6.  Corporate institutionalisation of circumcision in the Cold War era

In the United States, however, Gairdner's paper was ignored, and the old myths repackaged by doctors such as Guttmacher held sway instead. Medical textbooks became even more insistent that obstetricians should examine every newborn boy to check whether his foreskin was adherent, unretractible or too long , and to perform an immediate circumcision if such symptoms of "phimosis" were present – as they nearly always were. In 1953 obstetricians Richard L. Miller and Donald C. Snyder published an influential paper in the American Journal of Obstetrics and Gynecology, calling for the immediate circumcision of all males straight after birth. Ignoring Gairdner and relying heavily on the writings of Wolbarst, they insisted that "phimosis" required immediate surgical correction, and asserted that circumcision would "reduce the incidence of onanism", heighten male libido and "increase longevity and immunity to nearly all physical and mental illness." They also stated that circumcision immediately after birth was convenient for the doctor and in the financial best interests of the hospital. Leading obstetrical textbooks were soon rewritten to include Miller and Snyder's recommendations. [65, 66]

6.1  The new cancer scare

During the 1950s, with syphilis under control thanks to penicillin, cancer regained its position as the most feared disease. Between 1943 and 1951 the number of articles on cancer in popular magazines increased by 182 per cent, a further 32 per cent between 1951 and 1955, and another 72 per cent from 1955 to 1957. In keeping with this renewed and increased alarm, Ravich published a new paper, "Prophylaxis of cancer of the prostate, penis and cervix by circumcision", in which he alleged that 25,000 deaths annually from cancer were really caused by the foreskin, and that between 3 and 8 million American men then living had contracted prostate cancer through the influence of their foreskin. Ravich concluded that a program of mass compulsory circumcision was necessary as an "important public health measure". [67] Ravich's theory of cervical cancer was taken up by Dr Ernest Wynder at the Manhattan Memorial Centre  for Cancer and Allied Diseases, and in 1954 he published  a lengthy paper that purported to show that universal neonatal circumcision of males could eliminate cervical cancer in women. [68} Again, a popular news magazine (in this case, Time) gave warm coverage to Wynder's claims, thus giving them both publicity and credibility, and encouraging public support for the burgeoning circumcision industry. [69]

Meanwhile, there were also a few calls for circumcision of girls and women. During the 1950s some American physicians stepped up their efforts to popularise circumcision of adult females – here meaning excision of the clitoral hood as a hygiene measure. In 1959 Dr W.G. Rathmann published an article in which he promoted the idea of female circumcision as a cure for psychosomatic illness and marital problems. He also took the opportunity to tout his newly-patented female circumcision clamp. [70]

6.2  Kaiser, Gomco and Europe

In the 1950s an increasing number of corporation-managed hospitals and insurance companies entered the now profitable business of routine neonatal circumcision. Private hospitals instituted policies of immediate and automatic circumcision of all male neonates, often in the delivery room. At the Kaiser Foundation Hospital in 1950, out of 889 live male births, 812 (92 per cent) were circumcised immediately after birth. [71] Likewise, many urban hospitals adopted the policy of circumcising any boys who missed out at birth when they were brought in for other common procedures, such as having their tonsils removed.

In the late 1950s the American circumcision industry sought to spread the practice to Europe, with a particular focus in east and west Germany, the latter under extensive American influence as a result of the post-war occupation. Around 1957 the Gomco corporation established a distribution network in Ulm [72], and in the same year Kaiser worked with Otto Dietz, a minor official in the East Berlin secret police, to introduce circumcision in east Germany [73]. In 1959 150 babies born in a state-run clinic in Darmstadt, west Germany, were experimentally circumcised without anaesthesia a publicity stunt for the Gomco clamp [74], and in1963 Dr H. Koester arranged for the maternity clinic at the University of Giessen to adopt a policy of automatically circumcising all boys born there, again using the Gomco clamp. In 1968 a further demonstration of its speed and efficiency was arranged in east Germany [ 76].

By the early 1970s, however, the experiments had aroused the disfavour of both east and west German authorities, and the experiments came to an end. Gomco promptly turned its attention to Denmark and in 1973 arranged for 18 Danish newborns to be cut. [77]. Along with publicity photos of the clamp, the results were praised by the Danish medical press. The Danish public, however, were less impressed and strenuously resisted the idea of allowing their children's sexual organs to be surgically altered for any reason, and the campaign faded away.

It is easy to see that Gomco's attempted push into Europe had nothing to do with health, but was entirely a commercial venture.

