Genital Autonomy:: Protecting Personal Choice

Genital Autonomy

George C. Denniston · Frederick M. Hodges · Marilyn Fayre Milos Editors

Genital Autonomy Protecting Personal Choice

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Editors George C. Denniston University of Washington Robbins Road 45 98358 Norland USA

Frederick M. Hodges University of Berkeley Post Office Box 5815 94705-0815 Berkeley USA

Marilyn Fayre Milos National Organization of Circumcision Information Resource Centers San Anselmo California USA [email protected]

ISBN 978-90-481-9445-2 e-ISBN 978-90-481-9446-9 DOI 10.1007/978-90-481-9446-9 Springer Dordrecht Heidelberg London New York Library of Congress Control Number: 2010933645 © Springer Science+Business Media B.V. 2010 No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from the Publisher, with the exception of any material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Preface

Why would anyone object to circumcision? For that matter, why would anyone hold an international symposium on this subject? In those countries and cultures where circumcision is ubiquitous, most people would probably ask these questions when confronted with this book. Indeed, most people from circumcising cultures accept circumcision as normal, necessary, and good. These peoples cannot imagine that circumcision is a violation of human rights or that it is harmful to any degree. One might as well try to convince them that dentistry is a harmful violation of human rights. Fundamentally, most people in circumcising cultures condone circumcision not because they are evil, malicious, sadistic, or insane, but because they have been conditioned to believe that circumcision is good, desirable, and honorable. In cultures where circumcision is not the norm, however, an entirely different perspective emerges. People in (for want of a better word) “genitally intact” cultures are horrified at the idea that someone would cut off part of the genitals of another person—especially a baby. The act is seen as misguided at best and demented at worst. Where, then, does the truth lie? Can science provide objective answers? Most people—including most scientists—imagine that “science” can be likened to an impartial and omniscient calculating machine that emits absolute truths when questions are fed into it. Indeed, the mythos of “science” has come to replace the oracles of the ancients. The majority of intelligent and educated people in ancient Greece probably had as much faith in the oracle at Delphi as modern Westerners have in “science” today. Medical journals now occupy the space once reserved only for holy scriptures and are revered as sources of objective and inviolable truth. Instead of soothsayers and sacred texts, we have scientists and science journals that proclaim the newly discovered truths. The high level of credulity and absolute faith in the statements published in science journals does not appear to be threatened even when whistle blowers reveal evidence of fraud, data manipulation, scientific misconduct, cover-ups, and corruption (Vastag, 2006). Even though respected medical and science journals have made headline news for having published studies that used falsified data, the people’s trust and faith in these journals never wavers. The journals Science, The New England Journal of Medicine, the Journal of Clinical

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Oncology, Immunity, the Journal of Experimental Medicine, and The Annals of Internal Medicine are among the top journals to have published fraudulent studies in recent years (Black, 2006). How many published studies based on fraudulent data go undetected? One meta-analysis found that a pooled weighted average of 1.97% (N = 7, 95% CI: 0.86–4.45) of scientists admitted to having fabricated, falsified, or modified data or results at least oncea serious form of misconduct by any standardand up to 33.7% admitted other questionable research practices. In surveys asking about the behavior of colleagues, admission rates were 14.12% (N = 12, 95% CI: 9.91–19.72) for falsification, and up to 72% for other questionable research practices (Fanelli, 2009). We trust the praiseworthy scientific method and have faith that self-styled scientists adhere to the scientific method when producing their scientific studies, but should we? Most people do not feel qualified to judge whether a published paper in a science journal has adhered to the scientific method. Instead, we spare ourselves the difficult task of critical thinking and instead have faith that the paper was produced honestly. This faith, however, is at the crux of the circumcision debate. It is interesting to note that circumcision is usually ubiquitous in countries where science education in the public schools is weakest. In third-world Muslim countries, where circumcision is endemic and in the United States, where mass circumcision was forced on the populace starting after World War II, the teaching of science in the public schools is far less adequate than it is in European public school systems. As predicted, in Europe, circumcision is practically unheard of among native Europeans. Could this be because the Europeans are better educated in science and therefore better able to judge the merits of a claim made by a medical doctor? Is this because Americans have blind faith in doctors and Europeans are more skeptical? When doctors claim that the results of their research prove that circumcision can prevent AIDS, most Americans blindly accept the veracity of this claim. Obviously, without an adequate education in science, they do not feel themselves qualified to question either the methodology or the results. Moreover, not only are the claims unchallenged, but the doctor himself remains unchallenged. Few laymen question his motivations. After all, since circumcision is a good thing, any doctor claiming that circumcision is beneficial must be a good doctor. It would not occur to the average layman that a doctor could deliberately be perpetrating a hoax or conspiring to commit scientific fraud. We like to imagine that the scientific method has the power to strip away any and all personal biases, motivations, or dark and disturbing psychosexual impulses from the researchers. Unfortunately, it does not have this power. Human psychology, especially when disturbed, unbalanced, and determined, can have a corrosive and corrupting effect on any endeavor, including science and religion. The papers presented in this volume address these topics from a variety of angles. They are each infused with a healthy skepticism that questions and dissects the true motivations of the doctors, witch doctors, and “holy men” who promote and profit from circumcision. With the greatest compassion, many of our authors also examine the blind faith that the victims have in the perpetrators. It is difficult to convince

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someone that everything he has been told about circumcision is a lie. It is equally difficult to convince a man that the body parts taken from him and destroyed might have been of value. Nevertheless, our authors do not shy away from the challenge of gently awakening the world to the fact that much of the world’s people have been deceived and abused at the hands of a small group of perpetrators who have alternately used science and religion as a smokescreen to hide the truth in order to trick their victims into compliance. It is our hope that readers of this volume will have their eyes opened a bit wider and begin to have faith in their own abilities to think for themselves and question extravagant claims—especially those that result in the permanent loss of a body part or result in a child being injured to any degree. Seattle, Washington Berkeley, California San Anselmo, California

George C. Denniston Frederick M. Hodges Marilyn Fayre Milos

References Black A. (2006) Fraud in medical research: A frightening, all-too-common trend on the rise. NaturalNews.com. April 18, 2006. http://www.naturalnews.com/019353.html Fanelli D. (2009) How many scientists fabricate and falsify research? A systematic review and meta-analysis of survey data. PLoS ONE. 4(5):e5738, doi: 10.1371/journal.pone.0005738. Vastag B. (2006) Cancer fraud case stuns research community, prompts reflection on peer review process. JNCI. 98(6):374–376, doi: 10.1093/jnci/djj118.

Acknowledgments

The work of putting on the symposium from which the papers in this book were drawn is the product of many hands. We would like to thank David Smith, Margaret Green, and the many members of NORM-UK who worked so diligently to make the symposium at Keele University a success. We are also honored to acknowledge Marie Fox and Michael Thomson, professors at Keele University School of Law, who co-sponsored our symposium, presented papers, and contributed significantly to this book. Special thanks are due to Gaye Blake-Roberts, Director of the Wedgwood Museum and renowned speaker and author on British ceramics, for the lovely Wedgwood plates with the International Child for Genital Autonomy that she had commissioned as a gift for each of the symposium presenters, and for hosting the reception of our gala dinner in the beautiful university rooms, where a fine collection of ceramics was made available for the enjoyment of symposium attendees. We thank Ken Brierley and Sheila Curran for their tireless efforts in helping to make the symposium a successful event. Of course, we would like to thank our contributors, whose papers have added to our body of information about a crucially important human rights issue. And, finally, we acknowledge those who have survived the pain and trauma of genital cutting, those who have the courage to speak out against harmful traditional practices, and everyone who works to protect the genital integrity rights of those who are too little to defend or protect themselves. Together, we are making a safer world for the children.

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Contents

1 “Three-Fourths Were Abnormal”—Misha’s Case, Sick Societies, and the Law . . . . . . . . . . . . . . . . . . . . . . . . . J. Steven Svoboda

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2 Older Minors and Circumcision: Questioning the Limits of Religious Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . Marie Fox and Michael Thomson

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3 These Goalposts Don’t Move: Non-Medical Circumcision of Boys in the Tasmanian and Australian Context . . . . . . . . . . Paul Mason

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4 Mass Campaigns of Male Circumcision for HIV Control in Africa: Clinical Efficacy, Population Effectiveness, Political Issues . Michel Garenne

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5 AIDS XVII, Mexico City: Reason for Hope or Panic? . . . . . . . . John Geisheker

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6 Circumcision Psychopathology . . . . . . . . . . . . . . . . . . . . George C. Denniston

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7 Physical Effects of Circumcision . . . . . . . . . . . . . . . . . . . John Warren

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8 Complications of Circumcision: A Urologist’s Viewpoint . . . . . . James L. Snyder

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9 NOCIRC of Italy: Scientific Activities 2006–2009 . . . . . . . . . . Franco Viviani, S. Bobbo, S. Malaguti, and D. Paolini

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A Project About Male Circumcision in the Veneto . . . . . . . . . . M. Gloria de Bernardo

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The First Survey on Genital Stretching in Italy . . . . . . . . . . . Pia Grassivaro Gallo, Annalisa Bertoletti, Ilenia Zanotti, and Lucrezia Catania

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Knowledge and Opinions of North Italian Health Operators About Female Genital Mutilation . . . . . . . . . . . . . . . . . . . Pia Grassivaro Gallo, Ilenia Zanotti, Annalisa Bertoletti, Lucrezia Catania, and Miriam Manganoni

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Stretching of the Labia Minora and Other Expansive Interventions of Female Genitals in the Democratic Republic of the Congo (DRC) . . . . . . . . . . . . . . . . . . . . . Pia Grassivaro Gallo, Nancy Tshiala Mbuyi, and Annalisa Bertoletti

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Preventing Infibulation: Mana Sultan Abdurahman Isse at Merka, Somalia . . . . . . . . . . . . . . . . . . . . . . . . . . . Pia Grassivaro Gallo and Sandra Busatta

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Writing Rites Gone Wrong: Autobiography, Testimonials, and Their Relevance to the Debate Around Genital Alterations . . Chantal Zabus

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The Impact of Neonatal Circumcision: Implications for Doctors of Men’s Experiences in Regressive Therapy . . . . . . . . Robert Clover Johnson

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Circumcision Memory . . . . . . . . . . . . . . . . . . . . . . . . . Thomas W. Hennen

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Foreskin Restoration 1980–2008 . . . . . . . . . . . . . . . . . . . . R. Wayne Griffiths, J. David Bigelow, and James Loewen

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Restoration: The Foreskin and the American Dream . . . . . . . . Ron Low

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Genital Autonomy: The Way Forward . . . . . . . . . . . . . . . . David Smith

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Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . George Wald

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Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contributors

Annalisa Bertoletti Working Group of FGM, University of Padua, Padua, Italy J. David Bigelow National Organization of Restoring Men, Concord, CA, USA S. Bobbo Faculty of Psychology, University of Padua, Italy Sandra Busatta Working Group on FGM, University of Padua, Padua, Italy Lucrezia Catania Resource Center for Preventing and Curing FGM and Its Complications, University of Florence, Florence, Italy M. Gloria de Bernardo University of Verona, Verona, Italy; University of Padua, Padua, Italy, [email protected] George C. Denniston Doctors Opposing Circumcision (D.O.C.), Seattle, WA, USA Marie Fox School of Law, University of Keele, Staffordshire, UK Michel Garenne IRD (French Institute for Research and Development) and Institut Pasteur, Paris, France, [email protected] John Geisheker Doctors Opposing Circumcision, Seattle, WA, USA, [email protected] Pia Grassivaro Gallo Working Group of FGM, University of Padua, Padua, Italy, [email protected] R. Wayne Griffiths National Organization of Restoring Men, Concord, CA, USA, [email protected] Thomas W. Hennen Washington and California Bar Associations, Attorney Before the US Patent & Trademark Office, Des Moines, WA, USA, [email protected] Robert Clover Johnson Gallaudet University Press, Washington, DC, USA, [email protected] James Loewen National Organization of Restoring Men, Concord, CA, USA

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Contributors

Ron Low Northwestern University, Kellogg Graduate School of Management, Chicago, IL, USA, [email protected] S. Malaguti Faculty of Psychology, University of Padua, Italy Miriam Manganoni Working Group on FGM, University of Padua, Padua, Italy Paul Mason Commissioner for Children, Tasmania, Australia, [email protected] D. Paolini Faculty of Psychology, University of Padua, Italy David Smith NORM-UK, Staffordshire, UK, [email protected] James L. Snyder American Board of Urology, American College of Surgeons, Virginia Urological Society, Clifton Forge, VA, USA, [email protected] J. Steven Svoboda Attorneys for the Rights of the Child, Berkeley, CA, USA, [email protected] Michael Thomson School of Law, University of Keele, Staffordshire, UK, [email protected] Nancy Tshiala Mbuyi Working Group on FGM, University of Padua, Padua, Italy Franco Viviani Faculty of Psychology, University of Padua, Padua, Italy, [email protected] George Wald Professor of Biology, Harvard University, Cambridge, MA, USA, [email protected] John Warren Royal College of Physicians, London, UK; NORM-UK, Staffordshire, UK, [email protected] Chantal Zabus Universities of Paris XIII & III-Sorbonne Nouvelle, Paris, France; Institut Universitaire de France, Paris, France, [email protected] Ilenia Zanotti Working Group of FGM, University of Padua, Padua, Italy

About the Authors

Peter Ball MA MB, BChir DA, is a retired family practitioner, Vice Chairman of NORM-UK, and the producer and director of a non-surgical foreskin restoration video. Tunbridge Wells, Kent, UK. Annalisa Bertoletti PhD, graduated in Psychology, University of Padua, and is a member of the Padua Working Group on FGM. Padua, Italy. J. David Bigelow PhD, earned his doctorate in psychology at Claremont Graduate School, is a retired college professor (Whittier College), therapist, clergyman, and author of The Joy of Uncircumcising% Exploring Circumcision: History, Myths, Psychology, Restoration, Sexual Pleasure and Human Rights. Pacific Grove, CA, USA. Sandra Bussata PhD, is Professor of Social Anthropology, University of Padua, and a member of the Padua Working Group on FGM, Padua, Italy. Lucrezia Catania is a member of the Padua Working Group on FGM. Padua, Italy. Georganne Chapin JD, is President and CEO of Hudson Health Plan, a non-profit Medicaid managed care company in New York’s Hudson Valley. She is also founder and President of the Hudson Center for Health Equity & Quality (Hcheq), an organization whose purpose is to contribute to policy and technology efforts toward healthcare reform. Georganne is the CEO of Intact America, an organization dedicated to keeping babies whole. She has taught Bioethics as well as Medicaid and Disability Law at Pace University School of Law, from which she received her law degree. She also holds an undergraduate degree in Anthropology from Barnard College and a Masters in Sociomedical Science from Columbia University. She serves on a number of non-profit Boards, including that of Attorneys for the Rights of the Child (ARC). Tarrytown, NY, USA. M. Gloria de Bernardo PhD, teaches Ethno-Anthropology and Social Anthropology, Surgery and Medicine Faculty, University of Verona and University of Padua. She is President of the Ethic Committee in “Clinical Practice, Hospital Institute of Verona, and has been a member of the Experimentation Committee, as an “Expert in Bioethic Science,” following her experience at the San Raffaele in Milan

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About the Authors

and at Lana Foundation in Padua. She is a member of the Medical Anthropology Italian Society (SIAM). She has written many articles for Etnoginecology Magazine, as a result of her personal research and her research with the Padua Working Group on FGM. She is the author of The Respect of Pain and Death in the Main Confessions. Padua, Italy. George C. Denniston MD (University of Pennsylvania School of Medicine), MPH (Harvard School of Public Health), founder and President of Doctors Opposing Circumcision (D.O.C.), co-author, Doctors Re-examine Circumcision, co-editor of the proceedings of the International Symposia on Circumcision, Human Rights, and Genital Integrity, Sexual Mutilations: A Human Tragedy, Male and Female Circumcision: Medical, Legal and Ethical Considerations in Pediatric Practice, Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, Flesh and Blood: Perspectives on the Problem of Circumcision in Contemporary Society, Bodily Integrity and the Politics of Circumcision, Culture, Controversy and Change, and Circumcision and Human Rights. He is also the former Associate Medical Director of the Planned Parenthood Federation of America. Olympic Peninsula, WA, USA. Marie Fox is Professor of Law at the University of Keele. Her main research interests are in the fields of Health Care Law, Animal Law and Feminist Legal Theory. Selected recent publications include: (with Jean McHale), 2nd edition of Health Care Law: Text, Cases and Materials (Sweet & Maxwell) 2006 (1204, xxxvi pages); “The Regulation of Xenotransplantation in the United Kingdom After UKXIRA: Legal and Ethical Issues” (with L. Williamson and S. McLean) (2007) 34(4) Journal of Law & Society 441–464; “Rethinking the Animal/Human Boundary: The Impact of Xeno Technologies” (2005) 26 Liverpool Law Review 149–167; (with Michael Thomson) “Cutting It: Surgical Interventions and the Sexing of Children” (2005) 12 Cardozo Journal of Law & Gender 82–97; (with Michael Thomson) “A Covenant with the Status Quo?: Male Circumcision and the New BMA Guidance to Doctors,” (2005) 31 Journal of Medical Ethics 463–469; (with Michael Thomson) “Short Changed? The Law and Ethics of Male Circumcision,” (2005) 13 International Journal of Children’s Rights 161–181; republished in M. Freeman (ed.) Children’s Health and Children’s Rights Leiden/Boston: Martinus Nijhoff Publishers, 2006. Staffordshire, UK. Michel Garenne PhD (demography), is Director of Research at the French Institute for Research and Development and is currently working at the Pasteur Institute, Emerging Diseases Unit, in Paris. He is also honorary Associate Professor at the University of Witwatersrand, Johannesburg. He directed the Niakhar Demographic Surveillance System in Senegal in the 1980 s and has collaborated with the Agincourt Health and Demographic Surveillance System in South Africa since 1992. He is the author of numerous publications on population and health issues in Africa, and has taught demography at several universities in Europe (Paris, Clermont-Ferrand, Heidelberg, Antwerp), and in the United States (Harvard). Paris, France.

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John Geisheker JD, LLM, is the General Counsel and Executive Director of Doctors Opposing Circumcision. Seattle, WA, USA. Pia Grassivaro Gallo PhD, Associate Professor of Anthropology, University of Padua’s Psychology Faculty, and former teacher of Applied Biology, Human Genetics, and Anthropogenetics. Her research on the biology of current human populations has taken place in several developing countries, particularly Somalia (from 1972 to 1985). At the invitation of the Somali Ministry of Public Health (1981), she was invited to take part in a scientific mission to Somaliland. From 1988, she has been responsible for the Padua Working Group on FGM, dealing with African immigrants in Italy. From 2000, she studied the expansive forms of the traditional interventions on female genitalia, carrying out field researchers in Central Africa (Uganda, Malawi, and Congo RDC). She was co-coordinator of the 8th International Symposium on Circumcision and Human Rights, Padua, Italy. R. Wayne Griffiths MS, MEd, a sociologist and educator, received his MS from BYU and his MEd from Oregon State University and did post graduate work at the University of Southern California in Los Angeles. He was an assistant professor of sociology and criminology at Armstrong State College in Savannah, Georgia. He is the co-founder and Executive Director of the National Organization of Restoring Men (NORM), which was founded in 1989. He has written and published a number of articles on foreskin restoration. Concord, CA, USA. Thomas W. Hennen JD, received a BS degree in Mechanical Engineering from Washington State University (1969) and a Juris Doctor in Law from the University of Maine School of Law (1973). He is a member of both the Washington and California Bar Associations and is admitted as an attorney before the US Patent & Trademark Office. He has spent 33 years of his professional career working as an Intellectual Property Attorney for government and corporate employers. Des Moines, WA, USA. Frederick M. Hodges Dphil (Oxon), is a medical historian, the co-author of What Your Doctor May Not Tell You About Circumcision: Untold Facts on America’s Most Widely Performed—and Most Unnecessary—Surgery (Warner Books 2002), and co-editor of the proceedings of the International Symposia on Circumcision, Human Rights, and Genital Integrity, Sexual Mutilations: A Human Tragedy, Male and Female Circumcision: Medical, Legal and Ethical Considerations in Pediatric Practice, Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, Flesh and Blood: Perspectives on the Problem of Circumcision in Contemporary Society, Bodily Integrity and the Politics of Circumcision, Culture, Controversy and Change, and Circumcision and Human Rights. Berkeley, CA, USA. Robert C. Johnson recently retired from a 24-year career as a writer and editor at Gallaudet University in Washington, DC, USA, where he wrote extensively about deafness-related research. He is co-editor of Testing Deaf Students in an Age of Accountability, published by Gallaudet University Press. In 2005, at the age of 60,

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determined to understand and overcome the root cause of difficulties with intimacy he had experienced all his adolescent and adult life, he decided to pursue an eclectic form of regressive therapy for a second time. Much to his surprise, during one session of this therapy, he began to re-experience his neonatal circumcision, an event he believes originally occurred within hours or minutes after birth, without parental consent (a frequent occurrence in 1945), many hours before he met his parents. His paper describes his journey from that shocking discovery to his current status as an anti-circumcision activist. Alexandria, VA, USA. James Loewen Photographer, discovered his circumcised status at age seven, which sparked his outrage. Artistic abilitiesas a child led him to a career as a photographer and many fascinating assignments, including a three-month project in1975, photographing the activities at the sex-change clinic of the notorious Dr. John Brown. In 1993, Loewen happened upon Jim Bigelow’s book, The Joy of Uncircumcising, and began connecting with others opposed to infant and childhood genital surgeries. His lifetime of questioning gender, sexual roles, and orientation has informed his artistic and intactivist activities. Currently he is making videos related to intactivism and hosting a YouTube channel, “intactivist1,” with many collected video clips related to the issue. Vancouver, British Columbia, Canada. Ron Low BS, MS, markets TLC Tugger foreskin restoration devices (http:// TLCTugger.com), hosts the Circumspect iTunes podcast series, and moderates the Foreskin-Restoration/Intactivist Network Internet forum (http://ForeskinRestoration.net/forum). Ron was circumcised at birth and has been a foreskin restorer since 2001. He was cited in the book Everything you know about Sex is Wrong, featured in the BBC documentary Circumcise Me?, and interviewed by major newspapers and Time magazine. He appears in the 2007 intactivist film Cut, and he presented the topic of foreskin restoration to a Mensa convention and to the Everyday Edisons reality show. In August of 2008, Ron demonstrated foreskin restoration to Howard Stern and his radio/TV audience of millions. Ron earned a Bachelors degree in Industrial Engineering from University of Illinois and a Masters degree in Services Marketing and Entrepreneurship from Northwestern University’s Kellogg Graduate School of Management. Chicago, IL, USA. Miriam Maganoni is a member of the Padua Working Group on FGM. Padua, Italy. Paul Mason is the Commissioner for Children [CfC] for Tasmania. The CfC is an officer of Executive Government, independent of the elected government of the day, appointed to advise the Government and to increase public awareness of matters relating to the health, welfare, care, protection, and development of children. Paul is a family lawyer with 30 years experience. Nancy Tshiala Mbuyi graduated in Nursing Sciences, University of Padua, and is a member of the Padua Working Group on FGM. Padua, Italy. Marilyn Fayre Milos RN, is the founder and Executive Director of the National Organization of Circumcision Information Resource Centers (NOCIRC), the

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coordinator of the International Symposia on Circumcision, Genital Integrity, and Human Rights, the editor of the NOCIRC Annual Report, and the coeditor of the proceedings of the International Symposia on Circumcision, Human Rights, and Genital Integrity, Sexual Mutilations: A Human Tragedy, Male and Female Circumcision: Medical, Legal and Ethical Considerations in Pediatric Practice, Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, Flesh and Blood: Perspectives on the Problem of Circumcision in Contemporary Society, Bodily Integrity and the Politics of Circumcision, Culture, Controversy and Change, and Circumcision and Human Rights. San Anselmo, CA, USA. David Smith was educated at St Joseph’s College, Market Drayton, and he qualified in business studies at Underwood College. He worked for Re-Solv, the solvent abuse charity, but he currently works full-time as General Manager of NORMUK, and is the organization’s only paid staff member. David created and is now the editor of NORM NEWS, the organization’s magazine for members. Staffordshire, UK. James L. Snyder MD, FACS, is a Diplomate of American Board of Urology, a Fellow of the American College of Surgeons, Past President of the Virginia Urological Society, Retired Commander, Medical Corps, United States Naval Reserve, who retired from medical practice in 2000. He has served as expert witness in several circumcision lawsuits. Clifton Forge, VA, USA. J. Steven Svoboda JD, focuses on civil litigation and human rights, and is the founder and Executive Director of Attorneys for the Rights of the Child (ARC), a non-profit organization addressing the illegality of involuntary genital surgery. Berkeley, CA, USA. Michael Thomson is Professor of Law, Culture & Society at the University of Keele. His research interests include Health Care Law, Law and Gender, and Law and Literature. His particular focus has been the regulation of reproduction and the relationship between law and gender. The focus of his most recent work is masculinity and the legal regulation of the male sexed body. He is the author of Reproducing Narrative: Gender, Reproduction and Law (Dartmouth, 1998) and Endowed: Regulating the Male Sexed Body (Routledge, 2007). Staffordshire, UK. Franco Viviani is Professor of Anthropology Applied to Psychology, Department of Psychology of Work and Socialization, Faculty of Psychology, University of Padua. His academic work has focused primarily on sport anthropology and then on the health-related issues that arise in the context of physical activity, fitness and health. He is President of the International Council of Physical Activity and Fitness Research and an active member of several scientific health-related associations, including the Presidium of NFH Shanghai, which organizes annual international congresses on nutrition, fitness and health. After developing an interest on female circumcision, he published books, research papers, and directed audio-visuals on the topic. He has published several papers and articles both on male and female circumcision and co-organized congresses, workshops and participated in debates on the

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topic. As he is the NOCIRC representative for Italy, informing the media whenever facts or public debates focus on male and female circumcision. John Warren MB BChir DCH FRCP, qualified in medicine at Cambridge University, England (1966). He obtained the Diploma of Child Health (1968), Membership of the Royal College of Physicians of London (1970), and was made a Fellow of the Royal College of Physicians (1987). After junior training posts, he was appointed a consultant physician in Harlow, Essex (1975), specialising in general internal medicine and respiratory disease. He became interested in problems surrounding infant circumcision when studying child health (1968), and followed up this interest in the early 1990 s, leading to the establishment of NORM-UK (1995), of which he has been chairman since its foundation. He retired from medical practice in 2006. Harlow, Essex, UK. Chantal Zabus is Professor of Postcolonial Literature and Gender Studies at the University Paris 13, a Researcher at the University of Paris 3-Sorbonne Nouvelle, and a Senior Scholar at the Institut Universitaire de France, Paris. She is the author of Between Rites and Rights: Excision in Women’s Experiential Texts and Human Contexts, Stanford UP, 2007); The African Palimpsest (Rodopi, 1991; rpt 2007); Tempests after Shakespeare (Palgrave, 2002). She has also edited Le Secret (with J. Derrida, Louvain, 1999), Changements au féminin en Afrique noire (L’Harmattan, 2000), Fearful Symmetries: Essays and Testimonies Around Excision and Circumcision (Rodopi, 2009), and she is currently editing Perennial Empires (with Silvia Nagy-Zekmi). Paris, France. Ilenia Zanotti PhD, received her degree in Psychology at the University of Padua. She is a member of the Padua Working Group on FGM. Padua, Italy.

