A short history of the world's most controversial surgery

David L. Gollaher, Circumcision: A history of the world's most controversial surgery, New York, Basic Books, 2000

Reviewed by Robert Darby

Introduction

Until Victorian physicians discovered its medical and moral efficacies, circumcision was scarcely known in the western world. Edward Gibbon had referred to it as a "singular mutilation" practised only by Jews and Turks and as "a painful and often dangerous rite" which discouraged converts to Judaism, and the following century Richard Burton observed that "Christendom practically holds circumcision in horror". This attitude is reflected in the ninth edition of the Encyclopaedia Britannica (1876) which discusses the practice as a religious rite among Jews, Moslems, the ancient Egyptians and tribal peoples in various parts of the world. The author of the entry rejected sanitary explanations of the procedure in favour of a religious one: "like other body mutilations ... [it is] of the nature of a representative sacrifice". By 1910 the entry had been turned on its head: "This surgical operation, which is commonly prescribed for purely medical reasons, is also an initiation or religious ceremony among Jews and Mahommedans": now it was primarily a medical procedure and only after that a religious ritual.

The entry explained that "in recent years the medical profession has been responsible for its considerable extension among other than Jewish children ... for reasons of health" (11th edition, Vol. 6). By 1929 the entry is much reduced in size and consists merely of a brief description of the operation, which is "done as a preventive measure in the infant" and "performed chiefly for purposes of cleanliness". Ironically, readers are then referred to the entries for "Mutilation" and "Deformation" for a discussion of circumcision in its religious context (14th edition, 1929, Vol. 5). As David Gollaher remarks in his fascinating exploration of the subject, by the late nineteenth century doctors made a sharp distinction between ritual circumcision (primitive, dangerous and bizarre) and the sort of preventive circumcisions they carried out (a rational medical necessity).

From tribal rite to modern medicine

In Circumcision: A history of the world's most controversial surgery Gollaher seeks to explain this transformation and to trace the rise of circumcision from its obscure origins as a tribal ritual to its current status as one of the most commonly performed surgical operations in the United States. It is less an integrated history than a series of loosely linked essays, covering different aspects of the subject: Judaism, Christian Europe, Islam, the practices of tribal cultures, the rise of medically-rationalised or "routine" circumcision in English-speaking countries in the late nineteenth century, the subsequent effort to demonstrate that the operation conferred significant heath benefits, the biology of the foreskin, the campaign against circumcision in the USA (the only country where the practice remains common today), and the circumcision of women. All these essays are valuable studies which shed light on a dark chapter of medical history and illuminate the path for future investigators, but the most deeply-researched and most valuable are those which cover modern or routine circumcision. While there is already a vast anthropological literature on Jewish and tribal circumcision, there is remarkably little reliable information available on the history of the other variety: as Edward Hyam (1990, p. 75) remarked, we know less about the introduction and rise of routine infant circumcision in Britain and the USA than about the rituals of some of the most obscure African tribes.

Gollaher writes that his aim is not merely to dispel this darkness, but also to "make the familiar strange. What people take for granted is not necessarily natural. In the US circumcision of newborns is so common that most parents and physicians scarcely think of it as surgery" (p. xii). Yet surgery it undoubtedly is, a delicate and usually bloody operation which first involves the separation of two joined mucous surfaces and then the amputation of a variable mass of live tissue which is not just skin, but an intricate web of blood vessels, muscle and nerves: an early practitioner, treating a five-month old baby for whooping cough (yes, by circumcising him), likened it to "resecting the femur of a grasshopper" (p. 83). The reality of the procedure is a far cry from the "snip" beloved of its advocates and gullible newspaper columnists.

Britain

Although several studies have analysed the survival of routine circumcision in the US (Lewis 1949, Wallerstein 1980, Romberg 1985; see also Dunsmuir and Gordon 1999), the first serious attempt to account for the rise of the practice in Britain was made by Ronald Hyam, who relates the popularity of circumcision at the turn of the century to three main factors. The first was the fear of racial decline and falling physical fitness standards, giving rise to a host of anxieties and counter-measures, including the belief that circumcision would produce healthier and more self-confident males and "contribute to the general improvement of the ... manliness of the future guardians of empire". The second was the sudden enthusiasm for Jewish child-rearing practices in response to reportedly low rates of syphilis and masturbation among Jewish (and thus circumcised) men and boys, and especially following the discovery by the parliamentary Committee on Physical Deterioration in 1904 that such children were better nourished and looked after. The third was the necessity for colonial administrators to work in hot or humid climates where hygiene of the uncircumcised penis was presumed to be difficult.

