The Unkindest Cut Essay, Research Paper

The Unkindest Cut

Audience: Those people who are undecided about circumcision

Routine neonatal circumcision is the subject of many debates in the United States. The practice has attracted passionate advocates and critics. From a global perspective, most of the world does not practice circumcision; over 80% of the world’s males are intact (not circumcised). Most circumcised men are Muslim or Jewish; the USA is the only country in the world that circumcises most of its male infants for non-religious reasons. This article refers mostly to the American practice, because the USA has the highest rate of non-religious circumcision and the most contentious debate about circumcision. The analysis presented here examines the available medical evidence relating to routine neonatal circumcision in order to weigh its risks, costs, and benefits.

Discussion about the advisability of circumcision in English-speaking countries that practice circumcision typically has focused on long-held beliefs about the health benefits of circumcision. The conflicting conclusions, beliefs and opinions surrounding circumcision, together with the tenacity with which advocates and opponents of circumcision maintain their viewpoints, suggest that deep psychological factors are involved. The strong motivation to circumcise male infants is shown by the fact that the practice continues even though no national medical organization in the world recommends it [1].

Infant pain and behavioral response to circumcision

To understand the long-term effects of circumcision, it is necessary to review the effects on the infant. The question of infant pain is often raised in debates about circumcision. Some physicians believe early work claiming that the newborn nervous system is not sufficiently developed to register or transmit pain impulses [1]. According to more recent work, this belief is ‘the major myth’ of physicians regarding infant pain; that babies cannot physically resist and stop the circumcision procedure also makes it easier to dismiss their pain [1]. Some doctors minimize circumcision pain by calling it “discomfort” or comparing it to the pain of an injection, although these studies have been refuted by empirical studies [2].

Anatomical, neurochemical, physiological and behavioral studies confirm that newborn responses to pain are ’similar to but greater than those in adult subjects’ [2]. Infants circumcised with no anesthesia, reflecting the common practice, experience not only great pain, but also an increased risk of choking and difficulty in breathing [3]. Increases in heart rate of 55 bpm have been recorded at 1.5 times the baseline rate [4]. After circumcision, the level of blood cortisol increased by a factor of 3-4 times the

level before circumcision [4]. As a surgical procedure, circumcision has been described as ‘among the most painful performed in neonatal medicine.’ Using a pacifier during circumcision reduced crying but did not affect the hormonal pain response [4]. An infant may also go into a state of shock to escape the overwhelming pain. Therefore, while crying may be absent, other body signals show that severe pain is always present during circumcision.

There is disagreement among physicians about using anesthesia during circumcision. Before the mid-1980s, anesthesia was not used because the medical community denied infant pain. That belief has changed among many physicians, but an anesthetic (local injection, the best option tested) still is not typically administered, because of a lack of familiarity with its use, as well as the belief that in introduces additional risk [4]. Although there is an indication that the risk is minimal, most physicians who perform circumcisions do not use anesthetics. When an anaesthetic is used, it relieves only some but not all of the pain, and its effect ashen before the postoperative pain does [5].

Behavioral changes in infants resulting from circumcision are very common, and can interfere with parent-infant bonding and feeding [6]. The American Academy of Pediatrics Task Force on Circumcision notes increased irritability, varying sleep patterns and changes in infant-maternal interaction after circumcision [6]. Canadian investigators report that during vaccinations at age 4-6 months, circumcised boys had an increased behavioral pain response and cried for significantly longer periods than did intact boys. The authors believe that ‘circumcision may produce long-lasting changes in infant pain behavior’ [6]. That study suggests that circumcision may permanently alter the structure and function of developing neural pathways.

The parents’ responses

The severe pain of circumcision and the changes to infant-maternal interaction observed after circumcision raise the question of the effects on the mother. The typical hospital circumcision is performed out of view of the parents, in a separate room. However, a few are observed by parents, and many Jewish ritual circumcisions are carried out in the homes of the parents. There are no studies of how these parents respond to observing their son’s circumcision. Some parents regret their son’s circumcision and report that they wish they had known more about circumcision before they consented to it. Margaret Pollack submitted the following comments in her letter to a magazine:

‘My tiny son and I sobbed our hearts out. After everything I’d worked for, carrying and nurturing Joseph in the womb, having him at home against no small odds, keeping him by my side constantly since birth, nursing him whenever he needed closeness and nourishment–the circumcision was a horrible violation of all I felt we had shared. I cried for days afterward’ [6].