Chapter 1

“Three-Fourths Were Abnormal”—Misha’s Case, Sick Societies, and the Law J. Steven Svoboda

Abstract Law, human rights, medical ethics, and social mandates reflect, transmit, and reinforce social norms. Well over a century ago, normality was redefined, and suddenly, “three-fourths of all male babies [had] abnormal prepuces.” Genital cutting presents a cluster of interwoven discriminations that violate law, human rights, and ethics. Differential terminology—MGC and FGC—facilitates differential treatment and unequal protection. Oregon’s Boldt v. Boldt case ended in the boy’s wishes being honored, but perhaps only due to the inexcusable 5-year delay in resolving the case and the conflation of custody and circumcision issues. This case eloquently demonstrates the law’s inability to effectively address male circumcision. Numerous authors from a variety of disciplines have forcefully contested the reigning paradigm whereby FGC is outlawed and MGC is legally tolerated. Some observers also note the further irony that cosmetic FGC by wealthy westerners is permitted while traditional FGC by developing world peoples is vilified. Activists against FGC are acknowledging their support of the movement for male intact rights. HIV/AIDS is the latest attempted justification for male genital amputation but utterly fails scrutiny, as even the Centers for Disease Control and Prevention (CDC) is finding itself compelled to concede in the face of growing protests in favor of children’s rights. Not only do most of the reasons for FGC parallel the rationales for MGC, but a surprising number of similarities link cultures around the world that practice MGC. Parents (as in Boldt v. Boldt), doctors, and society seek treatment, not the infant. Thus, the problem cannot be solved by a medical procedure, which circumcision never was anyway. Only human compassion can end the nightmare. Keywords Law · Human rights · Medical ethics · Religion · Male circumcision Law, human rights, and medical ethics reflect, transmit, and reinforce social norms. These official mandates are ultimately enforced by a country’s police power. Social mandates including culture, mythology, and religion enforce social norms through J.S. Svoboda (B) Attorneys for the Rights of the Child, Berkeley, CA, USA e-mail: [email protected]

G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9_1,  C Springer Science+Business Media B.V. 2010

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less official channels but can operate at least as potently, often complementing and enabling (and indeed, often helping give rise to) official mandates. Such social mandates have powerfully supported infant male circumcision. Sarah Waldeck points out that “when circumcision rates in the United States were more than 70%, nearly 10% of parents thought the procedure was required by law, much like . . . the installation of silver nitrate drops into a newborn’s eyes shortly after birth.”1 Mythology such as scientific misinformation and misplaced desire that a son “look like” his father has further facilitated the continued persistence of this Victorian holdover.2 Genital cutting persists because it is perceived to provide real or imagined benefits and to connect the cut individual to society along a variety of dimensions— cultural, economic, class-related, medical, mythological, psychological, sexual, religious, “scientific,” etc. Desired societal values that may help justify and institutionalize mutilations encompass courage, pride, fulfillment of the assigned sexual role, religious devotion, willingness to sacrifice oneself for society’s greater good, and many others.3 Regarding MGC in primitive cultures, Paige and Paige comment that “the boy who is circumcised is not himself the object of the ceremony, which is, in fact, conducted to impress others. . .”4 This observation calls to mind Ford’s apt observation regarding intersex surgeries on infants, which is every bit as applicable to male circumcision: “It is the parents and doctors of intersexed infants who are experiencing a medical emergency, not the intersexed infant.”5 Circumcision, therefore, “solves” a non-existent problem, utterly failing to address the infant’s needs while treating the child as a means to society’s ends rather than an end in himself, thereby violating Kantian ethics. Male circumcision, like female circumcision, as Prescott notes, never has been primarily a medical issue. Rather, its roots go deep into powerful religious beliefs and social customs that defy rational analysis.6 As Voskuil shows, menstrual blood and male genital bleeding are closely connected. As one of many examples, “in ancient Egypt boys going to be circumcised wore girls’ clothes and were followed by a woman sprinkling salt, a common substitute for menstrual blood.”7 Romberg notes, “One possible, intriguing motivation for male genital mutilation (both foreskin amputation and subincision—the ritual slashing of the underside of the penis) is menstrual envy.”8 As Bettelheim discusses, penile subincision is called “men’s menstruation.” Thus, men mimicked women’s power in the very ritual that affirmed their maleness, their entitlement to exclude women from positions of importance in the tribe and in religious leadership.9 The transformational power of genital modification must be appreciated to understand these practices’ persistence. A Nineteenth century physician’s medical journal article by S.G.A. Brown states in all seriousness that, “Fully three-fourths of all male babies have abnormal prepuces.”10 Such a redefinition of normality is inherent in the process of genital modification, and can be one of its goals. MGC purges the male body of the “female” foreskin, while FGC purges the female body of the “male” clitoris. Genital modification can promise to redefine normality by turning a boy into a man, a girl into a woman, or a non-virgin back into a virgin. Our S.G.A. Brown for the modern era may be the notorious Brian J. Morris, writing on “Why circumcision is a biomedical imperative for the twenty-first century.”11

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The exoticization of “African” FGC contrasts with the normalization of “American” MGC. An almost missionary evangelism characterizes anti-FGC activists’ opposition to these practices, while a culturally inert prurience regarding male circumcision reinforces the status quo. Law helps both processes by reifying and reinforcing social norms. Circumcision is tied up with three of the most powerful discourses in modern society—science, medicine, and religion, and a variety of other uncomfortable, controversial and deeply emotional issues including psychological denial and parental authority. No wonder there is so much argument.12 Genital cutting presents a cluster of interwoven discriminations—racial, genderbased, age-based, and class-based—that violate law, human rights, and ethics. We know that human rights treaties—the supreme law of the land and applicable either through ratification or through customary law—forbid circumcision based on such important principles as the rights of the child, the right to freedom of religion, and the right to the highest attainable standard of health. Human rights treaties are binding in the US either through ratification (as with the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social, and Political Rights) or through customary law (as with the Convention on the Rights of the Child, of which we remain the only non-ratifying country in the world with a functioning government). The United Nations has already endorsed in official documents the principle that male genital cutting (MGC) qualifies as a human rights violation, at least under certain circumstances.13,14 A presentation by Attorneys for the Rights of the Child and the National Organization of Circumcision Information Resource Centers centrally addresses male circumcision as a human rights violation and is part of the official UN record.15 The legal status quo, whereby female genital cutting (FGC) is severely punished while MGC is not punished either criminally or civilly as long as it is done “competently” and with “consent” of the parents, must be unstable. Differential terminology—MGC and FGC—facilitates differential treatment. We do not speak of male rape and female rape. We do not speak of female incest and male incest. A priori, there is no reason (and no justification) for this gender-stratified taxonomy. Of course, it does help to obscure the clear violation of equal protection that otherwise might become evident whenever a legal action relating to MGC makes it into court. One recent lawsuit has already become the most famous circumcision-related legal case ever. In Boldt v. Boldt, the Oregon custody case filed in 2004 in which a recently converted Jewish father had been seeking the circumcision of his son Misha against the wishes of the boy’s mother, the Oregon Supreme Court (OSC) reversed the trial court’s and the court of appeals’ previous decisions in favor of the father. The OSC remanded (returned) the case to the trial court for further proceedings, including a determination of the boy’s wishes in the matter. The final paragraph of the OSC’s ruling held: If the trial court finds that M agrees to be circumcised, the court shall enter an order denying mother’s motions. If, however, the trial court finds that M opposes the circumcision, it must

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J.S. Svoboda then determine whether M’s opposition to circumcision will affect father’s ability to properly care for M. And, if necessary, the trial court then can determine whether it is in M’s best interest to retain the existing custody arrangement, whether other conditions should be imposed on father’s continued custody of M, or change custody from father to mother.16

At the remand hearing, held in April 2009, the then 14-year-old boy testified privately to the judge with neither parent present. Misha told the judge he did not want to be circumcised, nor did he want to be Jewish, and the judge accepted that testimony on the record in the courtroom. In June 2009, she issued an order finding significant cause to warrant testimony as to whether custody should be returned to the mother. The great irony, as attorney John Geisheker points out, is that the unconscionable delay may be the very factor that saved him, giving him time to grow and develop self-confidence to the point where no one could fail to be swayed by his desires.17 Thus the most obvious solution, to let the boy grow old enough to make his own decision, was reached not deliberately but more or less by default and through the passage of time. Despite the happy end result, Geisheker was troubled by the gratuitous linkage of circumcision with custody. Ironically, this procedural point may be precisely what got the case onto the Oregon Supreme Court docket in the first place, as family law matters are rarely reviewed by courts of general jurisdiction [and in fact are exempt from such review]. It is appalling to put the child in the position of choosing surgery to stay with dad, or freedom from surgery with his mom.

Geisheker notes that the Court mentioned only the child’s right to be heard, but did not recognize its paramount duty to protect him.18 Misha’s case is a sad commentary upon American life and constitutional principles. Boldt v. Boldt eloquently demonstrates that in the US, at least, the law to date has not been able to effectively grapple with such a heavily contextual and cultural practice as male circumcision. To date, with one known exception, all awards and settlements have occurred in cases involving either a “botched” procedure or a lack of informed consent. At least three times, courts have avoided squarely addressing the legality of male circumcision by diverting the discussion into such peripheral, procedural issues as standing. Judicial views of standing are politically and culturally shaped in response to social mandates. Although MGC is currently illegal under existing laws and human rights treaties, if properly and objectively interpreted free of cultural bias, American cultural blindness has prevented recognition of this.19 Elsewhere in the world, Tasmania’s Law Review Commission recently released a lengthy issues paper questioning the legality of male circumcision.20 Sweden has regulated circumcision and the practice was recently made illegal in South Africa, with religious and medical exceptions included that threaten to swallow the rule. While the practice is not otherwise explicitly prohibited anywhere in the world, it is of course illegal worldwide under a broad range of prohibitions imposed by statute, common or civil law, human rights treaties, and customary law.” By contrast, world opinion has determined that girls’ bodies are more important than tradition, and that any cutting of the female genitals is female genital mutilation, now banned by law in many countries. Under the reigning paradigm,

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discrimination against men is regarded far less seriously than discrimination against women. Despite a blatant violation of the equal protection principles enshrined in the United States Constitution and human rights treaties, courts are reluctant to affirm claims of equal treatment not yet socially approved. A movement brought primarily or exclusively on behalf of males seems to cause discomfort to individuals, institutions, and society.21 However, signs are appearing on the horizon that such balancing acts are becoming more difficult to sustain. Numerous authors from a variety of disciplines are concluding that, due to basic issues of justice as well as equal protection principles, genital cutting is genital cutting, whether done on a male or female body.22 Two commentators have forcefully argued that given the American laws against FGC, MGC must also be illegal under the US constitutional principle of equal protection.23,24 After an exhaustive review of legal and human rights implications of circumcision, European human rights scholar Jacqueline Smith concludes that the differential treatment is simply indefensible. “By condemning one practice and not the other, another basic human right, namely the right to freedom from discrimination, is at stake. Regardless of whether a child is a boy or a girl, neither should be subject to a harmful traditional practice.”25 Dena Davis finds “troubling implications for the constitutional requirement of equal protection, because the law appears to protect little girls, but not little boys, from religious and culturally motivated surgery.”26 Sirkuu Hellsten concludes that “from a human rights perspective, both male and female genital mutilation, particularly when performed on infants or defenseless small children . . . can be clearly condemned as a violation of children’s rights.”27 Anthropologist Kirsten Bell notes the contradictory policies of international health organizations, “which seek to medicalize male circumcision on the one hand, oppose the medicalization of female circumcision on the other, while simultaneously basing their opposition to female operations on grounds that could legitimately be used to condemn the male operations.”28 R. Charli Carpenter criticizes the United Nations’ double standard with regard to “harmful traditional practices,” a term the UN defines to exclusively address women and girls while ignoring “the most obvious one of all—the genital mutilation of infant boys, euphemistically known as . . . circumcision.”29 In addressing male circumcision within an article primarily devoted to female circumcision of Egyptian Nubians, Fadwa El Guindi calls feminists to task for their “arrogant and ethnocentric” focus on saving ostensibly helpless African women while ignoring “the cruelty of American male infant circumcision.30 One of the anthropologists who has been working on FGC the longest, Janice Boddy, forthrightly asks, “Why is there no outrage remotely parallel to that which leads some writers to insist that circumcised women are entirely alienated from the essence of the female personality [citations omitted]? Is it because these excisions are performed on boys, and only girls and women figure as victims in our cultural lexicon?” A bit later in her article, Boddy proffers a possible explanation for the widely disparate views: “intuitively, men and boys are not ‘natural’ victims.”31 Fox and Thomson suggest a possible reason for this collective failure of our intuition.

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They write that a “harm/benefit assessment [footnote omitted] lies at the heart of the male circumcision debate,” contending that legal and ethical tolerance of male circumcision can be attributed to traditional constructions of male bodies as resistant to harm or even in need of being tested by painful ordeals, and of female bodies, by contrast, as highly vulnerable and thus in need of greater protection.32 Oddly enough—and demonstrating the pervasive power of the “tough male” stereotype—although Fox and Thomson emphasize that MGC is always risky surgery, mentioning adverse outcomes, they neglect the most obvious harm of all: the harm of being deprived of an integral and erotically significant part of the penis. Sami A. Aldeeb Abu-Sahlieh argues forcefully and simply. “The right to physical integrity is a principle. We must accept or reject genital cutting in totality. If we accept this principle, we must refrain from cutting of children’s genitals regardless of their sex, their religion, or their culture.”33 Audrey Macklin34 and Christine Mason35 reach similar conclusions. From an ethical perspective, the procedures look even more analogous, for, as Bell comments, “each operation involves an unnecessary bodily violation that entails the removal of healthy tissue without the informed consent of the person involved.”36 Moreover, as ritual forms of MGC are medicalized under the influence of western health agencies and educational institutions, defenders of male circumcision justify the procedure with medical rationales that are strikingly similar to those used to support excision of female genitalia. Ylva Hernlund and Bettina Shell-Duncan note another disturbing form of unequal protection, an exception from the harsh treatment of FGC practices by foreigners that is carved out, as it were, for the benefit of usually wealthy women practicing cosmetic versions of FGC that are becoming popular in the US: If contradictory responses to nonconsensual genital surgeries on female and male minors respectively reveal inconsistencies, the same can be said when comparing FGC and an increasingly common type of plastic surgery, popularly referred to as female genital cosmetic surgeries or ‘designer vaginas.’ Such procedures include labia minora reduction, labia majora remodelling, pubic liposuction and lifts, and clitoral reduction (see www.altermd.com), some of which resemble quite closely—in results, if not in the context of the surgeries—genital cutting procedures done ‘traditionally’ in African societies.37

Fuambai Ahmadu finds physical parallels that belie the attempted distinction of the practices: Ironically, in the name of sexual liberation, these wealthy or middle-class Western women spend thousands of dollars to become as ‘closed’ as virgins, while ordinary Somali immigrants in Norway line up at hospitals to be ‘opened’ at public expense, under the same banner. Unlike these ‘mutilated’ African women, no one seems to question the credibility of Western women with surgical ‘designer vaginas’ who report increased psychological and physical sexual satisfaction after drastic genital operations.”38

Such clashes in interpretation cannot be reduced to theoretical conundrums but impact lives in concrete ways. In a fascinating turn of events, Somali women in Sweden who wished to perform a minor form of sunna circumcision that removes essentially no tissue from the girls were bewildered to be told that this was illegal. They found this hard to understand because pricking

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the clitoris to induce minor bleeding does not, generally speaking, lead to permanent changes. Besides that, such a procedure is far less invasive than what is done to male infants at Swedish hospitals during male circumcision and what is permitted on young women who have their genitals pierced, as well as on women who go through genital plastic surgery. In a strictly medical sense, then, there is no reasonable motive to forbid pricking girls’ genitalia while permitting male circumcision, genital plastic surgery, and genital piercing for aesthetic or erotic reasons.39

Thus, the equal protection puzzle has gotten one step more bizarre. To paraphrase Orwell, it is no longer simply “cut male genitalia good, cut female genitalia bad,” but rather now, “cut male genitalia good, cut Western female genitalia also good, cut African female genitalia bad.” Ahmadu, born in Sierra Leone and educated in the US, who returned to her homeland for a circumcision as an adult, is perhaps the person best positioned to comment on such disjunctions: “[T]he greatest irony of all is the increasing number of clinical female genital surgeries performed on women in the West for cultural reasons when the same are condemned for African women because ‘culture is no excuse for mutilation.’”40 Sally Sheldon and Stephen Wilkinson cogently ask if this differential treatment of FGC and cosmetic genital surgery can be justified. The authors propose several possible theories for distinguishing the two—consent, oppressiveness, injury, and offensiveness of the practices—and, one by one, demolish each of them. They conclude that each reduces to cultural privileging of certain practices over others.41 Lois Bibbings argues, reasonably enough, that: . . .any legal regulation of body-altering practices should be consistent. In addition if restrictions are to be imposed they should be constructed according to valid health concerns and should treat the practices according to the risks involved, rather than merely enforcing dominant notions of the acceptable body.”42 The parameters of the issues discussed often predetermine the conclusions reached. As Fox and Thomson note, pain is often entirely omitted from the discussion of MGC’s effects. Astoundingly, even Fox and Thomson neglect any discussion of loss of tissue, inadvertently following in the path of countless prior authors, who limit themselves to toting up “risks” v. “benefits.” If, as Fox and Thomson argue, the male body in general is regarded as less susceptible to injury than the female, the penis seems to be the most invulnerable part of all, nearly any injury to which (short of amputation) is construed as harmless. As Juliet Richters points out, dulling ourselves to the harm caused by loss of the foreskin is facilitated by conceiving of the penis as a battering ram (rock-hard and actively “masculine”), not an organ expected to receive pleasurable sensation (potentially implying softness and passive “femininity”).43 Margaret Somerville astutely observes that, while we would be shocked by the notion of amputating girls’ breasts to protect against later breast cancer, as a society we accept the idea of removing the foreskin as a prophylactic against cancer of the penis or HIV. The reason is simple. [W]e value breasts—we see it as a serious harm to women to lose them—and we do not value foreskins, in fact they are often devalued—spoken of as ugly, unaesthetic and unclean. Yet both are part of the intact human body, and both have sexual and other functions.44

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The evidence thought to show a “potential health benefit” for MGC may in fact be an artifact of its cultural acceptability and long history in American society. As Miller45 and Waldeck46 have eloquently argued, MGC in the United States, despite the hospital setting, is more of a cultural ritual than a health measure, as most parents agree to the operation out of habit [and based on social mandates], because other parents agree to it, because they are accustomed to the appearance of the cut penis, and because they do not want their boys to look different. Regardless of one’s views about adults, one tends to see male babies and female babies as both equally innocent and equally vulnerable. It is now evident that activists against FGC agree on this point. In July 2008, I was in the audience at a London press conference as Efua Dorkenoo frankly told us that she wholeheartedly supported the genital integrity movement, and that the anti-FGC movement had simply made a strategic decision not to openly support intactivism as doing so would make protection of females harder. Two months later, on the eve of the symposium at which this talk was presented, two prominent UK organizations that hitherto have labored on opposite gender sides of the genital integrity battlefront, FORWARD and NOHARM-UK, launched a new joint campaign promoting the right of all men and women to say no to unnecessary genital surgery. This is a landmark development. At the press conference announcing this collaboration, FORWARD echoed Dorkenoo in noting that in the 1980s, the anti-FGC movement made a strategic decision not to support intactivism. FORWARD affirmed that male genital integrity is equal in importance to female genital integrity. Today the most striking asymmetries between male and female genital cutting lie in the fact that powerful international agencies are promoting the first as a “scientifically proven” health precaution while campaigning against the latter as a significant threat to health. The UNAIDS and WHO have failed to acknowledge the well-established fact that rates of new HIV infection have been declining for over a decade as the disease comes under increased control. AIDS is not, and never will be, a critical public health problem in developed countries, where the disease remains largely confined to the traditional sub-cultures: gay men and intravenous drug users.47 Even if the African studies are valid, their results are totally inapplicable to the developed world because the virus is a different strain, and because of radical differences in methods of transmission and in access to education, hygiene, and healthcare. Moreover, Lawrence Green et al., showed in Future HIV Therapy that, relative to circumcision, condoms are 95 times more cost-effective at preventing HIV. Posing circumcision as a vaccine may make it easier to compel its adoption, though as we move closer and closer to a genuine vaccine against HIV, they also may highlight the utter failure of this fanciful metaphor.48 And compelling its adoption is exactly the goal the US Centers for Disease Control (CDC) has, until recently, been vigorously pursuing. However, due to the worldwide pro-intact trends in media statements and popular opinion regarding intact rights, in September 2009 the CDC found itself forced to issue a statement on its website affirming its commitment to hearing both sides of the issue.49 To date, this promise remains unfulfilled. Only one token representative of intact rights

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has had any participation in the CDC’s process, while it has consulted a panoply of “experts” with anti-foreskin views. CDC edicts tend to be faithfully followed by US doctors and hospitals. If the CDC were to issue a pro-circumcision recommendation, circumcision could go the route of Hepatitis B vaccines in the US. After the CDC recommended that the first Hepatitis B shot be given to newborns while still in hospital (despite the fact that the virus is sexually transmitted and thus newborns are not at risk unless their mother is positive). Nurses and doctors then virally passed on the CDC recommendations to parents, to the point where today parents are informed at the hospital that a Hepatitis B shot is required, and all US newborns receive the shot more or less automatically right after birth. If this dire scenario came to pass with MGC, it would mean that circumcision would once again predominate among the vast majority of US newborns. Commonalities between the very diverse cultures that practice genital cutting are astonishing. In a study by Reed Riner of 144 pre-industrial cultures, genital cutting was performed in 23. Of the 23, some cultures cut the genitals of both boys and girls, or boys but not girls, but not a single culture cut girls and not boys. “This suggests,” Riner comments, “that female genital modification is somehow dependent on the cultural presence of male genital modification, and that if we explain the latter we have, for the most part, explained the former.”50 Clearly a powerful process of association is at work, contradicting current legal and popular conceptions of FGC and MGC as radically different phenomena. All of these 23 cutting cultures, without exception, and none of the 121 nonpracticing cultures, can be described, to quote another observer’s formulation, as subsistence “societies with powerful and sometimes massive fraternal interest groups, chronic internal warfare and feuds, and tight contractual control over women and marriage.”51 Cutting cultures invariably provide special training in aggression, in the manly behaviors associated with warfare, and the male role, for the boys. MGC thus represents a permanent, dramatic, bloody, public ritual of submission of the individual to the group, of the father to his “fathers.” Along similar lines, Hellsten observed that all forms of genital cutting are derived from ideas of the place of human sexuality in society, are intended to alter sexual function in some way, and are performed in the belief that the procedure—no matter how physically injurious—will in some way improve the subject’s life.52 In our society, circumcision’s popularity may have been facilitated by our tendency to solve problems by cutting things, often by cutting things out.53 Episiotomy, circumcision, and Caesarian sections are the most common forms of cutting, and all involve the genital tract. As famed anti-FGC activist Hanny Lightfoot-Klein demonstrated, parallel justifications buttress alteration of male genitals and of female, including claimed enhancement of physical beauty, medical reasons, improving sex, asserted universality, as an initiation rite, cleanliness, religion, and looking like other modified humans. Similarly, Dr. Robert S. Van Howe observes that “the reasons cited by families for altering the genitalia of their children are nearly identical whether it is a girl in Africa or a boy in the United States,” namely, “cleanliness,

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preventing illness, religion, looking like other children or like their parents, fear of promiscuity, and acceptance of the altered genitalia as more attractive by the opposite sex.”54 As Henrietta Moore aptly summarizes matters, “The West, it turns out, has culture like everyone else.”55 In a recent article summarizing these issues inadvertently, as it were, famed author and new mother Erica Jong lays out her numerous “misgivings about circumcision,” but nevertheless in the end, offering no explanation, she allows her son’s genital cutting to proceed against her own instincts. “Don’t mark him! I wanted to shout, but instead I laughed hysterically at all the mohel’s jokes.”56 We cannot help but note Jong’s fascinating yet chilling mention of “hysteria,” a word that is etymologically and subconsciously related to hystera (womb) and thus to hysterectomy, itself another excision of a sexual organ to solve a perceived social problem and a procedure that is often unnecessary. The truth comes out. Regardless of the efforts of those who would keep it in, sooner or later, human compassion comes into full play, and the truth comes out.

