Wednesday, July 15, 2009

Circumcision & Human Behavior

Medical doctors adopted male circumcision from religious practice into medical practice in England in the 1860s and in the United States in the 1870s. No thought was given to the possible behavioral effects of painful operations that excise important protective erogenous tissue from the male phallus. For example, Gairdner (1949) and Wright (1967), both critics of male neonatal non-therapeutic circumcision, made no mention of any behavioral effects of neonatal circumcision.[1] [2]

The awakening

Other doctors, however, were beginning to express concern about the behavioral effects of male circumcision.

Levy (1945) studied the behavioral effects of various operations, including circumcision, on young children.[3] He found that children who had undergone operations experienced an increase in anxiety and various fears, including night terrors, fear of physicians, nurses, and strange men. The oldest age group exhibited greater hostility and aggression. Levy compared their behavior to that of soldiers who suffered from what was then called "combat neurosis," and now recognized as post-traumatic stress disorder. Anna Freud (1952) pointed out that operations on the genitals, such as circumcision, would cause "castration anxiety."[4] Cansever (1965) tested Turkish boys before and after circumcision.[5] Cansever reported severe disturbances in functioning, including regression in behavior, and withdrawal of the ego as protection against outside threats. Cansever also observed various anxieties, including castration anxiety. Foley (1966) noticed that circumcised men are more likely to be biased in favor of circumcision.[7] Moreover, he said that circumcised men are more likely to engage in "problem-masturbation" but non-circumcised men were equally unlikely to engage in "problem-masturbation." Grimes (another critic of non-therapeutic neonatal circumcision) (1978), apparently unaware of the research described above, sounded an alarm:

"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 infant's new surroundings."[8]

Behavior during unanesthetized circumcision

Gunnar et al. (1981) studied the relationship of system cortisol levels to behavioral state. Gunnar et al. report that, as system cortisol rises, infants increase wakefulness and crying.[9] Malone et al. (1985) report that infants show little change in behavior due to limb restraint (of the type used for circumcision).[10]

Porter et al. (1986) report that newborn infants who are undergoing unanesthetized cirumcision emit cries of extreme urgency.[11] The studies, carried out with the aid of computer spetrographic analysis, show that infants who have been circumcised vocalize their anguish with higher pitch, fewer harmonics and shorter cries. The most invasive procedures produced the most urgent cries, as judged by observers. Porter et al. (1988) report that vagal tone decreases as the pitch of the cry increases.[12]

Gunnar et al. (1988) report that infants decrease distressed behavior when given a non-nutritive pacifier, although system cortisol does not decrease.[13]

Behavior immediately after unanesthetized circumcision

Studies show that circumcision affects the sleep of newborn boys. Emde et al. (1971) studied the sleep of boys who had had a non-therapeutic circumcision with the Plastibell device.[14] Emde et al. report that non-therapeutic circumcision "was usually followed by prolonged nonrapid eye movement (NREM) sleep." The authors considered this type of sleep "to be consistent with a theory of conservation-withdrawal in response to stressful stimulation."
Anders & Chalemian (1974) studied the sleep of boys who had had a non-therapeutic circumcision with a circumcision clamp. They report significant increases in wakefulness after circumcision.[15]

Marshall et al.(1979) studied newborn infant behavior using the Brazelton Neonatal Behavior Assessment Scale.[16] The study shows that infants change their behavior for at least 22 hours after circumcision. In a second study, Marshall et al. (1982) showed that circumcised infants kept their eyes closed during feeding or did not feed at all. Marshall et al. considered that mother-infant interaction and bonding was disrupted by the stress of circumcision.[17]

Numerous observers report that circumcision inteferes with the normal feeding behavior of circumcised boys. La Leche League leaders (1981) suggest that circumcision should be delayed for a time.[18] Marshall et al. (1982) found that circumcision interfered with normal feeding behavior.[17] Howard et al. (1994) report that "babies feed less frequently and are less available for interaction after circumcision."[19] Howard et al. report that some newly circumcised babies are unable to suckle at the breast and require formula supplementation. Lee (2000) also comments on the difficulty with feeding that circumcised boys exhibit.[20] Breastfeeding provides the best nutrition for infants and is of key importance in giving an infant a good start in life with optimum mother-infant bonding, health, and well-being,[21] so non-therapeutic infant circumcision should not be allowed to interfere with breastfeeding.

