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The Sexual and Psychological Consequences of Infant Circumcision

Executive Director, Intact, Toronto, Ontario, Canada.

Introduction

Since infant circumcision became widespread in North America for what were thought to be medical reasons, the debate over the advantages and disadvantages of the procedure has focused on surgical risks and supposed prophylactic medical benefits. With this pseudo-medical argument of the mid 1900s came the assertion that circumcision had no effect on the sex life of the adult, though there has never been any evidence to support this claim. North American medical schools often teach nothing of the foreskin—perhaps the only disregarded tissue on the human body. The evidence that circumcision causes damage has often been ignored, minimized, or ridiculed, both by the medical profession and the general public. However, even a casual glance at the literature on the subject points to a large body of evidence of significant harm.

Sexual Consequences of Circumcision

Contrary to what is popularly conceived today, circumcision had long been known to be desensitizing to the penis. In fact, in North America, one 19th century rationale for circumcising both males and females was to decrease the sexual sensitivity of the genitals and thereby reduce the incidence of masturbation, a much vilified act thought to cause a wide variety of diseases, including insanity.[1] These excerpts from medical journals and texts of the late 1800’s illustrate this point graphically.

There can be no doubt of [masturbation’s] injurious effect, and of the proneness to practice it on the part of children with defective brains. Circumcision should always be practiced. It may be necessary to make the genitals so sore by blistering fluids that pain results from attempts to rub the parts.[2]

In consequence of circumcision the epithelial covering of the glans becomes dry, hard…the sensibility of the glans is diminished, but not sufficiently to interfere with the copulative function of the organ or to constitute an objection... It is well authenticated that the foreskin...is a fruitful cause of the habit of masturbation in children... I conclude that the foreskin is detrimental to health, and that circumcision is a wise measure of hygiene.[3]

In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement, and preventing the recurrence of the practice in those whose will-power has become so weakened that the patient is unable to exercise entire self-control.[4]

The reasons why circumcision continued to be inflicted on males but not females are not clearly understood, but I suggest that existing models of femininity, which made it easier to convince little girls not to touch their genitals, and the emergence of a pseudo-medical rationale specific to male circumcision both played a part.

Recent anatomical studies by Taylor, et al now irrefutably demonstrate the existence of special nerves in, and therefore the sexual importance of, the foreskin. Primarily, these special nerves are found in what Taylor calls the ridged band of the prepuce—not a general area but rather a very strict, anatomically distinct band.[5] This specialized skin and mucous membrane, with its specialized nerves, is anatomically very similar to the clitoral prepuce, and the special nerve bundles found there are also found in the clitoris and the clitoral prepuce, but not commonly in the glans penis.[6] In the male, the distal position of this ridged band and its narrowness is such that it is always removed in circumcision, regardless of the method used.[7]

The word "specialized" for these nerve bundles is appropriate because they are not like other sensory or "free" nerve endings found generally on the skin. These nerve clusters are found only in the juncto-cutaneous areas of the body, such as the vulva, clitoris, and clitoral prepuce, the lips, and the peri-anal area. In all cases, these nerves are responsible for erotic sensation, though generally only in the genital area do they trigger orgasm.[8]

Damage to the glans caused by circumcision has been well-documented. Such damage takes two forms:

Circumcision performed in the newborn period traumatically interrupts the natural separation of the foreskin from the glans that normally occurs somewhere between birth and age 18. The raw, exposed glans penis heals in a process that measurably thickens the surface of the glans and results in desensitization of the head of the penis. When circumcision is performed after the normal separation of the foreskin from the glans, the damage done by forcible separation of these two parts of the penis is avoided, but the glans must still thicken in order to protect itself from constant chafing and abrasion by clothing.[9]

Zdenek observes that "rete ridges of the epidermis are irregular and vary in height depending on location, age, and presence or absence of a foreskin."[10]

The sexual damage caused by circumcision also affects the sexual partner of the circumcised man. Because the natural lubrication of the skin sheath is lost, abrasion and trauma to the female sexual partner is increased.[11][12] This would presumably also affect a male sexual partner.

That these differences result in altered sexual behaviour in the adult has also been documented. Laumann et al showed that circumcised men needed to resort to a wider variety of sexual practices in order to achieve orgasm.[13]

Impotence and loss of sensitivity has been linked to adult circumcision,[14] and increased sexual dysfunction after circumcision is supported by animal studies of both bulls[15] and rats.[16] Human infant circumcision would not be supposed to have a similar result if there were some mechanism by which nerves lost in infancy could regrow in childhood. Such effects are sometimes found in the case of infant brain lesion where normal function can be regained if the damage is done before a threshold age. In the case of circumcision, however, the nerves do not regrow, probably because the mucosa needed to support the specialized nerve endings has been excised. Cold has found that infant circumcision results in amputation neuromas, an indication that the sensitivity of the severed nerves is not regained.[17]

Psychological Consequences of Circumcision

There is little consensus in the field of psychology save that behaviour is mediated through the central nervous system,[18] and that early childhood trauma affects adult behaviour. By trauma we generally mean either ‘wound’ (in the field of medicine) or ‘emotional shock’ (in the field of psychology). Since a wound caused by circumcision would be presupposed to cause pain in the absence of anesthetic, and pain is a primary cause of emotional shock, we can see that circumcision results in both types of trauma.