6.3  Professional opposition to circumcision

There was some opposition to forcible circumcision. In 1956 and 1959 Dr Richard K. Winkelmann, a fellow in dermatology at the Mayo Clinic, published two studies which documented the intense innervation of the foreskin and identified it as  specific erogenous zone. [78, 79] In a period that was intensely hostile to sexual enjoyment, however, his studies were ignored. In 1954 Ravich's theory that the foreskin caused cancer of the prostate was disproved [80], and in 1962 the hypothesis that it caused cervical cancer in women was falsified [81]. In 1963 a further study invalidated Wolbarst's contention that smegma was carcinogenic. [82] In 1965 the trend towards scepticism was boosted when the Journal of the American Medical Association published Dr William Morgan's provocatively titled paper, "The rape of the phallus". In this article Morgan debunked all the then current arguments used by hospitals to justify involuntary circumcision and initiated a controversy within the American medical profession that continues to this day. [83]

An even more significant article, on the nature of the juvenile foreskin, was published in 1968. The British pediatric journal, Archives of Diseases of Childhood, carried an account of the exhaustive research of the Danish pediatrician Jakob Oster, who had examined the incidence of preputial adhesions in 9,545 Danish schoolboys aged 6 to 17 years. [84] Like Gairdner, Oster's findings disproved the phimosis myth and demonstrated that adhesions between the foreskin and glans were not a birth defect, but a perfectly normal stage of penis development. He further showed that separation between glans and foreskin was a gradual biological process that often took ten years or more to complete. His research revealed that no interventions were needed in normal cases and, more importantly, that inappropriate attempts to hasten development (e.g. by tearing the foreskin from the glans) could damage both structures and actually bring about the phimosis it was supposed to fix. Oster's study significantly advanced scientific understanding of the foreskin was widely read by the British and European medical community; in the United States it was pretty much ignored.

In 1970, however, the spark ignited by Morgan was fanned into flame in an article by Noel Preston, "Whither the foreskin?", in JAMA. [85] The paper debunked all the reigning circumcision myths and influenced the American Academy of Pediatrics to publish the following revolutionary statement in the fifth edition (1971) of its Standards and Recommendations for Hospital Care of Newborn Infants: "There is no valid medical indications for circumcision in the neonatal period." [86]

In the late 1970s, as Americans became increasingly aware of the abuses of power rampant in the nation's social institutions, grass roots movements against the forced circumcision of American children began to emerge. In the face of ridicule and hostility from health care professionals, many American parents began to refused to allow their sons to be circumcised. At the same time, developments in medical ethics that brought the concept of informed consent into the surgical arena required doctors to explain the probable outcome of any surgery, state the known risks, offer alternative treatments for the problem and obtain written consent from the patient. Circumcision, too, now required a consent form, but since the person being operated on was not capable of giving informed consent, spokesmen for the circumcision industry claimed that parents could give consent by proxy. By presenting  involuntary circumcision the parents' choice, circumcision advocates obscured the vital fact that the person who ran the risks and had to bear the lifelong consequences of the surgery was still not permitted a choice in the matter. Critics countered that doctors had no legal power to concede control of the baby's genitals to the parents because doctors had no legal power over his genitals in the first place.

6.4  Backlash from the circumcision industry

The high-water mark of involuntary circumcision was reached in the 1970s. With or without parental consent, hospital practice raised the incidence of neonatal circumcision to 90 per cent in the late 1970s and early 1980s. Circumcision advocates from urban areas took positions in small rural hospitals in America's heartlands and instituted new circumcision programs in regions of the country where it had not been known.

At the same time, baby care guides, popular medical magazines and health texts circulated myths to the effect that a boy not circumcised in infancy would suffer terrible psychological damage if he ever saw that his father's circumcised penis differed from his own. [87-89] (Oddly enough, this had not been raised as a problem when the father was uncircumcised and the boy cut, though you would think that a person would be more upset at lacking something his father possessed than possessing something his father lacked.) Another myth that was particularly effective in exploiting middle class anxieties about conformity and social status was that an uncut boy would be made to feel weird and inferior to his circumcised classmates in school locker-rooms. [90]

Accurate information on the anatomy and physiology of the foreskin was omitted from American textbooks and replaced with the pseudo-science of the circumcision lobby. [91, 92] Even anatomical representations of the penis in standard urology texts silently omitted the foreskin and showed the penis as circumcised, as though it were that way by nature [93]. The few drawings of the anatomy of the natural penis that could be found generally represented the foreskin incorrectly. The normal human penis became a strange and alien anomaly to the new generation of Americans – physicians and laymen alike – most of whom had never seen one. As an example of the outdated information being given to American medical students, here is a quote from the 1970 edition of Campbell's Urology, the standard urology textbook:

Consistent with these Edwardian notions, it also advised circumcision as a precaution against masturbation:

The Victorian masturbation hysteria was apparently still alive and well in American medical textbooks in the scientific seventies.

