
Kasai, 112–116, 120–122
Kellogg, John Harvey, 150, 157
Kenya, 52–53, 64, 141–142
Keratinization, 76, 79, 157, 194
Kikuyu, 64, 141–142
Kivu, 112, 114, 118, 121
Koran, 229
L
Labiadectomy, 139
Labial manipulation, 121
Labia stretching, 111–124
Langerhans cells, 78
Law, 1–10, 16–19, 21–22, 25–27, 29–31,
39–41, 43–46, 82, 90–91, 129, 132, 138,
147, 158, 187
250
Legislation, 27, 39–40, 85–86, 95–96
Lesotho, 52–53, 55
Levi, 223
Liberia, 52, 62
Litigation, 19, 21, 27
London, 8, 127, 211–213
Lower Shebelli River, 126
Lubumbashi, 120
Luo, 64
Lysozyme, 78
M
Malawi, 52–54, 98, 100, 118,
121–123
Malays, 220
Male and Female, 5, 8, 57, 64, 107, 139, 141,
211, 215, 221, 224–226
Mana Sultan, 125–133
Marion’s case, 43–44
Mary, 225
Mason, Paul, 39–46, 212
Masturbation, 78–79, 120, 138–139, 141,
150, 157
Mbenzola State Hospital of Mbuji-Mayi, 114
Mbuji-Mayi Hospital, 113–114
Mead, Margaret, 57
Medical ethics, 1, 46, 70
Mediterranean, 224
Meissner’s corpuscles, 77, 192
Memory, 139, 145, 151–152, 156–160, 162,
167–187, 205
Méndez, Cristóbal, 140–141
Meningitis, 83
Mensa Bulletin, 200
Merchant of Venice?, The, 140
Merka, 125–133
Meru, 142
Mexico City, 61–66, 218
Mezizah, 143
Michaelangelo, 230
Michal, 223
Midianites, 223
Milah, 90, 143
Misha, 1–10, 18–28
Moabites, 219
Monasterio, Gabriela, 163
Morgan, W.K.C., 229
Moses, 219, 223–225, 236
Moses Maimonides, 220, 224, 226, 231
Mucosa, 63, 75, 77–78, 190–191, 197
Mucosal loss, 75
Muslims, 17, 31–32, 45, 55, 63, 68–69, 86, 88,
90–91, 106, 122, 142, 145–146
Index
Mutilation, 2, 4–5, 7, 27, 41, 57, 88, 96, 98,
103–109, 112, 121, 132, 138, 141, 180,
182–183, 207, 212, 218, 220–222, 224,
226, 229–230, 235, 237–238
Mythology, 1–2
N
Nandi, 142
National Cancer Institute, 237
National Health Service, 96
National Institute for Clinical Excellence
(NICE), 214
National Organization of Circumcision
Information Resource Centers (NOCIRC),
3, 68, 85–93, 215
National Organization of Restoring Men
(NORM), 68, 76, 162, 194–195, 197, 207,
212, 214–215
New Guinea, 221
Niger, 52, 218
Non-maleficence, 46
NORM-UK, 68, 76, 212, 214–215
Nuremberg Code of Ethics, 68
O
Obstetricians, 69, 82–83, 98–99, 104, 107–108,
112, 114, 176, 230, 233
Obstetrics, 100, 114, 138, 152
O’Donnell, Brian, 61, 63
Oregon, 3–4, 17–21, 23, 25, 28
Oregon Supreme Court (OSC), 3–4, 17, 20–21,
23, 25, 28
Oster, Jakob, 228–229
P
Padua, 98, 107, 109, 112, 124
Padua Working Group, 112
Pain, 7, 17, 28, 30, 76, 140–142, 150–153,
156–159, 162–163, 168, 170–172,
179–184, 186, 193, 196, 224, 230,
232–233, 235
Parental rights, 16–18, 20–22, 26, 29–31,
43–44
Parma, 98, 100
Penis, 2, 6–8, 25, 76–79, 81, 83, 120,
137–138, 142–146, 150, 152, 156,
158, 161, 163, 168, 179–182, 184–186,
189–190, 192–197, 199–201, 207–210,
218, 220–222, 228–230, 234–235, 238
PEPFAR, 64–65
Perineum, 83, 190
Peripenic muscle, 190, 198
Pertussis, 50
Peru, 220
Index
Pharaoh, 143, 219, 223
Pharaonic infibulations, 131–132
Philistines, 220, 223
Phimosis, 25, 42, 84, 90, 137, 197, 206, 228
Phoenicians, 219
Plants, 114, 116–118, 121–122
Poetry, 126–131
Political power, 57
Population effectiveness, 49–58
Portugal, 140
Power abuse, 57
Prepuce, 2, 77, 84, 90, 142, 144–145, 190–192,
219, 228, 231
Preston, E. Noel, 150, 229
Primal Integration, 152–153
Primal Scream, The, 151