Hyam notes, in particular, that it was widely believed that normal males were more susceptible to venereal disease in hot climates, and that British Army doctors in India were vigorously in favour of the procedure and operated on their soldiers at the first sign of trouble (Hyam 1990, pp. 74–9). Hyam's account is not without serious gaps. He does not explain why hygiene in hot climates came to be seen as a problem only after the rise of circumcision in a cool climate, nobody having worried about the issue when the British first entered India in the eighteenth century; nor does not explain why it was believed that removal of the foreskin would produce healthier males; and he discounts the supposed value of circumcision in curbing masturbation as an explanation for its rise. On this point he is clearly mistaken, and his own discussion make little sense without the conviction that masturbation was in itself a major health hazard and one of the factors contributing to national decline. The main reason for the sudden enthusiasm for Jewish child rearing practices was the impression that their little boys did not masturbate, a contention which would have surprised Portnoy, but which was widely debated in the medical journals of the time and eagerly confirmed by Jewish physicians, who were understandably pleased that the gentile world was at last beginning to see virtue in a ritual it had traditionally abhorred. The advice that boys should be circumcised to discourage masturbation continued to be repeated in pediatric and urological textbooks right up until the 1960s.

More convincing on this point is Moscucci (1996), who shows that circumcision was increasingly recommended as a cure for male masturbation from the 1850s onwards. She points out that part of this process was the demonisation of the foreskin as a source of nervous and physical disease and agrees with Hyam that circumcision was central to the late Victorian redefinition of manliness in terms of self-restraint and cleanliness: "Widely believed to dampen sexual desire, circumcision was seen positively as a means of both promoting chastity and physical health" (p. 65). Moscucci also discusses the contrasting case of female circumcision and clitoridectomy and explains how, after a brief vogue in the early 1860s for treating "hysteria" and epilepsy, the procedures fell rapidly into disfavour. Although the latter operation continued to be performed in the US until the 1950s, it had disappeared from the English surgical repertoire by the end of the nineteenth century. Moscucci's findings have been confirmed and amplified by the meticulous research of Frederick Hodges (1997, 1999), whose account of the rise of routine circumcision in the US appears to have been published too late for Gollaher to take full advantage of it.

United States of America

Gollaher shows that the history of routine circumcision in the US begins with Dr Lewis A. Sayre, a distinguished orthopaedic surgeon, who discovered in 1870 that a wide range of childhood illnesses was apparently caused by a tight foreskin and could be cured by circumcision. He performed this operation on a number of boys suffering from various forms of paralysis of the legs, all of whom were restored to health, and the future of the treatment was assured. What was the physiological basis for this miracle? Working with the nerve force theory of disease then current (which held that disease was caused by imbalances in the body's nervous forces), Sayre hypothesised that "peripheral irritation" from the foreskin could produce "an insanity of the muscles" which would then act on their own accord, without direction from the brain. As he wrote in 1870:

Many of the cases of irritable children, with restless sleep, and bad digestion, which are often attributed to worms, is [sic] solely due to the irritation of the nervous system caused by an adherent or constricted prepuce. ... Hernia and inflammation of the bladder can also be produced by the severe straining to pass water in some of these cases.

Sayre eventually consolidated his convictions in a book entitled On the deleterious results of a narrow prepuce and preputial adhesions, published in Philadelphia in 1888.

