"A source of serious mischief":
The demonisation of the foreskin and the rise of preventive circumcision in Australia

To the sensitive, excitable, civilized individual, the prepuce often becomes a source of serious mischief. In the East the ... secretions between it and the glans [are] likely to cause irritation and its consequences; and this danger was perhaps the origin of circumcision -- William Acton, 1865

Diseases desperate grown, By desperate appliances are relieved -- Hamlet IV. ii. 9

Part 1.  Introduction

Synopsis

Between the 1890s and the 1920s there was a minor revolution in the treatment of the male body in Australia. From being an anomaly peculiar to Jews or a mutilation practised by savages, circumcision became the mark of a clean, healthy boy and one of the stigmata of a gentleman. In this paper I trace the outlines of this transformation and show how a combination of medical advice, sexual fears (particularly fear of sexual pleasure) and social ambition led to the introduction circumcision as an all but inescapable incident in the life of the Australian boy. More specifically, I argue that this institutionalisation of male genital mutilation, eventually dignified under the euphemism "routine neonatal (or infant) circumcision", was a direct response to the nineteenth century's search for a cure for the imaginary disease of spermatorrhoea, and its phobia about masturbation specifically, and that Australia inherited the medical wisdom on these matters from Britain and the US with very little local discussion and scarcely a murmur of dissent.

The British background

Although the Australian experience of routine circumcision generally follows the pattern established in Britain and the United States, it has its own historical trajectory and several distinctive features. Until the twentieth century, most Australian doctors were trained in Britain, and they applied the medical wisdom they had acquired back home. The only significant differences concern chronology and incidence. Routine circumcision started a generation later than in Britain and continued long after it had been abandoned there, reflecting the growing influence of US medicine after the Second World War. The practice was also more widespread than in Britain, where it was common among the rich but relatively rare among the poor; in Australia all classes were affected equally, reflecting the greater social equality here and wider access to the latest medical advances. In the 1980s and 1990s the practice declined to a far greater extent than in the US.

The essential conditions for the rise of routine circumcision—or preventive circumcision as I prefer to say, acknowledging that its purpose was to prevent a variety of supposed problems (1)—are thus much the same in Australia as in Britain. They can be briefly summarised in five points.

1.  The taboo against masturbation began as religious prohibition, but during the nineteenth century it was medicalised as belief in God and the afterlife declined. Taking over the role of priests, doctors argued that knowledge of the harmful effects of masturbation here on earth was a more effective deterrent to immoral behaviour than fear of eternal damnation.

2.  The medicalistion of the taboo led to the invention of a new and imaginary disease called spermatorrhoea. This meant any loss of semen other than in heterosexual intercourse and included wet dreams, spontaneous emissions and sexual adventures outside the marriage bed as much as masturbation. Such a scarce and precious fluid had to be hoarded, or disease, debility and death would follow. Lallemand, Acton, Courtenay, Milton and others wrote eloquently on this subject, pathologising normal male sexuality in the process.

3.  The nerve force theory of disease, current until displaced by the discovery of germs in the late nineteenth century, held that diseases could be caused by imbalances in nervous force. Excessive excitement in one region could induce a drain of energy from another, thus provoking illness in the affected parts. It was really a nerve-based version of the old theory of the four humours, but it persisted in explanations of how masturbation caused harm until well into the twentieth century, and it is far from dead today. Parts of the body known to be particularly sensitive, such as the foreskin, were thus implicated in the generation of disease, and it came to be blamed for tuberculosis, rickets, convulsions, polio ("paralysis") and any other problem doctors were unable to cure.

4.  The outcome of these developments was what I have called the demonisation of the foreskin. It ceased to be seen as a normal part of the body and became a pathogenic structure guilty of provoking a host of medical problems—either indirectly by encouraging masturbation, or directly by disrupting the body's nervous equilibrium by its morbid sensitivity. The most extreme version of this case was put by the fanatical Dr Remondino, but most doctors shared his general viewpoint.

