Psychological issues of male circumcision

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Male circumcision is a surgical amputation of the foreskin, which contains more than one-half of the erogenous epithelium of the penis. The amputation most frequently carried out on infants and small boys who cannot and do not give consent for the loss of so much of their penis. There are many psychological issues of male circumcision that arise from the painful, traumatic involuntary loss of the part of the penis with the erogenous tissue that provides much sexual sensation.

History

Moses Maimonides wrote in the 12th century:

Similarly with regard to circumcision, one of the reasons for it is, in my opinion, the wish to bring about a decrease in sexual intercourse and a weakening of the organ in question, so that this activity be diminished and the organ be in as quiet a state as possible. … In fact this commandment has not been prescribed with a view to perfecting what is defective congenitally, but to perfecting what is defective morally. The bodily pain caused to that member is the real purpose of circumcision. … For if at birth this member has been made to bleed and has had its covering taken away from it, it must indubitably be weakened.[1]

So we see that circumcision has long been used to effect behavior change.

Profound lack of understanding of psychological issues

There was little awareness of emotional and psychological issues when child circumcision was being promoted in the late 19th century and early 20th century. For example, Douglas Gairdner made no mention at all of pain, behavior changes, or psychological issues in his landmark 1949 paper.[2]

Increasing awareness

David Levy (1945) reported on abnormal behavior in children who had undergone surgical operations, including circumcision, among other operations. Levy reported such emotional sequelae as:

  • Conditioned fear
  • Dependency fears and regressions.
  • Latent fear.
  • Phobias.
  • Anxiety states.
  • Hostility reactions.
  • Obsessions.
  • Hysteria.

Levy saw a relationships to what was then called combat neurosis and now known as postraumatic stress disorder (PTSD).[3]

Anna Freud, daughter and Sigmund Freud, and a pioneer child psychologist read Levy's paper. She wrote (1952):

Ever since the discovery of the castration complex analysts have had ample opportunity in their therapeutic work to study the impact of surgical operations. on normal and abnormal development. By now it is common knowledge that surgical interference with the child's body may serve as the focal point for the activation, reactivation, grouping and rationalization of ideas of being attacked, overwhelmed and (or) castrated. … Ever since the discovery of the castration complex analysts have had ample opportunity in their therapeutic work to study the impact of surgical operations. on normal and abnormal development. By now it is common knowledge that surgical interference with the child's body may serve as the focal point for the activation, reactivation, grouping and rationalization of ideas of being attacked, overwhelmed and (or) castrated.[4]

British child psychologist Gocke Cansever tested twelve Turkish boys before and after circumcision. Cansever (1965) confirmed the conclusions of Anna Freud (1952) and reported:

The results of the tests showed that circumcision, performed around the phallic stage is perceived by the child as an act of aggression and castration. It has detrimental effects on the child's functioning and adaptation, particularly on his ego strength. By weakening the controlling and defensive mechanisms of the ego, and initiating regression, it loosens the previously hidden fears, anxieties, and instinctual impulses, and renders a feeling of reality to them. What is expressed following the operation is primitive, archaic and unsocialized in character. As a defensive control and protection against the surge of the instinctual forces coming from within and the threats coming from outside, the ego of the child seeks safety in total withdrawal, this isolates and insulates itself from disturbing stimuli.[5]

Emde et al. (1971) being curious about changes in infant behavior after painful heel sticking, decided to test baby boys before and after routine (non-therapeutic) circumcision performed without anesthesia. Not surprisingly, they found that circumcision changed behavior. They concluded:

Routine hospital circumcision, done without anesthesia, was chosen as a potential stressor which might be expected to produce prolonged bombardment of pain pathways. Two studies, one without polygraphic manipulation and one with EEG and polygraphic manipulation and one with EEG and polygraphic recording, resulted in similar findings. Circumcision was usually followed by prolonged, non-REM sleep. Effects of circumcision were demonstrable in terms of an increase in the amount of non-REM sleep (p<0.01) and a decrease in latency to the onset of non-REM sleep (P<0.05). Infants were used as their own controls and were compared with non-circumcised males for statistical analysis. Postcircumcision increase in non-REM sleep was also reflected in an increased total number of non-REM sleep periods and an increased number of extremely long non-REM sleep periods.[6]