Notes 1. Waldeck S. (2003) Using circumcision to understand social norms as multipliers. Univ Cincinnati Law Rev. 72:455–526 (citing Stein et al. 1982). 2. Scott S. (2006) Circumcision mythologies in conflict with logic, reason, and common sense. Presented at Ninth International Symposium on Circumcision, Genital Integrity, and Human Rights, Seattle. 3. Svoboda JS. (2001) The limits of the law: Comparative analysis of legal and extralegal methods to control child body mutilation practices. In: Denniston GC, Hodges FM, Milos MF. (eds.) Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem. London: Kluwer Academic/Plenum Press. 4. Paige KE, Paige JM. (1981) The Politics of Reproductive Ritual. Berkeley, CA: University of California Press, p 149. 5. Ford K-K. (2000–2001) ‘First, do no harm’—The fiction of legal parental consent to genitalnormalizing surgery on intersexed infants. Yale Law Rev. 19:469–488 [here, p 477]. 6. Prescott JW. (1989) Genital pain v. genital pleasure—Why the one and not the other? Truth Seeker. 1(3):14–21. 7. Voskuil D. (1994) From genetic cosmology to genital cosmetics: Origin theories of the righting rites of male circumcision. Presented at Third International Symposium on Circumcision, College Park, Maryland [cited November 12, 2009]. Available at URL: www.nocirc.org/symposia/third/voskuil.html 8. Romberg R. (2005) Male circumcision as a feminist issue [cited November 12, 2009]. Available at URL: www.noharmm.org/feminist.htm 9. Bettelheim B. (1965) Symbolic wounds. In: Lessa WA, Vogt EZ. (eds.) Reader in Comparative Religion. New York, NY: Harper & Row, pp 237–238. 10. Brown S.G.A. (1896–1897) The mosaic rite of circumcision: A plea for its performance during childhood. J Orificial Surg. 5:299–304. 11. Morris B. (2007) Circumcision: An evidence-based appraisal. Bioessays. 29:1147–1158. 12. Svoboda JS, Darby R. (2009) A rose by any other name?—Symmetry and asymmetry in male and female genital cutting. In: Zabus C. (ed.) Fearful Symmetries: Essays and Testimonies Around Excision and Circumcision. Amsterdam and New York, NY: Rodopi, pp 251–297. 13. United Nations Commission of Experts’ Final Report. (1994) UN Doc. No. S/1994/674 (1994), section IV.F

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14. United Nations. (2002) Fourth Report on War Crimes in the Former Yugoslavia (Part II): Torture of Prisoners [cited November 12, 2009]. Available at URL: www.ess.uwe. ac.uk/documents/sdrpt4b.htm 15. Written statement submitted by the National Organization of Circumcision Information Resource Centers (NOCIRC), a non-governmental organization on the Roster. (2002) [cited November 12, 2009]. UN Doc. No. E/CN.4/Sub.2/2002/NGO/1. Available at URL: www. unhchr.ch/Huridocda/Huridoca.nsf/(Symbol)/E.CN.4.Sub.2.2002NGO.1.En?Opendocument 16. In the Matter of the Marriage of Boldt and Boldt. (2008) Oregon Supreme Court Case No. S054714 [cited November 12, 2009]. Available at URL: www.publications. ojd.state.or.us/S054714.htm 17. Geisheker J. (2009) Boldt case update. Atty Rights Child Newslett. 7(3):8–9 [here, p 8]. 18. Geisheker J. (2008) Special section—Boldt case commentary. Atty Rights Child Newslett. 6(3):6. 19. Smith J. (1998) Male circumcision and the rights of the child. In: Bulterman M, Hendriks A, Smith J. (eds.) To Baehr in Our Minds: Essays in Human Rights from the Heart of the Netherlands. Utrecht: Netherlands Institute of Human Rights (SIM Special No. 21), pp 465–498 [cited November 12, 2009]. Available at URL: http://www.cirp.org/library/ legal/smith/ 20. Tasmania Law Reform Institute. (2009) Issues Paper 14: Non-Therapeutic Male Circumcision [cited November 12, 2009]. Available at URL: http://www.law.utas.edu.au/reform/ malecircumcision.htm 21. Svoboda JS. (2006) Genital integrity and gender equity. In: Denniston GC, Gallo PG, Hodges FM, Milos MF, and Viviani F. (eds.) Bodily Integrity and the Politics of Circumcision—Culture, Controversy, and Change. New York, NY: Springer, pp 149–164. 22. Svoboda JS, Darby R. (2009) A rose by any other name?—Symmetry and asymmetry in male and female genital cutting. In: Zabus C. (ed.) Fearful Symmetries: Essays and Testimonies Around Excision and Circumcision. Amsterdam and New York, NY: Rodopi, pp 251–297. 23. Povenmire R. (1998) Do parents have the legal authority to consent to the surgical amputation of normal, healthy tissue from their infant children? J Gend Soc Policy Law. 7:7–123. 24. Bond SL. (1999) State laws criminalizing female circumcision: A violation of the equal protection clause of the fourteenth amendment. John Marshall Law Rev. 32:353–380. 25. Smith J. (1998) Male circumcision and the rights of the child. In: Bulterman M, Hendriks A, Smith J. (eds.) To Baehr in Our Minds: Essays in Human Rights from the Heart of the Netherlands. Utrecht: Netherlands Institute of Human Rights (SIM Special No. 21), pp 465–498 [cited November 12, 2009]. Available at URL: www.cirp.org/library/legal/smith/ 26. Davis DS. (2006) Genital alteration of female minors. In: Benatar D. (ed.) Cutting to the Core: Exploring the Ethics of Contested Surgeries. Oxford: Rowman & Littlefield Publishers, pp 63–75. Davis also finds a violation of free association under the First Amendment, in that some religions’ practices are lawful and other religions’ practices are criminalized. 27. Hellsten S. (2004) Rationalising circumcision: From tradition to fashion, from public health to individual freedom—Critical notes on the cultural persistence of the practice of genital mutilation. J Med Ethics. 30:248–253. 28. Bell K. (2005) Genital cutting and Western discourses on sexuality. Med Anthropol Quart. 19(2):125–148 [here, p 131]. 29. Carpenter RC. (2004) A response to Bronwyn Winter, Denise Thompson and Sheila Jeffreys, ‘The UN approach to harmful traditional practices: Some conceptual problems’: Some other conceptual problems. Int Fem J Polit. 6:2:308–313 [here, p 309]. 30. El Guindi F. (2007) Had this been your face, would you leave it as is—Female circumcision among the Nubians of Egypt. In: Abusharaf RM. (ed.) Female Circumcision: Multicultural Perspectives. Philadelphia, PA: University of Pennsylvania Press, pp 27–46 [here, p 42]. 31. Boddy J. (2007) Gender crusades: The female circumcision controversy in cultural perspective. In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting in Global Context. New Brunswick, NJ: Rutgers University Press, pp 46–66.

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32. Fox M, Thompson M. (2005) A covenant with the status quo: Male circumcision and the new BMA guidance to doctors. J Med Ethics. 31:463–469 [here, p 467]. 33. Aldeeb Abu-Sahlieh SA. (2007) Male and female circumcision: The myth of the difference. In: Abusharaf RM. (ed.) Female Circumcision: Multicultural Perspectives. Philadelphia, PA: University of Pennsylvania Press, pp 47–72 [here, p 72]. 34. Macklin A. (2007) The double-edged sword: Using the criminal law against female genital mutilation in Canada. In: Abusharaf RM. (ed.) Female Circumcision: Multicultural Perspectives. Philadelphia, PA: University of Pennsylvania Press, pp 207–223 [here, pp 211–212]. 35. Mason C. (2001) Exorcising excision: Medico–legal issues arising from male and female genital surgery in Australia. J Law Med. 9:58–67 [here, p 67]. 36. Bell K. (2005) Genital cutting and western discourses on sexuality. Med Anthropol Quart. 19(2):125–148 [here, p 130]. 37. Hernlund Y, Shell-Duncan B. (2007) Transcultural positions: Negotiating rights and culture. In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting in Global Context. New Brunswick, NJ: Rutgers University Press, pp 1–45 [here, p 19]. 38. Ahmadu F. (2007) Ain’t I a woman too? Challenging myths of sexual dysfunction in circumcised women. In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting in Global Context. New Brunswick, NJ: Rutgers University Press, pp 278–310 [here, p 284]. 39. Johnsdotter S. (2007) Persistence of tradition or reassessment of cultural practices in exile? In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting in Global Context. New Brunswick, NJ: Rutgers University Press, pp 107–134 [here, p 126]. 40. Ahmadu F. (2007) Ain’t I a woman too? Challenging myths of sexual dysfunction in circumcised women. In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting in Global Context. New Brunswick, NJ: Rutgers University Press, pp 278–310 [here, p 285]. 41. Sheldon S, Wilkinson S. (1998) Female genital mutilation and cosmetic surgery: Regulating non-therapeutic body modification. Bioethics. 12(4):263–285. 42. Bibbings L. (1996) Touch: Socio-cultural attitudes and legal responses to body alteration. In: Bentley L, Flynn L. (eds.) Law and the Sense. London: Pluto, pp 176–198 [here, p 188]. 43. Richters J. (2006) Circumcision and the Socially Imagined Sexual Body. Health Sociol Rev. 15:248–257. 44. Somerville M. (2000) The Ethical Canary: Science, Society and the Human Spirit. Toronto, ON: Viking, p 204. 45. Miller G. (2002) Circumcision: Cultural-Legal Analysis. Va J Soc Policy Law. 9:497–585. 46. Waldeck S. (2003) Using circumcision to understand social norms as multipliers. Univ Cincinnati Law Rev. 72:455–526. 47. See Chin J. (2007) The Aids Pandemic: The Collision of Epidemiology with Political Correctness. Oxford: Radcliffe Publishing. 48. HIV Vaccine Trials Network. (2009) AIDS Vaccine Study Reassures Skeptics [cited November 12, 2009]. Available at URL: www.hvtn.org/media/news.html#thailand 49. Centers for Disease Control and Prevention. (2009) Status of CDC Male Circumcision Recommendations [cited November 12, 2009]. Available at URL: www.cdc.gov/hiv/ topics/research/male-circumcision.htm 50. Riner RD. (1989) Circumcision: A riddle of American culture. Presented at First International Symposium on Circumcision, Anaheim, CA. [cited November 12, 2009]. Available at URL: www.nocirc.org/symposia/first/riner.htm 51. Paige KE, Paige JM. (1981) The Politics of Reproductive Ritual. Berkeley, CA: University of California Press, p 123. 52. Hellsten S. (2004) Rationalising circumcision: From tradition to fashion, from public health to individual freedom—Critical notes on the cultural persistence of the practice of genital mutilation. J Med Ethics. 30:248–253 [here, pp 249–250].

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53. Noble E. (1991) Just say no: Issues of empowerment. Presented at Second International Symposium on Circumcision, San Francisco, CA. [cited November 12, 2009]. Available at URL: www.nocirc.org/symposia/second/noble.html 54. Hernlund Y, Shell-Duncan B. (2007) Transcultural positions: Negotiating rights and culture. In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting in Global Context. New Brunswick, NJ: Rutgers University Press, pp 1–45 [here, p 19]. 55. Hernlund Y, Shell-Duncan B. (2007) The failure of pluralism? In: Shell-Duncan B, Hernlund Y. (eds.) Transcultural Bodies: Female Genital Cutting in Global Context. New Brunswick, NJ: Rutgers University Press, pp 311–330 [here, p 311] 56. Jong E. (2008) Next time boychick, we take the whole thing. Huffington Post [cited November 12, 2009]. Available at URL: www.huffingtonpost.com/erica-jong/next-time-boychick-wetak 1_b_83994.html

Chapter 2

Older Minors and Circumcision: Questioning the Limits of Religious Actions Marie Fox and Michael Thomson

Abstract On two occasions the Court of Appeal in England has addressed the legality of non-therapeutic circumcision performed on a minor unable to provide consent. Both cases involved disputes in post-separation families where one parent sought a male child’s circumcision against the wishes of the other parent. In January 2008, the Supreme Court of Oregon was faced with a similar factual situation in the case of Boldt v Boldt. However, the boy at the center of the dispute in Boldt was significantly older than in the English cases. The Supreme Court therefore concluded that the testimony of the boy himself, who is now 13, was required and remanded the case for a re-hearing in order that the trial court could specifically address his wishes with regard to circumcision. In this paper, we offer a critique of the Oregon Court’s somewhat elliptical reasoning in the Boldt case. We argue that cases involving male circumcision of older children raise important ethico-legal issues, which the Boldt judgments gloss over, and which English courts have yet to confront in the context of circumcision. Consequently, our aim in this paper is to use Boldt as a lens through which to explore and inform UK practice. We argue that this case fits into a characteristic pattern according to which judges, law makers, and professional bodies shy away from confronting key ethico-legal questions raised by the tolerance in Anglo-American society of non-therapeutic genital cutting of male infants. In raising explicitly for the first time the position of older minors, the factual situation in Boldt affords us an opportunity to begin to address the limits of parents’ rights to determine the future religious identity of their children. In seeking to analyze how Boldt and the questions to which it gives rise might inform UK law we focus on three issues. The first is the right of the boy at the center of the dispute to determine which medical treatments or interventions to his body are permissible. The

M. Thomson (B) School of Law, University of Keele, Staffordshire, UK e-mail: [email protected] This paper, presented at the Keele University Symposium on Circumcision, Genital Integrity, and Human Rights (September 2008), was first published in Medical Law International, 2008, Vol. 9, pp 283–310 © 2008 A B Academic Publishers. It is edited here for inclusion in the publication of our symposium papers.

G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9_2,  C Springer Science+Business Media B.V. 2010

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father’s subsequent petitions for reconsideration and for certiorari mean that, when the boy’s testimony is finally heard by a court, it is likely that he will be 14 or 15 years of age. We aim to assess how a UK court might respond if faced with the task of determining whether a minor could choose circumcision for himself in such a scenario. A subsidiary question here is the extent to which circumcision procedures are appropriately categorized as “medical treatment.” Finally, we offer some more tentative thoughts on what limits may legitimately be placed on parental rights to make choices for their children when their choices are motivated by religious belief. Keywords Informed consent · Law · Human rights · Medical ethics · Male circumcision

Introduction In the UK, a very limited body of case law has addressed the legality of male circumcision. The issue has been confronted explicitly only in the context of disputes about the practice in post-separation families. Thus in two appellate level cases UK courts have been required to intervene where one parent—motivated by an understanding of the requirements of religious observance—has expressed an intention to circumcise a minor against the wishes of the other parent.1 In both cases the Court of Appeal emphasized that such an “important” and “irreversible”2 decision should not be taken against the wishes of one parent, and ruled that the children concerned should not be circumcised. This position is also adopted in the British Medical Association’s guidance on the issue, which stresses that “where a child has two parents with parental responsibility, doctors considering circumcising a child must satisfy themselves that both have given valid consent.”3 Where healthcare providers are aware of a conflict the issue must be referred to the High Court.4 The focus of our work on circumcision to date has considered secular and non-therapeutic neonatal circumcision—that is, those neonatal circumcisions that express non-religious parental choices. This work has been informed by feminist ethics, which values bodily integrity and embodied choices, and adopts the position that the legal status of non-therapeutic circumcision is less legally clear cut than is often assumed. In earlier work, and in the context of non-religious practice, we have questioned the extent to which courts and professional guidance have adopted an unduly narrow focus and sidestepped the fundamental issue of whether circumcision can ever be regarded as in the best interests of a child when not therapeutically indicated.5 Sherry Colb has observed that it is only parental conflict that “allows scrutiny of practices that would ordinarily go unexamined and permits us to ask a question that we usually refrain from asking: Is circumcision in the best interests of the child?”6 We would argue that her observation is equally applicable to UK law. Notwithstanding the dominance of the best interests standard in UK child law and its statutory enshrinement in s 1(1) of the Children Act 19897 pervasive common sense notions that male circumcision is a routine, accepted and safe procedure8 mean that the question Colb poses rarely surfaces explicitly.

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Colb’s point is exemplified in the leading UK case, which concerned a dispute over a 5-year-old boy. His father—a non-practicing Turkish Muslim—wanted J to be circumcised so as to identify him with his father and confirm him as a Muslim. Having considered J’s probable upbringing, the Court of Appeal concluded that J should not be circumcised because he was not, and nor was he likely to be, brought up in the Muslim religion. Rather he had a mixed heritage and “an essentially secular upbringing”9 and was unlikely to have such a degree of involvement with Muslims as to justify circumcising him for social reasons. Wall J. consequently ruled that “The strained relationship between the parents, and the fact that as a circumcised child J would be unlike most of his peers, increases the risk that J will suffer from adverse psychological effects from being circumcised.”10 However, the judge accepted that the position was different where the parents were in agreement that the procedure be performed, notwithstanding his acknowledgement that “a case can be made for describing ritual male circumcision without any medical need for it as an assault on the bodily integrity of the child.”11 We argue that the court’s implicit assumption that where the family unit is intact the parents are best placed to decide is problematic. Given the tacit nature of this acceptance, it is perhaps unnecessary to add that the court failed to set out the parameters of this parental liberty or impose any limitations on it. The recent US decision by the Oregon Supreme Court in the case of Boldt v Boldt12 has prompted us to re-visit this fundamental issue of where appropriate limits may be placed on the exercise of parental rights to choose this procedure. Male circumcision is a contentious practice, which raises a host of ethico-legal concerns. The questions it prompts include, on what basis, if any, should elective surgery with its accompanying risks be carried out on healthy children? How are the risks and benefits of surgery to be calculated and to what extent, if at all, may documented medical risks be outweighed by putative social or cultural benefits, such as a sense of community or religious belonging? In deciding on surgical modification, how much value should be accorded to the notion of bodily integrity? Whose views should prevail when parents or those with parental responsibility disagree? In a multi-cultural society how far should religious practices be open to critical scrutiny, and what role, if any, should law play in scrutinizing choices made on the basis of religious belief? Clearly we cannot hope to do justice to such wide-ranging concerns within the compass of this paper. However, we argue that it is indefensible that courts on both sides of the Atlantic entrusted with resolving these disputes on the basis of the child’s best interests consistently downplay or ignore such questions. In particular, we contend that it is problematic for the Oregon Supreme Court to wholly disregard the central issue of what precisely is so compelling about religious beliefs that, prima facie, they seem to allow parents to choose non-therapeutic procedures that require their child to run risks and suffer pain, in order to excise healthy tissue for no proven health benefit?13 Scant attention has been accorded to this issue in the two English decisions, although we shall argue that in comparison to the US position, English law, while far from satisfactory, does at least offer greater safeguards to protect the minor’s decision-making power over his body. In seeking to analyze how Boldt and the questions to which it gives rise might inform UK law, we are concerned with three particular issues. The first is the right

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of the boy at the center of the dispute to determine which medical treatments or interventions to his body are permissible. Petitions by the father for reconsideration and for certiorari, which have now been denied, mean that when the boy’s testimony is finally heard by a court it is likely that he will be 14 or 15 years of age. We aim to assess how a UK court might respond if faced with the task of determining whether a minor could choose for himself in such a scenario. Specifically, given that this case concerns a minor on the threshold of adolescence, our aim is not to question legal responses to religious circumcision per se, but rather to consider at what point a minor may be entrusted with the decision himself. A subsidiary and linked question here is the extent to which circumcision procedures are appropriately categorized as “medical treatment.” Finally, we offer some more tentative thoughts on what limits may legitimately be placed on parental rights to make choices for their children when those choices are motivated by religious belief, and would entail surgical alteration. We examine the efforts of legal scholars who have attempted to formulate a framework to guide such balancing exercises. However, the problems which bedevil such accounts lead us to confine our exploration here to the narrower question of how the interests of religious parents can be balanced with the developing interests of a minor who is sufficiently mature to understand the procedure and its effects—both real and potential—on his embodied choices.14 In beginning our exploration of circumcision as an aspect of faith and how this marries with values that Anglo-American law claims to embody, such as respect for autonomy and bodily integrity, we start by outlining the Oregon case in order to explore the degree to which the case extends some of the issues raised in the English case law. It should be stressed that we are not offering a comparative analysis. Rather Boldt is being relied upon as a factual situation, which foregrounds questions English law has yet to address in this context.15 The analysis we offer focuses on omissions in the reasoning of the Oregon courts. Finally, we address how the judgment in the second of the two English cases—Re S—may sketch a way forward for the balancing of children’s rights and the collective religious or cultural interests of communities. In addressing this balancing or negotiation of interests, our starting point is a desire to reach decisions that will promote so far as possible the interests and autonomy of minors. To that end, in balancing the individual and collective interests at stake, we attempt to respond to a question posed by Priscilla Alderson when considering “who should decide and how” regarding surgical interventions on children. She poses the crucial question, “could we promote more just, benign, and efficacious ways of making decisions about surgically shaping children?”16

Boldt: Disputing Custody On 25 January 2008, the Supreme Court of Oregon reversed an earlier decision of the Court of Appeals and the judgment of the circuit court and remanded back to Jackson County Circuit Court the case of Boldt v Boldt. Specifically, the Supreme Court required the lower court to resolve the factual issue of whether Misha, the 12-year-old son of the estranged parties to the action, consented to the

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circumcision, which lay at the heart of the dispute. Although the circumcision procedure constituted only part of an ongoing custody battle in the Oregon case, Boldt nevertheless replicates aspects of the UK case law, particularly given the nature of the parties’ religious commitment. During the parties’ marriage, Misha was raised in the mother’s faith as a member of the Russian Orthodox Church. On dissolution of the marriage the father converted to Judaism under the United Synagogue of Conservative Judaism. Having informed Misha’s mother of his own conversion, he raised with her the possibility that the boy, who resided with his father, would also convert and the necessity of circumcision in this event. The protracted litigation in Boldt prompted a complex set of hearings and rulings. The particular dispute regarding Misha’s circumcision commenced on 1 June 2004. On that date, the mother filed a motion for a temporary restraining order to prevent the father from having Misha circumcised that evening. In response, the father (who was legally qualified and represented himself) asserted that as sole custodian he had the (sole) authority to make the decision. Further, he claimed that Misha wanted the circumcision in order to convert to Judaism and that the boy’s doctor had recommended the procedure for medical reasons, and was prepared to perform the circumcision. In reply, the mother submitted an affidavit alleging that the father intended to have Misha circumcised against the boy’s wishes and claiming that Misha was afraid to contradict his father on the issue. She expressed concern about the possibility of permanent injury to her son, and sought a change in custody (supporting the ongoing action for such a change). Responding, the father contended that the court lacked authority to grant the mother’s motions, as it would breach his constitutionally protected freedom of religion. He also denied that there had been the requisite substantial change of circumstances that would justify a change in custody, and claimed that such a change would be contrary to Misha’s best interests in any event. He reiterated that surgery was medically advisable independent of the religious justifications, and claimed that although the child’s wishes were “legally irrelevant,”17 Misha wanted to be circumcised. In support of this final claim, he provided affidavits from his new domestic partner and from Misha’s half-brother. An affidavit was also submitted from Misha’s urologist, Dr Ellen, who stated that Misha understood the nature of the procedure and did not appear to be coerced. The medic also pointed to medical concerns that would justify the procedure, suggesting that Misha’s circumcision would greatly reduce his risk of penile cancer and certain infections. Following the filing of briefs and a hearing conducted by telephone, the court concluded both that it had jurisdiction over the parties and (in sharp contrast to the position in English law as outlined in Re J) that the decision whether a child should have elective surgery was reserved to the custodial parent. Nevertheless, given that the parties’ previous custody order appeals were still pending, the court prohibited Misha’s circumcision until those appeals were decided. Finally, the court held that the mother had not demonstrated sufficient grounds for an emergency change of custody. The form of the judgment was objected to by both parties. A further hearing was conducted by telephone, which resulted in a supplemental judgment affirming the

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court’s finding that his father’s decision to have Misha circumcised was not a change of circumstances sufficient to trigger an evidentiary hearing. The mother further appealed this supplemental judgment, leading to the Court of Appeals affirming without opinion. The Supreme Court allowed review of this decision. Concurring with the trial judge, the Supreme Court held that decisions regarding elective surgery for a child are reserved to the custodial parent. This supported the father’s contention that his decision to circumcise was insufficient basis for changing a custody order or holding an evidentiary hearing on the issue. In his action, the father was joined by amicus curiae American Jewish Congress, American Jewish Committee, Anti-Defamation League, and the Union of Orthodox Jewish Congregations of America in support of the position that Misha’s attitude to the circumcision was “legally irrelevant.” In addition, the Court stated that notwithstanding the extensive medical evidence, which both parties and amici had presented (the mother and Doctors Opposing Circumcision noting “significant medical risks,”18 the father describing associated risks as de minimus19 ) the Court need not decide which evidence regarding the attendant risks and benefits was more persuasive. The Court concluded: [A]lthough circumcision is an invasive medical procedure that results in permanent physical alteration of a body part and has attendant medical risks, the decision to have a male child circumcised for medical or religious reasons is one that is commonly and historically made by parents in the United States. We also conclude that the decision to circumcise a male child is one that generally falls within a custodial parent’s authority, unfettered by a noncustodial parent’s concerns or beliefs—medical, religious or otherwise.20

Consequently, it ruled that, had the mother asserted a change in circumstances solely on the basis of her concerns or beliefs regarding circumcision this would have been insufficient. However, her assertion that Misha himself objected to the circumcision, prompted the Court to rule that: In our view, at age 12, M’s attitude regarding circumcision, though not conclusive of the custody issue presented here, is a fact necessary to the determination of whether mother has asserted a colorable claim of a change of circumstances sufficient to warrant a hearing concerning whether to change custody. That is so because forcing M at age 12 to undergo the circumcision against his will could seriously affect the relationship between M and father, and could have a pronounced effect on father’s capability to properly care for M. . .. Thus if mother’s assertions are verified the trial court would be entitled to reconsider custody.21 Ultimately, the case was remanded to the trial court in order to determine Misha’s state of mind regarding the procedure. In the meantime the father issued petitions which seek: first that the Supreme Court of Oregon re-consider its decision and secondly, a Writ of Certiorari that the Supreme Court of the United States consider whether the Oregon Supreme Court’s decision violates the First Amendment of the US Constitution (protecting free exercise of religion) and whether it violates the father’s parental rights, which are guaranteed by the Due Process Clause of the Fourteenth Amendment to the US Constitution. In October 2008, these petitions were refused.22 Although no reasons were stated by the Supreme Court for its refusal and the Boldt case undoubtedly raises important constitutional issues,

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there is a general reluctance on the part of Federal courts to intervene in custody disputes, which are left to individual States to determine23 When the case is eventually re-heard by the Jackson County Circuit court, should that court find that Misha did oppose the procedure it would then have to determine whether his opposition is such that it will affect his father’s ability to care for him properly. If necessary, the court would then have to decide whether it would be in Misha’s best interests to nevertheless retain the existing arrangement, or whether conditions would have to be imposed on the father’s continued custody, or whether the court should order a change in custody to the mother. Hence, in view of Misha’s age, the Boldt case poses important questions, which English courts have yet to confront in the circumcision context, particularly regarding the limits of parental decision-making powers over an older child. In this paper, our focus is on the two novel issues that it raises—when the rights of older minors to make embodied choices accrue? and what, if any, limits may law place on parental rights to choose irreversible bodily interventions for their children? Although, as we discuss below, these questions have arisen in UK courts in other contexts—such as transplantation, blood transfusions, sterilization and abortion—they have not before been raised in a circumcision case. For reasons that we outline below, this procedure raises issues, which differ in significant respects from the earlier precedents. With regard to both novel issues raised by Boldt, we suggest that the Oregon courts left a number of important aspects of the case unexplored.