5.  Circumcision played a vital role in the establishment of the modern medical profession. Finding a cure for spermatorrhoea (including masturbation) was the testing ground on which regular medical practitioners sought to establish their credentials and to demarcate themselves from the quacks. William Acton, F.B. Courtenay and, in Australia, James Beaney were vehement in their denunciations of the remedies for spermatorrhoea proposed by these charlatans, but essentially it was a battle for professional turf and the right to manage all the functions of the body. Unfortunately for the regular doctors, until circumcision became an option, the treatments they could offer differed little from those of their rivals.

The godfather of preventive circumcision is undoubtedly William Acton, physician to Queen Victoria and the leading authority on men's sexual health in the mid-nineteenth century. His most influential book, The functions and disorders of the reproductive organs, first published in 1857, was still being reprinted in the early 1900s; it was widely read in Australia and probably the principal source of information on male sexuality. It is surprising that David Gollaher, (2) in his otherwise informative work on the history of circumcision, does not discuss Acton's contribution, so perhaps we need to be reminded of what he wrote about the foreskin.

In none of the many editions of his treatise on the male reproductive organs did Acton advocate general circumcision, but his comments on the necessity for sexlessness in children and continence in young men, coupled with his belief in the pathological irritability of the foreskin, prepared the ground. Anxious to guard against its emergence, he was concerned that a long or tight foreskin was often the cause of sexual precocity in children and recommended that boys be taught "to draw back [their] foreskin and thoroughly cleanse the glans penis every day". (3) Acton realised that this routine might lead to the very manipulations it was designed to prevent but asserted that his own experience had been to the contrary. Conceding, perhaps regretfully, that circumcision was "never likely to be introduced amongst us", (4) he was confident that his own precautions—parental watchfulness, cleanliness, fresh air and tiring exercise—should be sufficient "in most cases to remove all ill effects arising from the existence of the prepuce", but he was adamant that the foreskin itself was the root of all the problems that arose:

that the prepuce in man ... is the cause of much mischief, medical men are pretty well agreed. It affords an additional surface for the excitement of the reflex action, and ... aggravates an instinct rather than supplies a want. In the unmarried, it additionally excites the sexual desires, which it is our object to repress.

This was ominous enough, but Acton added an even more anxious footnote:

to the sensitive, excitable, civilized individual, the prepuce often becomes a source of serious mischief. In the East, the ... secretions between it and the glans [are] likely to cause irritation and its consequences; and this danger was perhaps the origin of circumcision. That the existence of the foreskin predisposes to many forms of syphilis, no one can doubt; and ... I am fully convinced that the excessive sensibility induced by a narrow foreskin ... is often the cause of emissions, masturbation, or undue excitement of the sexual desires. (5)

Already the foreskin is to blame for syphilis, masturbation, the arousal of sexual desire and the febrile excitability of modern man. Acton is obviously attracted to the idea of the preventive removal of such a malignant part of the body, and in later editions of his book, reflecting the advance of circumcision in British medical practice, he notes that some authorities had suggested "the universal performance of circumcision" as a means of guarding against childhood sexual precocity and masturbation specifically. (6) He countered that the benefits of circumcision were only speculative and continued to believe (with remarkably poor powers of prediction) that the procedure would never become general "amongst us". How wrong Acton was on this point was demonstrated by the next generation of physicians in Britain and the US, as they took up his strictures against the foreskin and developed them vigorously. (7)

Circumcision in Australia today

The decline of circumcision in Australia is easier to document than its rise. From the 1920s to the 1960s it was all but universal, Chester Eagle (born 1933) commenting on the "mostly circumcised penises" of his contemporaries at Melbourne Grammar in the late 1940s. (8) Change was signalled on 24 April 1971, when the Australian Paediatric Association (APA) resolved that "new born male infants should not, as a rule, be circumcised", (9) and the incidence of the practice declined steadily thereafter. Figures quoted by Wallerstein show a circumcision rate of 49.6 per cent in 1973-74, 48.6 per cent in 1974-75 and 43.7 per cent in 1975-76. (10)  The Australian College of Paediatrics (ACP) released a stronger statement in 1983, raising human rights as well as medical issues, and this was reissued in 1991. (11)  In 1996 it estimated the current rate of infant circumcision at 10 per cent. (12)  One mother has told me that when her first son was born in Sydney in 1983 hospital staff asked her if she would like him circumcised; when the second was born in 1988 the possibility was not mentioned. (13) Until recently it seemed safe to say that the practice began to decline in the late 1960s and largely died out in the 1980s, except among those who do it to their children for cultural or religious (mainly Jewish or Islamic) reasons.

