This classic study, by a business executive, industrial engineer and researcher in television, marketing, sociology, economics, education and health, who was communications coordinator in the department of community medicine of Mount Sinai School of Medicine, New York, for five years, effectively rebuts all the claims made for circumcision to that date. Astonishingly little has changed in the 30 years since then.

Circumcision is a unique phenomenon. Its origins in antiquity are obscure, its original objectives unknown, its spread to all continents a source of speculation; yet this operation, this first ritual surgery devised by humans, is still in use. As a ritual, circumcision has been practiced for thousands of years. It is so deeply ingrained among many groups that there is little likelihood of the practice soon being abandoned.

But circumcision is more than merely ritual surgery. As a therapeutic measure, to correct a true defect, it is accepted worldwide. In the U.S., circumcision is allegedly employed therapeutically-to correct a pseudodefect. A third aspect, prophylaxis, has taken on even greater significance in the United States, where many more operations are performed for prophylactic reasons than for religious or therapeutic ones.

Thus the American practice is trifaceted; a religious rite, a therapeutic measure, and a prophylactic operation. No other surgical procedure can make such a claim. In fact, according to Dr. David Grimes, "Newborn circumcision eludes classification."¹ (Surgery is classified into four areas: repair of wounds, extirpation of diseased organs or tissue, reconstructive surgery, and physiologic surgery. Prophylactic circumcision fits none of these classifications.)

A century ago, ignorant of disease etiology, physicians introduced male circumcision to cure almost every disease imaginable. Despite later knowledge that most diseases did not have the remotest connection with this surgery, the practice was continued with ever-increasing frequency. Now when all claims for ills supposedly prevented by circumcision have been shown to be illusory, the surgery still continues unabated. The prophylaxis theories are myths; they are no longer acceptable hypotheses. In fact, the entire concept of "health" circumcision in the United States is beyond the bounds of medicine. Dr. Lendon Smith claimed (1969) that: "Circumcision now seems to be a national cultural trait in the United States."² This "national cultural trait" endows circumcision with mystical prophylactic powers and an entire health philosophy has been accreted around it. But the very concept of a "national cultural trait" is in error, because it obscures the real reason for the acceptance of circumcision in the United States. The issue is further clouded by some of the psychiatric approaches to circumcision.

Bruno Bettelheim, in his book Symbolic Wounds (1962), stated:

Dr. Bettelheim continued:

He went on to discuss circumcision in relation to penis envy and castration anxiety, and paraphrased Freud:

Attributing circumcision to penis envy and/or castration anxiety "explains" why women "impose" it, but does not take into account the simple fact that circumcision is not practiced by 75% of the human race. Is it possible that 75% of the world's population is unaware of sex differences and therefore do not suffer either penis envy or castration anxiety? There are no empirical data to support the Bettelheim thesis on this question.

The acceptance of the American circumcision practice for health reasons is based upon ignorance of the facts and fear; fear of taking issue with a well entrenched custom. Pessimism about changing the situation was noted by two physicians in 1963: 'One would hope the situation might change in the next century-but do not bet on it!"⁶

A New York City newsweekly, The Village Voice, published an article on circumcision in 1975 by Sylvia Topp, who conducted a series of interviews. She found in telephone interviews with a random sample of lO% of Manhattan obstetricians that more than half of them believed that circumcision is unnecessary. Nevertheless, they performed the operation on over 90% of the males they delivered in the belief that parents strongly desired surgery-so much so that, in their opinion, it would have been useless to try to convince the parents to reject the surgery. They therefore made no effort to do so.⁷ On the other hand, interviews with a nonrandom sample of mothers that Ms. Topp conducted revealed almost a diametrically opposite point of view: 2 out of every 3 mothers stated that if the doctor had suggested not circumcising the child, they would have accepted his opinion. The others were not certain what they would have done.⁸

There is, furthermore, a strange issue of medical "turf" in the employment of obstetricians to do circumcisions. The American Board of Obstetrics and Gynecology warned that: "Physicians who assume responsibility for the health of male patients for operative or other care will not be regarded as specialists in obstetrics-gynecology.''⁹ And yet thousands of routine circumcisions are performed annually by Board Certified obstetricians-gynecologists. These specialists seldom see the circumcision patient for follow-up. Dr. Grimes suggested that it would be better to have the circumcision performed by the child's physician, rather than the mother's, because better postoperative care could be provided, which would result in fewer complications.¹⁰

Dr. Edward B. Feehan (1977) suggested a profit motive in that there are communities in which the obstetrician provides all care for the newborn. The decision to do so is probably motivated by "custom and economics."¹¹

The question of monetary gain has been mentioned only briefly. While this may be a factor for some, most physicians perform the surgery either in the mistaken belief that it may do some good or because of the lingering fear that not doing it may cause harm. The charge of venality is easy to make but difficult to document. Moreover, opposition to routine circumcision should not be sidetracked by such an extraneous issue, but should instead be argued on the merits of the procedure. However, as Dr. D. Grimes (1978) commented, no one has determined the "cost-effectiveness ratio."¹² Grimes estimated that the cost of all newborn circumcisions in the United States ranged between $50,000,000 and $200,000,000 annually, plus the millions of personnel hours required, and suggested this money could be more wisely spent for immunization and health education.¹³