Other mothers have reported that watching their son’s circumcision was the ‘the worst day of my life.’ Some mothers clearly remember their son’s circumcision after many years; Pollack reported 15 years after the event. ‘The screams of my baby remain embedded in my bones and haunt my mind. His cry sounded like he was being butchered’ [6]. Parents may not express strong adverse reactions to a son’s circumcision for two possible reasons. First, because the feelings engendered by circumcision are so painful and are not generally supported by the community, they may be suppressed [6]. Second, as described earlier, if the infant goes into traumatic shock, he does not cry, and parents tend to interpret lack of crying as a sign that circumcision is not painful.

Circumcision as trauma

Studies investigating circumcisional pain have referred to circumcision as traumatic [4]. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association [4] is helpful in discussing the question of trauma as it relates to circumcision. Its description of a traumatic event includes an event that is beyond human experience, such as assault (sexual or physical), torture, and a threat to one’s physical integrity. An assault is a physical attack; torture is severe pain or anguish. It does not necessarily take account of intent or purpose, but focuses on the act itself and the experience of the victim.

From the perspective of the infant, all the elements in the DSM-IV description of traumatic events apply to circumcision; the procedure involves being forcibly restrained, having part of the penis cut off, and experiencing extreme pain. Based on the nature of the experience and considering the extreme physiological and behavioral responses, circumcision traumatizes the infant [6].

The question of an infant’s capacity to experience trauma needs to be emphasized. Wilson, an author with a national reputation for trauma research, supports the idea that trauma can occur ‘at any point in the life cycle, from infancy to the waning years of life’ [7]. In addition, the DSM-IV states that traumatic effects ‘can occur at any age’ [6]. Clinicians have documented that children are particularly vulnerable to trauma [7]. Psychic trauma seems to have a permanent effect on children, no matter how young they are when they are traumatized.

The possibility of circumcision resulting in traumatic effects on older children can be better explored because of the easier access to memory and the child’s ability to talk. Two reports have studied the ritual as practiced without anesthesia on children in Turkey. In the first report, testing subjects 4-7 years old shortly before and after the ritual yielded this result: ‘Circumcision is perceived by the child as an aggressive attack on his body, which damaged, humiliated and, in some cases totally destroyed him’

[7]. According to this study, circumcision resulted in increased aggressiveness and weakened the ego, causing withdrawl and reduced functioning and adaptation. Withdrawal is a defensive response that individuals use to protect themselves against further attack.

In the second study, children were observed to be ‘terribly frightened’ during the procedure, and ‘each child looked at his penis immediately after the circumcision as if to make sure that all was not cut off’ [7]. One 8-year-old boy fell ‘unconscious’ during the cutting and subsequently developed a stuttering problem. A few weeks later, parents being interviewed reported that their children exhibited increased aggressive behavior and experienced nightmares. In the same report, adults who were interviewed and recalled castration anxiety and other serious fears connected with their childhood circumcision, particularly if they had been deceived or forced by parents to undergo the procedure. Freud, who had a strongly critical view of circumcision, believed that it was a ’substitute for castration’ [7]. Castration anxiety resulting from circumcision may be related to the finding that symptoms from personal injury trauma often include fear of repetition of the trauma [7].

Long-term psychological effects

Without published studies, current knowledge of men’s feelings about their circumcision is generally based on reports from self-selected men who have contacted the Circumcision Resource Center (CRC) and other circumcision information organizations [8]. The feelings reported generally include anger, sense of loss, shame, and sense of having been victimized and violated, fear, distrust, grief, and jealousy of intact men.

The overwhelming majority of these men were circumcised as newborn infants. The memory of this event is not in their conscious awareness. Consequently, the connection between present feelings and circumcision may not be clear. However, some men attribute many negative feelings to their circumcision. Based on the responses of men who contacted the CRC, the origin of this attribution is in the impact of discovering one’s circumcision as a child. If a child grows in a community that has children who are not circumcised, it is probable that someday the circumcised boy will notice the difference. Under certain circumstances the realization that part of the penis was cut off can have trauma-like consequences, such as recurrent unwelcome thoughts and images. Attitudes about people, life and the future, may also be affected. Lack of awareness and understanding of circumcision, emotional repression, fear of disclosure, and non-verbal expression help keep circumcision feelings a secret [8].

Although men may be unaware of the effects of circumcision, the fear that their penis is somehow deficient is reported to be widespread in American culture [8]. Commercial interests have responded to this fear by advertising various methods of penile enlargement in men’s magazines. Male preoccupation with the penis is also reflected in a survey of what men think women find attractive in men. The data showed that men greatly exaggerated the importance of penis size as a physical attribute that attracts women [8]. The effect of circumcision on this result is now known.