Acts and Omissions We contend that Boldt v. Boldt is most insightfully read as a narrative characterized by omissions: the trial court omitted to ask Misha directly his wishes regarding the circumcision or to determine whether he was competent to decide for himself; at each level the judgments omitted any consideration of whether his circumcision was therapeutic or non-therapeutic; similarly the judgments failed to carry out an adequate cost/benefit assessment of claimed benefits and risks in order to determine whether performance of a (non-therapeutic) circumcision was in Misha’s best interests, and finally each of the courts omitted to propose any limits on parental decisions made in accordance with religious belief. Our primary concern for the purposes of this paper is the omission to consult Misha or seek to determine his capacity to reach this decision for himself.

Misha’s Wishes and Competence Determining Misha’s state of mind regarding the circumcision appears to have been an afterthought24 ; worthy of consideration only when the litigation reached the Oregon Supreme Court. From a UK perspective, this complete disregard of the child at the center of the dispute seems startling, given the boy’s relatively advanced age and the emphasis placed by UK law on prior consent to medical treatment in order

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to protect self determination and bodily integrity.25 The failure to consult Misha is particularly surprising given the parents’ sharply divergent accounts of his views. Moreover, it is difficult to reconcile with international standards, although it does chime with the US failure to ratify the International Convention on the Rights of the Child. Apart from Somalia, the US is the only nation that has yet to do so. Doris Buss has argued that the US failure to ratify is motivated in part by Christian Right fears that it will undermine parental rights by allowing States (or the UN) greater freedom to intervene in families.26 Certainly, although one needs to be wary about generalizing in relation to US law, the reasoning underpinning decisions reached in US state courts suggest a reluctance to interfere with parental rights, and indicate that US courts lag significantly behind the UK in their readiness to accept that children are not the property of their parents and have interests that are separable from their parents. For instance, a 1990 Alaskan judgment contained the following dicta: In such matters as deciding on the need for surgical or hospital treatment, the wishes of young children are not consulted, nor their consent asked when they are old enough to give expression thereto. The will of the parent is controlling, except in those extreme instances where the state takes over to rescue the child from parental neglect or to save its life. Similarly the right to grant or refuse a medical examination of a child belongs not to the child but to the parents.27

In the light of such dicta, it is perhaps unsurprising that US courts should cling to essentialist views that children are not to be entrusted with choices about medical interventions, and that it is age rather than an enquiry into capacity that determines where the locus of decision-making power lies. By contrast, we share Sarah Elliston’s view that determinations of capacity grounded in age alone are overly crude, so that: if respect for autonomy has the central value generally accorded to it in law and health care. . . those who are capable of exercising it should not be denied the freedom to do so simply because they have not met whatever age it is that is set for adulthood.28

The relevant UK case law that engages with the assessment of adolescent autonomy following Gillick29 has concerned minors aged between 14 and 17 who refuse medical treatment. In a now extensive line of cases, the courts have been reluctant to spell out exactly what the minor in question should understand in order to be deemed sufficiently mature to be entrusted with decision-making powers. The clearest attempt to do so remains a statement by Lord Scarman in Gillick itself, where he refers to “the attainment by a child of an age of sufficient discretion to enable him or her to exercise a wise choice in his or her own interests,”30 and to the minor achieving “a sufficient intelligence to enable him or her to understand fully what is proposed.”31 As Simon Lee has noted, this standard seems to set the threshold of understanding so high that many adults would fail to satisfy the test.32 Perhaps it is not surprising, then, that post-Gillick English law has consistently undermined the choices of seemingly Gillick-competent adolescents aged 14–17, at least where they refuse treatment.33 Michael Freeman has summarized the implications of this line of case-law:

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A child can say “yes” to medical treatment but cannot say “no.” This is the simple, indeed trite, conclusion to which one comes after an examination of the cases.34

The facts of Boldt are therefore an interesting prompt to consider whether a UK court might deem a 12- or 13-year-old competent to decide for himself whether to undergo irreversible surgery that involves the removal of healthy tissue. In the UK circumcision cases, the children involved were younger, allowing the courts to assume that competence was not an issue. Given the complex nature of the risk and benefits involved, this is supportable with regard to the 5-year-old subject of Re J, but it is at least arguable that more attention should have been devoted to the competence issue in Re S. Here, in relation to age, Baron J simply ruled that the children—then aged ten and almost nine years of age—were “too young to seek to favor one of their religions of origin in favor of the other.”35 It may well be true that a choice about the practice of religion requires greater maturity than a nine-yearold child will typically possess, and it is understandable that judges should prefer to engage with a definite criterion such as biological age. However, commentators have argued persuasively that relevant experience of illness, treatment, or disability may be a more salient factor than age in the acquisition of competence.36 This suggests that, in assessing competence, key factors are the situation in which children find themselves, how they are informed about the implications of a medical procedure, and the support they receive in reaching a decision about it. Provided such support is available, Alderson and Montgomery’s research with sick children suggests that even children as young as five years old may be capable of reaching at least some health decisions for themselves.37 In the case of circumcision, as recognized in Re J38 and the BMA’s 2006 guidance on the topic,39 the determination of best interests is complex, requiring medical risks to be weighed against social and cultural benefits. Nevertheless, we would argue that some older minors will be sufficiently mature to be entrusted with this decision themselves and that it is incumbent on courts to attend to this possibility. Our contention is supported by the ruling in Re S—that the decision should be deferred until the minor has attained legal competence, when he should be permitted to reach his own informed decision whether to be circumcised.40 We would argue that in reaching this conclusion the Court of Appeal exhibits a more informed understanding of the implications of surgical interventions for the older child than the Oregon courts. In Re S, of course, postponing the decision until the minor had attained capacity meant that the judges did not have to grasp the nettle and engage in an assessment of the minor’s capacity to decide about circumcision, though it did make it more likely that at some stage in the future UK courts will be faced with a dispute similar to Boldt. It is our contention that a UK court, faced with this issue, would, unlike the Oregon courts, be obliged to assess the ability of the minor to decide for himself whether the circumcision should proceed. Yet, even if a 12- or 13-year-old was deemed Gillick-competent, we accept that it would not necessarily follow that his wishes would be determinative—as the Oregon Supreme Court makes clear. This is also the legal position in the UK, where three of the most troubling English cases—Re E, Re S, and Re P41— have involved courts

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over-ruling the refusal of treatment on the basis of the adolescent’s religious beliefs. In each of these cases, the minors concerned seemed to possess the requisite maturity and understanding to decide for themselves, and were supported in their refusal by their parents; yet their wishes were disregarded in each case. In Re P, for instance, a 17-year-old’s refusal of blood products to treat his hypermobility syndrome was overridden, albeit with reluctance, by Johnson J., who acknowledged that P was almost an adult and that throughout his life he had been a “staunch and committed” Jehovah’s Witness.42 No justification is offered for disregarding the minor’s wishes in the light of these findings. One possible (unarticulated) reason may, however, be an unwillingness to accept that a child raised in a religious household could remain uninfluenced by such an upbringing. Such reasoning emerges more clearly in the case of Re E, where Ward J. stated, of a case involving a refusal of blood transfusions by a 15-year-old Jehovah’s Witness: Without wishing to introduce into the case notions of undue influence, I find that the influence of the teaching of the Jehovah’s Witnesses is strong and powerful. . . I am far from satisfied that at the age of 15 his will is fully free. He may assert it, but his volition has been conditioned by the very powerful expressions of faith to which all members of the creed adhere.43 This observation supports Margaret Somerville’s argument in relation to a comparable Canadian case: In our turn-of-the-millennium secular societies, a young person’s maturity is often assessed by how autonomous, independent, self determined and individualistic that person is. On these criteria a child from a family such as the Duecks’ [who were committed Christians] is unlikely to be found sufficiently mature to be held competent to consent to or refuse treatment.44

In the refusal of medical treatment cases, therefore, a key difficulty in assessing competence will be the complex judgment concerning the probable impact of the child’s religious upbringing on his competence to make an informed choice.

Medical Evidence and the Therapeutic/Non-therapeutic Boundary Grounds clearly exist for distinguishing the Boldt scenario from cases involving refusal of medical treatment by Jehovah’s Witness adolescents. The main distinction concerns the nature of medical evidence. In the refusal of treatment cases just cited, the refusal by the minor was potentially life-threatening and clearly flew in the face of well-substantiated medical evidence. The medical evidence in Boldt was much less compelling, and we argue that the cursory and unchallenged account of the medical evidence presented also fits into a familiar trajectory in debates about circumcision. We have contended elsewhere that circumcision has long existed as a procedure in search of a medical rationale.45 At different times, it has been promoted as a remedy for alcoholism, epilepsy, asthma, curvature of the spine, paralysis, malnutrition, night terrors, clubfoot, eczema, convulsions, promiscuity, syphilis, and

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cancer.46 These justifications have all been debunked, while contemporary efforts to justify the practice have proven inconclusive and frequently are based on methodologies that have been contested.47 Only in very rare cases can circumcision be categorized as therapeutic treatment and therefore the evidence cited by Dr. Ellen—, “that M’s circumcision would greatly reduce M’s risk of penile cancer and certain infections,”48 should not have gone unchallenged by the Oregon courts. While there is some evidence that chances of contracting penile cancer are reduced by circumcision, such cancers are extremely rare and once the benefit is quantified it is likely that it is outweighed by the direct and quantifiable risks of the procedure. Similarly, Dr. Ellen’s extremely vague reference to risk of “certain infections,”49 seems to hark back to (outdated) notions of the foreskin as unhygienic and a reservoir of disease, which continue to re-surface periodically.50 No evidence is presented that Misha suffered from any of the conditions—such as pathological phimosis, balanoposthitis and paraphimosis—which might indicate that a medical justification for this procedure (or one of the non-surgical alternatives) in fact existed; with the only evidence pointing to “glandular adhesions” on his penis. We speculate that if the Oregon Supreme Court had considered critically the nature of the medical evidence it would have been forced to the conclusion that this procedure was in reality being performed for non-therapeutic reasons.51 Clearly a determination that a procedure is non-therapeutic has legal effects. We would suggest that in circumcision cases the first step should therefore be for the judge to assess whether the procedure is therapeutic or non-therapeutic; and to require much more compelling reasons for the determination that it is medically indicated than those advanced in Boldt. If it is accepted that surgery is non-therapeutic, judges, in our view, should be reluctant to authorize the procedure in the absence of clear evidence that it is sought by the minor. This contention seems particularly compelling if any refusal or ambivalence on the part of the minor is supported by one of the parents. We accept that very different issues are raised where the refusal is of life-saving treatment (although the line at which a refusal becomes life-threatening is inevitably contested).52 UK case law states that tests of capacity will vary according to the gravity of the treatment proposed.53 While Elliston is surely right to argue that it is “the complexity of the decision, rather than the gravity of the treatment or the outcome, which demands greater intellectual capacity and discrimination,”54 the fact that a refusal of a circumcision is not life-threatening and could always be revisited at a later stage supports our contention that the refusal of such a procedure by a 12-year-old should be respected, as should any ambivalence he displays. As a result of its failure to specifically address Misha’s decision-making capacity, the Boldt judgment left open the question of whether it would be possible for a parent to sanction the circumcision of a 12-year-old against his wishes. Although it found that the boy should have been consulted, the judgment gave no indication that his wishes would be determinative. Indeed, the judges seemed to implicitly accept that electing to have a child circumcised is a legitimate parental action regardless of the child’s wishes. If this is indeed true, when is parental choice limited by a minor’s objections? At 14 or 15 years? English courts have only fleetingly addressed the

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limits to a parent’s power to consent where procedures are non-therapeutic. In Re B Lord Templeman stated that “sterilization of a girl under the age of 18 should only be carried out with the leave of a High Court judge” with the parents being made parties to the action if they wish to appear.55 In the case of Re P, where parents opposed their 15-year-old daughter having an abortion on religious grounds, ButlerSloss J. directed that the pregnancy should be terminated in accordance with the girl’s wishes notwithstanding an acknowledgement that “I must give great weight to [the parents’] feelings. . . and I must take into account their deeply and sincerely held religious objection. . .”56 By contrast, in none of the cases on non-therapeutic circumcision have judges sought to place any limits on parental choices. However, the fact that parental wishes cannot be determinative seems to be enshrined in the BMA guidance, which notes that circumcision has medical and psychological risks and that it is essential that the procedure is carried out only where it is demonstrably in the child’s best interests.57 While stressing the importance of respecting parental rights, the guidance pays considerable attention to how the child’s best interests are to be assessed. It states unambiguously that parental preference alone is insufficient to justify circumcision—parents must explain and justify their preference with reference to the child’s interests. Relying on its publication, Consent, rights and choices in health care for children and young people,58 and thus offering a valuable insight into guidelines for wider medical practice, the BMA provides a checklist of factors that may be relevant to a best interests assessment for non-therapeutic circumcision. The criteria listed extend well beyond the medical and have an unambiguous focus on the patient. The guidelines foreground the relevance of the patient’s own wishes, feelings, and values; the patient’s ability to understand what is proposed and weigh up the alternatives; and the patient’s potential to participate in the decision if provided with additional support or explanations.59 This emphasis on the patient highlights the ethical desirability of patients being supported to make decisions about their own bodies where possible, rather than deferring to the judgments of others, including their parents.

What if Misha Chose Circumcision? As we have noted, UK case law addressing adolescent autonomy generally has been concerned with refusal of treatment or procedures. This makes it intriguing to speculate on how a court would respond to a 12- (or 13- or 14-) year-old who purports to consent to an invasive and irreversible procedure like circumcision. It follows from our starting point, which seeks to promote autonomous decision-making that an adolescent should be free to make this choice provided he is sufficiently mature and well informed. In facilitating his decision-making, however, we think it would be important to acknowledge that a minor caught up in such a custody dispute is more likely to feel ambivalence than certainty about his decision. We also believe a court should bear in mind that electing to undergo the procedure has irreversible consequences, whereas refusing it does not. Whereas it would always be open to an intact boy to elect to be circumcised in the future, the child who is circumcised

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lacks any meaningful choice once he has attained competence.60 Thus, in an interesting reversal of the general position in English law, choosing the procedure would seem to demand a higher level of competence than refusal, given the way that its irreversibility limits future choices. As we discuss below, recognition of the implications of such a choice is one of the positive features of the judgments by the English courts in the case of Re S. Furthermore, given our argument that the proposed circumcision in Boldt was non-therapeutic, such a choice seems more analogous to choosing other cosmetic body modifications than consenting to medical treatment. This poses the question of what, if anything, differentiates male circumcision from other bodily practices that many jurisdictions, including the UK, do not allow minors to consent to until they reach 16 or 18? Thus, for instance, no one under 18 can consent to be tattooed,61 and under UK law even a competent adult woman is deemed unable to validly consent to excision or other “mutilation” of her genitalia.62 Although it remains unclear whether UK legislation permits women to consent to cosmetic surgery on their genitalia,63 doctors in this jurisdiction would not accede to a request for transgender surgery from an adolescent.64 We would also question whether a girl under the age of 16 would be able to validly elect surgery purely in order to have a “designer vagina,” given the risks of such surgery.65 Nevertheless, given the hazy dividing lines between cosmetic and reconstructive surgeries and the inadequate regulation of private providers of various genital surgeries66 it is not inconceivable that such procedures would be carried out privately. It is interesting therefore to speculate on what approach a court might take in the event of litigation. We would suggest that, in line with the legislative prohibition on tattooing, English courts would be reluctant to find that a minor, however mature, could validly consent to such surgeries, even though transgender surgery may be considered therapeutic. If we are correct in this assertion, it begs the question of what, if anything would distinguish the choice of a minor to be circumcised, other than a specific exemption for religious beliefs. Thus, if the Boldt scenario were to arise in the UK, and a court found that, having reflected carefully, the boy wanted to be circumcised, to permit such a choice the court would, in our view, have to acknowledge a religious exemption to current criminal law standards. As we have noted, our starting position rooted in the promotion of adolescent autonomy suggests that a free, persistent, and properly informed choice of circumcision by a competent 12- or 13-year-old merits respect. However, the complexities of this decision, and analogies that may be drawn with other surgeries, some of which are legally prohibited, leads us to argue that the field of consent to various forms of bodily intervention and the age at which they may legitimately be chosen merits a fuller policy consideration. Currently, under both common law and statute the regulation of a range of forms of bodily interventions varies considerably—ranging from prohibition through oversight by a court to parental freedom to decide, and in our view such inconsistency is undesirable. Yet the UK Government’s failure to revisit the recommendations of the English Law Commission’s 1990 Consultation paper on the issue suggests that little political will exists to do so.67 In the meantime we would suggest that some form of court oversight is required when an older minor presents for a non-therapeutic circumcision and that good ethical practice requires

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a health professional to refer the decision to court.68 This at least means that the minor’s understanding of the documented risks that accompany the procedure,69 and the pain that an adolescent is likely to experience,70 as well as his motivations, can be fully examined.

Omitting Religious Freedoms The complex nature of the decision-making in such cases is complicated further when the religious rights of parents, accorded protection in the US under the First Amendment to the Constitution and in the UK under the Human Rights Act 1998 by Article 9 of the ECHR, are at stake. As James Dwyer notes, “Many people, including judges, find parents’ claims to exclusive child-rearing authority to be at their most compelling when motivated by religious belief.”71 In common with the other omissions we have identified, the Oregon Supreme Court side-stepped claims regarding the father’s exercise of his protected religious beliefs and practices. The father and amici argued that he had a “constitutionally protected right to circumcise his son”72 grounded in circumcision’s fundamental and sacred place in the Jewish tradition. The father further asserted that an evidentiary hearing would usurp the role of the custodial parent and violate his constitutionally protected rights.73 The Court explicitly accepted his contention regarding his rights as custodial parent, but failed to address itself to the question of his First Amendment rights. In accepting the primacy and exclusivity of the custodian parent’s authority and in failing to consider the question of the father’s religious freedoms, the (expansive) parameters of these rights and freedoms are left unclear. While we see the court’s reluctance to engage with this issue as regrettable, once again it is understandable, given the contested terrain it would require judges to negotiate. As Herrara notes, in adjudicating disputes between the state and religiously-motivated parents over medical treatment of their children: From a legal perspective, there exists no consistent body of principles or precedent that the court might enforce. . . From an ethical standpoint, it is hard to think of an action that the state might take that would not be problematic in light of its competing responsibilities. Central among the state’s duties are the need to protect the vulnerable and the need to protect the fragile structure of religious freedom.74 Since the balance between these values is so difficult to maintain it is unsurprising that judges want to duck the task of engaging in this exercise. Significantly, to the extent that the judges and legal scholars have sought to articulate these competing responsibilities, it has once again been in the context of refusal of life saving treatment by parents. Given this context, it is no surprise to find that the litigated cases have concerned minority faiths rather than established ones like Christianity or Judaism. Equally it is unsurprising that the outcome has been a judicial willingness to over-ride the beliefs of Jehovah’s Witnesses75 and members of the Amish community.76 As Herrara states, the “most familiar conflicts involve families affiliated with Amish, Christian Science and Jehovah’s Witness religions.”77 In fact this observation perhaps serves to question her assertion that religious freedom is

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“fragile,” since in Anglo-American law it seems it is only fragile where the religion is not an established one, such as Christianity or Judaism. As Dwyer points out, in fact when it comes to established religions their practices are typically construed as simply not being harmful: We commonly excuse parents, legally and morally, for inflicting upon their children what most people would regard as harm, when parents act on the basis of religious belief. While states have prosecuted some parents for causing their children to die by failing to obtain necessary medical care, even though the parents had sincere religious objections to medical care, these cases represent only the most extreme situation and mask a quite widespread but generally overlooked phenomenon.78 Aside from refusal of life saving treatment, the only other context in which courts have addressed the issue of parental rights to determine their children’s healthcare is where parents refuse to have their children vaccinated on religious grounds. Here, as Silverman and May note, judges “have consistently held that public health concerns override religious beliefs. . . [and] found it legitimate. . . to evaluate the sincerity, strength and religious basis of a person’s beliefs in deciding whether to grant exemption from mandatory childhood vaccination.”79 Once again, it is notable that parents who oppose immunization have tended not to belong to established faith traditions,80 reinforcing the suspicion that law is less likely to protect the religious beliefs of those whose faith community is not well settled in law. A more intractable dilemma arises if one seeks to interrogate religious justifications for a procedure—such as male circumcision—which, in most cases, does not pose a life-threatening risk and is practiced by well-established religious communities. Questioning the legitimacy of these procedures becomes still more difficult where they are commonly and historically accepted to the point where, as Caroline Bridge notes, they have become “almost part of the mainstream.”81 In this paper, space precludes a full consideration of religious justifications for circumcision and of the limits that may be placed on a parent’s right to vindicate their religious beliefs. We do, however, endorse Dwyer’s argument that where religious beliefs are cited by parents in healthcare cases, this often results in a failure to separate out the interests involved in a way that would recognize the “separate personhood and distinct interests of children.”82 He notes that “lower federal and state courts have consistently interpreted the Free Exercise Clause of the First Amendment to guarantee parents a right to control the mental and physical lives of their children.”83 In our view, Boldt certainly fits into this pattern whereby children seem to be treated in law as objects rather than subjects.84 Yet, while we believe it is crucial to scrutinize the limits of parental rights to surgically alter their children’s bodies on the basis of religious beliefs, the dangers of addressing this question in the abstract are evident in those rare articles where legal scholars have attempted to suggest ways of legally regulating parental choices to circumcise male children. At the outset, we suggested the desirability of formulating a framework within which to consider limits to parental rights to choose for their children on the basis of religious beliefs. Such a project is too ambitious to attempt within the space constraints here, so instead we limit ourselves to some thoughts on attempts by these

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other scholars to do so. The most thoughtful attempt to frame a legal response to parents’ choice to circumcise their sons is provided by Margaret Somerville.85 We have much sympathy with Somerville’s ethical stance, and with the difficulties of her task, but here we use her framework to demonstrate how such attempts can lead to problematic, and in all probability counter-productive, legal proposals. Somerville suggests that “as our knowledge of the risks and harms of circumcision expands, the range of circumstances in which undertaking routine circumcision on any child is a breach of a reasonable standard of medical care also expands.”86 Having surveyed Canadian law, which is similar to UK law in relevant respects,87 she concludes that, given the limitations on parental rights to refuse treatment on religious grounds, “it is far from clear that the parent’s right to freedom of religion would validate infant male circumcision carried out for religious reasons,”88 and that circumcision would often amount to assault. Turning to the limits the state might place on parents’ rights to inscribe religious beliefs on the bodies of their children, Somerville proposes a seven-stage framework for addressing the competing societal interests in promoting religious freedom while protecting the rights of the vulnerable. Some of these proposals are eminently sensible—including her arguments that it is necessary to start from the position of respecting religious beliefs; and that coercive methods to interfere with religious practices should not be used unless there is evidence that serious harm to children cannot otherwise be avoided. However, others are more problematic. For instance, her proposal for religious exemptions to a general prohibition on male circumcision,89 seems to contradict her earlier assertion that religious belief cannot validate infant male circumcision. Similarly, Somerville contends that: when infant male circumcision is carried out as an absolute religious obligation, the burden of proof, which is usually on those carrying out infant male circumcision to show that the surgical procedure is justified, would shift to those opposing it to show that it should be prohibited.90

Leaving aside the inevitable quibbles about how an “absolute religious obligation” would be interpreted, this religious exemption and shift in the burden of proof seems to confront us squarely with the very question the Boldt judgments ignored, of what makes religious beliefs unique in that prima facie they can or should justify parents consenting to non-therapeutic procedures that require their child to run risks and suffer pain, in order to excise healthy tissue for no health benefit?91 In a UK context, Howard Gilbert has argued that the court in Re J erred in finding male circumcision lawful. In his view, the ruling failed to protect a vulnerable class of children and is inconsistent with the ECHR. In response, Gilbert proposes a range of legislative “solutions”: Parliament is faced with at least three possible options: (i) to prohibit male circumcision unless it is justified as medically necessary; (ii) ritual circumcision is only to be carried out on a male who can give his lawful consent; (iii) ritual circumcision is lawful provided it is carried out in accordance with the guidelines laid down by Parliament [e.g. that the procedure be performed by a registered physician].92 As with Somerville’s mooted framework, there is a failure to adequately flesh out how any of these schemes would work. More problematic is his invocation of the

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criminal law to ban the practice, which fails to acknowledge the ineffective history of colonial attempts to stamp out circumcision in other countries. Such histories show that attempts to outlaw common practices almost inevitably generates reactance that simply mobilizes support for the procedure amongst the communities affected.93 These examples make us very conscious that to question whether limits should be imposed on parental rights to choose circumcision can easily lead one to propose sweeping, unworkable, or overly punitive recommendations. Thus, in recognition of the fine line we are treading, we limit our analysis here to the narrower question of what limits to religious expression might be suggested by the Boldt situation. Specifically, and returning to where we started with Priscilla Alderson, how can we promote more just and benign ways of making decisions about surgically shaping children,94 particularly where those children are approaching the age at which they can reach decisions for themselves? In the following section, we argue that where the minor is competent to decide for himself he should be entrusted with the decision, and in the case of an older minor on the threshold of competence the decision should be deferred until he has acquired sufficient maturity. This position goes some way to answering Alderson’s question: In cases of uncertainty and disagreement, are parents always the best choice makers? Surgically shaping children throws into extra sharp relief questions about coercion, rights, moral choice, and the “intimate family”. . .. But if parents override children’s reasonable views about their own body, the family is hardly intimate in terms of loving equality.95

In arguing for the inclusion of older minors in the decision making process (or indeed allowing competent minors to make the decision), we turn to a fuller consideration of the second of the two English cases to have considered circumcision decision-making in the post-separation family.