Researchers in Britain and America noticed that male infants in America, where most males were circumcised in the 1970s behave differently from female infants, while male infants in Britain do not behave differently from female infants. Richards, Bernal, & Brackbill (1976) said:

The extent to which circumcision does contribute to gender differences in behavior during the neonatal period, or subsequently, obviously demands detailed and focused study. Most certainly, the published description of any sample using male neonates should indicate circumcision status. At present, with rare exception, this information does not appear in any account of subject characteristics.[7]

Grimes (1978) also expressed concern, writing:

In contrast to the sometimes dramatic somatic responses of the neonate to operation without anesthesia, the psychological consequences of this trauma are conjectural. Psychoanalyst Erik Erickson has described the first of eight stages of man as the development of basic trust versus basic mistrust. For the baby to be plucked from his bed, strapped in a spread eagle position, and doused with chilling antiseptic is perhaps consistent with other new-found discomforts of extrauterine existence. The application of crushing clamps and excision of penile tissue, however, probably do little to engender a trusting, congenial, relationship with the infants new surroundings.[8]


Behavioral effects of unanesthetized infant circumcision

The focus then turned to investigation of the effects of unanesthetized infant circumcision. Doctors then falsely believed that newborn infants could not feel pain,[9] so they blamed the observed effects on "stress", not pain.

Luther, Kraybill & Potter (1976) tested cortisol and cortisone in the blood of newborn infants before and after circumcision. Dramatic increases in cortisol and a lesser increase in cortisone was recorded.[10]

Rawlins, Miller & Engel (1980) investigated the blood oxygen content after unanesthetized non-therapeutic circumcision. They reported that blood oxygen content decreased during non-therapeutic neonatal circumcision, although it returned to baseline or above later.[11]

Marshall et al. (1980) tested newborn boys before and after plastibel circumcision. They reported that boys have a greater capacity for memory than previously believed, that infants behave differently after circumcision, that future researchers must consider and record the circumcision status of their subjects, and that boys might actually be feeling pain. They suggested that anesthesia by dorsal penile nerve block might be appropriate.[12]

Gunnar et al. (1981) studied the effect of circumcision of male infants on serum cortisol and behavior. The authors identified circumcision as "a potential traumatic event experienced by the majority of newborn males in this country (United States)." The authors reported that serum cortisol during unanesthetized circumcision rose to about four times the pre-circumcision level. Behavior paralleled the increase in cortisol. They reported that "neonatal circumcision is performed without anesthesia and it is clearly stressful for the infant.[13]

Marshall et al. (1982) studied the effect of circumcision on mother-child interaction (primarily breastmilk substitute feeding behavior) in a hospital setting. They reported: "The experimental group exhibited fewer intervals of uninterrupted feeding than did the control group."[14]

Gunnar et al. (1984) tested the effects of a pacifier during circumcision. They reported:

The results showed that stimulating the newborn with the pacifier reduced crying by about 40%. Reducing crying, however, had no significant effect on adrenocortical response. Elevations of serum cortisol predicted average behavioral state following circumcision, whereas crying during circumcision did not. Furthermore, there was evidence that the neonatal adrenocortical system was sensitive in variations in surgical procedures. The results indicate the importance of obtaining data on both behavioral and hormonal systems in studies of stress and coping in human newborns.[15]

Porter et al. (1986) recorded the pain cries of boys undergoing circumcision. They reported that "Subjective judgments and objective quantitative data converge to demonstrate that infants' cries are perceived as varying and objectively, do systematically vary with respect to the the intensity of the painful stimuli."[16]

Porter et al. (1988) recorded the cries of boys undergoing non-therapeutic child circumcision. They found that the pitch of the cries increased as stress (euphemism for pain) increases.[17]

The research reported in this section clearly establish the the distress shown by male infants during unanesthetized circumcision does not come from being restrained, that infants feel extreme pain, that sucking on a pacifier does not reduce pain, although it may reduce crying, and that neonatal non-therapeutic circumcision is traumatic for the child.