There are still those who doubt the physical pain of circumcision, and by extension any psychological effects. This school of thought either maintains the insensitivity of the foreskin, which I have already dealt with, or the inability of the infant nervous system to perceive or process pain. While there has never been any evidence whatsoever to support either hypothesis, the myth continues. I suggest that many such people have never actually witnessed a circumcision as it is commonly performed in hospitals and clinics today, which is still, in the majority of cases, done without any anesthetic. Moreover, any discussion of North American men must take into account that anesthetic for circumcision is a relatively new idea, and that any contemporary men who were circumcised at birth were almost certainly not given any pain relief whatsoever.

A. Early Effects

Rather than there being good scientific evidence that infants do not feel pain, the contrary is the case. Neonatal infant responses to pain are "similar to but greater than those in adult subjects,"[19] and investigators have reported that the level of pain of circumcision is "among the most painful performed in neonatal medicine"[20] and "would not be tolerated by older patients."[21]

That such pain affects infant behaviour should hardly be surprising. Richards presents "both circumstantial and direct evidence that circumcision of male infants leads to behavioral changes."[22] The circumcision status of babies in American studies is rarely, if ever, corrected for as a factor in demonstrating behaviour differences between male and female infants, such as sensory thresholds or sensitivity to sensory stimuli, and preference for sweet substances. In fact, in examining studies that show gender differences between male and female infants, Richards points out that "in some American studies using circumcised infants, reported gender differences may instead be the result of the altered behavior of circumcised males."[23]

Another immediate effect of circumcision is that infants feed less frequently. In particular, circumcision led to a decrease in postoperative breastfeeding. Howard concluded that, after circumcision,

the observed deterioration in ability to breast-feed may potentially contribute to breast feeding failure. Furthermore some neonates in this study required formula supplementation because of maternal frustration with attempts at breast-feeding, or because the neonate was judged unable to breast-feed postoperatively. This finding is disconcerting because early formula supplementation is associated with decreased breast-feeding duration.[24]

Other studies which demonstrate the effects of circumcision on infant behavior point out the alteration of sleep patterns[25] and psychophysiology.[26] Citing Dobbing, Richards points out that "the human brain is particularly vulnerable to exogenous and endogenous influences during the period of its maximum growth rate, from the latter part of pregnancy until approximately 18 months postnatal."[27]

B. Long-term Effects

Those that admit that the procedure causes pain, but dismiss the long-term negative effects of circumcision often theorize that because the adult cannot remember the event, there can be little or no long-term psychological effects. This theory is in direct conflict with established psychological thought, which maintains that unremembered trauma may actually have the greater effect. If such a theory were to be applied elsewhere, we would maintain that a child sexually molested at an age so young that it can not be consciously remembered as an adult would suffer no ill effects from the experience.

On the contrary, there is considerable evidence that demonstrates that the effects of circumcision are not short-lived. Immerman proposes that circumcision not only affects localized nerves, but also causes permanent cortical reorganization in the brain. These changes in the brain not only affect the areas responsible for sensation in the (now) excised foreskin, but also the emotional centre of the brain related to adult sexuality. Such changes in the brain must be aligned with changes in behaviour, and "the earlier in the male’s life the circumcision occurs, the more impact the ablation would be expected to have on his nervous system, and hence, his behavioural tendencies." Specifically, Immerman concludes that circumcision "would be expected to affect the overall sexual behaviour of that individual…to lower excitability or raise the threshold of sexual arousal," and refers to circumcision as "low-grade neurological castration."[28]

Richards agrees that the neurological impact of circumcision is long-term, pointing out that

in view of all the evidence showing long-term behavioral, physiological, anatomical, and even neuropharmacological effects of ‘minor’ events on early animal development (e.g., Levine,1969), we would be unwise to assume without empirical demonstration that the circumcision effects are short-lived.[29]

A recent study by Taddio demonstrates that neonatal circumcision increases the perception of pain in four-month-old children during inoculation. The study found that postoperative anesthetic did not reduce this effect.[30]

In addition to changes in sexual behaviour, circumcision has been proposed to cause more disturbing changes to adult male psychology. Goldman finds that the effects of infant circumcision on the adult "appear to be consistent with the symptom pattern of post-traumatic stress disorder [PTSD]."[31] This observation is supported by Rinehart, who found that the circumcision-related symptoms of his patients were "no different from the experience of rape victims, combat veterans,… [and]…female circumcision victims."[32] The symptoms of PTSD include avoidance of the topic and emotional numbing,[33] which may explain why many men do not complain about their circumcision. Other symptoms of PTSD include recurrent thoughts and dreams about the trauma, feelings of powerlessness, inappropriate anger, and extreme forms of panic, rage, and violence.