Deciding with Older Minors As in Re J and Boldt, Re S negotiated a dispute between parents, which stemmed in part from the parent’s different religious traditions. While the marriage endured, the children—a 10-year-old girl and 8-year-old boy—were brought up according to the tenets of the Jain faith. Upon separation, a joint residence order was made, and the High Court considered the mother’s application to circumcise the boy and convert him and his sister to the Muslim faith. The application was opposed by the children’s father, who was a Jain Hindu. The High Court judge, Baron J, whose ruling was upheld by the Court of Appeal, seemingly based her refusal of the application in part on the following finding: The mother is a devout Muslim but she has put her religion in second place when it has suited her. Her relationship with the father lasted from 1982 until 1998 and they continued in the same household until 2002. Whilst living with the father the household style was not Muslim but predominantly Jain.96

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Whilst it might be easy to read a convenient enmity into the judge’s characterization of the mother’s faith (a reading which would necessarily be pared of its specificity in the details of the parties before the court) the judgment deserves an open reading. Compared with the elliptical nature of the reasoning in Boldt, the judgment of Baron J., which was endorsed by the Court of Appeal in Re S, compares favorably. In the first place it is clear that a child may not be circumcised without reference to the court where one of his parents is opposed to the procedure. As we have argued above, this requirement could usefully be extended to all cases where an older child presents for a non-therapeutic circumcision. Secondly, in contrast to Boldt, the judgment seeks to disentangle the interests of parents and children, rather than assuming that they are synonymous. Thus, the judge observes that “the current problem stems not from the children’s needs but from the need of the mother to portray her marriage as being to a Muslim man.”97 Thirdly, as we have noted above, the Court’s recognition that the decision properly belongs to the boy himself when he reaches the stage of Gillick-competence squares with a better understanding of the embodied experiences of adolescents and a more robust defense of the values of autonomy and bodily integrity. Thus Baron J. observes that: Circumcision once done cannot be undone. It may have an effect on K if he wishes to practice Jainism when he grows up. He has been ambivalent about his religion and is not old enough to decide or understand the long-term implications. It is not in his best interests to be circumcised at present. . . By the date of puberty K would be Gillick competent and so he could make an informed decision.

We also suggest that this proposal accords with recent campaigns challenging the current paradigm for the surgical treatment of children born with intersex conditions,98 and which is gaining acceptance as the most appropriate approach in the case of male circumcision.99 Indeed, such an approach has also emerged in communities where circumcision is part of religious practice.100 This growing consensus on the desirability of postponing non-therapeutic surgeries until the child is competent to decide, has, as we have argued elsewhere, been the product of a movement to uncover the harms inflicted by early non-consensual intersex surgery. In the case of male circumcision, clearly much work remains to be done on this process of uncovering harms, given that so many of the harms of the practice are rendered invisible even to “caring” or “good” parents, and that the legitimizing power of legal culture and religious faith causes harms that it fails to recognize to effectively disappear.101

Concluding Thoughts The discourse of the intimate family that tries to exclude a public ethic of justice, by denying children’s rights, paradoxically invokes public concepts of parents’ rights, and thereby invites justice to reenter by the back door in its most dangerous form of defending the status quo, in which unaccountable power falls to the powerful.102

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It is notable that circumcision is slowly gaining more attention in academic and medical publications and in the general media. In general, such discussion and reporting is limited to and focuses on (disputing or confirming) some of the medical risks briefly outlined above. Whilst this development is welcome and clearly contributes to the uncovering of harms that is required, it is also necessary for commentators (and indeed decision-makers) to take into account issues of bodily integrity,103 the desirability of keeping future choices open, and the possibility of psycho-sexual harms, as well as possible negative effects on future sexual experience and enjoyment. Such issues can be brought to the fore if we pay attention to accounts of the ways in which some men have experienced their circumcision status. Qualitative studies, such as that conducted by Hammond in the US and published in the British Journal of Urology International in 1999, do much to complicate the idea that male circumcision is sufficiently de minimus that it should be left to parental choice.104 Hammond’s study ably details the range of negative physical, sexual and emotional effects that may follow routine juvenile circumcision. While acknowledging the particularity of such experiences, simultaneously we need to recognize that a general failure to unpack these harms may be attributed not only to the unwillingness of doctors and parents to see them, but also to deeper rooted problems with the concept of harm. For this reason, although we find much of the critical discourse around female circumcision and the punitive legal response to it problematic, we would contend that one positive feature of how female circumcision is legally regulated is the unambiguous acceptance that the procedure is harmful. We would certainly argue that all forms of harm inflicted on young children whose bodies are molded and redesigned by surgeons are comparable, regardless of whether the motivation is to “normalize” or “perfect.” The harms of male circumcision have been rendered less visible and contentious by the long history and widespread acceptance of the practice in North America, the United Kingdom and Australia. We would argue that legal, medical and religious cultures have contributed to this. Stipulating that decision-making must include the older minor and deferring decisions until they can be taken by a competent minor, in our view marks a necessary shift to articulating the factors that are pertinent to regulating this form of genital cutting and promoting a more open dialogue about how harm is to be quantified. Acknowledgements We would like to thank Rohee Dosgupta for research assistance on this article, which was funded by the AHRC Centre for Law, Gender and Sexuality and the anonymous reviewer for helpful input. We also thank the following colleagues for offering helpful comments on earlier drafts and/or access to materials: Georganne Chapin, John Geisheker, Manolis Melissaris, Jean McHale, Shaun Pattinson, David Smith, and Steven Svoboda.

Notes 1. Re J (Specific Issue Orders: Muslim Upbringing & Circumcision). (1999) 2 FLR 678 [Family Division]; Re J (A Minor) (Prohibited Steps Order: Circumcision), sub nom Re J (Child’s Religious Upbringing and Circumcision) and Re J (Specific Issue Orders: Muslim Upbringing & Circumcision) [2000] 1 FLR 571 [Court of Appeal]; Re S (Specific Issue Order: Religion: Circumcision) [2005] 1 FLR 236 [Family Division]; S (Children) [2004] EWCA Civ 1257 [CA].

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2. Per Butler-Sloss P in Re J [CA], ibid., p 577. 3. British Medical Association. (2006) The Law and Ethics of Male Circumcision: Guidance for Doctors. London: BMA (unpaginated) available at www.bma.org.uk/ ap.nsf/Content/malecircumcision2006 (last accessed 19 August 2008). 4. Ibid. 5. Fox M, Thomson M. (2005) A covenant with the status quo? Male circumcision and the new BMA guidance to doctors. J Med Ethics. 31:463–469; Short changed? The law and ethics of male circumcision. Int J Child Rights. 13:161–181 (2005); Reconsidering “best interests”: Male circumcision and the rights of the child. In: Milos M. (ed.) Human Rights and Circumcision. New York, NY: Springer (2008). 6. Colb S. (2007) Divorce, religion, and circumcision: What a conflict tells us about parental rights. Find Law: Legal News and Commentary. November 28 (unpaginated). 7. See Elliston S. (2007) The Best Interests of the Child in Healthcare. London: RoutledgeCavendish. 8. See Buss D. (2000) The christian right and the international rights of the child. In: Bridgeman J, Monk D. (eds.) Feminist Perspectives on Child Law (London: Cavendish) for the argument that the US failure to sign this document has been motivated in part by Christian Right fears that it will undermine 306 parental rights by allowing the state (or the UN) to intervene in families, thereby undermining parental rights, as well as by broader concerns regarding threats to US sovereignty. 9. Per walljinrej [FD], supra n. 1, p 699. 10. Ibid., p 697. 11. Ibid., p 688. 12. Boldt and Boldt, p 344 Ore. 1; 176 P.3d 388 (2008). 13. Gey S. (1990) Why is religion special? Reconsidering the accommodation of religion under the religion clauses of the first amendment? Univ Pittsbg Law Rev. 52:1549–1595. 14. For a consideration of legal responses to bodily interventions and embodied choices see Fletcher R, Fox M, McCandless J. (2008) Legal embodiment: Analysing the body of healthcare law. Med Law Rev. 16:321–345. 15. We shall argue below that the decision to circumcise may differ in significant ways from other contexts, such as organ transplantation, blood donation or sterilization, in which English courts have, at least to a limited extent, confronted the older child’s right to decide for him or herself. 16. Alderson P. (2006) Who should decide and how? In: Parens E. (ed.) Surgically Shaping Children: Technology, Ethics and the Pursuit of Normality. Baltimore, MD: John Hopkins University Press, pp 157–175 at 157. 17. Boldt, supra n. 12, p 391. 18. Ibid., p 393. 19. Ibid. 20. Ibid., p 394. 21. Ibid. 22. Green AS. (2008) US Supreme Court rejects Oregon’s circumcision, abortion cases. The Oregonian. October 7, Both petitions are on file with the authors. 23. See, for instance, Newdow V. (2004) United States Congress, Elk Grove Unified School District et al., p 542 US 1. 24. See note 27 below for an indication of the reasoning underpinning disputed health choices, which seems to indicate that this failure to consult Misha may be characteristic of the practice in US courts. 25. On the central value of autonomy, see, for instance, Brazier M. (2006) Do no harm – Do patients have responsibilities too? Camb Law J. 397–422; Morgan D. (2001) Where do I own my body and how. In: His Issues in Medical Law. London: Cavendish, pp 83–104. 26. See Buss D. (2000) “How the UN stole childhood”: The christian right and the international rights of the child. In: Bridgeman J, Monk D. (eds.) Feminist Perspectives on Child Law. London: Cavendish, pp 271–294.

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27. J.D. v. Vaughan Clinic, P.C. 572 So. 2d 1225 (Ala., 1990). Dicta to similar effect are to be found in Feldman v. Feldman 378 NJ Super 83, 874 A2d 606 (2005) at 611 and Bencomo v. Bencomo 112 Ha 511, 147 P3d 67 (2006) at 72. Unsurprisingly, these authorities are relied on by the father in Boldt in his petition to the US Supreme Court. 28. Supra n. 7, p 75. 29. The landmark House of Lords ruling. In: Gillick v. West Norfolk and Wisbeck Area Health Authority [1985] 3 All ER 402 held that parental rights to decide should yield to the rights of a child who possessed sufficient maturity and understanding to appreciate the implications of the decision. 30. Per Lord Scarman in Gillick, ibid., p 424. 31. Ibid., p 423. 32. Lee S. (1987) Towards a jurisprudence of consent. In: Bell J, Eekelaar J. (eds.) Oxford Essays in Jurisprudence, 3rd Series (Oxford: OUP). On the test for adults see s.1 Mental Capacity Act 2005. 33. Re R (A Minor)(Wardship: Medical Treatment) [1992] 1 F.L.R. 190; Re W (A Minor) (Medical Treatment: Court’s Jurisdiction) [1992] 2 F.C.R. 785; South Glamorgan County Council v. W and B [1993] 1 F.L.R. ; Re E (A Minor) (Wardship: Medical Treatment) [1993] 1 F.L.R. 386; Re S (A Minor: Medical Treatment) [1994] 2 F.L.R. 1065; Re L (Medical Treatment: Gillick Competency) [1998] 2 F.L.R 810 Re M (child: refusal of medical treatment) [1999] 2 F.C.R. 577; Re P (Medical Treatment: Best Interests) [2004] 2 F.L.R. 1117. For discussion of the retreat from Gillick and limits to the parental power to consent, see McHale J, Fox M. (2007) Healthcare Law: Text and Materials, 2nd ed. London: Sweet and Maxwell, pp 451–477. 34. Freeman M. (2005) Re-thinking Gillick. Int J Rights Child. 13:211–217 at 211. 35. Per Baron J in Re S [FD], supra n. 1, p 256. 36. For example, Hammond L. et al. (1993) Children’s Decisions in Health Care and Research. London: Institute of Education. 37. Alderson P, Montgomery J. (1996) Health Care Choices: Making Decisions with Children London: Institute for Public Policy Research. 38. Re J, supra n. 1. 39. Supra n. 3. 40. Re S, supra n. 1. 41. For citations supra see n. 33. 42. Re P, supra n. 33, p 1120. 43. Re E, supra n. 33, p 389. 44. Somerville M. (2000) The Ethical Canary: Science, Society and the Human Spirit. Toronto, ON: Viking/Penguin Canada, p 192 (discussing the case of Tyrell Dueck, a thirteen year old boy who was refusing chemotherapy on the basis of his Christian beliefs.) 45. Supra n. 5. 46. Miller GP. (2002) Circumcision: Cultural-legal analysis. Va J Soc Policy Law. 9:497–537 at 502–503. 47. In terms of the historically persistent claim that neonatal circumcision protects from sexually transmitted infections see Dickson NP, Van Roode T, Herbison P, Paul C. (2008) Circumcision and risk of sexually transmitted infections in a birth cohort. J Pediatr. 122(3):383–387. This study concluded that its findings were consistent with recent population-based cross-sectional studies in developed countries, which found that early childhood circumcision does not markedly reduce the risk of the common STIs in the general population in such countries. 48. Boldt, supra n. 12, p 391. 49. Ibid. 50. See Miller, supra n. 46. 51. Critics of routine circumcision have noted the tendency to characterize circumcisions performed for social, cultural, or religious reasons as therapeutically indicated: see, for

36

52. 53. 54. 55. 56. 57.

58. 59.

60.

61. 62. 63. 64.

65. 66.

67.

68.

M. Fox and M. Thomson example, Derby R, Svoboda JS. (2007) A rose by any other name? Rethinking the similarities and differences between male and female genital cutting. Med Anthropol Quart. 21:301–323 at 304. See Bridgeman J. (1993) Old enough to know best? Leg Stud. 13:69. Re Wand, Re R, supra n. 33. Supra n. 7, p 80. Re B (A Minor) (Wardship: Sterilisation) [1988] 1 A.C. 199. In Re P (a minor) (1981) L.G.R. 301. Supra n. 3. Similarly in recently issued guidance the GMC emphasizes that [i]f you are asked to circumcise a male child, you must proceed on the basis of the child’s best interests and with consent’: GMC, Personal Beliefs and Medical Practice March 2008, para 14. BMA. (2001) Consent, Rights and Choices in Health Care for Children and Young People. London: BMJ Books. The remaining relevant criteria that are listed are: • the patient’s physical and emotional needs; • the risk of harm or suffering for the patient; • the views of parents and family; • the implications for the family of performing, and not performing, the procedure; • relevant information about the patient’s religious or cultural background; and • the prioritizing of options which maximize the patient’s future opportunities and choices. Attempts at foreskin restoration are enduring: see Gilman S. (1999) Making the Body Beautiful: A Cultural History of Aesthetic Surgery. Princeton, NJ: Princeton University Press, pp 137–144; but have not proven successful: see Section 6 Foreskin restoration: Historical and contemporary considerations. In: Denniston GC, Hodges FM, Milos MF. (eds.) Male and Female Circumcision: Medical, Legal and Ethical Considerations. New York, NY: Kluwer/Plenum, 1999. The Tattooing of Minors Act 1968, s. 1 The Female Genital Mutilation Act 2003, s.1(1). Sullivan N. (2007) “The price to pay for our common good”: Genital modification and the somatechnologies of cultural (in)difference. Soc Semiotics. 17:395. See Groskop V. “My body is wrong” The Guardian August 14, 2008. Indeed even the less invasive option of administering puberty-suppressing drugs remains highly controversial, and in the UK is not available to those under 16: Giordano S. (2008) Lives in a chiaroscuro. Should we suspend the puberty of children with gender identity disorder? J Med Ethics. 34:580–584. For a discussion of the tensions that exist in legal responses to “Female Genital Mutilation” and cosmetic genital surgery see Sullivan, supra n. 63. On the inadequate regulation of cosmetic surgery more generally see Latham M. (2008) The shape of things to come: Feminism, regulation and cosmetic surgery. Med Law Rev. 16:437–457. See Consent in the Criminal Law, Consultation Paper 139 (London: Law Commission, 1995). Notwithstanding the wide-ranging nature of the consultations and the considerable academic literature it spawned—see for instance, Ormerod D, Gunn M. (1996) Second law commission consultation paper on consent: Consent—a second Bash? Crim Law Rev. 694–703—no proposals for legislation in the field have emerged. In the minutes of a Law Commission meeting on “Consent as a Defence” on May 28, 1998 it was noted that “The responses to the consultation papers were highly polarized, particularly on the issue of consent for non-sexual offences, and no consensus emerged. Bearing in mind the matters we have already reported on, the amount of work that would be required to reach conclusions on the very difficult and sensitive issues involved and the urgency attaching to our work, we have decided that it would not be worthwhile for us to produce any further report on this topic” [copy on file with authors]. However it should be noted that the GMC guidance to doctors stipulates only that “if parents cannot agree and disputes cannot be resolved informally, you should seek legal advice about whether you should apply to the court” supra n. 57, para 14.

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69. While complication rates from routine circumcision are low, the chances of these complications being mutilatory, infective, or haemorrhagic are high: Williams N, Kapila L. (1993) Complications of circumcision. Br J Surg. 80:1231–1236; Gerharz EW, Haarmann C. (2000) The first cut is the deepest? Medicolegal aspects of male circumcision. BJU Int. 86:332–338. Indeed, complications are potentially catastrophic, since death, gangrene, and total or partial amputation are known adverse outcomes: Hodges FM, Svoboda JS, Van Howe RS. (2002) Prophylactic interventions on children: Balancing human rights with public health. J Med Ethics. 28:10. For a recent reported instance of death as a result of circumcision in the UK see Moyes S. “7-Day-Old Died After Circumcision” Daily Mirror February 15, 2007. 70. In this regard, it is interesting that advocates of neonatal male circumcision tend to argue — despite evidence to the contrary—that newborns do not experience pain: Benatar M, Benatar D. (2003) Between prophylaxis and child abuse: the ethics of neonatal male circumcision. Am J Bioeth. 3:35–48 at 37–38 and accompanying references; Warnock F, Sandrin D. (2004) Comprehensive description of newborn distress behavior in response to acute pain (newborn male circumcision). Pain 107:242–255. 71. Dwyer J. (1994) Parents religion and children’s welfare: Debunking the doctrine of parents’ rights. Calif Law Rev. 82:1371–1347 at 1377. 72. Boldt, supra n. 12, p 393. 73. Ibid. 74. Herrera CD. (2005) Disputes between state and religion over medical treatment for minors. J Church State. 47:823–839 at 824. 75. See e.g. Jehovah’s Witnesses v. King County Hospital 390 US (1968). 76. See e.g. Wisconsin v Yoder 406 US 205 (1972). 77. Supra n. 74, p 823. 78. Dwyer JG. (1996) The children we abandon: Religious exemption to child welfare and education laws as denials of equal protection to children of religious objectors. North Carol Law. 74:1321 at 1322. 79. Silverman RD, May T. (2001) Private choice versus public health: Religion, morality and childhood vaccination law. Margins. 1:505–521 at 505–506. 80. In a UK context see Re C (Welfare of Child: immunisation) [2003] 2 F.L.R. 1095. 81. Bridge C. (2002) Religion, culture and the body of the child. In: Bainham A, et al. (eds.) Body Lore and Laws. Oxford: Hart, pp 265–287 at 284. 82. Supra n. 78, p 1398. 83. Ibid, p 1403. In similar vein, Paula Monopoli writes that “Children in this country [the US] are still being martyred on the alter of their parents religious beliefs”. (1991) Allocating the costs of parental free exercise: Striking a new balance between sincere religious belief and a child’s right to medical treatment. Pepperdine Law Rev. 18:319–352 at 319. 84. O’Donovan K. (1993) The child as legal object. In: Family Law Matters. London: Pluto. 85. See her Altering baby boy’s bodies: The ethics of infant male circumcision. In: The Ethical Canary, op. cit. n. 44, pp 202–219. 86. Ibid., p 212. 87. The law governing assault in the Canadian Criminal Code is similar in relevant respects to the definitions of assault under the Offences against the Person Act 1861, as is the prevalence of the best interests test. 88. Supra n. 85, p 212. 89. Not only are the boundaries of such exemptions difficult to police, but they have been attacked as undermining the entire principle of child welfare/protection in other contexts such as education: see Monopoli, supra n. 83. 90. Supra n. 85, pp 216–217. 91. See Gey, supra. n. 13. 92. Gilbert H. (2007) Time to reconsider the lawfulness of ritual male circumcision. Eur Hum Rights Law Rev. 279–294 at 291. 93. See Zabus C. (2007) Between Rites and Rights: Excision in Women’s Experiential Texts and Human Contexts. California, CA: Stanford University Press, pp 35–37.

38 94. 95. 96. 97. 98. 99.

100. 101. 102. 103.

104.

M. Fox and M. Thomson Alderson, supra, 16, p 157. Ibid., p 170. Per Baron J in Re S [FD], op. cit. n. 2, p 256. Ibid. Domurant Dreger A. What to expect when you have the child you weren’t expecting. In: Parens E. (ed.) supra n. 16, pp 523–566 at 259. Fortin J. (2005) Children’s Rights and the Developing Law, 2nd ed. London: Butterworths, pp 329–32, Elliston, supra. n. 7, pp 98–99; Hinchley G. (2007) Is infant male circumcision an abuse of the rights of the child? BMJ. 335:1180. Hinchley, ibid. Goldman R. (1998) Questioning Circumcision: A Jewish Perspective. Boston, MA: Vanguard Publications. See for a fuller discussion, West R. (1997) Caring for Justice. New York, NY: University Press and Fox and Thomson, “Short Changed?” Supra n. 5. Alderson, supra n. 16, p 170. Darby and Svoboda have argued that the “most obvious and universally experienced harm of all [is] the deprivation off an integral, visually prominent, and erotically significant feature of the penis”: supra n. 51, p 304. Hammond T. (1999) A preliminary poll of men circumcised in infancy or childhood. 83(Supp 1) BJU International 85. See also, Darby R, Cox L. (2007) Objections of a sentimental character: The subjective dimension of foreskin loss. unpublished paper (copy on file with authors).

Chapter 3

These Goalposts Don’t Move: Non-Medical Circumcision of Boys in the Tasmanian and Australian Context Paul Mason

Abstract This paper examines reasons given by proponents for circumcision of minors, which include clinical indications, prophylaxis, religion, and culture. It examines the legal authority by which the professional or lay operator performs surgery on a person with that person’s consent. The paper focuses on the capacity of a parent to give valid consent for surgery performed on children, in the context of Tasmanian and Australian Statute and common law, and the fountains of English common law. It considers the relevance of “Gillick-competence” of the child patient and discusses whether a legal response based on notions of residual parental “rights,” of “family rights,” and of “cultural/religious rights” and the paramountcy principle of the child’s best interests are consistent tests by which to protect the rights of the child. These rights issues are routinely absent from the reductionist arguments of proponents. The paper concludes that the only consistent way to challenge the arguments of child circumcision proponents is to insist on the individual rights of the individual child, including rights to choose a religion, rights to protection from cruel treatment and abuse, rights to be consulted in decisions that have permanent effects on the child’s life experience, and a right emerging from the international response to FGM—the right of genital autonomy. Keywords Genital autonomy · Informed consent · Law · Human rights · Medical ethics · Male circumcision

Human Rights Legal Context Australia does not have a Bill of Rights: rights are protected through legislation, common law, policy, and education.