In October 1972 the American Academy of Pediatrics appointed a committee to discuss circumcision in order to provide guidance to health insurers who had been asking whether neonatal circumcision should be covered in their insurance policies. The outcome was never officially released, but the conclusion was unofficially presented by Dr Thomas Guthrie to an AMA conference in June 1973. He argued for even more widespread neonatal circumcision and the continuation of insurance coverage. [96]

Female circumcision  had not entirely disappeared from American medical practice. In 1973 Dr Leo Wollman, a gynaecological surgeon at Maimonides Hospital, Brooklyn, published an article in which he argued for female circumcision (meaning excision of the clitoral hood) as a cure for frigidity. [97] Wollman's appeal was geared to the ethos of the sexual revolution of the 1970s, when sexual pleasure was at last becoming recognised as a legitimate part of life and even the responsibility of the medical profession. Surgical modifications of the male and female genitalia, it was argued, would improve the quality of orgasm. This was the exact opposite of the message communicated a century before, when one of the chief virtues of circumcision was (correctly) held to be its effect in reducing sexual sensation. The sudden reversal of argument convinced critics that American circumcision advocates were willing to say anything in order to push circumcision onto a gullible but increasingly suspicious public.

To make matters worse for the circumcision lobby, in 1975 the American Academy of Pediatrics issued a further policy on circumcision that concluded:

6.5 Legal action for children's rights

In the 1980s men finally began to wake up to what had been done to them as infants, and several lawsuits against doctors and hospitals in California were filed, charging that hey had violated  the constitutional rights of the plaintiffs by circumcising them without consent. [99, 100] The cases were filed in order to establish that parents do not have the right to consent by proxy to medically unnecessary surgery on their children, basing their claim on the 1975 AAP policy that circumcision was not medically necessary. The acknowledged lack of medical justification for circumcision put circumcisers at risk of litigation, but more importantly the constitutional challenge to the legality of subjecting children to involuntary circumcision threatened to dismantle a lucrative medical sideline – which in 1986 was estimated to generate some $200 million annually. [101] If neonatal circumcision were to survive, new medical excuses would have to be found.

6.6  The urinary tract infection scare

In the mid-1980s the new excuse was provided by urinary tract infections (UTIs). Although nothing on this rare condition had ever appeared in a popular magazine, the medical literature reflected a surge of research interest. A search of Medline uncovered only four publications on UTIs for the period 1966 to 1974; 65 from 1975 to 1979; and 350 from 1980 to 1984. While the national incidence of UTIs had not altered from 1966 to 1989, the astounding 8,650 per cent increase increase in the number of published studies showed clearly that UTIs were the next big thing, and it was not long before the foreskin was being blamed as a risk factor. In 1982 Drs Charles Ginsburg and George McCracken published a report of a study of 100 infants with acute UTIs. Because only 3 of the 62 males were circumcised, the authors speculated that lack of circumcision might increase susceptibility, though they admitted that "perineal hygiene was inadequate in many patients". [102]

In 1985, evidently intrigued by this lead, Dr Thomas Wiswell, then a neonatologist at Brooke Army Medical Centre, Texas, sought to verify it with his own studies, and soon published in Pediatrics the first of many studies promoting the theory that the foreskin increased the risk of UTIs and that circumcision was therefore a valuable prophylactic. [103] Wiswell's first review of hospital charts implied a UTI incidence of 1.4 per cent in uncircumcised boys and 0.14 per cent in circumcised boys, though he did not take into account such relevant factors as whether the babies were breast-fed (breast milk carries powerful antibodies) or the fact that many of the uncircumcised boys had been subjected to premature retraction of their foreskin, thus making it likely that the infection had been communicated by the doctor or nurse. Such questions were simply not asked. Although the difference between the two groups was very small (1.2 percentage points), it was made to appear much larger by being described as a 10 per cent increase. Circumcision enthusiasts hailed the results of Wiswell's research as a new indication for circumcision and just what they needed to defeat the emerging legal and human rights challenges.