Trauma of circumcision

There is now fairly extensive evidence of the effect of the trauma of non-therapeutic circumcision on behavior later in life.

Glover (1929) reported a case in which the memory of a traumatic circumcision was repressed.[18]

Taddio et al. (1995) (1997) studied the behavior of circumcised boys in comparison to the behavior of intact boys at the time of routine vaccination. Taddio et al. (1995) reported:

Male circumcision is the most common neonatal surgical procedure. It causes intense pain and measurable changes in behaviour that last up to 1 day. We found that circumcision status was associated with increased infant pain response to routine vaccination at 4-6 months. Circumcised boys had significantly longer crying bouts and higher pain scores. That both outcome measures, pain index, and cry duration, were influenced by circumcision lends credibility to our observations. During the second (HIB) vaccination, circumcision status was more clearly associated with the observed pain response than after DPT. The DPT injection might have had a priming effect in circumcised infants which led them to exhibit even more pain after the HIB injection. The effects of memory and reinforcement on later nocioceptive experience in neonates are not known. Because memory of pain is believed to be important in subsequent pain perception, and the main structures for memory are functional in the neonatal period, it is conceivable that pain from circumcision may have long-lasting effects on pain response and/or perception.[19]

Taddio et al. (1997) followed with a larger second study in which circumcised boys were compared with intact boys at time of vaccination four to six months after birth. Three measures to determine pain were used. Once again circumcised boys showed greater response to the pain of vaccination than intact boys.

Taddio et al. reasoned that:

It is, therefore, possible that the greater vaccination response in the infants circumcised without anaesthesia may represent an infant analogue of a post-traumatic stress disorder triggered by a traumatic and painful event and re-experienced under similar circumstances of pain during vaccination.

and concluded:

The results of this study are consistent with studies of pain response in animals and behavioural studies in humans showing that injury and tissue damage sustained in infancy can cause sustained changes in central neural function, which persist after the wound has healed and influence behavioural responses to painful events months later. Pretreatment and postoperative management of neonatal circumcision pain is recommended based on these results. Investigation of the neurological basis of these effects is warranted.[20]

Chamberlain (1989) confirms that babies remember pain.[21]

Male circumcision is part of the culture of the Philippine Islands. Boys usually are not neonatally circumcised. Instead, circumcision is done when they are somewhat older. Some are medically circumcised while others are circumcised in a traditional manner. Ramos & Boyle (2001) studied the psychological effects of circumcision on Philippine boys. They reported that sixty-nine percent of traditionally circumcised boys and fifty-one percent of medically circumcised boys met the criteria for a diagnosis of post-traumatic stress disorder (PTSD).[22]

Boyle et al. (2002) report:

A traumatic experience is defined in DSM-IV as the direct consequence of experiencing or witnessing of serious injury or threat to physical integrity that produces intense fear, helplessness or (in the case of children) agitation (American Psychiatric Association, 1994). The significant pain and distress described earlier is consistent with this definition. Moreover, the disturbance (e.g., physiological arousal, avoidant behaviour) qualifies for a diagnosis of acute stress disorder if it lasts at least two days or even a diagnosis of post-traumatic stress disorder (PTSD) if it lasts more than a month. Circumcision without anaesthesia constitutes a severely traumatic event in a child's life.[23]

Circumcision trauma in adults

Famed trauma expert Bessell van der Kolk, M. D. (1989) reports that traumatized persons tend to repeat the trauma on themselves or others, resulting in harm to others, harm to self, or being re-victimized. He writes:

Some traumatized people remain preoccupied with the trauma at the expense of other life experiences and continue to re-create it in some form for themselves or for others.[24]