This state of affairs is not unique to circumcision. According to a 1978 Congressional Committee, the results of accepting the concept that "The doctor knows best" were 2 million unneeded operations, a loss of more than 10,000 lives, and a cost of $4 billion in 1977 alone. Perhaps the most alarming aspect of this surgical scandal is that it is not a new development but is, instead, a frequently told story about which little corrective action has been . The New York Times reported (1978) that Rep. John Moss noted that has not been a significant decline in unnecessary surgery, although this matter had been called to public attention 3 years ago.¹⁴

If the medical establishment moves this slowly in respect to surgery, it should come as no surprise that the situation vis-a-vis circumcision-minor surgery-may not change even in the next century. The medical profession often stresses how much it knows, but seldom admits how little is known. Dr. Ernest W. Saward, Associate Dean of the Rochester School of Medicine, recently wrote (1977):

Dr. H. H. Hiatt (1975), listing numerous procedures that were in vogue in the recent past but are no longer used, noted that because they remained on the "medical commons" too long, valuable health resources were squandered.¹⁶ Dr. Grimes, commenting on Dr. Hiatt's study, stated that when certain medical practices were discontinued, it was not because they were necessarily replaced by improved methods, but because it was found that they were of no benefit to the patient." Dr. Hiatt decried the fact that when a medical procedure has been widely adopted, it is not given up even after there is proof that the procedure has no value.¹⁸ He further commented that physicians should use techniques only when they are quite certain that they will do good. Physicians should not be in the position of demonstrating that a procedure is merely not dangerous.¹⁹

The editor of the Australian Journal of Medicine declared (1971) that some medical procedures take a long time to die, and that of all procedures which should have passed from the scene, neonatal circumcision is "among the most stubborn."²⁰

According to a health consumer publication (1977), tonsillectomy and adenoidectomy (T and A) are also cases in point.

The medical profession admits that too many T and A's have been and are performed unnecessarily. Yet the operation continues, although at a diminishing rate. Therefore, it is probably asking too much to expect that the profession would also admit that millions of circumcisions have been and are needlessly performed. Circumcision is not innocuous; trauma, morbidity, mortality do occur. Moreover, the tissue removed is little understood, the prepuce, like the earlobe, has long been considered a useless appendage. However, the earlobe is at least useful for ornamentation. There is evidence in acupuncture that the earlobe is useful for anesthesia and/or therapy. If the earlobe is a useful part of the body, what about the prepuce?

A few years ago (1974) two sex therapists made a cogent observation: ' 'At any given moment in history, the things people do, even their thoughts and opinions, are largely governed by what their societies find acceptable."²²

Unfortunately, tradition dies hard in medicine. It took decades for Semmelweis' theories of simple childbirth sanitation to be adopted, and decades before Freud's Viennese colleagues would even seriously consider his theories. Natural childbirth is still often frowned upon. Psychiatrist Mary Jane Sherfey, in addressing the question of the medical profession's slowness to accept change, quoted the famous German physicist Max Planck: "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die off, and a new generation grows up that is familiar with it. "²³

Bertrand Russell put it another way: ' 'I venture to propose ... a doctrine which may, I fear, appear wildly paradoxical and subversive. The doctrine in question is this: That it is undesirable to believe a proposition when there is no ground whatsoever for supposing it true."²⁴

But circumcision has gone far beyond the bounds of reason or medicine and has involved the least likely government agency.

Probably the most outrageous circumcision "study" of the century was reported in the New York Times in 1977.²⁵ The Central Intelligence Agency (C.I. A.) reported that in 1961 it had arranged to have 15 boys, aged 5 to 7, circumcised. The boys were from low-income families; their ethnic backgrounds were not identified. The New York Times article stated that the objective of the research was to determine whether castration anxieties were caused by circumcision. The C.I.A. documents were "heavily censored"; however one report noted that the research sought to determine whether such "emotional disorders" as homosexuality were related to castration complexes. Queries to the C.I. A. revealed that the research findings had been destroyed. No information was available as to whether parental consent had been re-quested or given. Clearly this "study" represents surgical and psychiatric experimentation with human subjects in violation of accepted medical practices and government regulations.

The New York Times reported the story without immediate or delayed comment. So did the Washington Post. A few days later, Richard Cohen, a Washington Post columnist, wrote a blistering attack not only on the C.I. A. but on the silence that had ensued:

The press carried no criticism or protest from any section of the medical establishment, or any government official, of this prostitution of a surgical technique or of the surgeons who performed the operations. It is not that th C.I. A. is immune to criticism. In recent years hundreds of this agency's cloak and-dagger acts have been attacked-from the media to the pulpit to Congress. Why then no comment when the issue is circumcision? Is the subject sacrosanct?

The status of American circumcision practice was summarized by Dr Karen E. Paige in 1978:

Thus, both male and female circumcision are described as ritual, not rational. At least the male operation maintains an aura of medical benefit, and sexual enhancement (reduction of premature ejaculation) is claimed as an incidental advantage. In female circumcision, however, no health benefits are suggested; the rationale is strictly limited to improved sexual response.