Indeed, a letter in response to Wiswell's study addressed the lawsuits directly. The author, Dr Aaron Fink (1926-1994) was a urologist in the mould of Wolbarst and Ravich and a long-time agitator for universal neonatal circumcision. He was clearly disturbed at the possibility that circumcisers might face the risk of legal action from their victims and ridiculed the idea that circumcision required the consent of the person on whom it was performed. [104] In his reply, Wiswell agreed that the medical indication he had discovered removed the need to obtain consent before operating. [105] McCracken was less convinced, however, and commented that "because the long-term outcome of UTI in uncircumcised male infants is unknown, it is inappropriate at this time to recommend circumcision as a routine medically indicated procedure." [106]

Nonetheless, medical texts and popular magazines quickly incorporated UTIs into their list of why the baby should be circumcised [107-109]. Magazines such as Newsweek and US News and World Report ran feature stories on Wiswell's discoveries and hailed them as the answer to those who were trying to stop circumcision. [110, 111] Since few males ever experience a UTI the UTI myth had little power to influence fathers, but research had shown that it was the mother, more often than the father, who signed the circumcision consent form. [112-114] Among girls, however, unpleasant and painful bouts of UTI are relatively common [115, 116], and the new UTI scare proved quite effective in frightening young mothers into agreeing to the circumcision of their sons. Unlike STDs and cancer, which did not affect men until they were sexually active adults and old men, UTIs could affect infants. Wiswell's warning that the foreskin posed a serious threat to the baby's health, and even his life, in the first few weeks, and that it could increase the risk of complications such as kidney failure, meningitis and death, naturally alarmed many parents and convinced them that they had better get the baby done "just to be on the safe side". [117-118]

At this point Wiswell tried to turn the legal tables by suggesting that if insurers did not cover circumcision they might be held legally liable if a baby contracted UTIs. "If ten years from now there are uncircumcised children on dialysis with kidney damage associated with UTI , insurers who would not pay for circumcision might be held liable," he wrote [119]. At the same time, oddly enough, he stated that "I tell them [parents] that I personally don't like the procedure and don't recommend it, but if they want it performed I will do it."

A further effect of the UTI scare was to persuade pro-circumcision forces in the AAP to agitate for a new circumcision policy. In 1989 a new task force was established under the chairmanship of Dr Edgar Schoen (b. 1925), a pediatrician at the Kaiser Foundation Hospital, Oakland, since 1954, and a fanatical advocate of universal circumcision. (Kaiser, it will be recalled, was the commercial medical services company that tried to sell Gomco circumcision  clamps to Germany and Denmark in the 1960s.) After intense debate the Task Force produced a new and highly equivocal statement that took Wiswell's UTI hypothesis into account but stopped short of recommending a return to routine circumcision:

By closing the legal loophole in the 1975 statement, the new policy protected circumcisers from legal action while avoiding any overtly unscientific or unverifiable claims. Sensitive to the awkward fact that European countries had steadfastly rejected American attempt to export circumcision, Schoen (from his office in the Kaiser Permanente Medical Centre) made another attempt to badger northern European countries into adopting programs of routine circumcision on the United States model. [121] The terse reply to his overtures, written by two of Sweden's most eminent physicians and published in a leading Swedish medical journal, invoked a number of critical issues that he had never considered: fairness, human rights and medical ethics. Pointing out that it was a violation of a person's human rights to be subjected to such a procedure without informed consent, the authors observed that it was only fair to postpone a decision on the matter until the boy was old enough to make his own decision. The authors explained that since an ethics committee on experimental animals would never accept clinical trials involving circumcision without anaesthetic on laboratory animals, Europe could hardly justify subjecting its own children to such pain and suffering. [122]

NOTE

In relation to the following two sections it should be noted that this study was written in 1995-96 when the notion that the foreskin was a major risk factor for HIV-AIDS, and that circumcision was therefore an important part of any anti-HIV strategy, was no more than the speculation of cranks. At that time there was no predicting that the idea would be seized upon by the international AIDS industry, given massive funding, and presented to the world as the definitive solution to the AIDS problem in Africa, and probably in other underdeveloped regions as well. What we can observe is the consistency of the historical pattern: as soon as a new disease leaps to the forefront of public anxiety, circumcision enthusiasts suggest that the foreskin has something to do with it and yet more circumcision is the answer. In fact, the claim that mass circumcision is necessary to control AIDS is largely a re-run of the nineteenth century conviction that mass circumcision was necessary to control syphilis; in each case, an incurable disease had so terrified the public that they were ready to accept almost anything if it offered the possibility of increasing their safety without the need to change their habits.