P. Mason (B) Commissioner for Children, Tasmania, Australia e-mail: [email protected]

G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9_3,  C Springer Science+Business Media B.V. 2010

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A federal constitutional system—legislative, executive, and judicial powers— is distributed between various federal institutions and six states (Tasmania is one) and two self-governing Territories. Treaty-making power remains with the Commonwealth/Australian Government, but States may be responsible for legislation that affects compliance with treaty implementation (e.g., general criminal law of assault, murder, etc.). International law, including treaty law in the absence of legislation expressly applying it to domestic law, cannot impose obligations on individuals nor create rights in domestic law. It remains a legitimate and important influence on the development of the common law; may be used interpreting legislation and the common law. So, for instance, if a decision rests on a test of “reasonableness” or “best interests,” Australia’s international commitments will be an important head of argument. • Before ratification of a treaty, Commonwealth Government assesses conformity or consistency of existing legislation against treaty obligations, If State legislation is inconsistent with treaty obligations, the Commonwealth Government may consider passing its own legislation to bring Australia’s laws back into line with international obligations.

• Australia is a party to various international human rights instruments, including the United Nations Convention on the Rights of the Child (UNCROC), and an international obligation on Australian Government to “respect and ensure the rights set forth in the present Convention to each child within . . . jurisdiction without discrimination of any kind”1 and to “undertake all appropriate legislative, administrative and other measures for the implementation of the rights recognized in the present Convention.”2 Genital cutting of children for reasons not medically indicated amounts to a breach of rights set out in the UNCROC and other international conventions despite acknowledgement in UNCROC of the need to “respect the responsibilities, rights, and duties of parents . . . or other persons legally responsible for the child, to provide, in a manner consistent with evolving capacities of the child, appropriate direction and guidance in the exercise by the child of the rights recognized in the . . .” Convention.3 Routine circumcision for religious, cultural, or social reasons is a breach of Article 19 of UNCROC (State parties to take all appropriate measures “to protect the child from all forms of physical or mental violence, injury or abuse, maltreatment”) and of Article 24 (right to health, which obliges State parties to take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children).4 Article 14 of UNCROC provides that State parties “shall respect the right of the child to freedom of thought, conscience and religion.”

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Parental Authority Even if it is within the scope of parental authority and responsibility (in the sense described in Article 5 of UNCROC) to provide religious guidance and direction, does this extend to taking action that amounts to an irreversible marking of a child to conform to religious tenets and beliefs? Especially so where the child is of an age and maturity to be capable of expressing an opinion on the matter as provided in Article 12 of UNCROC (State parties “shall assure to the child who is capable of forming his or her own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child”). There is no effective remedy for a child seeking to enforce any provision of UNCROC directly in an Australian court. A limited avenue of redress exists under the Human Rights and Equal Opportunity Commission Act 1986 (HREOCA). The Human Rights and Equal Opportunity Commission has the function of inquiring into acts or practices that may be inconsistent with or contrary to the rights set out in the human rights instruments scheduled to or declared under the HREOCA, one of which is UNCROC. Where the Commission is of the opinion that an act done or a practice engaged in by a person is inconsistent with or contrary to any human right, it is required to report to the Attorney General in relation to the inquiry (leads to report tabled in Parliament). Relevant acts and practices are limited to an act or practice done by or on behalf of the Commonwealth or an authority of the Commonwealth. The Commission is required to perform this inquiry function when requested to do so by the Minister, when a complaint is made in writing to it that an act or practice is inconsistent with or contrary to any human right, or it appears to the Commission to be desirable to do so. There is no complaint avenue to the UN Committee responsible for monitoring compliance with UNCROC.

Domestic Protection • Reliance on criminal law and common law of each State and Territory with regard to assault, parental consent to surgery, or medical treatment of children unable to consent because of age and maturity, and it is the jurisdiction of Family Court to resolve disputes between parents about issues of parental responsibility and/or authorize performance of “special medical procedures” on children in circumstances where it is beyond the scope of parental authority to consent to such procedures. • The criminal law in Tasmania criminalizes “female genital mutilation”5 and provides that the consent of the person upon whom the operation was performed or

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of that person’s parent or guardian is not a defense to a charge under the relevant section. Section 178C of the Criminal Code: ◦ excuses “a surgical procedure for a genuine therapeutic purpose” or “ a sexual reassignment procedure” • provides that the fact that a surgical procedure is performed as, or as part of, a cultural, religious, or other social custom is not, of itself, a genuine therapeutic purpose. There are no equivalent provisions specifically criminalizing (or permitting) the performance of non-therapeutic genital cutting of boys. • The sexual reassignment procedure exception is open ended and contains no safeguards that would ensure that performance of the procedure is in the best interests of the child as distinct from an attempt, however well meaning, to “normalize” that child’s genitalia.

Pros and Cons: The Medical Argument Proponents of routine circumcision of healthy baby boys and male children argue that the procedure is in the best interests of the child for medical reasons and cite endless studies and statistics to support their contentions that routine circumcision “confers a lifetime of medical, health and sexual benefits.”6 Many, if not all, of the claimed benefits of routine circumcision or male genital cutting have been questioned or disproved. It is beyond the scope of this paper and outside the expertise of the author to undertake a detailed analysis of the claims and counter claims. The Royal Australasian College of Physicians 2004 Policy Statement on Circumcision accepts that there is no medical indication for neonatal circumcision and sets out the accepted remaining indications for it. This Policy has been labeled as “ill-conceived”7 on the basis that it “downplays the wide-ranging lifelong benefits of circumcision in prevention of urinary tract infections (UTI’s), penile and cervical cancer, genital herpes and chlamydia in women, HIV infection, phimosis and various penile dermatoses, and at the same time overstates the complication rate. . ..” A response8 published in the same journal raises issues about definitions used in studies relied upon, statistics, assumptions inherent in the critique by Morris et al., and raises other questions completely ignored by Morris et al., such as “the genuine ethical concerns of parents about whether they have the right to consent on behalf of an infant to a procedure involving the permanent removal of a body part.”9 Proponents of male circumcision routinely assert in publications that “male circumcision is lawful.” Judges at all levels, from first instanced judges to ultimate appeal judges, routinely say the same thing, but always as obiter dicta, that is, an aside not essential to the logical process that resolves the immediate issue before the Court (the ratio decidendi). The consistent failure to give any reason for including circumcision in these asides indicates prejudice rather than impartial and balanced consideration.

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It is the shame of the legal profession that judges continue to make this pronouncement with no proper authority according to their own rules of analysis and judicial reasoning.

Effective Consent The legal position of a medical professional performing a non-therapeutic circumcision on an otherwise healthy male baby or male child is unclear. A fundamental common law right to bodily integrity underpins the criminalization of unlawful assaults and has been endorsed by the Australian High Court and Family Court in the context of consideration of the appropriateness or otherwise of “non-therapeutic sterilization” and other “special medical procedure” cases under the Family Law Act 1975. The Tasmanian Criminal Code Act 1924 provides that any person who unlawfully assaults another is guilty of a crime but that an assault is not unlawful where a person consents (subject to situations where consent is ineffective because of public policy reasons). Generally speaking, any medical treatment or surgical operation requiring contact with the body of a patient has the potential to be an assault. If non-therapeutic male circumcision is a “surgical operation,” a medical practitioner can lawfully carry out that procedure so long as: • the operation is performed in good faith and with reasonable care and skill • the operation is performed with the consent and for the benefit of the patient. Where the patient is a child who is too young to exercise a reasonable discretion, consent may be given by the child’s parent or by any person having the care of the child • the performance of the operation is reasonable having regard to all the circumstances.10 The circumstances in which a child or young person has the right to make his or her own decision about medical treatment are not clearly delineated. The High Court of Australia in Marion’s case11 : “The common law in Australia has been uncertain as to whether minors under 16 can consent to medical treatment in any circumstances.”(27) See the analysis by Devereux, “The Capacity of a Child in Australia to Consent to Medical Treatment—Gillick Revisited?” (1991) 11 Oxford Journal of Legal Studies 283 (hereafter “Devereux”), at pp 284–287. However, the recent House of Lords decision in Gillick v. West Norfolk AHA(28) [1985] UKHL 7; (1986) AC 112 is of persuasive authority. The proposition endorsed by the majority in that case was that parental power to consent to medical treatment on behalf of a child diminishes gradually as the child s capacities and maturity grow and that this rate of development depends on the individual child. Lord Scarman said (29) ibid., at pp 183–184: Parental rights . . . do not wholly disappear until the age of majority. . .. But the common law has never treated such rights as sovereign or beyond review

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P. Mason and control. Nor has our law ever treated the child as other than a person with capacities and rights recognized by law. The principle of the law . . . is that parental rights are derived from parental duty and exist only so long as they are needed for the protection of the person and property of the child. A minor is, according to this principle, capable of giving informed consent when he or she “achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed” (30) ibid., at p 189, and see pp 169, 194–195 (emphasis added).

• Neither a parent nor a fully competent minor can give an effective consent to all types of surgical operations or medical treatments. If the nature of the proposed treatment is invasive, irreversible and major surgery, and for non-therapeutic reasons, then court approval is required before such treatment can proceed.12 Marion’s case involved an application to the Family Court of Australia for an order authorizing performance of a hysterectomy and ovariectomy on Marion, who was a 14-year old intellectually disabled child. The purposes of the proposed procedures were prevention of pregnancy and menstruation and attendant psychological and behavioral consequences and to stabilize hormonal fluxes with the aim of helping to eliminate consequential stress and behavioral responses. The High Court decided that Marion’s guardian could not lawfully authorize the carrying out of the procedure without a Court authorization. The majority Judges in Marion’s case said: In a case such as the present one, it is primarily the prospect of surgical intervention which attracts the interest of the law. This is because the law treats as unlawful, both criminally and civilly, conduct which constitutes an assault on or a trespass to the person. Therefore it is the legality of the specific medical treatment amounting to a hysterectomy and ovariectomy . . . which must be the focus of this inquiry. However to characterize intervention compromising sterilization as ‘medical treatment’ is already to make assumptions and to narrow the inquiry, perhaps inappropriately. As will become clear, it is the very fact that sterilization implies more than medical, or surgical, treatment that is crucial to the central issue in this case13 (my emphasis).

The High Court went on to say: There are features of a sterilization procedure, or more accurately, factors involved in a decision to authorize sterilization of another person, which indicate that, in order to ensure the best protection of the interests of a child, such a decision should not come within the ordinary scope of parental power to consent to medical treatment.14

• The crux of the High Court’s decision is that Court authorization is required for a medical procedure that: ◦ Requires invasive, irreversible, and major surgery; and ◦ Is not for the purpose of curing a malfunction or disease ◦ Court authorization is required because of:

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• the significant risk of making the wrong decision, either as to a child’s present or future capacity to consent or about the best interests of a child who cannot consent; and ◦ the consequences of a wrong decision are particularly grave. Subsequent cases about “special medical procedures” illustrate that the principles are not limited to sterilization and that there is a need to consider the specific procedure being contemplated from the perspective of what is in the best interests of the particular child. Other cases have concerned sex change therapy and surgery, again in pubescent and adolescent children. The Queensland Law Reform Commission15 concluded: The common law operating in Queensland appears to be that if the young person is unable, through lack of maturity or other disability, to give effective consent to a proposed procedure and if the nature of the proposed treatment is invasive, irreversible and major surgery and for non-therapeutic reasons, then court approval is required before such treatment can proceed. The court will not approve the treatment unless it is necessary and in the young persons’ best interests. It is not clear whether the test applied by the High Court is capable of extension to non-therapeutic circumcision of healthy boys.

Even if Court approval is required, the Family Court’s parens patriae does not extend to children whose parents have never married. If Marion represents the law, and if it applies to routine circumcision, then the Court of competent jurisdiction will be the Supreme Court of the State in which the child is resident.

Relevance of Paramountcy Principle—Best Interests The Family Court does have jurisdiction to determine disputes between parents (married or not) over “specific issues” relevant to parental responsibility, including circumcision. His Honor Strickland J in K and H [2003] Fam CA 1364 rejected a father’s application for an order permitting circumcision of an approximately 18-month-old boy for cultural and religious reasons and granted an application by a mother for an injunction restraining the father from permitting or causing to permit the child to be circumcised. The father, who was born in Tanzania and was raised a Muslim, argued that his Islamic faith and cultural issues obliged him to ensure his son was circumcised. Strickland J did not question that this was a procedure that parents are able to consent to as an aspect of their parental authority “unlike, for example, sterilization for non-therapeutic purposes.” Court involvement occurred simply because the parents could not agree. The Judge decided it was not in the best interests of the child to be circumcised, a procedure described as one that “is not medically indicated.” Factors of relevance included uncertainty about which religious path the child would follow, his ability to continue to be exposed to his father’s religion and culture even if uncircumcised, the fact he would be predominantly exposed to his mother’s culture and religion.

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Medical Ethics The Royal Australasian College of Physicians 1998 publication “Ethics: A Manual for Consultant Physicians” lists the four moral values or obligations of most relevance in medicine as autonomy, beneficence, non-maleficence, and justice.16 Autonomy Autonomy (or self rule) has been defined as the capacity to think and decide, and the capacity to act on the basis of such thought freely and independently. It is a basic moral obligation to respect each person’s autonomy. Respect for the autonomy of a patient is the moral principle on which the debate on informed consent has hinged. Beneficence The principle of beneficence relates to the obligation to do good/to act in the patient’s best interest. Non-maleficence Non-maleficence refers to the duty of not doing harm. Harm can include psychological, emotional, or social harm as well as physical damage.17 Justice This principle is related to the fair distribution of resources.

“Autonomy” is defined in the Concise Medical Dictionary18 as “selfdetermination, or the freedom to behave in ways that accord with one’s own values and objectives. Respect for the autonomy of the patient is one of the four principles of medical ethics.”

What Next? The Tasmanian Law Reform Institute is undertaking a project to review the current law regulating the circumcision of male children in Australia, with particular reference to Tasmania. The project will examine the criminal and civil responsibility of those who perform, aid, or instigate the procedure and will consider many of the issues raised above. This topic for law reform was suggested by the Tasmanian Commissioner for Children. An issues paper will be released in 2009.19

Notes 1. 2. 3. 4.

Article 2 UNCROC. Article 4 UNCROC. Article 5 UNCROC. Refer Narulla R. (2007) Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation. Aust J Hum Rights. 12(2):89–118, April 2007. 5. Section 178A of the Criminal Code Act 1924. 6. Taken from www.circinfo.net visited July 14, 2008. 7. Morris B, Bailis S, Castellsague X, Wiswell T, Halperin D. (2006) RACPs policy statement on infant male circumcision is ill-conceived. Aust N Z J Public Health. 30(1):16–21.

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8. Richters J. (2006) A critical commentary on RACP policy statement on infant male circumcision: A response. Aust N Z J Public Health. 30(1):2–24. 9. Ibid., p 23. 10. S51 Criminal Code Act 1924 (Tasmania). 11. Department of Health and Human Services v JMB and SMB (Marion=s case) [1992] HCA 15 per Mason CJ, Dawson J, Toohey J and Gaudron J at p 7. 12. Ibid. 13. Marion=s case op cit at p 4. 14. Ibid., p 20. 15. QLRC Circumcision of Male Infants@ Miscellaneous Paper December 1993 at p 38. Statement of the law is based on the High Court of Australia decision Secretary Department of Health and Community Services v JWB and SMB (Marion=s case) (1992) 175 CLR 218. 16. Refer p 8 of the publication Ethics: A Manual for Consultant Physicians@ Ethics Committee of the RACP December 1998. 17. Concise Medical Dictionary. Oxford University Press 2007. Oxford Reference Online. Oxford University Press. State Library of Tasmania. 18. Aautonomy. (2007) n@ Concise Medical Dictionary. Oxford University Press. Oxford Reference Online. Oxford University Press. State Library of Tasmania. 19. http://www.law.utas.edu.au/reform/malecircumcision.htm

Chapter 4

Mass Campaigns of Male Circumcision for HIV Control in Africa: Clinical Efficacy, Population Effectiveness, Political Issues Michel Garenne

Abstract This paper reviews the demographic evidence for the relationship between male circumcision and HIV infection in national or sub-national African populations. A meta-analysis based on 18 countries, representing more than half of the population of sub-Saharan Africa, shows no relationship [standardized odds ratio = 1.00; 95% CI: 0.96–1.05]. There were even more countries in which HIV prevalence was higher among circumcised persons than countries where it was lower. In only five countries, the odds ratio of HIV prevalence (circumcised/intact) was significantly different from 1.0; three countries where it was higher, and two countries where it was lower. The contrast between lack of demographic impact and results from clinical trial is striking, and can probably be explained by the low clinical efficacy in situations of intense and repeated exposure, and by the interactions with the many other determinants of HIV spread. This paper also addresses some ethical and political issues, and in particular raises the question of power abuse, which may lie in the practice of genital mutilations and relevant international recommendations. Keywords Male circumcision · HIV/AIDS · Clinical efficacy · Population effectiveness · Randomized controlled trials · Ecological studies · Sub-Saharan Africa

Introduction In the study of the impact of public health interventions, two types of evidence can be opposed: the measure of “clinical efficacy,” or “biological effect,” shown in general by clinical trials or epidemiologic studies, and the measure of “population effectiveness,” or “demographic impact,” shown by their effect in large populations M. Garenne (B) IRD (French Institute for Research and Development) and Institut Pasteur, Paris, France e-mail: [email protected]

G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9_4,  C Springer Science+Business Media B.V. 2010

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or by comparison between populations. Clinical trials aim primarily at demonstrating a biological effect, but they do not guarantee a large demographic impact. Conversely, a demographic impact is sometimes observed even when clinical trials tend to indicate a low effect. When clinical efficacy is very high (say above 95%), the population impact is usually marked, and close to what can be expected from clinical trials. When clinical efficacy is moderate (say around 50%), the population impact is often small, when not negligible. In rare studies, one also finds cases of population impact despite low clinical efficacy. Let us give a few examples in the field of vaccines. The measles vaccine has a very high clinical efficacy, considered to be above 95%. This has been shown repeatedly in numerous randomized clinical trials all over the world, and similar values are found in case control studies (Redd et al., 1999). The measles vaccine is also an “efficient” vaccine: when administered on a large scale, not only does it protect those who received it, but it also tends to reduce the transmission, and even to stop epidemics through herd immunity. Measles was virtually eradicated from the United States in the early 1980s by mass vaccination campaigns, and came back only because it was re-introduced from foreign countries (Wood and Brunell, 1995). The cholera vaccine has an efficacy of about 50% in clinical trials, but has virtually no demographic impact: it does not stop epidemics, and its protection is short lasting (Tacket and Sack, 2008). This is why it is not recommended in public health programs. The pertussis vaccine (whoopingcough) is a vaccine that has a very low efficacy in clinical trials, and has been shown to provide no protection against infection by the germ (Bordetella pertussis). However, it has a very large population effect, stopping epidemics and protecting individuals against the severe forms of the diseases, and its population effectiveness is close to that of the measles vaccine (Edwards and Decker, 2008; Pollard, 1980). This is why it is used in most vaccination programs, and it is part of the Expanded Program on Immunization recommended by the World Health Organization. Similar comparisons can be made in the field of contraception, an issue more closely related to the control of sexually transmitted infections (STIs). The hormonal contraceptives (pill, injectables, implants) or the barrier methods, such as the Intra-Uterine-Device (IUD), have a very high efficacy in clinical trials, usually above 99%. They also have very high population effectiveness: women who use them properly have no unwanted pregnancy, and populations who use them on a large scale have a low fertility, close to that desired by couples. On the contrary, the Rhythm Method (Knauss-Ogino Method), which is based on very sound biological evidence and has a moderate efficacy in clinical trials (around 50%), has virtually no population effect nor any individual effect: women who use it tend to become pregnant sooner or later, and no country was able to control its fertility only with this method (Labbok and Queenan, 1989). Its only visible effect is a lengthening of birth intervals, which does not permit to bring fertility from 7 or 8 children to 2 children, as do very effective methods. The withdrawal method (coitus interruptus) will never be investigated in clinical trials since it involves primarily

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a very personal behavior, but was shown empirically to have a major population impact since this was the most common method to control fertility in Europe before 1950. The case of efficacy and effectiveness of male circumcision for controlling HIV transmission bears some similarity with that of the rhythm method to control fertility. In a series of recent clinical trials, male circumcision was found to have an average clinical efficacy against HIV transmission (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). Is this enough to make recommendations for general use? Beyond clinical efficacy and demographic impact, are there not other issues related with such a practice? In this paper, we will focus on a lack of evidence showing a demographic impact of male circumcision on the HIV epidemics in sub-Saharan Africa, the continent most hard hit by the disease. We also address briefly some of the ethical issues raised by the recommendation for male circumcision (WHO/UNAIDS, 2007), viewed from an international health perspective.

Methods In order to investigate the population impact of male circumcision, we will use several comparisons: – Comparing population groups that are circumcised and not circumcised in the same country, which assumes comparable exposure to the disease (prevalence or incidence); – Comparing sub-groups known to have different risks, in the same way; – Comparing countries that are practicing or not practicing circumcision. There are serious caveats involved in these comparisons. In Africa, sub-groups practicing—or not practicing—male circumcision are usually defined by ethnicity or religion, sometimes associated with social status or urban residence, and may not be comparable in terms of exposure, since they have different value systems, different marriage patterns, and different sexual behaviors. The case is even worse for country comparisons, where many other factors could bias the comparisons, and we will see some examples later. Nevertheless, when a public health intervention is very efficient, its demographic impact is largely independent of any social variable, such as social status, religion, or ethnicity. There are many examples in the literature, and they apply similarly to the fields of vaccination, contraception, or medical treatments. The effect of vaccines, hormonal contraceptives, antibiotics, antimalarial drugs, etc., is basically the same in all countries in the world, and their population effect is simply proportional to the population coverage. Therefore, when there is no visible demographic impact, one can seriously question the usefulness of a public health intervention.

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Results HIV Prevalence and Proportion Circumcised at National Level The first comparison deals with HIV prevalence between circumcised and intact men in generalized epidemics, some 20–25 years after the onset of the HIV epidemic, that is the situation in years 2002–2007. It measures basically a net effect of circumcision, before changing behavior (condom use, reducing number of partners) really took off and changed the ecological correlations. The data are drawn from the Demographic and Health Surveys (DHS), which are large scale surveys based on representative samples of African populations [all available on the DHS website], and on a similar survey conducted in South Africa, not part of the DHS program (South Africa, 2002). For a statistician, this is the best scenario for testing a potential demographic impact, since the surveys display at the same time the HIV serologic status and the circumcision status for men aged 15–49 or 15–59 years. A first analysis was done a few years ago, and published in 2008 in the African Journal of AIDS Research (Garenne, 2006, 2008). The data were updated with more recent surveys (Congo, Zambia, South Africa), so that 18 countries’ surveys are now included, covering about 55% of the population of sub-Saharan Africa.

Table 4.1 HIV seroprevalence by circumcision status in African countries Percent

Percent HIV+

Ratio circumcised/intact

Country

Circumcised

Circumcised

Intact

RR

Burkina Faso Cameroon Côte d’Ivoire Congo Kinshasa Ethiopia Ghana Kenya Lesotho Liberia Malawi Niger Rwanda South Africa Swaziland Tanzania Uganda Zambia Zimbabwe Meta-analysis

89.7 91.8 96.0 97.7 92.3 95.3 83.4 48.6 97.8 20.7 99.5 11.1 35.3 8.2 69.7 24.9 12.5 10.5

1.8 4.1 2.8 1.0 0.9 1.6 3.0 22.8 1.1 13.2 1.0 3.5 12.3 21.8 6.5 3.8 10.8 16.6

2.9 1.1 3.8 0.0 1.1 1.4 12.6 15.2 0.0 9.5 0.0 2.1 12.0 19.5 5.6 5.6 12.5 14.2

0.62 3.73 0.74 1.00 0.82 1.14 0.24 1.50 1.00 1.39 1.00 1.67 1.03 1.12 1.16 0.68 0.86 1.17 1.00

Significance NS

∗

NS NS NS NS ∗ ∗

NS ∗

NS NS NS NS NS ∗

NS NS NS

Note: Sources of data are published DHS reports and HSRC study for South Africa. ∗ p < 0.05.

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Results show no effect of male circumcision in national African populations: the standardized odds-ratio was 1.00 (95% CI: 0.96–1.05), which means that, on the average, circumcised and intact men have the same HIV prevalence (Table 4.1). Out of the 18 countries studied, 12 have an odds ratio equal or higher than one (more HIV among circumcised men), 3 of them statistically significant (Cameroon, Lesotho, Malawi), and 6 have an odds ratio lower than one (less HIV among circumcised men), 2 of them statistically significant (Kenya and Uganda). Note that these results are based on large numbers: some 73,800 men sampled, who are representative of the general population. This is the most reliable evidence that we have on the population impact of male circumcision in Africa.