Behavior at vaccination

Hepper (1996) surveys and reports research that indicates memory commences to function in the fetus at about the 23rd week of gestation.[22] Infant memory continues to function through the birth experience and afterward. Anand & Hickey (1987) firmly established that newborn infants have fully functioning pain pathways.[23] When an infant is subjected to a painful and traumatic experience all the necessary factors are present to create posttraumatic stress disorder (PTSD). Boyle et al. (2002) describe the etiology of PTSD:

"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. The significant [circumcision] 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."[24]

PTSD is a normal response to an abnormal and terrifying experience. One would, therefore, expect to find PTSD in circumcised boys.

Taddio et al. (1995) compared the behavior of circumcised boys with the behavior of girls at the age of 4 to 6 months when vaccination with DPT occurred. Taddio et al. report that circumcised boys demonstrate a much greater response to the pain of the vaccination than do girls.[25] In a second study, Taddio et al. (1997) compared the behavior of circumcisied boys with the behavior of non-circumcised boys at vaccination. [26] Similarly, the circumcised boys demonstrated a greater response to the pain of vaccination than did the non-circumcised boys. Taddio et al. commented:

"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."[26]

Taddio et al. suggested that the pain of circumcision "may have long-lasting effects on future infant behaviour."[26]

Circumcision of boys is nearly universal in the Philippine Islands for cultural reasons. Ramos & Boyle (2001) studied the psychological effects of circumcision in Phillipine boys. They report a high incidence of PTSD in these boys. Sixty-nine percent of boys who had been circumcised by the traditional "tuli" Philippine ritual circumcision and 51 percent of boys who had been medically circumcised satisfied the DSM-IV criteria for PTSD.[27]

Behavior in later life

There is increasing evidence that male circumcision influences the behavior of adult males. Menage reports PTSD after genital surgery.[28] More specific to male circumcision, Rhinehart reports finding PTSD in adult males in his clinical practice in which the stressor was neonatal circumcision.[29] Rhinehart lists symptoms of:

* 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[29]

Van der Kolk (1989) reports that persons who have been traumatized have a compulsion to repeat the trauma and to find new victims on which to re-enact the trauma they suffered.[30] This may apply with full force to victims of circumcision. The circumcision of an infant is a way to reenact the trauma of circumcision.[31] The compulsion to circumcise is very strong and has resulted in unlawful batteries and abductions to circumcise an unwilling victim.[32] [33] [34] [35] [36]

There is some evidence that adverse experiences in the perinatal period (from the 28th week of gestation through the first seven days of extra-uterine life) cause self-destructive behavior in adult life.[37] [38] [39] [40] Circumcised males may tend to be more self-destructive, but more research is needed to verify the effect traumatic non-therapeutic circumcision has on self-destructive behavior.

The condition of the male phallus impacts a male's feeling of well-being. A phallus diminished by the loss of the erogenous foreskin to circumcision necessarily adversely affects one's feelings about one's self, resulting in uncomfortable feelings of low self-esteem. There is, therefore, a strong tendency to deny that any loss occurred. Minimization of the loss is a common defense mechanism; ridicule of the subject is another. Persons who have lost body parts must grieve their loss.[41] Failure to grieve and accept the loss puts one in permanent denial of loss.[42] Many men who have been circumcised do not want non-circumcised males, including their own sons, around to remind them of their irreversible loss. For these emotional reasons, as Foley (1966) observed, there tends to be a strong irrational bias in favor of universal circumcision among circumcised males.[7] Many fathers who were victims of neonatal circumcision, for the reasons described above, adamantly insist that any male offspring be circumcised.[24] This phenomenon has come to be called "the adamant father syndrome." Circumcision, therefore is a repeating cycle of trauma in which circumcised infant males grow up to be adult circumcisers.[31]

Behavior of circumcised medical doctors

Medical doctors in Australia, Canada, and the United States practiced circumcision in the twentieth century, so these nations have a heavy proportion of circumcised men, some of whom become medical doctors. These circumcised male doctors share the same bias in favor of male circumcision as do other circumcised males.[7] [31] [43] Male doctors who were circumcised as infants are more likely to recommend circumcision of infants to parents.[44]

The Australian Paediatric Association recommended non-circumcision—genital integrity—in 1971;[45] thereafter, the incidence of circumcision among Australia's newborn plummeted.[46] At the present time, in regard to genital integrity status, Australia is, in effect, two nations, one of which has mostly circumcised men and the other that has mostly intact men. The dividing point is the year 1978, because the incidence of genital integrity among newborn boys rose above 50 percent in that year.[46] The ever-increasing percentage of genitally intact younger men in the population is causing increasing anxiety and distress among some older circumcised males. There now is a peculiar phenomenon happening in Australia, where one sees middle-aged men trying to restore Australia's medical practice back to that which prevailed before 1971. This is, of course, an attempt to defend the culture-of-origin and is carried out for the emotional reasons described here, although, as Goldman reports, pseudo-scientific reasons are advanced .[31]