What gets forgotten is that AIDS is not a particularly contagious disease and that you have to go to some trouble to contract it; apart from blood transfusions, tattoos, surgery and intravenous drug use (where circumcision would obviously make no difference), the only way you can get AIDS is through unprotected intercourse with an infected partner. The simplest way to run no risk of HIV infection, therefore, is not to be promiscuous and to practise safe sex. This policy has successfully kept HIV infection at a low level in countries such as Australia, Germany and Britain, but western health agencies seem to have much the same attitude towards Africans as Eugene Hand exhibited towards American Blacks: because they are too stupid to use condoms and too sex crazed not to be promiscuous, the only thing that can be done is to circumcise them in the hope of slightly reducing the risk. The foreskin is targeted not because it is a particularly useful point of intervention, but because it is an easy target for surgical removal and a once-off procedure, after which the agencies can congratulate themselves that they have done all they can.

It should also be remembered that there are strong cultural pressures to use the AIDS scare as the latest means of preserving circumcision as a routine procedure among the cultures that traditionally practise it. The billions poured into the World Health Organisation and UNAIDS represent a bizarre alliance between American medical research money, African tribalism and Muslim religiosity, all of which forces have an emotional commitment to finding new and "scientific" justifications for continuing their traditional practices.

6.7  The HIV scare

In the early 1980s the arrival of a new and terrifying infection in the form of HIV-AIDS (as it later became known) gave the circumcision lobby a juicy new opportunity to incriminate the foreskin in the generation of disease. First to capitalise on the opportunity, as early as 1986, was the  egregious Aaron Fink, who was able to persuade the New England Journal of Medicine to publish his speculation that the presence of the foreskin made men more susceptible to infection. [123] On the basis of this theory, throughout 1987 and 1988 Fink lobbied the California Medical Association to adopt a resolution endorsing routine neonatal circumcision as "an effective public health measure". His efforts were rejected by the Scientific Committee of the CMA in 1987, but in 1988 he managed to get his resolution passed on the voices at a CMA meeting. This attracted some national attention, unlike his other new reasons for circumcision – group B-streptococcal disease and "sand balanitis" [124, 125] These connections were evidently too far out even for the gullible American media.

Fink's theory about the foreskin and AIDS, however, was eagerly taken up by other American circumcisionists, such as Francis Plummer and Stephen Moses, who have campaigned tirelessly for new programs of neonatal circumcision as a precaution against HIV acquisition in later life.

6.8  The future of involuntary circumcision

Since the 1980s private hospitals have been in the business of supplying the foreskins they harvest to private biological research laboratories and pharmaceutical companies that require human tissue as raw research material, as well as manufacturers of cosmetics and artificial skin. They have also supplied foreskins to transnational corporations such as Advances Tissue Sciences (San Diego), Organogenesis and BioSurface Technology, companies that have recently emerged to reap profits from the sale of products made form harvested human tissues. [126-129]

Despite the efforts of Schoen, Fink, Wiswell etc, the incidence of circumcision in the United States began to fall in the early 1980s, and the downward trend accelerated in the 1990s. The fall was not due so much to the policies of the AAP, which most doctors ignored, but to the educational efforts of popular and professional anti-circumcision groups. Official figures show that the incidence of neonatal circumcision in the western states, where such groups were most active, fell from 64 per cent in 1979 to 34 per cent in 1994. As a result of an increase in the rate in the Midwest, however, the national figures fell much less – from 64 per cent to 62 per cent over the same period.

In February 1996 a research team at the University of Manitoba led by Dr John Taylor published the results of the most significant investigation of the anatomy and physiology of the foreskin since Winkelmann. Their paper, "The prepuce: Specialized mucosa of the penis and its loss to circumcision", described the structural and functional components of the foreskin and established its rich innervation and vascularisation, clearly evolved to constitute an erogenous zone and to enhance erotic experience. Since circumcision had originally been instituted precisely for the purpose of destroying these very features, it is not surprising that the medical establishment was reluctant to acknowledge Taylor's work, let alone face the obvious implications. Other bodies, however, have paid attention, including the Australian College of Paediatrics and the Canadian Pediatric Society, both of which published policies on circumcision in 1996. Each recommended  that circumcision of newborns be not performed, and pointed out that circumcision without informed consent was a violation of accepted principles of both medical ethics and human rights. [131, 132]

Around this time, too, prominent figures from the world medical community condemned the American practice of routine circumcision of infants as both medically unnecessary and morally wrong. The consensus among critics was that irrespective of the validity of the health arguments for circumcision, the fact that it was done without consent made it an unacceptable  intrusion into the personal lives of individuals and an unwarranted deprivation of their private property. [133-138] The constitutional conflict between human rights and the American medical establishment's assumption that it knows best what's good for boys may be settled in the courts.