Other doctors were quick to take up Sayre's findings and push them further. Soon adherent prepuces were being discovered all over the country and their removal alleviating the symptoms of numerous childhood complaints; one doctor reported a case of "brass poisoning completely cured". Dr Norman Chapman, a disciple of Sayre, suggested that the incidence of adhesive foreskins, while it had never been calculated, was probably higher than people realised. Since "a long and contracted foreskin" was so often a source of "secondary complications", he went on to propose that it was "always good surgery to correct this deformity ... as a precautionary measure, even though no symptoms have as yet presented themselves". Chapman suggested in 1882 that Christians had much to learn from Jews in this respect:

Moses was a good sanitarian, and if circumcision was more generally practised at the present day, I believe that we would hear far less of the pollutions and indiscretions of youth; and that our daily papers would not be so profusely flooded with all kinds of cures for loss of manhood.

Thus the preventive career of the operation was launched. As Gollaher observes, this declaration represents an important transition in thought: circumcision becomes not just a treatment for existing problems, but an anticipation designed to prevent possible "complications" in the future. The road to routine infant circumcision was now open.

These medical arguments for circumcision soon meshed with the fear of seminal loss, the taboo against masturbation and the desire to minimise sexual activity more generally. The same doctor who could not explain why circumcision cured brass poisoning nonetheless resolved in 1882 that

whether it be curative or not it is conservative, and removes one source of irritation from an exquisitely sensitive organ. I would favour circumcision, however, independent of existing disease, as a sanitary precaution. ... (1) The exposure of the glans to friction etc. hardens it, and renders it less liable to abrasion in sexual intercourse, and consequently venereal ulcer. (2) It is acknowledged to be useful as a preventive of masturbation. (3) It certainly renders the accident of phymosis and paraphymosis impossible. (4) It prevents the retention of sebaceous secretion and consequent balanitis. (5) It probably promotes continence by diminishing the pruriency of the sexual appetite.

Masturbation continued to be regarded as the cause of a whole raft of physical and mental diseases, but now it was seen as an intermediate link in a chain of cause and effect which originated with the foreskin. The demonisation of this part of the body was completed by Dr Peter Charles Remondino, an ardent crusader for circumcision who spent many years collecting information for a rambling tome published as History of circumcision from the earliest times to the present: Moral reasons for its performance in 1891. As its title suggests, this book was less a history of circumcision than an argument for its universal application, and the main reason for doing it was to escape the "malign influence" of the foreskin:

it can reach from afar the object of its malignity, striking him down unawares in the most unaccountable manner; making him a victim to all manner of ills, sufferings and tribulations; unfitting him for marriage or the cares of business; making him miserable and an object of continual scolding and punishment in childhood, through its worriments and nocturnal enuresis; later on, beginning to affect him with all kinds of physical distortions and ailments, nocturnal pollutions, and other conditions calculated to weaken him physically, mentally, and morally; to land him, perchance, in jail or even in a lunatic asylum. Man's whole life is subject to the capricious dispensations and whims of this Job's-comforts-dispensing enemy of man.

The horrific consequences of masturbation are now ascribed to the mere possession of a foreskin.

The masturbation phobia

Gollaher recognises the importance of their determination to prevent masturbation in doctors' efforts to introduce widespread circumcision, but he is imprecise as to the chronology and does not seem to appreciate that it was their prior conviction that masturbation was harmful which inspired them to seek the aetiology of common diseases in the condition of boys' genitals. He places the masturbation issue after the work of Sayre (1870s) and the hygiene fad which followed the discovery of germs (1890s onwards), but the masturbation grand peur goes back to eighteenth century: to the anonymous Onania, or the heinous sin of self pollution (c. 1716), and Simon-Andre Tissot's Onanism, or a treatise on the disorders produced by masturbation (1758), from which nearly all the 19th century's invective against the practice can be sourced: Tissot was still being quoted as an authority by English doctors (such as William Acton) in the 1860s. The proposition that circumcision could be used to discourage, prevent or even cure masturbation emerged in Britain in the 1850s: the aim, in Dr D. Yellowlees' later words, was "so to fix the prepuce that erection becomes painful and erotic impulses very unwelcome"; his recommendation was the insertion of two safety-pins through the foreskin, with the result that "erection causes a painful dragging on the pins, and masturbation is effectually prevented" (Yellowlees 1892, p. 785).