Behavior of circumcised medical authors

The high proportion of circumcised males in the medical community create a distorted, biased medical literature.[47] Goldman (1999) writes:

"One reason that flawed studies are published is that science is affected by cultural values. A principal method of preserving cultural values is to disguise them as truths that are based on scientific research. This 'research' can then be used to support questionable and harmful cultural values such as circumcision. This explains the claimed medical 'benefits' of circumcision."[31]

Hill (2007) writes:

"The medical literature on circumcision is voluminous and contentious. Circumcised doctors create papers that overstate benefits and minimize harms and risks. When these doctors publish such claims, other doctors come forward to refute them....The result is an unending debate driven by the emotional compulsion of circumcised men."[43]

Female doctors from a circumcising culture of origin have been known to contribute pro-circumcision pieces.

Most American medical editors are circumcised men. They share the pro-circumcision bias of other circumcised men. They tend to select papers for publication that conform to their bias. The literature, therefore, is filled with pro-circumcision papers written by circumcised doctors. The behavior of these circumcised doctors has served for a century to prolong the practice of a nineteenth century surgical operation that has no medical indication and is injurious to infants and children.

Behavior of medical societies

Medical societies in the English-speaking nations have a high proportion of male members (fellows) who are circumcised. The societies that represent medical specialities that practice circumcision have found themselves unable to adequately address the problem of circumcision and to repudiate this harmful, outmoded practice.

Goldman writes:

"Although medical committee members highly value rationality, a rational and objective evaluation of an emotional and controversial topic like circumcision can be difficult. It is suggested that the potential psychological and social factors surrounding the practice of circumcision could affect the values and attitudes of circumcision policy committee members, the attitude toward evaluating the circumcision literature, and the publishing of circumcision literature itself. If the members are polarized, the process of negotiating to arrive at a consensus statement could introduce additional psychosocial factors that could affect the final policy."[48]

Dr. Goldman published the two articles cited here in the United Kingdom and Canada, not the United States. This may be a testimony to the bias and censorship present in the medical literature of the United States.


All of the behavioral changes described in this paper are negative, unfavorable, or maleficial in nature. No positive, favorable, or beneficial behavioral changes have been found.

The English-speaking nations have a high proportion of circumcised males and, therefore, a high proportion of psychically-wounded males. A society containing so many psychically-wounded males cannot be as healthy as it should be. The United States has clung to circumcision even after Australia and Canada have rejected circumcision of infants. Consequently, the United States has the highest proportion of circumcised males to intact males and the greatest injury to society.

The best way to stop the cycle of trauma is to stop circumcising infants.[31] [42] Non-traumatized intact infants usually do not grow up to become circumcisers, so the cycle of trauma would end.

Additional Reading

Miller A. Appendix: The Untouched Key: Tracing Childhood Trauma in Creativity and Destructiveness. Anchor Books (Doubleday) New York, 1991.
Goldman R. Circumcision: The Hidden Trauma. Boston: Vanguard Publications, 1997.
Fleiss P, Hodges FM. What your Doctor May Not Tell You About Circumcision. New York: Warner Books, 2002.
Ritter TJ, Denniston GC. Doctors Re-examine Circumcision. Seattle: Third Millennium Publishing Company, 2002.