7.  Conclusion

The historical record makes it clear that in the late nineteenth century American physicians sought to institutionalise genital mutilation of both boys and girls as a means of eliminating childhood sexuality, and that their efforts were successful in the case of boys, unsuccessful in the case of girls. Doctors circumcised boys to denude, desensitise and disable the penis to such an extent as to make masturbation impossible, or at least not worth the effort. Clitoridectomy of girls was introduced for the same reason. While the medical establishment's use of popular fears about masturbation to justify mass circumcision  has remained pretty constant since Victorian times, the subsequent supplementary  excuses offered to justify circumcision follow a clearly defined pattern: whatever incurable disease happens to be the focus of national attention at any given time will be the disease that circumcision advocates will cite as a reason for circumcision. In the 1870s, when epilepsy was the disease of the moment, circumcision advocates claimed that circumcision could cure and prevent epilepsy. In the 1940s, when STDs were the focus of national health fears, they claimed that circumcision could prevent the spread of STDs. In the 1950s, when everybody was obsessed with cancer, circumcision advocates claimed that circumcision could prevent all sorts of cancers – of the penis, of the tongue of the prostate and of the cervix. Since the late 1980s, when HIV-AIDS became the greatest health scare since the Black Death, circumcision advocates have predictably claimed that circumcision is the answer to AIDS control.

Ironically, and despite these claims, the United States, for all that most of the men are circumcised, does not have a particularly good health record, and on most indicators is well behind places such as Japan and Scandinavia, where circumcision is practically unknown. Today the USA has both the highest percentage of sexually active, circumcised men and one of the highest rates of genital cancers and STDs in the western world. The paradox implicit in this history is that even though mass circumcision has been ineffective as a public health measure, and has done little to control either cancers or STDs, the American medical establishment has clung to its faith in circumcision and consistently sought to find new justifications for it. Their priority does not seem to have been maximising public health, but maximising their foreskin harvest. Such unscientific allegiance to an ineffective and harmful surgical procedure, when good sense would suggest the adoption of more conservative and more effective strategies, suggests that there may be a deeper, non-rational dynamic behind circumcision advocacy, and that it is not just  matter of simply applying, as they so often claim, the discoveries of medical science to public health policy. [139]

The history of the institutionalisation of involuntary circumcision in the United States demonstrates that American society has been willing to apply what it takes to be scientific measures at the expense of personal liberty. It is tempting to dismiss circumcision as merely a quaint example of medical quackery pursued by a handful of zealous doctors. We would do better to remember that in the name of scientific progress, millions of American citizens have been subjected to genital mutilation and deprived of an integral, functional and beautiful part of their body. In the face of increasing international criticism and constitutional challenges we must wonder how much longer the medical establishment will be able to continue to indulge in the kinds of illogical thinking and disregard for human rights that underpin their commitment to circumcision as prophylaxis and therapy.

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49.  A.L. Wolbarst, Circumcision and penile cancer, Lancet 1932:1, 150

50.  H.C. Bazett et al, Depth, distribution and probable identification in the prepuce of sensory end-organs, Archives of Neurology and Psychiatry 27, 1932, 489

51.  G.A. Diebert, The separation of the prepuce in the human penis, Anatomical Record 57, 1933, 387

52.  R.H. Hunter, Notes on the development of the prepuce, Journal of Anatomy 70, 1935, 68

53. A.F. Guttmacher, Should the baby be circumcised?, Parents Magazine 16, September 1941

54.  ibid

55.  ibid

56.  J. Ewing, The causal and formal genesis of cancer, in Cancer Control, Chicago 1927, 168

57.  A. Ravich, The relationship of circumcision to cancer of the prostate, Journal of Urology 48, 1942, 298

58.  Circumcision vs cancer, Newsweek 21, 1943, 110

59.  Who's Who in America, 42nd edn, 1982-83, 2752

60.  M.L. Gerber, Some practical aspects of circumcision, United States Navy Medical Bulletin 42, 1944, 1147

61.  L.L. Heimoff, Veneral disease control program, Bulletin of the US Army Medical Department 3, 1945, 93

62.  E.A. Hand, Circumcision and venereal disease, Archives of Dermatology and Syphilology 60, 1949, 341

63.  Circumcision and VD, Newsweek 30, 1947, 49

64.  D. Gairdner. The fate of the foreskin: A study of circumcision, British Medical Journal 1949:2, 1433

65.  R.L. Miller and D.C. Snyder, Immediate circumcision of the newborn male, American Journal of Obstetrics and Gynecology 65, 1953, 1-11

