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 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.

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.

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).

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.

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.

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.

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.

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.

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, 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.

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.

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.

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.

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."

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.

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."

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.

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.

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.

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.