Case Studies Let us give a closer look at a few selected countries, for which, contrary to expectations, the risk ratio of HIV prevalence (circumcised/intact) is higher than 1. In Tanzania, HIV prevalence is moderate, with some 6.3% of men infected. The epidemic has been going on for about 25 years, since the western part of the country is close to the epicenter of the epidemic, located around Lake Victoria. There are some 110 ethnic groups recorded in Tanzania, some 70% practicing male circumcision. This is a quasi-experimental situation. In Tanzania, HIV prevalence is higher among the circumcised groups (6.5% versus 5.6%). This is due in part to a correlation with urbanization: urban areas are at the same time more circumcised and have more HIV. But even if one controls for urbanization, the HIV prevalence is the same in the two groups: 9.7 and 9.5% in urban areas; 5.2 and 4.6% in rural areas, none of these differences being significant (Tanzania, 2005). Lesotho is a tiny country embedded in South Africa. The main feature of Lesotho is its ethnic homogeneity, all people belonging to the same group: the Southern Sotho. The country has been exposed for about 15 years to HIV, and prevalence is very high, with 19.3% of adult men infected. About half of the men are circumcised, which is again a quasi-experimental situation, almost ideal given the homogeneity of the ethnic composition. Here again, the profile of HIV prevalence is contrary to expectations: circumcised men are more infected by HIV: 22.8% versus 15.2% for intact men, and this is true in both urban (28.6% versus 17.3%) and rural areas (21.8% versus 14.5%), in the various ecological zones, and for various measures of social status (Lesotho, 2005). Malawi is a country located in South-Eastern Africa. Malawi has a rather high prevalence, with about 10% men infected, and the epidemic has been going on for about 20 years. Malawi is characterized by a strong dichotomy between North and South, and the dozen of ethnic groups recorded have major differences in demographic profiles and sexual behavior. The North is less circumcised and has less HIV, whereas the South is more circumcised and has more HIV, again contrary to expectations. As was the case in other countries, controlling for urbanization does not change the main picture: more HIV among the circumcised men. Ironically, when stratified by region, the relationship between circumcision and HIV

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prevalence is inverted: the more circumcised in a region, the higher is the seroprevalence (Malawi, 2005). A recent publication, based on a 2002 survey, also showed a similar pattern in South Africa, where about a third of the population is circumcised and HIV prevalence amongst the highest on record: there was no difference in HIV prevalence in 2002 between the two groups, even after controlling for a variety of factors (Connolly et al., 2008).

HIV Incidence, and Dynamics of the HIV Epidemic in South Africa Some authors have argued that male circumcision could change the dynamics of the epidemic by strongly reducing incidence and the net reproduction rate (Ro). This is not the case in South Africa, the only country where one can pursue this type of analysis, because routine HIV prevalence is recorded every year and published over a long period of time. South Africa also has a useful feature for analysis: about one third of men are circumcised; circumcision is primarily ethnic specific, and provinces are also largely ethnic specific. So, by comparing the dynamics of the HIV epidemic by province, one may infer the effect (or lack thereof) of circumcision in the general population. The nine provinces were classified into three groups: low, medium and high level of circumcision. Two indicators of the dynamics of the epidemic were computed: the average incidence between 1994 and 2004, and an estimate of the net reproduction rate of the epidemic between 1994 and 2004. Results again show no clear relationship between the prevalence of male circumcision and the prevalence of HIV: differences in incidence were small: 2.0, 2.5, 2.1%, and differences in net reproduction rates were even in the opposite order: higher in provinces with high level of circumcision than in those with low level (see details in Garenne, 2008). If one compares two contrasted provinces: one with no circumcision, the North-West province, populated by Tswana, and one with widespread circumcision, the Eastern Cape province, populated by Xhosa, one finds no difference in the dynamics of the epidemic from 1994 to 2004, and levels of seroprevalence were basically the same in 2004. In conclusion, large-scale demographic surveys, as well as routine seroprevalence surveys among pregnant women, do not show any consistent population impact of male circumcision on either HIV prevalence or HIV incidence. Male circumcision does not appear to be the “Magic Bullet” presented by other researchers and based on results from clinical trials.

Other Evidence of a Lack of Demographic Impact These findings are not really new, and could have been anticipated. Robert Van Howe conducted a large scale meta-analysis of the effect of male circumcision on

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HIV and other STIs in many risk groups, and found no protective effect. He even found a small increased risk in his meta-analyses (Van Howe, 1999a, b). Comparing the United States, where male circumcision is widespread, to Europe where it is rare, also goes rather in the opposite direction: more HIV in the former, and even more HIV transmitted heterosexually if one excludes cases imported from Africa in Europe. Even in the USA, the African-American population is more circumcised than average, and it is also more affected by HIV (Siegfried et al., 2007). Let us also remember that, in Africa, about 70% of men are already circumcised, probably the highest rate in any continent: this did not hamper Africa to host the largest epidemic in any continent. A quick comparison with Eastern Asia (China, Japan) where virtually no men are circumcised and where HIV prevalence is extremely low is illuminating: the correlation goes in the opposite direction— the less circumcision, the less HIV prevalence. In contrast, when one makes similar comparisons with vaccination coverage for diseases or with contraceptive use for fertility, one finds the expected correlations.

Controversy About Geographical Correlations Several studies conducted in the 1980s argued that African countries more affected by HIV were also less circumcised (Bongaarts et al., 1989; Moses et al., 1990; Weiss et al., 2000). This has been confirmed by recent population based studies, but is obviously correlated with other important confounding factors affecting sexual behavior, in particular, religion: Islam recommends male circumcision, but is very much opposed to any form of premarital and extramarital intercourse for women, therefore strongly reducing the risk of sexual transmission of diseases. In another paper, we argued that HIV was more closely related with marriage pattern and permissiveness, both being measured simultaneously by premarital fertility (having a birth prior to first marriage). The map displaying premarital fertility levels is in fact close to the map of HIV prevalence levels, revealing the other confounding factors (Zwang and Garenne, 2008). Therefore, the ecological correlation between HIV prevalence and male circumcision appears misleading, and seems to reflect primarily other determinants of HIV spread. However, one should note that no country for which we have reliable data where male circumcision is widespread (>85% circumcised), including non-Muslim countries, such as Congo-Kinshasa, had a high level of seroprevalence (>5% among adults 15–49). This fact has never been properly explained, and deserves more research. In summary, whatever the correlations, one has to remember that even a country half circumcised, such as Lesotho, can have a very large epidemic, with levels of seroprevalence close to the highest on record. This seems to give a far better picture of what could be the potential impact of mass circumcision campaigns: basically negligible in generalized epidemics.

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Population Impact Versus Clinical Efficacy The difference between the effect of male circumcision in clinical trials and the lack of any significant demographic effect may seem puzzling at first glance. The main reason seems to be the low level of clinical efficacy: a 50% reduction in risk is likely to have only a small demographic effect. Indeed, under repeated exposure, any circumcised man will eventually become infected, as will intact men. Circumcision does not really provide any protection, but simply reduces the risk at each exposure. This may delay the time to infection, but will rarely change the ultimate outcome, a situation similar to the effect of the rhythm method for contraception. The potential effect of mass circumcision campaigns will lead only to a very small impact, which will be buried into the many other factors of HIV transmission. If male circumcision had a 99% protective efficacy, the situation would have been different.

Discussion Rationale for Making Public Health Policies Let us ask now a simple question, based on the findings of the clinical trials: is a 50% reduction in risk enough to make a policy? The answer is clearly no. For instance, if one compares with the field of contraception: the rhythm method is also 50% efficient in clinical trials, but is not recommended, because there are much better strategies available for birth control. Likewise, the cholera vaccine is also 50% efficient in clinical trials, but is not recommended, because there are much better strategies available for controlling cholera. There are also better alternative strategies to control HIV, summarized under the acronym “ABC” (for Abstinence, Be faithful, Condom use), which have worked in Africa and elsewhere: changing risky behavior worked well, for instance, in Uganda (Low-Beer, 2002; Low-Beer and Stoneburner, 2003), and condom use worked extremely well in Thailand (Brown et al., 1994). We do not have a full account of what has been happening in Africa since year 2000, but in almost all countries for which data are available, prevalence and incidence among young adults have been going down over the past 10 years, as a result of changing behavior. These ABC strategies seem to be able to change the course of the HIV epidemics. On the other hand, no country has ever been able to control an STI with male circumcision only. Let us remember the case of Japan: this country has among the lowest rates of HIV and of any STI, and makes a very wide use of condoms. This seems to be a far better strategy for controlling sexually transmitted infections.

Ethical Considerations This paper focuses on the lack of demographic impact to be expected from male circumcision. Of course, there are many other dangers associated with mass

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circumcision campaigns. Firstly, at population level, shifting from ABC strategies, which, from experience, are the most likely to change the course of the epidemic to a strategy that has no chance of doing so, seems to be a serious mistake. Secondly, at the individual level, giving the impression that male circumcision “protects” against HIV transmission may have adverse effects: by giving a false sense of protection, it may induce riskier behaviors, and ultimately increase transmission. In this case, it will also have negative effects on the confidence that individuals have in the health system and in health education messages.

Ultimate Rationale of Male Circumcision Male circumcision is a form of genital mutilation with numerous implications, amply documented in this book and in the ten international symposia organized over the past 20 years. This in itself raises many ethical issues, widely documented elsewhere (Aggleton, 2007; Doctors Opposing (male) Circumcision, 2006; Clark, 2006). Beyond individual cases when it is recommended for medical reasons, at population level male circumcision appears as a form of power abuse, especially when made compulsory, or at least strongly recommended. It is especially questionable when used on infants, children, or adolescents since it violates their rights, but is also questionable when recommended for consenting adults. Numerous studies have highlighted the stakes behind this practice. For traditional societies, where circumcision is compulsory for adolescents, the power abuse comes from the elders. This is best expressed by Margaret Mead (1949), who had such a powerful insight on male circumcision. In her famous book, Male and Female, she says: . . . in South America, in Africa and in the South Seas, there are tribes in which the old men’s antagonism to the springing sexuality of the young induces fears that are later reduced in pantomine, cruel initiatory rites in which the young men are circumcised, their teeth knocked out, and, in various ways they are reduced and modified and humbled, and then permitted to be men.

When religious leaders recommend circumcision for newborns or young boys, the power abuse comes from religious hierarchy and applies to the whole society: by requesting the parents to accept the circumcision of their sons, the religious establishment ensures its power over the whole family. Robert Darby (2005) in his book, A Surgical Temptation, showed that the development of male circumcision for newborn infants in Victorian England is also a form of power abuse, this time coming from the medical establishment over the families. This came at a time when the political power of physicians and surgeons in society increased dramatically, and a new form of “biopower” emerged. The question that can be raised now is whether recommending mass circumcision campaigns for Africans, in the absence of clear evidence of any demographic impact, is not a new form of power abuse, this time from newly established groups:

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international institutions and lobbies? This question certainly deserves further comments and in-depth discussions.

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Redd SC, Markowitz LE, Katz SL. (1999) Measles vaccine. In: Plotkin SA, Orenstein WA. (eds.) Vaccines. Philadelphia, PA: W.B. Saunders, pp 222–266. Tacket C, Sack D. (2008) Cholera vaccine. In: Plotkin SA, Orenstein WA. (eds.) Vaccines. Philadelphia, PA: Elsevier-Saunders. Siegfried N, Muller M, Volmink J, Deeks J, Egger M, Low N, Weiss H, Wlaker S, Williamson P. (2007) Male circumcision for prevention of heterosexual acquisition of HIV in men (Review). The Cochrane Library. South Africa. (2002) The Nelson Mandela/HSRC study of HIV/AIDS, 2002. Human Science Research Council, Cape Town, South Africa. [available on web site: www.hsrcpress.ac.za] Tanzania – Commission for AIDS (TACAIDS), National Bureau of Statistics (NBS), and ORC Macro. (2005) Tanzania HIV/AIDS Indicator Survey 2003–2004. Calverton, NY: TACAIDS, NBS, and ORC Macro. Van Howe RS. (1999a) Does circumcision influence sexually transmitted diseases? A literature review. BJU Int. 83(Supp 1):52–62. Van Howe RS. (1999b) Circumcision and HIV infection: Review of the literature and metaanalysis. Int J STD AIDS. 10:8–16. Weiss HA, Quigley MA, Hayes RK. (2000) Male circumcision and risk of HIV infection in subSaharan Africa: A systematic review and meta-analysis. AIDS. 174:2361–2370. Wood DL, Brunell PA. (1995) Measles control in the United States: Problems of the past and challenges for the future. Clin Microbiol Rev. 8(2):260–267. WHO/UNAIDS. (2007) Recommendations from expert consultation on male circumcision for HIV prevention. Available at: http://www.who.int/hiv/mediacentre/news68/en/index.html Zwang J, Garenne M. (2008) Premarital fertility and HIV/AIDS in Africa. Afr J Reprod Health. 12(1):64–74.

Chapter 5

AIDS XVII, Mexico City: Reason for Hope or Panic? John Geisheker

Abstract The XVIIth International Conference on AIDS in Mexico delivered a pleasant surprise to those of us who exhibited on behalf of the International Coalition for Genital Integrity: most of the African women delegates to whom we spoke, AIDS workers on the front lines, were skeptical that male circumcision (MC) would prove an HIV panacea of any worth. Indeed, many delegates described MC as a double trap for women. They worried aloud that “medically circumcised” men will tout themselves as uniquely immune to HIV and thus in no need of a condom. Delegates also noted that circumcision only protects HIV(–) men from HIV+ women, to only 60%, if it does that. It delivers no protection to HIV(–) women from infected men. Well-financed proponents of MC locked out any discussion or open forum on the issue in Mexico, and were quick to claim, “the train has already left the station.” How soon this first-time public health condemnation of a normal body part, an apparent well-financed fait accompli, stumbles remains the interesting question. Keywords Genital integrity · HIV · AIDS · Male circumcision · Cost benefits ratio In August 2008, three of us—the author, along with Georganne Chapin and Brian O’Donnell—traveled to Mexico City to staff a booth at the XVIIth International AIDS Conference. Georganne and I are lawyers by training. Georganne also runs Intact America and another nonprofit organization. Brian is a Physician Assistant, certified as an HIV specialist by the American Academy of HIV Medicine. Our intent was to highlight the risks and foolishness of the plan, floated by the World Health Organization (WHO), the US President’s Emergency Plan for AIDS Relief, the Joint United Nations Program on HIV/AIDS (UNAIDS), and the Gates Foundation, to introduce male circumcision (MC) as a putative HIV preventative. Our 10-foot banner, Male Circumcision: A Dangerous Distraction of Poor Ethics and Bad Medicine, stretched directly across from the main elevator, and—through J. Geisheker (B) Doctors Opposing Circumcision, Seattle, WA, USA e-mail: [email protected]

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pure good fortune—was the first thing the delegates saw upon entering the exhibit hall. Our message was highly controversial. Often, our booth was crowded with conference delegates waiting to engage us, and visitors, including other conference exhibitors, wanting to chat before and after official hours. Multiple delegates from virtually every country in Africa, except Liberia and Tunisia, and many others from around the world sought us out. Our most effective argument, if confined to 60 or 90 seconds, was a simple and effective four-part critique, which we adapted as the occasion warranted: 1. The cost of male circumcision (MC) would siphon off much of the available AIDS funding. Money should properly go to condoms and education, which are affordable and have been proven effective. These simple methods only wait strong endorsement from local governments. Such plans barely have been implemented, and have also been thwarted by previous US administrations, apparently responding to pressure from religious interests. 2. MC carries substantial risks in village settings, where trained personnel, antiseptic conditions, and even clean water are scarce, and where follow-up care for infection and botches are non-existent. 3. Even if MC confers the 60% protection for men claimed by its advocates, this is not vaccine-level protection. Presenting MC as a “magic bullet” yielding “lifetime protection” as proponents have done is an irresponsible and unethical invitation to an epidemiological disaster if proven methods of sexual hygiene are not also practiced rigorously. Moreover, if simple methods of sexual hygiene are necessary to decrease the risks of infection even in a circumcised male, why bother with the cost and risks of MC? 4. MC increases—inarguably and obviously—the risk of infection to women. Even the claimed effect only protects men from infected women and then only to 60%—if you believe the studies. Even if we accept the findings of the three randomized controlled trials that allege a protective effect for circumcision (and there is much criticism of the methodology in the scientific press), circumcision would do nothing to protect an HIV-negative woman from an infected male. Thus, we were able to argue that medically circumcised men are likely to present themselves, especially to poor or illiterate village women, as rendered surgically immune to HIV. This last point seemed to resonate best with those delegates with whom we spoke. To visitors who remained longer at our booth, we offered the following additional arguments: Some men are likely to boast that their “medical” circumcision confers unique protection from HIV, and is thus superior to tribal or bush initiation rites. Indeed, the white, North American proponents of MC for Africa publicly claimed in Mexico City that traditional African MC methods “are not thorough enough,” raising the lucrative, and for some proponents, a giddily titillating prospect of re-circumcising all of the hundreds of millions of

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already ritually circumcised males in Africa. Their own studies showed that circumcised men felt “confident” they would not catch HIV, which suggests a dangerous, misguided reliance on Western medicine. Proponents apparently sensed neither the risk nor the irony. Focusing on MC creates a parallel disincentive to use condoms, which provide other benefits—notably preventing unwanted pregnancies, as well as control of other sexually transmitted infections. Brian O’Donnell, who had worked in HIV programs in South Africa, observed that promoting condoms and emphasizing their correct use has never been made a priority. In that country, for example, the only condom available for free (and ironically called “CHOICE”) smelled medicinal, and was available in only one size. Two or three health ministers who stopped by our booth remarked that they were afraid that if the word got out in their predominantly Muslim countries that circumcision protected men from HIV, all the work they had done to encourage the use of condoms would be forgotten and the incidence of HIV and other STDs would go up. Many predicted that HIV would also increase in Sub-Saharan Africa, as a result of men believing that their newly performed circumcisions will confer protection. Medical care in Africa has already proved a vector for HIV infections, as expensive one-use supplies are routinely re-used, when HIV-infected men and women, not yet tested or as yet undetectable, seek medical attention for any reason.1 This problem will explode with mass circumcision, as the supposed “single-use” surgical kits will be redeployed within populations with high HIV prevalence. The shortage of skilled circumcisers will be an ongoing problem, and will exacerbate the already significant risks and harms of circumcision. Proponents of MC admitted that there will never be sufficient resources, financial or human, to enlist physicians or surgeons for their massive, continent-wide plan. Instead, they conceded that the best they could do is train paraprofessionals to perform this single procedure and no other. In fact, they admitted in Mexico City that most likely to be trained are “bush” circumcisers, men who for centuries have used unsanitary techniques that kill a hundred or more South African young men each year. It is unlikely those same practitioners will observe consistent antisepsis let alone be trained to deal with the many complications that MC creates even in the modern hospital settings of the developed world. “Bush” circumcisions are themselves a proven vector for HIV. Bush circumcisers will not suddenly begin to autoclave their pot shards, sharpened sticks, and discarded razor blades, simply because US medical consultants request they do so.2 Male genital cutting (MGC) might halt the progress made in discouraging female genital cutting (FGC), or worse, may cause it to spring up unbidden where it never flourished before. One reason is that, if mucosal tissue is the culprit, women have much more of the “warm, moist, mucosa,” so feared by male circumcision proponents, than men. Example: A Tanzanian study of

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circumcised women shows a similar protective effect, though that study has received very little press for obvious reasons.3 We repeatedly emphasized that, from an ethical standpoint, there is no distinction between male and female cutting, and others were also pointing this out. Georganne reported that, at one session she attended, an African woman in the audience at a panel on male circumcision asked the question: “How shall we tell our people that girls must be left with the bodies that God gave them, while at the same time we propose to cut all of our boys?” Unfortunately, this perspective was not featured at the conference. Promoting MC pits one culture against another. In Kenya, the Luo tribe (the tribe of Barack Obama’s father) does not circumcise, yet they are being blamed for the HIV epidemic by the Kikuyu, who do practice circumcision. During recent hostilities, Kikuyu men kidnapped and forcibly circumcised any Luo men or boys they could entrap.4 Such tribal tensions will be exacerbated if circumcision is introduced indiscriminately, risking the same genocide that ravaged the Hutu and Tutsi in Uganda. Indeed, the Luo already blame white researchers for the perception that they are the source of HIV/AIDS. MC will enforce and propound genital cutting traditions for centuries to come. Anthropologists note that genital cutting, especially of children, is invariably intractable, as its victims grow up to impose it on the young and powerless as it was imposed on them. This cycle, as FGC opponents have noted, is difficult to break. Thus, the WHO HIV plan will have a tragic side-effect: genital cutting rituals, which South Africa, for instance, has tried to outlaw for minors, will become “medicalized” and normalized, blessed by the Western medical establishment, and hence nearly impossible to eradicate. The United States itself is an example of this phenomenon, with its 140-year genital-cutting tradition (girls were included for many decades) brokered and sustained by the medical establishment entirely for reasons of its own. The belief that genital amputations are the ultimate and preferred solution to sexually transmitted diseases will become a deeply rooted and unquestioned custom in Africa, which already has many different and ancient traditions of genital cutting imposed on children. Even if the WHO/PEPFAR/Gates Foundation plan eventually fails, for reasons of cost, or morbidity, or “patient” resistance—or an AIDS vaccine is eventually found—the notion of genital cutting as a first-line medical intervention will have done massive anthropological damage. It may take centuries to recover from this Western interference in diverse African cultures, and tens of millions of children are likely to pay the highest price. After 5 days of engaging about 800 people—many of whom were AIDS workers on the front lines in Africa—at our booth, in elevators, and on our daily bus-ride, we were able to draw some sobering conclusions: Europeans from all countries and backgrounds with only rare exceptions agreed with our message. Our few vocal critics were invariably North Americans,

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some doubtless with a financial, professional, personal, or religious stake in legitimizing and promoting male circumcision. African women were the most astute in their instant recognition of the social risks; African men were less so, as you might expect. The vast majority of these women—to be fair, educated, traveled, and urbane—thought the WHO, UNAIDS, PEPFAR, Gates Foundation plan was not only wasteful, but also a “trap” for village women. They often arrived already skeptical and took little effort to convince. The question remains whether their resistance will make a difference at the local level or whether they will be marginalized or steamrolled by the huge sums of money flowing toward their local officials from the proponents of MC.

All in all, this was an inspiring, if exhausting, experience. The conundrum remains how First-World circumcision proponents can remain so single-minded and intransigent while individual citizens of the target countries they claim to be “saving” understand the village-level risks and costs. We think this is simply a modern example of colonial medicine, complicated by a failure to learn from past failed efforts, such as vasectomy programs in India and an almost exclusive medical-model approach. A number of social scientists present complained to us that their warnings had been ignored in favor of purely biomedical computer modeling. Most of all, though, the increasing focus on male circumcision is due to the huge sums, hundreds of millions, made available by the Gates Foundation and UNAIDS, and publicly represented by former US president Bill Clinton, who appeared again, as he had in Toronto in 2006. We wonder whether a Health Minister of a small, impoverished African country (or a Johns Hopkins or Harvard professor reeling in lucrative grants) would turn away billions of dollars, no matter how it was earmarked. Indeed, we observed that much of that money is likely to evaporate through graft and political corruption and will never be used for its stated purpose. Flying back to the States, by chance I found myself seated next to Dr. Marcus Conant, an HIV physician from San Francisco (featured in the film And the Band Played On), who, before the advent of anti-retroviral therapies (ART), lost thousands of patients to AIDS. Initially, I did not know who he was. When he asked me whether I was at the conference, I offered him my Doctors Opposing Circumcision business card, to which he said, “Well, meet another doc opposing circumcision.” He went on to say, “I do not feel that widespread circumcision is a panacea for stopping the AIDS epidemic.” And, indeed, WHO and UNAIDS are already floating that plan, without the slightest qualm, having moved swiftly, in barely five years, from voluntary adult circumcisions (about which, epidemiological worries aside, there is little to say if there is honest informed consent) to MC for infants, where consent is irrelevant, mandates easy to impose, and the bioethics disgraceful. Since August of 2008, several interesting developments have changed the scheme to impose circumcision as a panacea for HIV: The recent Wawer study showed that circumcised men were more likely to transmit HIV to the female partner than the uncircumcised male, 21% vs. 13%, more

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than a 150% differential. The study was aborted due to “futility.” It would be interesting to know what the long-term sero-conversion results might have been. Surely, this rate would rise over time. The author of the study, an admitted “MC-for-Africa” proponent, confessed that she was “disappointed” but admitted, “the data are what they are.”5 An HIV vaccine, actually a combination of two vaccines previously found ineffective individually, has shown a 30% reduction in HIV, though that conclusion has been hotly contested.6 If proven, even a vaccine showing a 30% reduction is in practice better than the 60% claim of prophylaxis via circumcision, since a vaccine has the potential to protect everyone in all directions, every vector—male, female, adult, or child, regardless of infection source or sexual practice. By contrast, even MC proponents admit that the African randomized controlled trials, if they are to be believed, indicate that MC only protects heterosexual men from infected women, a single, one-way vector among many. We strongly doubt, however, the veracity of the results of these studies. Campaigns to encourage condom use, “all the time, every time,” have been successful in Eastern Uganda, Senegal, Swaziland, and Thailand, and death rates and new infections are dropping due to better access to anti-retroviral therapies.7 Of course, a vaccine with an effective rate of 90% or more would still be the goal and, at that point, mass circumcision campaigns, by comparison, would be so expensive and cumbersome to implement they would be ludicrous to promote and would soon perish. Nevertheless, before that day finally arrives, how many African cultures and how many millions of men and boys will be damaged by circumcision? Acknowledgments I wish to thank my colleagues, Georganne Chapin and Brian O’Donnell, for their fellowship in Mexico City as well as their assistance in preparing this analysis of our advocacy there.

