The following letter from Dr V. Raveenthiran in the Journal of Pediatric Surgery replies to the speculations of a certain Steven Moreton on the supposed “hygienic” or “health” origins of non-therapeutic circumcision.

Dr. Moreton has placed many contentious arguments regarding circumcision. I agree with him that tracing the origins of this ancient procedure is not an easy task; however, the exercise is not completely irrelevant to modern medical practice. Circumcision is the only surgical operation that is either passionately patronized or vehemently condemned — not only by laity but also by medical practitioners [1]. Influence of lobbying groups is such that even the medical literature is more often distorted [2] as it is evident from frequent reversal of policy recommendations by professional bodies such as American Academy of Pediatrics [3]. Dichotomized circumcision politics, which potentially affects millions of children, can be better understood only by studying its historical evolution.

Historically several hypotheses have been proposed regarding the origins and purpose of circumcision [1,4–8]. They include: (1) Religious sacrifice in fulfillment of the covenant with God; (2) Tribal rite of passage into adulthood; (3) Demonstration of leadership qualities such as courage and endurance of pain which are prerequisite of being elected as chieftains; (4) Deterrent of premature indulgence into procreative life; (5) Superstitious act of ensuring or enhancing virility and fertility; (6) Measure of personal hygiene in xeric environments; (7) Symbol of social status (paradoxically both nobility and slavery); (8) Symbolic emasculation – either humiliating or punitive – of war prisoners and slaves; (9) Mark of clan identification especially during exodus and riots; (10) Aesthetic procedure to enhance men's sexual attractiveness; (11) Imitation of a leader's malformation (aposthia) by his followers; (12) Modifier of sexual pleasure (paradoxically both enhancer and suppressor); (13) Dissuader of masturbation and sexual perversions; (14) Magical repellent of demons that were believed to dwell in preputial sac; (15) Castration substitute employed by jealous fathers to discourage sons from having incestuous affair with mothers; (16) Indigenous technique of creating gender awareness and masculine identity; (17) Superstitious act of separating males from androgynous child and (18) Method of oath taking by men enrolled to guard a particular primitive society.

To the aforementioned long list, Moreton adds “his own theory” of ‘prophylactic origins of circumcision’. It is nothing new but a plagiarized version of an archaic concept that was originally expressed by Herodotus when he first saw circumcised Egyptians in circa 450 BCE. Since then this speculation has been repeated in many avatars — the latest of which claims that circumcision was originally intended to avoid irritation of desert sand accumulating underneath the foreskin [9]. However, Darby exposed the fallacies of hygiene theory and firmly laid it to rest [10,11].

Rhetoric on protective health benefits of circumcision has only camouflaged over time to match unconquered diseases of the given era. For example in late 19th century, when infectious and neurological diseases were poorly understood, Merrill Ricketts claimed circumcision to prevent or cure paralysis, neurasthenia, eczema, elephantiasis, tuberculosis, enuresis, impotence, epilepsy, hysteria and even acne [1,12,13].

Although all of them are now disproved, devotees of circumcision have not abandoned the worship; but simply moved on to build newer altars. They now claim circumcision to be preventive of penile cancer, sexually transmitted infections including HIV, cervical carcinoma, and urinary tract infection. Surprisingly, these misleading claims are often included in medical textbooks. It is now emerging that evidences for these claims are scant, invalid, weak and distorted [1–3]. As we snigger today at the impossible list of Merrill Ricketts, so will our successors chuckle at contemporary claims of hygiene and prophylaxis. From Merrill Ricketts to Moreton, misconception of foreskin hygiene is perpetuated by the dogma wherein the smegma is vilified as an irritant. It defies logic as to how a physiological secretion of body can be harmful [1]. Myths surrounding smegma have long been dispelled [14] and hence Moreton is trying to resurrect a buried lie.

Moreton got his anthropological lessons wrong when he stated that this operation must have been adopted by primitive men on seeing the health benefits enjoyed by an occasional child born without prepuce (aposthia). It is widely acknowledged that primitive societies did not consider malformed children as human beings. Even minor anomalies were considered a bad omen and such babies were either killed or allowed to die by abandoning in wilderness [15]. Therefore a child born with aposthia in prehistoric times was unlikely to have survived long enough to demonstrate the benefits of preputial absence.

I maintained that prehistoric men of paleolithic era were unlikely to have inflicted self-injuries as it would have been a survival disadvantage. I also cited Taves’ experiment wherein circumcision was hypothesized to increase glans friction during intromission. Moreton refutes both these assertions by citing tribal rituals and clinical studies finding infrequent coital injuries in circumcised men. Moreton appears to have mistaken ‘prehistoric men’ for ‘tribal men’ and ‘penile intromission’ for ‘sexual intercourse’. For example, intromission is just the act of inserting the penis into the vagina while intercourse is the full range of act that culminates in orgasm (Oxford English Dictionary). Circumcision certainly makes intromission unpleasant which is why it was projected as masturbation dissuader. Sexual pleasure and coital injuries are determined not only by the status of circumcision but by many other factors such as degree of vaginal lubrication, force of pelvic thrust, coexisting diseases, genital malformations, psychological inclination of partners and coital posture. Unfortunately none of the studies cited by Moreton take all these covariables into consideration. Further, an equally good number of “robust” studies published in high impact journals indicate that coital injuries and impaired sexual pleasure are more frequent in circumcised men [16–19]. This is what I dismiss as dichotomized literature.