66. J.P. Greenhill, Obstetrics, 13th edn, Philadelphia 1960, 1049; N.J. Eatman and L.M. Hellman (eds), Williams Obstetrics, 12th edn, New York 1961, 1101

67.  A. Ravich and R.A. Ravich, Prophylaxis of cancer of the prostate, penis and cervix by circumcision, New York State Journal of Medicine 51, 1951, 1519

68.  E.L. Wynder et al, A study of environmental factors in cancer of the cervix, American Journal of Obstetrics and Gynecology 68, 1954, 1016

69.  Circumcision and cancer, Time 63, 1954, 96

70.  W.G. Rathmann, Female circumcision: Indications and a new technique, GP 20, 1959, 115

71.  O. Dietz and E.C. Dougherty, Vergleichende studie zur frage der beschneidung in Deutschland und in den Vereinigten Staaten, Deutsche Gesundheitswesen 12, 1957, 193

72. A. Kelami, Die sogennante Gomecotomie als methode der wahl fur circumcision, Der Chirug 37, 1966, 512

73. Dietz and Dougherty, as cited

74.  K.B. Hofmeister, Uber erste erfahrungen mit der routinemassigen beschneidung des neugeborenen in Deutschland, Geburtshilfe und Frauenheilkunde 19, 1959, 20

75.  H. Koester, Zur frage der Zirkumzision neugeborenen knaben, Geburtshilfe und Frauenheilkunde 23, 1963, 934

76.  O. Dietz, Erfahrungsbericht uber 2800 Zirkumzisionen, Dermatologische Monatsschrift 156, 1970, 1029

77.  J.E. Bock and H. Rebbe, Neonatal circumcisio, Ugeskrift for Laeger 135, 1973, 1890

78.  R.K. Winkelmann, The cutaneous innervation of the human newborn prepuce, Journal of Investigative Dermatology 26, 1956, 53

79. R.K. Winkelmann, The erogenous zones: Their nerve supply and its significance, Proceedings of the Mayo Clinic 34, 1959, 39

80.  E.C. Gibson, Carcinoma of the prostate in Jews and circumcised gentiles, British Journal of Urology 26, 1954, 227

81.  E. Stern and P.M. Neely, Cancer of the cervix in reference to circumcision and marital history, Journal of the American Medical Women's Association 17, 1962, 739

82.  D. Govinda Reddy, Carcinogenic action of human smegma, Archives of pathology 75, 1963, 414

83.  W.K.C. Morgan, The rape of the phallus, Journal of the American Medical Association 193, 1965, 223

84.  J. Oster, Further fate of the foreskin: Incidence of preputial adhesions, phimosis and smegma among Danish schoolboys, Archives of Diseases of Childhood 43, 1968, 200

85.  E.N. Preston, Whither the foreskin? A consideration of routine neonatal circumcision, Journal of the American Medical Association 213, 1970, 1853

86.  American Academy of Pediatrics, Hospital Care of Newborn Infants, 5th edn, Evanston 1971, 110

87.  Boston Children's Medical Centre, Pregnancy, Birth and the Newborn Baby, Boston 1971, 285

88. V.E. Pomeranz and D. Schultz, The Mothers and Fathers Medical Encyclopedia, Boston 1977, 109

89.  B. Livermore, Like father, like son, Health 19, 1987, 15

90.  S. Barton, Your Child's Health, New York 1991, 113

91.  W.H. Masters et al, Human Sexuality, 4th edn, New York 1992, 58

92.  M.A. Miller et al (eds), Kimber-Gray-Stackpole's Anatomy and Physiology, 17th edn, New York 1977, 577

93.  R.S. Snell, Atlas of Clinical Anatomy, Boston 1978, 136

94. M.F. Campbell, The male genital tract and the female urethra, in M.F. Campbell and J.H. Harrison (eds), Urology, 3rd edn Philadelphia 1970, Vol. 2, 1836

95.  ibid

96.  R. Burger and T.H. Guthrie, Why circumcision?, Pediatrics 54, 1974, 362

97.  L. Wollman, Female circumcision, Journal of the American Society of Psychosomatic Dentistry and Medicine 20, 1973, 130