Primal therapy, 151–153
Principles of Ethics, 68
Prophylaxis, 66, 221, 227
Psychopathology, 67–73
Puberty, 32, 114, 117, 142, 219–222, 224, 229
Q
Queensland Law Reform Commission, 45
R
Rabbis, 226, 231, 236
Randomized controlled trials, 62, 66
Re-evaluation Co-counseling, 152
Regressive psychotherapy, 150, 152–154
Reichian Therapy, 152
Reich, Wilhelm, 152, 154, 234
Religion, 1, 3, 6, 9–10, 17, 19–20, 23,
28–32, 40, 45, 51, 55, 121–122, 129,
225, 229
Religious freedom, 28–31
Religious hierarchy, 57
Remondino, Peter Charles, 138
Restoration, 76, 161–162, 189–198,
199–210
Restoration devices, 194–196
Rhinehart, John, 153
Ridged band, 77–78, 157, 190–191
Risks, 7, 9, 17, 19–21, 23, 25–30, 33, 45, 51,
53, 55–56, 61–63, 65, 72–73, 83–84, 129,
131, 186, 212, 228
Ritual defloration, 118–120, 122
Ritual modifications, 98
Ritual stretching, 98–100
Royal Australasian College of Physicians,
42, 46
Russian Orthodox Church, 19
Rwanda, 52, 117, 120–122
251
S
Sacrifice, 2, 129, 143, 187, 236–237
Samoans, 220
Sattouf, Riad, 140, 144–145
Saul, 223
Schwartzenegger, Arnold, 144
Sechem, 223
Semites, 219–220, 223
Sensory nerve endings, 75, 78
Sepsis, 83
Seroprevalence, 52, 54–55
Seth, 225
Sierra Leone, 7
Sierra Madre, 217
Simeon, 223
Skin bridges, 83
Social customs, 2, 42
Social norms, 1, 3, 127
Somalia, 22, 125–133
Somatic Experiencing, 152
Somerville, Margaret, 7, 24, 30
South Africa, 4, 52–54, 63–64
South America, 57, 220
Spain, 140
Spanish Inquisition, 140
Staffordshire, 215
Stern, Howard, 208–210
Stoppard, Miriam, 214
Stutterford, Thomas, 214
Sub-Saharan Africa, 51–52, 63
Sudan, 140, 231
Sunna Gudnin, 126, 131
Sunnah, 145
Supreme Court of Oregon, 18, 20
Surgical Temptation, A, 57
Swaziland, 52, 66
Sweden, 4, 6, 228
Syphilis, 24, 129, 228
T
Tacoma, 168, 172
Tacoma General Hospital, 168, 172
Tallahassee, 217–218, 230, 235
Talmud, 224, 226, 236
Tanzania, 45, 52–53
Tasmania, 4, 40–41, 46, 212
Tasmanian Criminal Code, 43
Tasmanian Law Reform Institute, 46
Templeman, Lord, 26
Ten Commandments, 236
Thailand, 56, 66
Thutmose, 219
Tissue expansion, 189, 193, 198, 207
252
Tonsillectomy, 227
Toronto, 65, 127
Tradition, 4, 28–29, 31, 64, 82, 90–92, 105,
114, 120, 122, 126, 129, 131–132, 145,
219, 224–226, 229, 235
Trauma, 69, 142, 150, 152–162, 182
Treaty law, 40
Tshiala Mbuyin, 100
Tutsi, 64, 117, 120–121
U
Uganda, 52–53, 56, 64, 66, 98, 100, 118,
121–123
UNAIDS, 8, 51, 61, 65
UN Convention on the Rights of the Child
(UNCROC), 3, 22, 40–41
Union of Orthodox Jewish Congregations of
America, 20
United Kingdom (UK), 8, 16–19, 21–23,
25–28, 30, 33, 68, 76, 212, 214–215
United Nations (UN), 3, 5, 22, 40–41, 61, 138,
140, 146
Index
United States (US), 2–9, 17, 20, 22, 28, 33, 50,
55, 61–65, 68, 81, 84, 138–139, 145–146,
157, 204, 207, 227–228, 230
United Synagogue of Conservative Judaism, 19
University of Padua, 98
USA, 55, 88, 91–92, 168, 191–192
V
Vaccines, 8–9, 50–51, 56, 62, 64, 66
Vereshack, Paul, 152, 155–156
W
Waldeck, Sarah, 2, 8
Washington, 168
World Health Organization (WHO), 8, 50–51,
61, 64–65, 98, 105, 112, 121, 212
Z
Zambia, 52, 121
Zimbabwe, 52
Zimberoff, D., 152, 154, 160–161
Zipporah, 143, 223–224

Genital Autonomy: Protecting Personal Choice

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