Van der Kolk finds that victims of violence have a compulsion to repeat the trauma, either as victimizer, or again as victim, and that those victimized as children are more vulnerable to this compulsion than adults.[34] This may explain why, even in the absence of medical need and with foreknowledge of the damage of circumcision, many fathers elect to have their sons circumcised. It may also explain why North American, Australian, and, to a lesser degree, British doctors with similar foreknowledge continue to do this surgery on unconsenting minors in the absence of medical indications or benefit.^* Perhaps more alarming is the effect that repetition compulsion has on society in general. Van Der Kolk notes that "re-enactment of victimization is a major cause of violence… [and that] …criminals have often been physically or sexually abused as children."[35]

[* In the countries in which circumcision is commonly performed by doctors (Australia, Britain, Canada, and the U.S.A.), it is unique in this regard-there is no other surgery performed on minors for the sole reason of parental preference. Moreover, in these countries doctors who perform circumcisions are also unique-no other practitioner (tattoo artist, body piercer, etc.) would be allowed to permanently alter the body of a minor, even if the consent of the minor was given.]

Conclusion

There is little doubt that both the adult man’s sexual sensitivity and his partner’s comfort are diminished by infant circumcision. What is less recognized by most lay people is the possibility that circumcision may lead to an increase in violent behaviour. Goldman writes that "whatever affects us psychologically also affects us socially."[36] It seems self-evident that, a baby should be as free from pain as possible for normal neurological, and, therefore, psychological, development. It also seems self-evident that in order for a man to have a normal sex life, his penis should be intact.

Currently, both the professional and the public debate surrounding the propriety of infant circumcision requires a more thorough understanding of the sexual, psychological, human rights, legal and ethical consequences of this procedure. Moreover, if the culture-wide denial of the effects of circumcision is to be overcome, public awareness of the available scientific data must be increased.

Further Reading

Alice Miller discusses the effects of early child abuse and trauma on later violent and self-destructive behaviour. Alice Miller is a Swiss psychoanalyst. Her books include The Drama of the Gifted Child: The Search for the True Self, Thou Shalt Not Be Aware: Society's Betrayal of the Child, Banished Knowledge: Facing Childhood Injuries, and For Your Own Good: Hidden Cruelty in Child-rearing and Roots of Violence, The Untouched Key: Tracing Childhood Trauma in Creativity and Destructiveness.] Anchor Books (Doubleday) New York.

Krupnick J, Horowitz M. Stress response syndromes. Arch Gen Psychiatry 1981; 38: 428-35

Visit the Circumcision Information Resource Page at www.cirp.org. This the only Circumcision-related site listed in the British Medical Journal.

 