1. Gairdner D. The fate of the foreskin: a study of circumcision. Br Med J 1949;2:1433-7.
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2. Wright JE. Non-therapeutic circumcision. Med J Aust 1967;1:1083-6.
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3. Levy D. Psychic trauma of operations in children: and a note on combat neurosis. Am J Dis Child 1945;69:7-25.
4. Freud A. The role of bodily illness in the mental life of children. Psychoanalytic Study of the Child 1952; 7:69-81.
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5. Cansever G. Psychological effects of circumcision. Brit J Med Psychol 1965;38:321-31.
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6. Richards MPM, Bernal, JF, Brackbill Y. Early behavioral differences: gender or circumcision? Dev Psychobiol 1976;9(1):89-95.
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7. Foley JM. The unkindest cut of all. Fact 1966;3(4):2-9.
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8. Grimes DA. Routine circumcision of the newborn: a reappraisal. Am J Obstet Gynecol 1978;130(2):125-29.
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9. Gunnar MR, Fisch RO, Korsvik S, Donhowe JM. The effects of circumcision on serum cortisol and behavior. Psychoneuroendocrinology 1981; 6(3):269-75.
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10. Malone SM, Gunnar MR, Fisch RO. Adrenocortical and behavioral responses to limb restraint in human neonates. Dev Psychobiol 1985;18:435-46
11. Porter FL, Miller RH, and Marshal RE. Neonatal pain cries: effect of circumcision on acoustic features and perceived urgency. Child Dev 1986;57:790-802.
12. Porter, FL, Porges SW, Marshall RE. Newborn pain cries and vagal tone: parallel changes in response to circumcision. Child Dev 1988;59:495-505.
13. Gunnar MR, Connors J, Isensee, Wall L. Adrenocortical activity and behavioral distress in human newborns. Dev Psychobiol 1988;21(4):297-310.
14. Emde RN, Harmon RJ, Metcalf D, et al. Stress and neonatal sleep. Psychosom Med 1971;33(6):491-7.
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15. Anders TF, Chalemian RJ. The effects of circumcision on sleep-wake states in human neonates. Psychosom Med 1974;36(2):174-9.
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16. Marshall RE, Stratton WC, Moore JA, et al. Circumcision I: effects upon newborn behavior. Infant Behavior and Development 1980;3:1-14.
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17. Marshall RE, Porter FL, Rogers AG, et al. Circumcision: II effects upon mother-infant interaction. Early Hum Dev 1982; 7(4):367-74.
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18. The Womanly Art of Breastfeeding, 3rd ed. Franklin Park, IL: La Leche League International, 1981: 92-93. (ISBN 0-912500-10-7)
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21. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005;115(2):496-506.
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25. Taddio A, Goldbach M, Ipp E, et al. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995;345:291-2.
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26. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997;349(9052):599-603.
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27. Ramos S, Boyle GJ. Ritual and medical circumcision among Filipino boys: evidence of post-traumatic stress disorder. In: Denniston GC, Hodges FM, Milos MF (eds) Understanding circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem. New York: Kluwer Academic/Plenum Publishers, 2001: pp. 253-70.
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28. Menage J. Post-traumatic stress disorder in women who have undergone obstetric and/or gynaecological procedures. J Reprod Infant Psychol 1993;11:221-28.
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30. van der Kolk BA. The compulsion to repeat the trauma: re-enactment, revictimization, and masochism. Psychiatr Clin North Am 1989;12(2):389-411.
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31. Goldman R. The psychological impact of circumcision. BJU Int 1999;83 Suppl. 1:93-103.
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32. Anonymous. Man killed for not going to circumcision school. SAPA, South Africa, Monday, 27 June 2005
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33. Anonymous. Man forcibly circumcised as crowd watches. The Nation, Nairobi, Kenya, 23 August 2002.
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34. Vusi Mona. A bit mundane and a little more light. [opinion] City Press, South Africa, 13 July 2002.
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35. Anonymous. 'Spy' cut up about initiations. African Eye News Service, 27 August 2002.
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36. Anonymous. Take boys home, parents urged. South African Press Association (SAPA), 3 July 2002.
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37. Salk L, Lipsitt LP, Sturner WQ, et al. Relationship of maternal and perinatal conditions to eventual adolescent suicide. Lancet 1985;i:624-7
38. Jacobson B, Eklund G, Hamberger L, et al. Perinatal origin of adult self-destructive behavior. Acta Psychiatr Scand 1987;76(4):364-71.
39. van der Kolk BA, Perry JC, Herman JL. Childhood origins of self-destructive behavior. Am J Psychiatry 1991; 148;1665-71.
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41. Maguire P, Parks CM. Coping with loss: surgery and loss of body parts. BMJ 1998;316(7137):1086-8.
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42. Denniston GC. An Epidemic of Circumcision. Third International Symposium on Circumision, University of Maryland, College Park, Maryland, May 22-25, 1994.
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43. Hill G. The case against circumcision. J Mens Health Gend 2007;4(3):318-23.
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44. LeBourdais E. Circumcision no longer a "routine" surgical procedure. Can Med Assoc J 1995;152(11):1873-6.
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45. Belmaine SP. Circumcision. Med J Aust 1971;1:1148.
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46. Young H. Circumcision in Australia.
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47. Fleiss PM. An analysis of bias regarding circumcision in American medical literature.In: Denniston GC, Hodges FM, Milos MF. (eds) Male and Female Circumcision: Medical, Legal, and Ethical Consideratons in Pediatric Practice. New York: Kluwer Academic/Plenum Publishers, 1999: pp. 379-402.
48. Goldman R. Circumcision policy: a psychosocial perpective. Paediatr Child Health 2004;9(9):630-3.
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Blogger Latinalonestar said...

Absolutely wonderful!!! I will be referencing this for others.

10:36 PM

Blogger DrMomma said...

Very well written. May I re-post and link in our Peaceful Parenting Blog?

7:18 AM

Anonymous Anonymous said...

Thanks for the informative information - I enjoyed reading it! I always enjoy this blog. :) Cheers,

9:21 PM


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