Negative feelings about the penis are related to the idea of body image; this includes value judgements about how the body is thought to appear to others, and can have a great impact on how men live their lives are conducted [8]. In addition, the concepts of self and body image are interconnected and affect personal psychology. A diminished body image can diminish a person’s social and sexual life. Those who have a bodily loss fear the judgement of others and the weakening of personal relationships. The feeling of ‘not being a whole man’ can be especially distressing [7].

An aspect of self can be identified with a particular body part, as masculinity is typically identified with the penis. When that part is wounded there is often a corresponding intellectual wound to the self and a loss of self-esteem. How much of a connection there might be between low male self-esteem is uncertain. Low self-esteem often induces feelings of shame and these are projected by attacking the self-esteem of others; shame isolates us from others and from ourselves. A physical loss, like circumcision, can be a source of shame.

The link between adult circumcision, loss of sensitivity, and impotence has been noted in the medical literature [8]. Since infant circumcision also decreases sexual sensitivity [8], it is likely than circumcision is an unrecognized factor in the high rates of impotence in American men and by association, is also detrimental to male psychological health. Higher rates of impotence were associated with increased levels of anger and depression. Self-esteem was also lower in impotent men [8]. The psychological response to impotence would compound any pre-existing psychological symptoms that have already been discussed.

The motivation to circumcise

Although research shows harmful effects of circumcision, and there is much that is not known about the long-term effects. People want coherence and consistency in their beliefs and experience. If inconsistency occurs, called cognitive dissonance, beliefs tend to be aligned to fit experience [8]. The experience of many physicians is that they have performed it many times. Choosing to circumcise is a serious choice. After such a choice is made, people tend to appreciate the chosen alternative and depreciate the rejected alternative [8]. As a result, beliefs are adopted to conform with experience and support the decision to circumcise. An example of these beliefs as mentioned earlier is that newborn infants do not feel pain. Another common mistaken belief is that the prepuce has not useful purpose; one advocate of circumcision stated, ‘I believe that the prepuce is a mistake of nature’ [9].

Parents are solicited by hospital personnel to make a decision about circumcision, implying that it is an approved practice. Circumcision is the only surgery that is decided by lay people. Those parents who agree to circumcision for their newborn son are typically unaware of important information and may not understand what circumcision is. They fail to appreciate that circumcision is surgery. In one study, half of the mothers questioned did not know if the father of their child was circumcised [9]. In another study, 34% of men incorrectly identified their own circumcision status [9].

Physicians say they circumcise because parents request it; parents choose it because doctors do it. [9]. Communication between the physician and parents about circumcision is often insufficient for informed consent, largely because of emotional discomfort with the subject. Almost half the time there is no discussion between the physician and the mother about the medical aspects of circumcision [8]. If there is a discussion it may include incorrect tacit assumptions by physician and parent about what the other really wants or means [9]. These assumptions tend to lean toward the decision to circumcise. The parents’ lack of expertise leads them to defer to the physician’s supposed knowledge, thus contributing to communication deficiencies and a decision to circumcise. Although physicians do not require that parents choose circumcision, and parents believe that they are freely making their choice, physicians exercise control over the parents’ decision by controlling information and sometimes making a recommendation. [9].

The importance of conformity in the decision to circumcise is illustrated by a survey of parents of 124 newborn males born at an American hospital. The results showed that for parents making the decision, social concerns outweighed medical concerns. Parents’ reasons for circumcising were based mainly on an interest that the baby ‘look like’ his father, brothers and friends. Only 23% of the intact fathers had circumcised sons. In contrast, 90% of the circumcised fathers had circumcised sons. The authors concluded that the decision to circumcise ‘is more an emotional decision than a rational decision’ and has a strong base in social and cultural issues [9].

Any published evidence does not support the assumption, mostly on the part of circumcised men, that a boy would want to be circumcised if his father is circumcised. This idea may be part of a psychological defense mechanism called projection, the process of attributing feelings to others that belong to oneself. It is the circumcised father who may have some psychological issues if he looks different from his son. The fear of confronting these issues in themselves could motivate circumcised men to cling to the myth that intact sons will have such issues. Furthermore, when the first generation of American boys was circumcised, they looked different from their intact fathers. This myth was not prevalent then because intact men generally had no repressed feelings about how their penis looked. Pertinent information leads to the following deductions regarding the decision to circumcise for social or ‘matching’ reasons:

i. A circumcised boy who matches others may nevertheless have negative feelings about being circumcised. These feelings can last for a lifetime [8].

ii. It is not possible to predict before circumcision how a boy will feel about it later.

iii. Even though intact men are in the minority in the USA, there is no evidence that many of them are dissatisfied with being intact.

iv. An intact male who is unhappy about his status may feel different after learning more about circumcision and the important functions of the foreskin.

v. The social factor is much less of an issue for boys born in the USA today because of the lower circumcision rate [8].