Figures collected by NOCIRC Australia confirm this picture but reveal considerable variation from one state to another. In 1995-96 the national rate of neonatal circumcision (0–6 months) was 10.6 per cent, while the incidence in the states ranged from 5.4 per cent in Victoria to 17.2 per cent in Queensland, as shown in the following table: (14)

In the early 1990s it looked as though such preventive (non-religious) circumcision was set to disappear, but in recent years it has made a comeback: after falling to a low of 10.4 per cent in 1996, the national rate increased to 12.1 per cent in 2000. Most of this increase occurred in Queensland (from 16.3 to 20.6 per cent) and New South Wales (from 12.3 to 14.2 per cent), outweighing declines in Victoria (from 6 to 4.9 per cent) and the Northern Territory (9.3 to 5.9 per cent).  (15) The reasons for the disparities are not known, but it has been suggested that the high and rising rate in Queensland is due, at least in part, to the evangelical fervour of a prominent GP there, Dr Terry Russell, who apparently tells parents that an early circumcision is the equivalent of immunization against venereal disease, cancer of the penis and many other problems. The continuing popularity of such forcible circumcision among old guard medicos thus suggests that nineteenth century theories about the link between the foreskin and disease have lost little of their relevance. Russell writes that, if they had been circumcised, "a vast number of neonates would have been saved from UTI and its consequences of renal failure, septicaemia, meningitis, hypertension and death". Circumcision "may reduce the risk of STDs (syphilis, gonorrhoea, herpes and candida) and carcinoma of the cervix of female partners. It also prevents balanoposthitis and phimosis", not to mention such "potentially fatal conditions" as neonatal UTI, HIV/AIDS and cancer of the penis. (16) A hundred years earlier Dr Remondino had asserted:

Circumcision is like a substantial and well-secured life annuity; every year of life you draw the benefit, and it has not any drawbacks .... Parents cannot make a better paying investment for their little boys, as it insures them better health, greater capacity for labor, longer life, less nervousness, sickness, loss of time, and less doctor-bills, as well as increases their chances for an euthanasian death. (17)

Even the British Medical Journal found such an extreme advocacy "excessive and strained". (18) Any similarities between Russell's scientific approach and late Victorian quackery are purely coincidental.

The early spread of circumcision

Few statistical details are available for the period when the circumcision of infants and boys first became popular. Unlike the composer Percy Grainger (19) (born 1882), the writer Frank Dalby Davison (born 1893) did not leave us a nude photograph to prove he was intact, but in his last novel he clearly assumes that boys have foreskins to play with. (20) Patrick White (born 1912) was circumcised, but he was born in England to upper class parents, among whom the practice was then common. (21) The historian Russel Ward (born 1914) was "one of the very few boys in the whole World who had been circumcised", as he puts it in his autobiography, but his boyhood playmates in north Queensland were not; the extra-curricular uses they found for their foreskins would certainly have confirmed the fears of those who advocated removal on moral grounds. Significantly, his parents were respectable Methodists from "staid, puritanical South Australia" who found Queensland "uncouth and barbarous". (22) Russell Braddon (born 1921) does not reveal his own status, but he reports that in Changi prison during World War II the army doctors (mainly British) "circumcized practically every man who was not already circumcized" in the belief that the operation would improve the men's health prospects. (23)