Moreton asks for more evidences of circumcision originating as a punishment or humiliation of war prisoners. They are plenty to fill an entire issue of the Journal of Pediatric Surgery; suffice I mention a few of them. Diodorus Siculus (circa 100 BC) in his magnum opus Bibliotheca Historica described a bas-relief seen in the Tomb of Ozymandyas (Hellenized name of Rameses II) [20]. The sculpture, probably commemorating the King's victory in the Battle of Kadesh (circa. 1274 BC), was said to depict chain-bound war prisoners registered by a royal scribe in preparation for amputation of right hand or ‘private parts’. A pile of these excised organs was also seen in the foreground [5]. A more explicit description is found in the Old Testament. Saul wanted to avenge both David and Philistines. Hatching a cleaver plan, he asked David to bring 100 foreskins of philistines as dowry to marry his daughter Michal; And David brought 200 of them and took her hands in wedlock (Samuel 18:25–27). In another story, when Shechemraped Jacob’s daughter Dinah, her enraged brothers deceitfully circumcised all their enemies and humiliatingly killed them while they were still recovering from the sore (Genesis 34:1–31). Forced circumcision of enemies is also well documented as late as in British India.

The theory of punitive origin of circumcision is of some practical importance. I have observed that circumcision is more often promoted and defended by those who have undergone the procedure themselves [21]. Psychologically this appears to be a phenomenon of re-enacting the shame and trauma suffered during childhood [22]. In circumcised adults, I have seen this shame being sublimated into pride at some point of life. Perplexed by this paradox I looked into the history. Now, I could see the ‘shame’ in the punishment of captured enemies and the ‘pride’ in the sacrificial rites of Osiris cult. Osiris himself being punished by emasculation and its symbolic emulation by his followers could be the connecting links between the contrasting emotions of shame and pride.

Finally, I wonder if Dr. Moreton's communication suffers from serious conflicts of interest (COI) as he is the editor and contributor of a blog ‘promoting circumcision’. Certainly, I have no prejudice in exploring and writing the history of circumcision

V. Raveenthiran Department of Pediatric Surgery, SRM Medical College, 200, Fifth Street, Viduthalai Nagar, Kovilambakkam, Chennai 600117, India

References

[1] Gollaher DL. Circumcision: a history of the world's most controversial surgery. New York: Basic Books; 2000.

[2] Boyle GJ, Hill G. Circumcision-generated emotions bias medical literature. BJU Int 2012;109:E11.

[3] Frisch M, Aigrain Y, Barauskas V, et al. Cultural bias in the AAP's 2012 technical report and policy statement on male circumcision. Pediatrics 2013;131:796–800.

[4] Friedman DM. A mind of its own: a cultural history of the penis. London: Robert Hale; 2001.

[5] Remondino PC. Theories as to the origin of circumcision. History of circumcision from the earliest times to the present. London: FA Davis; 1891. p. 28–33.

[6] Amin Ud Din M. Aposthia — a motive of circumcision origin. Iran J Public Health 2012;41:84.

[7] Charles W. Motives for male circumcision among preliterate and literate peoples. J Sex Res 1966;2:69–88.

[8] Kaicher DC, Swan KG. A cut above: circumcision as an ancient status symbol. Urology 2010;76:18–20.

[9] Hutson JM. Circumcision: a surgeon's perspective. J Med Ethics 2004;30:238–40.

[10] Darby R. The riddle of the sands: circumcision, history, and myth. N Z Med J 2005; 118:U1564.

[11] Darby R. A surgical temptation: the demonization of the foreskin and the rise of circumcision in Great Britain. University of Chicago Press; 2005.

[12] Ricketts BM. The last fifty of a series of two hundred circumcisions. N Y Med J 1894; 59:431–2.

[13] Anonymous. Circumcision for the relief of acne. Hospital (Lond) 1902;31:339.

[14] Van Howe RS, Hodges FM. The carcinogenicity of smegma: debunking a myth. J Eur Acad Dermatol Venereol 2006;20:1046–54.

[15] Nun L. Neonaticide, infanticide and filicide. Israel: BN Publications; 2017.
[16] Bronselaer GA, Schober JM, Meyer-Bahlburg HF, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int 2013;111:820–7.

[17] Masood S, Patel HR, Himpson RC, et al. Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly? Urol Int 2005;75:62–6.

[18] Fink KS, Carson CC, De Vellis RF. Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol 2002; 167:2113–6.

[19] Boyle GJ. Circumcision of infants and children: short-term trauma and long-term psychosexual harm. Adv Sex Med 2015;5:22–38.

[20] Diodorus Siculus. Bibliotheca Historica (English translation); vol 1, sec 48:2.
Available from http://penelope.uchicago.edu/Thayer/E/Roman/Texts/Diodorus_Siculus/1C*.html, Accessed date: 30 September 2018.

[21] Muller AJ. To cut or not to cut? Personal factors influence primary care physicians’ position on elective circumcision. J Men's Health 2010;7:227–32.

[22] van der Kolk BA. The compulsion to repeat the trauma. Re-enactment, revictimization, and masochism. Psychiatr Clin North Am 1989;12:389–411.

Source V. Raveenthiran. Reply to letter to the Editor: Tracing the origins of circumcision. Journal of Pediatric Surgery, early view, 2018