In other words, if a woman is sexually unresponsive or responds poorly, the onus lies with her or, more to the point, with her genital anatomy- allegedly easily corrected by surgery. This sexual vicitimization of women-placing the blame solely upon their sexual anatomy and urging surgical remedy-is not abating, it is increasing.

With respect to male circumcision, there is some evidence that pediatricians are becoming more outspoken in their opposition. Dr. Sydney S. Gellis writing in the American Journal Diseases of Children (1978) made an impassioned plea for physicians to be more outspoken in discouraging newborn circcumcision. He concluded the article with these words: "Down, I say, with circumcision. . . . "²⁸ (The full quote is "Down, I say, with both circumcision and Fournier's syndrome." Fournier's syndrome is gangrene of the genitalia occasionally associated with circumcision. Dr. Gellis maintained that the term gangrene is sufficiently clear. To call it by a specific name obscures the situation.)

Certainly, the medical profession has the responsibility to conduct and to encourage research into all aspects of circumcision or any other surgery. For that matter, enlightened health consumers must also take responsibility to ask questions and to question answers. This volume is only an initial effort to review available information; much more work needs to be done. Hopefully, this book will encourage others to explore the subject and demystify it. Not to do so leaves the field wide open to abuse.

The medical profession bears responsibility for the introduction of prophylactic circumcision without scientific basis in the past and for its continued use and rationalization without scientific basis in the present. The profession seems to accept circumcision as a "national cultural trait" as much as do lay people. With evidence at hand to disprove the prophylactic benefits of the surgery, the medical profession has the responsibility to discourage this practice. The pretense of neutrality is a negative stance.

Today circumcision is a solution in search of a problem. The operation, as prophylaxis, has no place in a rational society. The final conclusion to be drawn is that routine infant health circumcision is archaic, useless, potentially dangerous, and therefore should cease.

Notes

1. David A. Grimes, "Routine Circumcision of the Newborn Infant: A Reappraisal," American Journal of Obstetrics and Gynecology, vol 130 no 2 Jan. 15, 1978, p. 128.

2. Lendon Smith, The Children's Doctor (Englewood Cliffs NJ: Prentice Hall, 1969), p. 195.

3. Bruno Bettelheim, Symbolic Wounds, 1st ed. (New York: Collier Books, 1962), p. 147. This book provides a copious bibliography.

4. Ibid.

5. Ibid.

6. R. A, Shaw and W. O. Robertson, ' 'Routine Circumcision,'' American Journal Diseases of Children, vol. 106, no. 2, Aug. 1963, p. 217.

7. Sylvia Topp, "The Argument Over Circumcision; The Case Against," The Village Voice, June 16, 1975, pp. 8 and 9.

8. Ibid.

9. Grimes, "Routine Circumcision," p. 127.

10. Ibid.

11. Edward B. Feehan, Letter to the Editor, Pediatrics, vol. 60, no. 4, Oct. 1977' p. 566.

12. Grimes, "Routine Circumcision," p. 128.

13. Ibid.,pp. 128-129. Also see Karen E. Paige, "The Ritual of Circumcision,' Human Nature, vol. 1, no. 5, May 1978, p. 46. Dr. Paige estimates the cost at $200 million annually.

14.Jane E. Brody, "House Panel Calls For More U.S. Control of Surgery," New Times, Dec. 27, 1978, p. 1.

15. Daniel S. Greenberg, Book review of Doing Better and Feeling Worse, by John H. Knowles (New York: W. W. Norton & Co., 1977), New York Times Book Review Section, July 24, 1977, p. 10.

16. H. H. Hiatt, "Protecting the Medical Commons: Who Is Responsible?," New England Journal of Medicine, vol. 293, 1975, p. 235.

17. Grimes, "Routine Circumcision," p. 128.

18. Ibid., p. 129.

19. Ibid.

20. Ibid.

21. Health Facts (New York: Center for Medical Consumers and Health Care Information), vol. 1, no. 6, Dec. 1977, p. 1.

22. Doris Jonas and David Jonas, "Ejaculation: Premature for Whom?," Physicians World, vol. 11, no. 7, July 1974, p. 92.

23. Mary Jane Sherfey, ' 'Some Biology of Sexuality,'' Journal of Sex and Marital Therapy, vol. 1, no. 2, Winter 1974, p. 100.

24. James Reston, "Silly Season Samples," New York Times, Aug. 12, 1977, p. A21.

25. "Circumcision Test in '61 Disclosed in C.I.A. Data," New York Times, Oct. 2, 1977, p. 35. (Reuters Dispatch, datelined Washington, D.C., Sept. 30, 1977.)

26. Richard Cohen, "C.I.A. Circumcision Study Secretly Circumscribed," Washington Post, Oct. 20, 1977, p. Cl.

27. Paige, "Ritual of Circumcision," pp. 46-47.

28. Sydney S. Gellis, "Circumcision," American Journal Diseases of Children, vol. 132, no. 12, Dec. 1978, p. 1169.