Because it commonly affects behavior, social science researchers have extensively investigated the issue of conformity and have verified what is suspected here; group pressure can lead people to abandon their judgement and conform. Conforming to group practice has also been shown to be more likely when the group is large. Furthermore, when the situation is ambiguous, people are influenced by the group, and the greater the ambiguity, the greater the influence of the groups on the judgement of individual members. The need for social approval drives our tendency to conform. Until the environment of conflicting information and general support for the practice changes, conformity will continue to be a strong factor in circumcision decisions by parents.

Religious circumcision

There are no empirical studies on the perceptual aspects of religious circumcision. The following information is based on communications to the CRC and limited related literature. Jewish circumcision is associated with the Torah account (Gen. 17:6-14) where God commanded Abraham and his male descendants to be circumcised. Because the Jewish practice precedes its documentation in the Torah by over a thousand years [10], the divine commandment for circumcision may have been a way to relieve the parents of any sense of responsibility or guilt. The real origin of Jewish circumcision is a matter of speculation. Muslim circumcision is not mentioned in the Koran, and Muslim scholars debate its religious basis [10].

Since many Muslims and Jews either do not know or do not necessarily accept religious beliefs associated with circumcision cultural beliefs have been adopted to replace religious beliefs associated with circumcision and defend the practice [10]. For example, Muslims and Jews reinforce circumcision by believing that all members of the group practice it. With this belief, Jews and Muslims put themselves under pressure to comply with social expectations to circumcise. Having an ally helps people to resist conformity [10], but those in religious groups who question circumcision believe that they are alone and have no choice. In effect, religious circumcision is not necessarily chosen out of religious belief, but is often done out of fear of rejection if it is not performed.

Progress is being made among Jews; articles questioning circumcision have been published in the Jewish press, and more Jews are choosing not to circumcise their sons [10]. Records show that hundreds of Jews in the USA, Europe, South America and Israel either have not circumcised or would not circumcise a son. In Israel there is an organization that publicly opposes circumcision [10].

Cultural values and science

Among physicians, support for circumcision has been based on supposed ‘rational’ factors, but as psychiatrist Wilhelm Reich wrote, ‘Intellectual activity has often a structure and direction that it impresses one as an extremely clever apparatus precisely for the avoidance of facts, as an activity which distracts from reality’ [10]. This appears to have been the case in those advocating circumcision. Science has been adopted as the great arbiter between fact and fiction. The scientific method is designed to help protect the scientific community and the public against flawed reasoning, but it is the flawed reasoning of supposedly reputable scientific studies that has contributed to the confusion on the circumcision issue.

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.

Conclusion

There is strong evidence that circumcision is overwhelmingly painful and traumatic. Behavioral changes in circumcised infants have been observed. The physical and sexual loss resulting from circumcision is gaining recognition, and some men have strong feelings of dissatisfaction about being circumcised. The potential negative impact of circumcision on the mother-child relationship is evident from some mothers’ distressed responses and from the infants’ behavioral changes. Long-term psychological effects associated with circumcision can be difficult to establish because the consequences of early trauma are only rarely, and under special circumstances, recognizable to the person who experienced the trauma. However, lack of awareness does not necessarily mean that there has been no impact on thinking, feeling, attitude, behavior and functioning, which are often closely connected. In this way, an early trauma can alter a whole life, whether or not the trauma is consciously remembered.

Defending circumcision requires minimizing or dismissing the harm and producing overstated medical claims about protection from future harm. The ongoing denial requires the acceptance of false beliefs and misunderstandings of facts. These psychological factors affect professionals, members of religious groups and parents involved in the practice. Cultural conformity is a major force perpetuating non-religious circumcision, and to a greater degree, religious circumcision. The avoidance of guilt and the reluctance to acknowledge the mistake and all that that implies help to explain the tenacity with which the practice is defended.

Whatever affects us psychologically also affects us socially. If a trauma is acted out on the next generation, it can alter countless generations until it is recognized and stopped. The potential social consequences of circumcision are profound. There has been no study of these issues perhaps because they are too disturbing to those in societies that do circumcise and of little interest in societies that do not. Close psychological and social examination could threaten personal, cultural and religious beliefs of circumcising societies. Consequently, circumcision has become a political issue in which the feelings of infants are unappreciated and secondary to the feelings of adults, who are emotionally invested in the practice. Awareness about circumcision is changing, and investigation of the psychological and social effects of circumcision opens a valuable new area of inquiry.