Rhinehart (1999) was a practicing psychiatrist who had patients with later life problems stemming from their neonatal circumcision. He listed some possibilities:

  • a sense of personal powerlessness
  • fears of being overpowered and victimized by others
  • lack of trust in others and life
  • a sense of vulnerability to violent attack by others
  • guardedness in relationships
  • reluctance to be in relationships with women
  • defensiveness
  • diminished sense of maleness
  • feeling damaged, especially in the presence of surgical complications such as skin tags, penile curvature due to uneven foreskin removal, partial ablation of edges of the glans and so on
  • sense of reduced penile size, a part cut off or amputated
  • low self-esteem
  • shame about not "measuring up"
  • anger and violence toward women
  • irrational rage reactions
  • addictions and dependencies
  • difficulties in establishing intimate relationships
  • emotional numbing
  • need for more intensity in sexual experience.
  • sexual callousness
  • decreased tenderness in intimacy
  • decreased ability to communicate
  • feelings of not being understood

Rhinehart concluded:

In my client population of adult men, serious and sometimes disabling lifelong consequences appear to have resulted from this procedure, and long-term psychotherapy focusing on early trauma resolution appears to be effective in dealing with these consequences. Early prevention by eliminating the practice of routine circumcision is seen as desirable.[25]

Feelings and behavior of circumcised men

Goldman (1999) described the long-term psychological effects of circumcision as "anger, sense of loss, shame, sense of having been victimized and violated, feal, distrust, grief, and jealousy of intact men.[26]

Goldman reported reasons why circumcised man say little about how truly feel:

  1. Accepting beliefs and cultural assumptions about circumcision prevents men from recognizing and feeling their dissatisfaction; e.g. being told when young that it was necessary for health reasons and not questioning that.
  2. The emotions connected with circumcision that may surface are very painful; repressing them protects men from this pain. If the feelings become conscious, they can still be suppressed.
  3. Those who have feelings about their circumcision are generally afraid to express them because their feelings may be dismissed or ridiculed.
  4. Verbal expression of feelings requires conscious awareness. Because early traumas are generally unconscious, associated feelings are expressed non-verbally through behavioural, emotional, and physiological forms.[26]

Circumcised men are likely to use minimization and ridicule as an ego defense when addressing the subject of circumcision.

Adamant father syndrome

It is now well established that circumcised men who become a father of a boy overwhelmingly want the boy to be circumcumcised.[27] [28] This phenomenon has come to be known as the adamant father syndrome.[29] Such circumcised fathers are driven to repeat the trauma of their own circumcision decades ago on their own son even acting contrary to current medical advice.[26]

However Goldman pointed out several reasons (from the viewpoint of the child) that a father should not insist on circumcising a boy:

  1. A circumcised boy who matches others may nevertheless have negative feelings about being circumcised. These feelings can last for a lifetime
  2. It is not possible to predict before circumcision how a boy will feel about it later.
  3. Even though intact men are in the minority in the USA, there is no evidence that many of them are dissatisfied with being intact.
  4. An intact male who is unhappy about it can choose to be circumcised, but this is rarely done. The estimated rate of adult circumcision in the USA is 3 in 1000.
  5. An intact male who is unhappy about his status may feel different after learning more about circumcision and the important functions of the foreskin.
  6. The social factor is much less of an issue for boys born in the USA today because of the lower circumcision rate (60% nationally, under 40% in some states.[26]

Circumcised medical doctors

Most male doctors in the United States are men who were circumcised as infants. Consequently, despite being medical doctors they have no personal knowledge of the human foreskin. These men share the trauma and attitudes of other circumcised men and are just as likely to want to repeat the trauma. LeBourdais (1995) pointed out that the "age of the attending physician, sex and circumcision status" were important factors in determining the likelihood of a baby boy being circumcised.[30]

Goldman also points out that, in making the decision regarding circumcision, parents tend to follow the perceived norm.