Australian doctors probably started performing circumcisions on a wide scale in the 1890s, by which time the operation was well established in Britain and the US. Herbert Moran refers to circumcision in the period 1890–1914 as though it was a commonplace or even routine procedure, (24) and in 1903 A.S. Joske, a surgeon in the children's department at the Alfred Hospital, Melbourne, reported that the number of children being operated on was "steadily increasing". (25) By 1906 a sceptical doctor in Brisbane referred sourly to circumcision as a "mania" of "twelfth-rate surgeons" who preached "a new gospel, the conversion of baby boys into Jews, not for their love of Judaism, but for the three or five guinea fee hanging on the operation". (26) Although Australia lagged behind the mother country it was more egalitarian; while in Britain the procedure was concentrated among middle, upper and professional classes, here "the poorer portion of our population is beginning to see the advantages of the operation". (27) There was very little discussion of the practice in the Australian medical press, and it seems likely that British-trained doctors brought it with them and that Australian-trained doctors read British and US textbooks which recommended it. In 1908 the Australasian Medical Gazette published a warm review of L. Emmett Holt's The care and feeding of children. (28) Holt was an expert on paediatric medicine in the US and a professor at the College of Physicians and Surgeons in New York. He was a zealous circumciser and recommended the practice in his influential textbook, The diseases of infancy and childhood, which became a standard work and went through eleven editions between 1897 and 1940. Where many doctors advised circumcision only when the infant foreskin could not be drawn back, Holt urged it in all cases "because of the moral effect of the operation"; the effects of neglect included "priapism, masturbation, insomnia, night terrors" and "most of the functional nervous disease of childhood". (29) Mary Truby King, author of a book on mothercraft popular in the 1930s, quoted "Professor Holt" on the nature of masturbation and continued with a sentence on the need for circumcision if the fault was found to lie with the foreskin. (30) In 1910 the same journal printed an enthusiastic review of Abraham Jacobi's textbook, Diseases of children, (31) and the author was, if possible, an even keener exponent of circumcision than Holt. Jacobi (1830–1919) was a founder of the American Pediatric Society, first Chairman of the Section on Diseases of Children of the American Medical Association and a leading figure in many other influential bodies. He strongly advocated the circumcision of all male infants as a means of preventing masturbation and cited his personal experience as a Jewish physician as evidence for the claim that circumcised boys did not masturbate (or not as much) and hence were not so susceptible to the many diseases which arose from the practice. (32) If this was typical of the material on which Australian doctors and medical students were being educated, it is not surprising that they came to hold such strong views in favour of circumcision.

With or without debate, the practice of circumcising male babies spread rapidly. In 1916 Sir Thomas Anderson Stuart, Dean of the Faculty of Medicine at Sydney University, remarked that "more and more the operation is being performed as a simple matter of hygiene". (33) By 1921 "some medical men" were advising "the circumcision of all children as a matter of routine". (34) In 1917, in a letter to the Medical Journal of Australia, J.I. Sangster of Brighton, South Australia, observed that "nowadays it has become a surgical fashion to advocate circumcision in every male infant", but he was a critic of the trend, objecting that many of the supporting arguments were based on supposition and doubting that nature was "so often at fault as to demand universal interference". (35) One other dissenting voice joined him in the wilderness, pointing out that circumcision was originally introduced as a religious ritual in which a part of the body was sacrificed. The routine removal of a normal and healthy structure, however, was "surely the last word in absurdity" and about as sensible as removing "the labia minora or the little toe". (36) These comments attracted neither support nor condemnation. The only other reference to circumcision I have located in the Medical Journal of Australia between 1914 and 1935 is a brief report that a certain Dr C.W.B. Littlejohn demonstrated four different methods of circumcision at a meeting of the Victorian branch of the British Medical Association in 1923; (37) the report did not reveal whether the demonstration was on live subjects. The steady advance of circumcision during the 1920s may be seen in the various editions of a guide for mothers prepared by Muriel Peck. The first edition (1925) makes no mention of the procedure, but by the fourth (1929) the foreskin is seen as a problem area that needs to be washed carefully yet not interfered with; if it is tight or long, medical advice should be sought, and if circumcision is considered necessary it should be done as early as possible. (38)

Read Part 2