98.  Report of the ad hoc task force on circumcision, Pediatrics 56, 1975, 610

99.  Two suits charge circumcision malpractice, Contemporary Ob/Gyn 28, 1986, 150

100.  Calif suit raises liability questions in circumcision, ObGyn News 21, 1986, 1

101.  Two suits

102.  C.M. Ginsburg and G.H. McCracken, Urinary tract infections in young infants, Pediatrics 69, 1982, 409

103.  T.E. Wiswell and J.W. Bass, Decreased incidence of UTIs in circumcised male infants, Pediatrics 75, 1985, 901

104.  A.J. Fink, In defence of circumcision, Pediatrics 77, 1986, 265

105.  T.E. Wiswell, Reply, Pediatrics 77, 1986, 266

106.  G.H. McCracken, Options in antimicrobial management of UTIs in infants and children, Pediatric Infectious Diseases Journal 8, 1989, 552

107.  F.W. Burch, Baby Sense, New York 1991, 226

108.  A. Santesteban, Child Care for the 90s, Bedford 1993, 18

109.  D. Dollemore et al, Symptoms: Their Causes and Cures, Emmaus 1994, 199

110.  Doubts about circumcision: Fewer boys are now cut, Newsweek 109, 1987, 74

111.  J. Silberener, Circumcision, US News and World Report 104, 1988, 68

112.  C.S. Rand et al, The effect of an educational intervention on the rate of neonatal circumcision, Obstetrics and Gynecology 62, 1983, 64

113.  G.O. Bean and C. Egelhoff, Neonatal circumcision: When is the decision made?, Journal of Family Practice 18, 1984, 883

114.  J.E. Lovell and J. Cox, Maternal attitudes towards circumcision, Journal of Family Practice 9, 1979, 811

115.  N.H. Eriksen et al, UTIs infection, etiology, diagnosis and treatment with effective antibiotics, Nordisk Medicin 104, 1989, 35

116. A.L. Shabad et al, The pathogenesis and treatment of UTIs in women, Urologiia I Nefrologiia 4, 1995, 8

117.  T.E. Wiswell, Risks from circumcision during the first month of life, Pediatrics 83, 1989, 1011

118.  T.E. Wiswell, Routine neonatal circumcision: A reappraisal, American Family Physician 41, 1991, 859

119.  S. Ahman, Academy holds fast to position on circumcision, Pediatric News 20, 1986, 38; more recent studies of UTIs can be found here.

120.  Report of the task force on circumcision, Pediatrics 84, 1989, 388

121.  E.J. Schoen, Is it time for Europe to reconsider newborn circumcision?, Acta Paedatrica Scandinavica 80, 1991, 573

122.  I. Bollgren and J. Winberg, Reply to Schoen, Acta Paedatrica Scandinavica 80, 1991, 575

123.  A.J. Fink, A possible explanation for heterosexual male infection with AIDS, New England Journal of Medicine 315, 1986, 1167

124. A.J. Fink, Is hygiene enough? Circumcision as a possible strategy to prevent group B streptococcal disease, American Journal of Obstetrics and Gynecology 159, 1988, 534

125. A.J. Fink, Circumcision and sand, Journal of the Royal Society of Medicine 84, 1991, 696

126.  B. Manson, Forget pork bellies, now its foreskins, San Diego Reader, 4 May 1995, 12

127.  S. Brewer, New skin twin life, Longevity, September 1992, 18

128.  R. Rosenberg, Companies see $1.5b market in replacement skin products, Boston Globe, 19 October 1992, 22

129.  C.T. Hall, Biotech's big discovery, San Francisco Chronicle, 25 October 1996

130.  J.R. Taylor et al, The prepuce: Specialized mucosa of the penis and its loss to circumcision, British Journal of Urology 77, 1996, 291

131.  Position statement on routine circumcision, Australian College of Paediatrics, Parkville, Vic, 1996

132.  Canadian Pediatric Society, Clinical practice guidelines: Neonatal circumcision revisited, Canadian Medical Association Journal 307, 1996, 769

133.  J. Menage, Male genital mutilation, British Medical Journal 307, 1993, 686

134.  L. Sorger, To ACOG: Stop circumcisions, ObGyn News 1 November 1994, 8

135.  P.M. Fleiss, Female circumcision, New England Journal of Medicine 322, 1995, 189

136.  S. Mullick, Circumcision, British Medical Journal 310, 1995, 259

137.  J.P. Warren et al, Circumcision of children, British Medical Journal 312, 1996, 377

138.  P.M. Fleiss, More on circumcision, Clinical Pediatrics 34, 1995, 623; a more recent statement by Paul Fleiss available here.

139.  J. Bigelow, The Joy of Uncircumcising, Aptos 1995, 89

Source

Originally published as "A short history of the institutionalization of involuntary sexual mutilation in the United States", in George C. Denniston and Marilyn Milos (eds), Sexual Mutilations: A Human Tragedy (New York: Plenum Press, 1997). The paper has been slightly edited in places for brevity and clarity.