Mixing religion and medical science

Goldman (1999) points out that some physicians allow their religious views on circumcision to influence the outcomes of scientific paper regarding male circumcision. This has created many scientifically flawed studies that distort, confuse the circumcision issue, and bias the outcome in favor of circumcision.[26] Some examples are Abraham L. Wolbarst, Ernest Hand, Abraham Ravich, Edgar J. Schoen, and Aaron J. Fink.

Circumcised doctors and circumcision policy

Goldman (2005) observes when circumcised doctors are appointed to a committee to develop circumcision policy they bring their cultural and personal biases to the table. Doctors who perform circumcisions need to justify their practice. Circumcised doctors may be under a compulsion to repeat the trauma.[24] Risks and certain injury are likely to be understated, while benefits are exaggerated. Human rights issues may be ignored. The likely result is a policy statement heavily biased in favor of circumcision.[31]

Depression, rage, and grief in circumcised men

Circumcised men historically have protected their feelings by denying that they have lost anything.

Research done since the 1960's forward to the present day has elucidated the nature, functions, and purpose of the foreskin. Circumcised men are learning what they have lost from the Internet, so they are less able to maintain the ego defense of denial of loss,[32] so they increasingly responding with feelings of anxiety, suicidal thoughts, depression, rage, PTSD and grief.[32] At least one case of suicide has been reported.[33]

Healing requires grieving the loss of a body part.[34] Unfortunately, Watson & Goldman (2017) report:

We found that therapists were reluctant to accept that the grief was real, were unaware of foreskin functions, denied circumcision had physical or psychological sequelae and minimized patient grief using humor, cultural aesthetics, controversial health benefits, sexism and an erroneous understanding of penile anatomy and sexual function. Male therapists were more likely to deny that circumcision is harmful and to be less empathetic than female therapists.[32]

Watson & Goldman recommend that men "embrace the anguish and try to feel it as strongly as they can." They also recommend non-surgical foreskin restoration "since it empowers the patient."[32]

Sources of help

Your Whole Baby maintains a short list of therapists knowledgeable in issues of circumcision grief.[35]

There is a new blog at Reddit, where grieving circumcised men discuss their feelings of grief.[36]

There is another blog at Reddit, where non-surgical foreskin restoration is discussed.[37]

More research needed

Preliminary investigation has established an association between child circumcision and alexithymia and autism spectrum disorder. Association does not establish cause and effect. More investigation and research is needed.

Bollinger and Van Howe (2011) associate alexithymia with the trauma of circumcision.[38]

Morten & Simonsen (2015) associate neonatal non-therapeutic circumcision with autism spectrum disorder.[39]

See also

Video

External links

References

  1. REFbook Maimonides, Moses (1963): The Guide of the Perplexed. Slomo Pines (ed.). University of Chicago Press. Retrieved 4 December 2019.
  2. REFjournal Gairdner, D.M. (1949): The fate of the foreskin: a study of circumcision, in: British Medical Journal. 2 (4642): 1433-1437, PMID, PMC, DOI. Retrieved 5 December 2019.
  3. REFjournal Levy, David (January 1945): Psychic trauma of operations in children: and a note on combat neurosis, in: Am J Dis Child. 69 (1): 7-25, DOI. Retrieved 4 December 2019.
  4. REFjournal Freud, Anna (1952): The role of bodily illness in the mental life of children, in: Psychoanalytic Study of the Child. 7: 69-81. Retrieved 4 December 2019.
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  16. REFjournal Porter, Fran Lang / Richard H. Miller / Richard E. Marshall (June 1986): Neonatal pain cries: effect of circumcision on acoustic features and perceived urgency, in: Child Dev. 57: 790-802, PMID. Retrieved 6 December 2019.
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  20. REFjournal Taddio, Anna / Joel Katz / A Lane Ilersich / Gideon Koren (1 March 1997): Effect of neonatal circumcision on pain response during subsequent routine vaccination, in: Lancet. 349 (9052): 599-603, PMID, DOI. Retrieved 8 December 2019.
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