Other physicians recommended mechanical restraints and other chastity devices, vasectomy, cauterisation of the urethra, insertion of electrodes into the bladder or rectum, puncturing the prostate with needles, blistering the penis with caustic liquids and even castration. If rarely carried out (though it was not unusual in the US, particularly in mental hospitals and orphanages) the last of these options was regularly recommended: (Sir) Jonathan Hutchinson, president of the Royal College of Surgeons, made his own views plain in a paper called, "On circumcision as a preventive of masturbation", but he would have gone further in chronic cases: "measures more radical than circumcision would, if public opinion permitted their adoption, be a true kindness to many patients" (Hutchinson 1890, pp. 267-9).

The problem with infibulation and mechanical restraints was that they were only temporary and relied too much on the cooperation of the patient; circumcision was more effective because it was permanent, irreversible and could be accomplished not merely without the patient's consent, but, given determined parents, against his active opposition. Gollaher recognises the puritanism and indeed the sadism of many doctors from this period, but he does not relate masturbation to the wider problem of spermatorrhoea, an imaginary disease which designated any loss of semen other than in intercourse with one's wife as pathological, and of which masturbation was held to be the most important cause. The deepest origins of routine circumcision lie in the extraordinary mental gymnastics by which normal male sexuality -- the production and emission of sperm -- was categorised as a life-threatening disease.

Rise of the medical profession

Gollaher is particularly revealing on the social and cultural pressures to which doctors were subject. He shows that they were not detached scientific observers, but professionals who delivered a service in return for a fee. They complained that their quack rivals, in the days before the profession secured a legislative monopoly over health provision, stirred up people's fears about genital disorders in order to sell them patent medicines, but notes that the doctors did much the same thing: projecting lurid scenarios of the disasters which would befall a child in later life unless they were paid to remove his foreskin in infancy. What emerges clearly from the book is how much opposition there has always been to the procedure from those whom it is meant to benefit. The much-reprinted Egyptian bas-relief of the operation shows a boy being restrained while it is done; many Jewish youths at the end of the ancient era tried to cover their semi-denuded glans in order to compete in the Greek athletics arenas, thus provoking the rabbis into making the operation more severe; and today there is a thriving medical industry in foreskin restoration.

Despite their enthusiasm for the vast health benefits of circumcision, doctors at the end of the nineteenth century were unable to convince more than a few adult men to undergo the procedure; many who had agreed to have it done backed out at the last minute. But doctors were able to persuade parents to let them amputate part of their babies' penis: as Gollaher sums up, "The ultimate popularity of circumcision depended not on convincing normal men to undergo the ordeal of surgery, but on targeting a group of patients who could not object" (p. 100). The analogy with vaccination, so popular among the diminishing band of circumcision advocates today, came into vogue at that time, as did the practice of strapping the baby down so that the operation could be performed without an anaesthetic.

What emerges from Gollaher's analysis is that the operation was less about health than power: priests over laymen, parents over children, doctors over parents, the collective over the individual: "Circumcision became a token of the medicalization of childbirth [and] a symbol of the rising authority of the medical profession over the laity", he writes (p. 108). He also shows that doctors knew little about biology (and almost nothing about the anatomy and physiology of the penis), were heavily influenced by their moral and religious beliefs, and had an opportunistic attitude to scientific evidence, citing only those texts which confirmed the validity of positions already held. They embraced circumcision as a miracle-working cure-all with much the same thoughtless enthusiasm which greeted Thalidomide in the 1960s, and often with equally tragic results: until surgical techniques were refined and aseptic conditions achieved, the incidence of complications (bleeding, gangrene, transmission of such serous diseases as syphilis, tuberculosis and tetanus, loss of the glans and shaft, meatal stenosis and ulcers) was high, and as late as the 1940s some 16 children a year in Britain died as a direct result of the operation (Gairdner 1949). It has never been proved that routine circumcision has saved a single life, but it is an undeniable fact that the operation has killed thousands and injured many more. In primitive conditions the toll is higher: only recently it was reported that 35 South African boys had died as a result of "bush" circumcisions carried out as part of their tribal initiation and several hundred had been hospitalised with "horribly injured genitals" (New York Times, 6 August 2001, p. A6).