Endnotes

1. Ralph A. Goodner, MD, "The Relation of Masturbation to Insanity, with Report of Cases," Medical News 1897.
2. Angel Money. Treatment Of Disease In Children. Philadelphia: P. Blakiston. 1887.
3. Jefferson C. Crossland, MD, "The Hygiene of Circumcision," New York Medical Journal, 1891.
4. John Harvey Kellogg, MD. "Treatment for Self-Abuse and Its Effects," Plain Facts for Old and Young. Burlington, Iowa: F. Segner & Co. 1888.
5. The prepuce: specialized mucosa of the penis and its loss to circumcision. Taylor, J. R., Lockwood, and Taylor, A. J. British Journal of Urology (1996), 77, 291-295.
6. Anatomy and Histology of the Penile and Clitoral Prepuce in Primates. Cold, C. J. and McGrath, K. A. Male and Female Circumcision, Denniston et al, eds. Kluwer Academic/Plenum Publishers, New York, 1999.
7. Interview with John Taylor, Anatomic Pathologist, Department of Pathology, Health Sciences Centre, University of Manitoba, Winnipeg Manitoba, Canada on www.intact.ca/taylor.html, 1998.
8. Interview with Christopher Cold, Anatomic and Clinical Pathologist, Marshfield Clinic, Marshfield, Wisconsin, U.S.A.
9. Human Sexuality: an Encyclopedia edited by Vern L. Bullough and Bonnie Bullough New York: Garland Pub., 1994. p. 119-122.
10. Zdenek, H and Munger, B. L. The Neuroanatomical Basis for the Protopathic Sensibility of the Human Glans Penis. Anatomisches Intitut der Univesität Hamburg, Abteilung für Funktionelle Anatomie, Hamburg (F. R. G.) and Department of Anatomy, The Pennsylvania State University, College of Medicine, The Milton S. Hershey Medical Center, Hershey PA 17033 (U.S.A.) (Accepted June 18th, 1985).
11. Human Sexuality: an Encyclopedia edited by Vern L. Bullough and Bonnie Bullough New York: Garland Pub., 1994. p. 119-122.
12. O'Hara, K., and O'Hara, J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU International, Volume 83, Supplement 1, Pages 79-84, January 1, 1999.
13. Laumann, E. O., Masi, C. M., Zuckerman, E. W. Circumcision in the United States. Journal of the American Medical Association, Vol. 277 No. 13, Pages 1052-1057. April 2, 1997.
14. Stinson J. Impotence and adult circumcision. J Nat Med Assoc1973; 65: 161.
15. Desrochers A, St. Jean G., Anderson D. E. Surgical management of preputial injuries in bulls: 51 cases (1986-1994). Can Vet J 1995;36:553-6.
16. Lumina A. R., Sachs B. D., Meisel R. L. Sexual reflexes in male rats: restoration by ejaculation following suppression by penile sheath removal. Physiol Behavior 1979;23:273-7.
17. Interview with Christopher Cold, Anatomic and Clinical Pathologist, Marshfield Clinic, Marshfield, Wisconsin, U.S.A.
18. Immerman, R. S. and Mackey, W. C. A Proposed Relationship Between Circumcision and Neural Reorganization. Journal of Genetic Psychology, Vol. 159, No. 3, pp. 367-378, September, 1998.
19. Hickey, A. K. Pain and its effects in the human neonate and fetus. New Eng J Med 1987: 317: 1321-9.
20. Ryan, C. and Finer, N Changing attitudes and practices regarding local anesthesia for newborn circumcision. Pediatrics 1994; 94:232.
21. Williamson P and Williamson M Psysiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics 1983: 71: 40.
22. Richards, M. P. M., Bernal. Early Behavioral Differences: Gender or Circumcision? Developmental Psychobiology, Vol. 9, No. 1, (January 1976): Pages 89-95.
23. Richards, M. P. M., Bernal. Early Behavioral Differences: Gender or Circumcision? Developmental Psychobiology, Vol. 9, No. 1, (January 1976): Pages 89-95.
24. Howard, C. R., Howard, F. M., and Weitzman, M. L. Acetaminophen Analgesia in Neonatal Circumcision: the Effect on Pain. Pediatrics, Volume 93 Number 4: Pages 641-646. April 1994.
25. Marshall, R. E., Stratton, W. C., Moore, J. and Boxerman, S. B. Circumcision I: Effects Upon Newborn Behavior. Infant Behavior and Development. 1980, Volume 3: Pages 1-14.
26. Richards, M. P. M., Bernal. Early Behavioral Differences: Gender or Circumcision? Developmental Psychobiology, Vol. 9, No. 1, (January 1976): Pages 89-95.
27. Marshall, R. E., Stratton, W. C., Moore, J. and Boxerman, S. B. Circumcision I: Effects Upon Newborn Behavior. Infant Behavior and Development. 1980, Volume 3: Pages 1-14.
28. Immerman, R. S. and Mackey, W. C. A Proposed Relationship Between Circumcision and Neural Reorganization. Journal of Genetic Psychology, Vol. 159, No. 3, pp. 367-378, September, 1998.
29. Richards, M. P. M., Bernal. Early Behavioral Differences: Gender or Circumcision? Developmental Psychobiology, Vol. 9, No. 1, (January 1976): Pages 89-95.
30. Taddio, A, Katz, J. Ilersich, A. L., Koren, G. Effect of Neonatal Circumcision on Pain Response During Subsequent Routine Vaccination. The Lancet, Vol. 349: Pages 599-603 (March 1, 1997).
31. Goldman R. Circumcision - The Hidden Trauma:How an American Cultural Practice Affects Infants & Ultimately Us All. Boston: Vanguard Publications, 1997:134.
32. Rhinehart, J. Neonatal Circumcision Reconsidered. Transactional Analysis Journal, Volume 29, Number 3, Pages 215-221, July 1999.
33. Goldman, R. The psychological impact of circumcision. BJU International, Volume 83 Supplement 1, Pages 93-102, January 1, 1999.
34. van der Kolk, B. A. The Compulsion to Repeat the Trauma: Re-enactment, Revictimization, and Masochism. Psychiatric Clinics of North America, Volume 12, Number 2, Pages 389-411, June 1989.
35. van der Kolk, B. A. The Compulsion to Repeat the Trauma: Re-enactment, Revictimization, and Masochism. Psychiatric Clinics of North America, Volume 12, Number 2, Pages 389-411, June 1989.
36. Goldman, R. The psychological impact of circumcision. BJU International, Volume 83 Supplement 1, Pages 93-102, January 1, 1999.

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