Female circumcision

The chapter on the circumcision of women will come as a revelation to those who deplore this practice as female genital mutilation but see no objection to the equivalent operation on boys. Gollaher points out that in tribal societies FGM has the same cultural significance as the circumcision of boys and that its advocates today justify it with a similar medical rationale: according to Islamic doctors, the health benefits include reduced sexual desire, lower risk of vaginal cancer and AIDS, less nervous anxiety, fewer infections "from microbes gathering under the hood of the clitoris" and protection against herpes and genital ulcers (pp. 193, 195, 199). More objective observers point out that proven sequelae include clitoral cysts, labial adhesions, urinary tract infections, kidney dysfunction, sterility and loss of sexual feeling, but the advocates are claiming no more than what supporters of the operation for boys have been asserting for decades. Given the similarity in anatomy between the structures in question, it is likely that what is true for one sex will be true for the other.

Why western agencies like the United Nations have designated female circumcision as an atrocity which must be stopped while ignoring the comparable operation on boys is an interesting question, and not one which Gollaher answers fully, though he is consistently perceptive and enlightening on this issue. The answer must lie mainly in the fact that millennia of Semitic custom and a century of routine male circumcision in English-speaking countries have desensitised us into seeing the procedure as mild and the result as normal; although doctors in the US performed a variety of operations on female genitals to cure nervous and other complaints until well into the 1950s, the practice never became routine, as it did with boys, with the result that it now seems outlandish and cruel. In the nineteenth century masturbation in girls was condemned as vigorously as in boys, and various genital surgeries were often recommended (and sometimes performed) as treatment; but by the 1890s, as Dr Yellowlees reluctantly concluded, they had been found "ineffectual and unsatisfactory".

Supporters of female circumcision in the cultures which still practise it are quick to identify the double standard at work here, pointing out that "American parents circumcise their newborns so that the sons will look like the fathers .... What, they ask, gives Americans the right to apply a different standard to African women" (p. 200)? The stance of the American Academy of Paediatrics on female circumcision -- a form of genital mutilation which members should actively discourage -- contrasts with its equivocating disapproval of the equivalent procedure on boys, even though it regards each as equally irrelevant to health (pp. 172-3, 200).

Some weaknesses

Although a significant contribution to medical and social history, Gollaher's study is not without its faults. The chapters on circumcision in its Jewish and Islamic contexts are not as deeply researched as those on the US experience, and he sometimes uses secondary materials as the source for basic religious texts when it would be better to cite scholarly editions of the originals. He does not explore the dialectic by which by which Jewish ritual circumcision and modern medical practice have been reinforcing each other since the late nineteenth century, nor the way in which Jewish religious leaders have cited modern medical practice as a weapon against reformers in their own community. In the mid-nineteenth century many modernising German Jews were keen to abolish circumcision along with various other anachronistic ritual observances, such as the doctrine of the uncleanness of women, only to be defeated by a strange coalition of conservative rabbis and progressive doctors who wanted to ensure that the operation was done in hygienic conditions. In Britain the increasing acceptance  of circumcision was a significant factor in the decline of anti-semitism, and doctors looked to Jews for instruction in how to carry out the procedure.

Nor does Gollaher examine the reasons why so many of the keenest advocates of universal circumcision have themselves been doctors with a Jewish background: from M.J. Moses and Abraham Wolbarst at the turn of the century to Edgar Schoen and Aaron Fink in recent times, many of the most eloquent and determined supporters of circumcision for all boys have themselves been Jews. It is impossible not to wonder whether their enthusiasm for circumcision is less an effect of their medical training than of their being brought up in a system of religious belief which teaches that the foreskin is "more unclean than all unclean things ... a blemish above all blemishes" and that "all who bathe with the uncircumcised are as though they bathed with carrion", as a Midrash text of the second century put it (cited in Glick 2001). Thomas Szasz has emphasised the religious origins of both the masturbation phobia and the vilification of the foreskin as physically and morally dirty. Just as the claim that masturbation caused organic disease was  a medicalisation of the old Judaeo-Christian prohibition on non-procreative sex, so the demonisation of the foreskin as itself a source of disease was little more than a medicalisation of the ancient Judaic taboo against it as one of many natural phenomena classified as spiritually unclean in that culture's religious schema (Szasz 1996). The contemporary confusion of circumcision with physical hygiene arises from this source.

Finally, Gollaher makes a serious historical error on the English "Jew Bill" of 1753, which he describes as targeting circumcision and mohels with special restrictions (p. 28). In fact the legislation had the opposite intent, which was to allow Jews who had lived in Britain for three years to become naturalised citizens without having to join the Church of England, thus giving them more opportunity to engage in commerce -- a progressive reform for the period. What made the bill (passed as the Jewish Naturalisation Act) "notorious" was the opposition it generated among the public, who launched such a vigorous campaign that it was eventually repealed. What is interesting about the pamphleteers etc is that they made circumcision central to their polemic and warned of a supposed Jewish plan to circumcise the entire male population if the bill became law; men were urged to protect "the best of Your property" and guard their threatened foreskins. It was an extraordinary outpouring of popular beliefs about sex, fears about masculinity and misconceptions about Jews, but also a striking indication of how central to their sexual identity men considered their foreskins at that time (Wolper 1982).

Conclusion

Circumcision: A history of the world's most controversial surgery is valuable not only as a study of circumcision; it is a useful text for students of medical, cultural and social history, religious studies, anthropology and the history and philosophy of science, in which connection its insights into the cultural bias in medical research and publication policy are particularly instructive. Gollaher has shone a bright light into a dark corner of medical history and made it possible to talk reasonably about a highly emotional subject which is still usually approached with an awkward silence or an embarrassed titter. He writes with admirable detachment on a subject which arouses violent passions, displaying coolness to towards anti-circumcision activists but an equal scepticism towards the claims of its advocates, whose medical arguments he finds wanting in rigour, logic and ethics and, despite more than a century of effort, quite inconclusive. He demonstrates that circumcision is a culturally determined practice which, in the Anglophone world, acquired a thick veneer of medical rationalisation. In time the operation will probably come to be seen as yet another deluded fad, along with bleeding, the water cure, electro-convulsive therapy and frontal lobotomies, an innovation for which Egas Moniz once received a Nobel Prize. These days the practitioners of infant circumcision are more likely to face claims for damages in a court of law than the plaudits of the Swedish Academy.

REFERENCES

Dunsmuir, W.D. and E. M. Gordon, "The history of circumcision", British Journal of Urology, Vol. 83, Supplement 1 (Circumcision), 1999, pp. 1-12

Gairdner, Douglas (1949), "The fate of the foreskin: A study of circumcision", British Medical Journal, Vol. 2, 24 December, pp. 1433-1437

Glick, Leonard (2001), "Jewish circumcision: An enigma in historical perspective", in Marilyn Milos, George C. Denniston and Frederick Hodges (eds), Understanding circumcision: A multi-disciplinary approach to a multi-dimensional problem, London and New York, Kluwer Academic and Plenum Press

Hodges, Frederick (1997), "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

Hodges, Frederick (1999), "The history of phimosis from antiquity to the present", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, London and New York, Kluwer Academic and Plenum Press

Hutchinson, Jonathan (1890), "On circumcision as a preventive of masturbation", Archives of surgery, Vol. II, pp. 267-9

Hyam, Ronald (1990), Empire and sexuality: The British experience, Manchester University Press

Lewis, Joseph (1949), In the name of humanity, New York, Freethought Press

Moscucci, Ornella (1996), "Clitoridectomy, circumcision and the politics of sexual pleasure in mid-Victorian Britain", in Andrew H. Miller and James Eli Adams ed., Sexualities in Victorian Britain, Bloomington, Indiana University Press

Romberg, Rosemary (1985), Circumcision: The painful dilemma, South Hadley, Mass., Bergin and Garvey Publishers

Szasz, Thomas (1996), "Routine neonatal circumcision: Symbol of the birth of the therapeutic state", Journal of Medicine and Philosophy, Vol. 21, pp. 137-48

Wallerstein, Edward (1980), Circumcision: An American health fallacy, New York, Springer

Wolper, Roy (1982), "Circumcision as polemic in the Jew Bill of 1753: The cutter cut", Eighteenth century life, Vol. 7, pp. 28-36

Yellowlees, D. (1892), "Masturbation", in A dictionary of psychological medicine, ed. D. Hack Tuke, London, Churchill, pp. 784-6