Notes 1. Brody S, Potterat JJ. (2005) HIV epidemiology in Africa: Weak variables and tendentiousness generate wobbly conclusions. PLoS Med. 2(5):e137. 2. Hrdy DB. (1987) Cultural practices contributing to the transmission of human immunodeficiency virus in Africa. Rev Infect Dis. 9(6):109–119. 3. Female Circumcision and HIV Infection in Tanzania: For Better or for Worse? Rebecca Y. Stallings, 2 Statisticus Consultoris, USA and Emilian Karugendo, National Bureau of Statistics, Tanzania. And see: http://www.ias-2005.org/planner/Presentations/ppt/3138.ppt 4. http://afp.google.com/article/ALeqM5gkiZSdchTFFEy7rFhYWAK4z6Zc8Q http://africanarguments.org/2009/07/watu-wazima-a-gender-analysis-of-forced-malecircumcisions-during-kenya’s-post-election-violence/ 5. www.thelancet.com “Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: A randomised controlled trial.” Wawer MJ, et al. The Lancet. 374(9685):229–237. July 18, 2009, doi:10.1016/S0140-6736(09)60998-3. 6. http://news.bbc.co.uk/2/hi/health/8272113.stm 7. http://news.bbc.co.uk/2/hi/8375297.stm

Chapter 6

Circumcision Psychopathology George C. Denniston

Abstract Circumcision psychopathology is defined as a personality disorder characterized by a cluster of interpersonal, affective, lifestyle, and antisocial traits and behaviors, including grandiosity, egocentricity, deceptiveness, shallow emotions, lack of empathy or remorse, irresponsibility, impulsivity, and a strong tendency to violate ethical norms. In this article, standard methods for the assessment of circumcision psychopathy are outlined. Circumcision psychopathy is conceptually similar to antisocial personality disorder (ASPD) from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). However, at the measurement level, the former places more emphasis on interpersonal and affective features and their links to broad antisocial tendencies, while the latter emphasizes overt antisocial behaviors. Its association with antisocial personality disorder (ASPD) and its implications for clinical and forensic issues, including risk assessment, crime and violence are discussed. Circumcision psychopathy is associated with an increased risk for antisocial behavior, deviant sexual impulses, and presents the mental health and criminal justice systems with a formidable therapeutic challenge. Keywords Male circumcision · Antisocial personality disorder · Psychopathology · Diagnostic and Statistical Manual of Mental Disorders · Antisocial behavior · Deviant sexual impulses

Introduction Circumcision psychopathy is a personality disorder common among medical and religious circumcisers as well as advocates of circumcision defined by a cluster of interpersonal, affective, lifestyle, and antisocial traits and behaviors, including grandiosity, egocentricity, deceptiveness, shallow emotions, lack of empathy

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or remorse, ruthlessness, determination, irresponsibility, impulsivity, cognitive dissonance, sexual deviance, and a strong tendency to violate ethical norms. This disorder has a long history among circumcisers operating within specific religious (Jewish and Muslim) groups and now, more recently among Western (specifically United States) medical professionals since the imposition of mass circumcision on the United States population in the middle of the twentieth century. The ethical and legal principles and instruments that would prohibit circumcision include the Nuremberg Code of Ethics, the Hippocratic Oath, every one of The American Medical Association’s Principles of Ethics, and the Good Medical Practice Statement of the General Medical Council in the United Kingdom. Doctors afflicted with circumcision psychopathy may be aware of these documents, but they either consider them irrelevant to circumcision or a hindrance to be ignored and suppressed. Because circumcision psychopathy is associated with so much social, sexual, and personal damage and distress, the basic and applied research endeavors are now supplemented by the provision of forums for victims to discuss their problems. Groups such as NORM-UK, NORM (US), Doctors Opposing Circumcision (DOC), and the National Organization of Circumcision Information Resource Centers (NOCIRC) have created affiliated groups where victims of circumcision are free to discuss their experience and seek counseling. Attempts to understand and deal with doctors afflicted by circumcision psychopathy, and to communicate research findings to professionals and the public, may be impeded by confusion about what is meant by the term. For this reason, we begin with a brief discussion of the construct of circumcision psychopathy, followed by a few comments about the conceptually related anti-social personality disorder (ASPD), described in the DSM-IV.

Circumcision Psychopathy Briefly, circumcision psychopathy is a personality disorder that includes a cluster of interpersonal, affective, lifestyle, and antisocial traits and behaviors. On the interpersonal level, medical professionals with circumcision psychopathy are grandiose, deceptive, dominant, superficial, and manipulative. Affectively, they lack guilt, remorse or empathy with their victims. The interpersonal and affective features are fundamentally tied to a deviant lifestyle that includes irresponsible, monomaniacal obsession with circumcision, ruthless determination to justify and impose mass circumcision, and a tendency to ignore or violate ethical conventions and mores. Typically, such offenders are circumcised males, though the disorder has been observed in female doctors.

Causes of Circumcision Psychopathy The common denominator linking all male offenders with circumcision psychopathy is that they themselves were subjected to circumcision in infancy. Latent post-traumatic stress disorder and other long-term psychological problems

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stemming from infant circumcision have been well documented.1 This psychological harm may stem from the trauma of the surgery, which is usually performed without benefit of anesthetic. The harm may also result from the shocking realization, later in life, that a significant part of the body was amputated. Sufferers of circumcision psychopathy, however, appear to have evolved a psychological coping mechanism designed to protect the ego by justifying the loss of the body part and, as with the Helsinki Syndrome, by identifying with the goals of the perpetrators. Still, other sufferers of circumcision psychopathy appear to have adopted the aggressive stance of “If I cannot have a foreskin, then I will make sure that no one else can have one either.” The second commonality linking all male sufferers of circumcision psychopathy is that they have deliberately and assiduously maneuvered themselves into professional positions where they can unleash their impulses to perform circumcisions or advocate for circumcision. Sufferers, therefore, are to be found among any professional group that is normally charged with performing circumcisions, such as pediatricians, obstetricians, urologists, and family practitioners. Similarly, sufferers without the impulse to perform circumcisions in a professional setting may manifest their disorder by moving themselves into research positions where they can carry out studies that appear to support mass involuntary circumcision. Currently, all of the putative studies purporting that circumcision prevents AIDS, most of which come from the pens of a small handful of researchers, provide very strong evidence of being the product of sufferers of circumcision psychopathy, as will be explained below. Female sufferers of circumcision psychopathy are rare, but do exist. Typically, they are motivated by misplaced loyalty to circumcised male family members, loyalty to the medical profession, or loyalty to a traditionally circumcising ethnic or religious community, such as Jews or Muslims. Many female offenders are motivated to rationalize the circumcisions that they performed in the past or motivated to rationalize and justify their personal responsibility for the decision to subject their own male offspring to circumcision. One researcher was privately informed by a female medical circumciser that she was motivated to perform circumcisions because she wanted to punish males “where it counts” for perceived injustices done to her and to other females throughout history. Psychopathy of this sort provides evidence to support Freud’s theory that circumcision is a partial and a symbolic castration.2

CPCL Assessment of Circumcision Psychopathy The Circumcision Psychopathy Checklist (CPCL) is designed to measure the clinical construct of circumcision psychopathy; however, because of its demonstrated ability to predict recidivism, it may be used in forensic assessments, either on its own or, more appropriately, as part of a battery of variables relevant to forensic psychology and psychiatry. Briefly, the CPCL is a twenty-item clinical rating scale that uses case history information, observation of the subject in public settings where he or she has

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advocated for circumcision to the lay public, careful observation of the subject’s actions and reactions when debating circumcision with professional critics of circumcision, analysis of the subject’s published writings on the subject of circumcision, and, finally, specific scoring criteria to rate each item on a 3-point scale (0, 1, 2) according to the extent to which it applies to a given medical professional. The items and the factors they comprise are listed in Table 6.1. Table 6.1 Circumcision Psychopathology Checklist F1 Interpersonal 1. Glibness—superficial charm used when dealing with the media, the public, and other medical professionals 2. Grandiose sense of self-worth 3. Pathological lying—lying about medical and anatomical facts to the public, to patients, and to parents of potential victims 4. Conning—manipulative Affective 5. Lack of remorse or guilt 6. Shallow affect 7. Callous—lack of empathy 8. Failure to accept responsibility 9. Conscious disregard or disdain for medical ethical standards, which, if followed, would prohibit circumcision F2 Lifestyle 10. Unquenchable need to find justifications for personal circumcised status 11. Paranoia—frequently among Jewish offenders, ‘Holocaust paranoia’ 12. Unquenchable need to defend ethnic identity, perceived to be under attack 13. Ruthlessness in dealing with opponents of circumcision 14. Irresponsibility—jeopardizing professional reputation through single-minded circumcision advocacy 15. Monomaniacal obsession with circumcision—obsession with finding new rationales to impose the surgery on others Antisocial 16. Sexual deviance—pedophilic or homosexual arousal while performing, or fantasies about performing, circumcisions 17. Sadistic impulse to control and/or destroy the sexual functions of other males 18. Disgust for and refusal to acknowledge normal penile anatomy and function 19. Disgust for individuals and ethnic groups with intact genitalia 20. Willingness to falsify or distort research data in order to promote circumcision

Total scores can range from 0 to 40 and reflect the degree to which the circumciser matches the prototypical psychopathic person. A CPCL cut-off score of 10 has proven useful for classifying people for research and applied purposes as psychopathic. Analysis reveals that CPCL scores in the upper range appear to reflect much the same level of circumcision psychopathy in North American male doctor

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offenders as they do in non-medical religious circumcisers. Nonetheless, we note that there are ethnic and gender differences in the functioning of individual CPCL items and in the external correlates of the CPCL and other measures of psychopathy. The patterning and significance of these differences are the subject of much of the current empirical research on circumcision psychopathy. When conducting an assessment, it is important to use all information available to provide a complete picture of the person. In each case, the CPCL must be used properly and in accordance with the highest ethical and professional standards. Clinicians who use the CPCL must be prepared to outline the information used to score the items and to explain and justify the manner in which they scored the items. There are no exclusion criteria for use of the CPCL. It can be administered to offenders with various professional involvements in the circumcision industry. Therefore, it is possible to have symptoms similar to psychopathy, as measured by the CPCL scales, and other psychiatric disorders (for example, delusions of grandeur in psychotic disorders, inflated self-importance in narcissistic personality disorder, and grandiose self-worth in psychopathy). A primary strength of the CPCL is its ability to provide empirical evidence that not all doctors who perform circumcisions are necessarily afflicted with circumcision psychopathy. Many doctors who perform circumcisions do so merely because they are innocently following orders and have no personal motivations behind their actions. While the excuse of “just following orders” does not exculpate a medical professional from a charge of wrong doing, as demonstrated in the Nuremberg Trials following World War II, it does elucidate the pressure placed on doctors to conform and obey while ignoring the ethical implications of their actions.

Factor Structure As shown in Table 6.1, F1 reflected the interpersonal and affective components of the disorder, whereas F2 was more closely allied with a socially deviant lifestyle (the lifestyle and antisocial factors in Table 6.1). The psychopathological factors are significantly interrelated. The pattern of correlations among the factors, as well as confirmatory factor analyses also confirm the presence of two broad factors, identical with the original F1 and the other the same as the original F2. Because the CPCL factors are substantially correlated, it is important to examine the combined effects of elevations on both of these factors. Put in more clinical terms, a syndrome of circumcision psychopathy is likely typified by a doctor who chronically presents with elevated scores on both factors, not just one of these factors. Consistent with this idea, preliminary research by this author found that the interaction of F1 and F2 was critical for predicting offenders’ ethical conduct in the professional setting, predisposition toward performing circumcisions, and violent and aggressive behavior toward opponents of circumcision.

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Antisocial Personality Disorder The DSM-IV states that Antisocial Personality Disorder (ASPD) “has also been referred to as psychopathy, sociopathy, or dissocial personality disorder The Disorders section for ASPD in DSM-IV clearly describes ASPD by personality features that are an essential part of the circumcision psychopathy construct.3 The association between ASPD and circumcision psychopathy is generally asymmetric: most people with ASPD are not psychopathic, whereas most of those who are circumcision psychopathic meet the diagnostic criteria for ASPD.

Assessment of Risk A detailed account of circumcision psychopathy as a risk for recidivism is beyond the scope of this article. Recidivism in this context means the inability of the offender to stop himself from seeking out more victims to circumcise. The predictive value of circumcision psychopathy applies not only to adult male offenders but also to adult female offenders. Although circumcision psychopathy appears to be more predictive of general circumcision behavior under the cover of a professional setting than sexual violence, its relation with the latter may be underestimated because many sexually motivated violent offences of this nature are rarely officially recorded by the criminal justice system. Such offenses, however, have been reported in the underground fetishistic and sadistic sexual pornographic literature in which doctors participate in covert homosexual circumcision orgies.4 Not only are the offences of psychopathic circumcisers likely to be more violent than those of other sex offenders, they tend to be more sadistic. In extreme cases, the—correlation between—psychopathy and sadistic personality is very high. One of the most potent combinations to emerge from research on circumcision offenders is circumcision psychopathy coupled with evidence of deviant sexual arousal. Private communications between this author and nursing staff in the maternity ward of an American hospital reported that circumcision recidivism was strongly predicted by a combination of a high CPCL score and obvious sexual arousal among circumcisers while performing circumcisions on infant boys. Deviant fantasies no doubt play an important role in facilitating this circumcision psychopathy—deviance pattern.

Treatment Unlike most other offenders, doctors with circumcision psychopathy appear to suffer little personal distress, see little wrong with their attitudes and behavior, and never seek treatment. They appear to derive little benefit from exposure to objective medical studies proving that circumcision is both ineffective at preventing or curing

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disease and that, in fact, it is harmful. They seem unable to accept the human rights argument that males have an inherent right to keep intact all the body parts with which they were born. This is hardly surprising, given that circumcision psychopathy is characterized by personality and behavioral propensities that are strongly entrenched and presumably difficult to change.

Conclusions Use of the CPCL to measure circumcision psychopathology in the most prominent advocates of mass, involuntary circumcision has resulted in a substantial amount of empirical evidence that circumcision psychopathy, as measured by the CPCL, is a predictor of circumcision recidivism and advocacy of circumcision among medical professionals. Although circumcision psychopathy is not the only risk factor for recidivism, i.e., circumcisions performed on multiple victims similar to the actions of a serial killer, it is unusually pervasive and too important to ignore. Treatment and management are difficult given the current societal tolerance for the activities of circumcisers, however, new initiatives based on current theory and research on circumcision psychopathy will serve to identify, isolate, and eventually disempower those medical professionals suffering from the highest degree of circumcision psychopathology. The CPCL is a powerful new tool in the field of correctional medical research that may help to reduce the societal and individual harm done by doctors with circumcision psychopathy.

Notes 1. Rhinehart J. (1999) Neonatal circumcision reconsidered. Trans Anal J. 29(3):215–21. 2. Freud S. (1939) Moses and Monotheism. London: Hogarth Press and the Institute of PsychoAnalysis, p 192. 3. Ibid., p 647. 4. See the comments reported at: http://www.sexuallymutilatedchild.org/fetish-c.htm

Chapter 7

Physical Effects of Circumcision John Warren

Abstract Male circumcision results in permanent changes in the appearance and functions of the penis. These include artificial exposure of the glans, resulting in its keratinization and altered appearance. Additionally, circumcision results in loss of 30–50% of the penile skin, loss of at least 10,000–20,000 specialized erotogenic nerve endings, loss of reciprocal stimulation of foreskin and glans, and loss of the natural coital gliding mechanism, etc. From the point of view of sensation and function, the most important effect is caused by the tissue loss itself. The most sensitive part of the penis is removed, and the normal mechanisms of intercourse and erogenous stimulation are disturbed. Keywords Male circumcision · Harm · Complications · Penile anatomy and physiology · Prepuce · Gliding mechanism

Introduction The physical effects of male circumcision can be considered under the following headings: 1. 2. 3. 4. 5. 6.

Cosmetic effects Glans externalized and keratinized Penile skin and mucosal loss of 33–50% Loss of sensory nerve endings Loss of reciprocal stimulation of foreskin and glans Loss of the gliding mechanism

J. Warren (B) Royal College of Physicians, London, UK; NORM-UK, Staffordshire, UK e-mail: [email protected]

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Cosmetic Effects Circumcision results in an altered appearance of the penis, which, to all intents and purposes, is permanent. While foreskin restoration may be carried out, it is not straightforward and the results are not perfect. It is comparatively easy for an intact man to be circumcised. Some men are perfectly content to grow up with a circumcised penis, while others can be very disturbed by it. Among circumcised men who have contacted NORM-UK for help, the appearance of their penis is often one of their main complaints. They frequently report avoidance of allowing others, particularly other men, to see them naked, and some, therefore, avoid sports. Penis size: This is a subject about which men have strong emotions. The effect of circumcision reduces flaccid penile length and width slightly, as the normal foreskin often overhangs the glans in the non-erect state. Width is reduced because of the loss of the double layer of skin covering the glans. The erect penis may also be somewhat shortened, as there may be insufficient penile skin to permit full erection. An Australian survey showed circumcised men, on average, to have erect penises 8 mm shorter than intact men (Talarico and Jasaitis, 1973; Richters et al., 1995). Skin color: In intact European males, the glans ranges in color from pink to dark purple, while in dark skinned men it ranges from pink to dark brown. Infant circumcision, carried out when the glans is adherent to the foreskin, results in scarring, pitting, and discoloration of the surface of the glans and, over the years, increasing keratinization is likely to lead to further loss of natural color (Fleiss, 1997).

Glans Externalized and Keratinized The normal glans is an internal structure, only exposed briefly during urination, washing, and sexual arousal. Its surface is moist, and is not keratinized. However, circumcision converts the glans into an external organ. Immediately after the operation, it retains its exquisite sensitivity, and contact with clothing causes considerable discomfort, but it soon becomes desensitized, probably as a result of the laying down of a layer of keratin on the epithelium. A few circumcised men report persistent discomfort from contact with clothing throughout their lives. The epithelium takes on the character of skin rather than mucous membrane. Not only is the appearance of the glans altered, but also there is a dramatic loss of sensitivity. Sorrells et al. (2007) mapped fine-touch pressure thresholds in the adult penis in circumcised and uncircumcised men, comparing the two populations. With regard to the sensitivity of the glans, they showed that the glans in the circumcised male is less sensitive to fine-touch pressure than that of the uncircumcised (intact) male. Bleustein et al. (2005) tested vibration, pressure, spatial perception, and temperature on the glans in the dorsal midline in circumcised and non-circumcised men, and failed to show any significant difference in sensation on the glans between the two groups after correcting for age, hypertension, and diabetes. What is clear is that the glans is the least sensitive region of the penis, in any case, and is only supplied with simple nerve endings, which sense deep pressure and pain (Sorrells et al., 2007; Bleustein et al., 2005; Halata and Munger, 1986).

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Tissue Loss from Circumcision It is the tissue loss that causes the most important functional effects of circumcision. What is lost? Thirty to fifty percent of the penile skin, the area in an adult being about 15 square inches (96 cm2 ), comprising nearly all of the inner and outer foreskin, is removed. The frenulum is sometimes removed. The inner foreskin includes the ridged band, a zone of specialized mucosa encircling the distal end of the inner foreskin, first described by Taylor and colleagues (1996). They described the ridged band in this way: When retracted, the inner surface of the prepuce displays two zones, ‘ridged’ and ‘smooth’. The first, a transversely-ridged band of mucosa 10–15 mm wide, lies against the true skin edge, forming the outer surface of the tip of the prepuce. In the dorsal midline, the ‘ridged band’ lies above the level of the adjacent ‘smooth’ mucosa and merges smoothly, on either side, with the frenulum of the prepuce. When magnified, the ridged mucosa has a pebbled or coral-like appearance. Unretracted, the adult ‘ridged band’ usually lies flat against the glans; retracted, the ‘ridged band’ is everted on the shaft of the penis. The remainder of the preputial lining between the ‘ridged band’ and the glans is smooth and lax. There is considerable variation in the degree of ridging: older subjects showed less and younger subjects more marked ridging. Some ridging was seen in all the prepuces examined.

Taylor and colleagues further noted that the ridged band is intensely vascularized, which is typical of components of the nervous system. The tightly pleated concentric bands of the ridged band have been likened to the elastic bands at the top of a sock. These expandable pleats arise from the frenulum and encircle the inner lining of the foreskin. They allow the lips of the foreskin to open and roll back, exposing the glans. The ridged mucosa also gives the foreskin its characteristic taper (Fleiss and Hodges, 2002). The importance of the ridged band lies in its innervation. When he described it, Taylor, a pathologist working on histology, reported that it showed focal, spiky, or more rounded and flatter ridges interspersed with sulci. Meissner’s corpuscles were more plentiful in some subjects than others but, perhaps significantly, they were only seen in the crests of the ridges, occasionally in small clumps that expanded the tips of corial papillae. End-organs were not seen in sulci between ridges. Special stains for nerve tissue showed the additional end-organs and myelinated nerve fibers in the ridges. In contrast, histological examination of the smooth zone of the mucosa showed no ridging and few Meissner’s corpuscles. Meissner’s corpuscles are mechanoreceptors for detection of light touch. They are distributed throughout the skin, but concentrated in areas that are particularly sensitive, such as the fingertips, palms and soles, lips, tongue, face, and genitals. It has been calculated that circumcision results in the loss of at least 10,000– 20,000 specialized erotogenic nerve endings (Winkelmann, 1959, 1956). Also lost in circumcision is about half the smooth muscle sheath that invests the penis, which is known as the dartos fascia and is temperature sensitive. The frenulum, a highly erogenous V-shaped structure that tethers the underside of the glans to the shaft, is frequently destroyed or damaged during circumcision. Circumcision removes several feet of blood vessels, including the frenular artery. This loss of the rich vascularity interrupts the normal flow to the shaft and glans, damaging the natural blood flow of the penis (Netter, 1997).

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The mucosal surface of the foreskin produces plasma cells, part of the body’s defense system. They secrete antibodies and antibacterial and antiviral proteins, including lysozyme. The list of structures lost includes lymphatic vessels, apocrine glands (producing pheromones, scent signals), sebaceous glands, and Langerhans cells (another part of the defense system).

Loss of Sensory Nerve Endings As already described, circumcision removes the part of the penis most richly supplied with sensory nerve endings, the ridged band. In general, the inner mucosal foreskin is more sensitive than the outer foreskin, which differs little from the shaft skin. This loss is borne out by the results shown by Sorrells et al. If we look at the figure showing fine-touch pressure thresholds, we notice that the lowest threshold is found at position 3, which is the dorsal preputial orifice rim, while the next lowest thresholds are found at 13 and 14, parts of the frenulum, and 4 and 5, which are the mucocutaneous junction and ridged band, respectively. In the circumcised penis, the lowest threshold is found at position 19, the ventral surface of the circumcision scar.

Loss of Reciprocal Stimulation of Foreskin and Glans The mobile sheath of the intact penis allows the foreskin to glide back and forth over the glans. As it does so, it repeatedly folds and unfolds itself. Inevitably, the tactile nerve endings in the glans and, more especially, in the foreskin are strongly stimulated by this action, whether the result of masturbation, foreplay, or penetrative intercourse. During intercourse, the ridged band is alternately stimulated by the glans, when it is turned inwards, and by the vaginal wall, when it is turned outwards. The smooth muscle in the foreskin ensures that it encloses the glans snugly.

Loss of the Gliding Mechanism Bigelow drew attention to the mechanical function of the foreskin during intercourse (Bigelow, 2002). This function provides more enjoyable intercourse for both partners. During sexual arousal, the vagina secretes lubricant fluid allowing penetration to occur comfortably. Then, during intercourse, the intact penis glides in and out of its own skin sheath with each thrust, reducing friction between the penile skin and the vaginal wall, and allowing the vaginal secretions to remain on its surface, rather than being drawn out as they tend to be by the thrusting of the circumcised penis, which during erection may have no slack skin at all. Masturbation is similarly affected. An intact man masturbates by manipulating his foreskin back and forth over his glans. In a circumcised man, this is not possible, and often a lubricant is needed to permit comfortable stimulation. Circumcision

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was originally brought into medical fashion in the nineteenth century because it was thought to prevent or at least discourage masturbation. Masturbation was then considered to be dangerous to health, though this has long since been disproved. In fact, circumcision does not prevent masturbation in the least, but it probably makes it less enjoyable, though this is hard to prove.

Conclusion In considering the physical effects of circumcision, we have seen how there is a permanent change in the appearance of the penis and the exposure of the glans, resulting in its keratinization and altered appearance. From the point of view of sensation and function, the most important effect is caused by the tissue loss itself. The most sensitive part of the penis is removed, and the normal mechanisms of intercourse and masturbation are disturbed. At the same time, we have learned about the function of the male foreskin, a subject that has been neglected by medical scientists in the past. We have not considered complications of the operation, but merely what ensues when everything goes according to plan.

References Bigelow J. (2002) The Joy of Uncircumcising! 2nd ed. Kearney, NE: Morris Publishing, p 17. Bleustein CB et al. (2005) Effects of circumcision on male penile neurologic sensitivity. Urology. 65:773–777. Fleiss PM. (1997) The case against circumcision. Mothering Mag Nat Fam Living. Winter:36–45. Fleiss PM, Hodges FM. (2002) What Your Doctor May Not Tell You About Circumcision. New York, NY: Warner Books, p 7. Halata Z, Munger BL. (1986) The neuroanatomical basis for the protopathic sensibility of the human glans penis. Brain Res. 371:205–230. Netter FH. (1997) Atlas of Human Anatomy, 2nd ed. (Novartis 1997): plates 238, 239. Richters J et al. (1995) Why do condoms break or slip off in use? An exploratory study. Int J STD AIDS. 6(1):11–18. Sorrells ML et al. (2007) Fine-touch pressure thresholds in the adult penis. BJU Int. 99:864–869. Talarico RD, Jasaitis JE. (1973) Concealed penis: A complication of neonatal circumcision. J Urol. 110:732–733. Taylor JR et al. (1996) The prepuce: Specialised mucosa of the penis and its loss to circumcision. Br J Urol. 77:291–295. Winkelmann RK. (1956) The cutaneous innervation of the human newborn prepuce. J Invest Dermatol. 26:53–67. Winkelmann RK. (1959) The erogenous zones: Their nerve supply and its significance. Proc Mayo Clin. 34:39–47.

Chapter 8

Complications of Circumcision: A Urologist’s Viewpoint James L. Snyder

Abstract Background: Although circumcision is the commonest surgical procedure performed on male neonates, complications still arise from all methods used by operators. Patients and Method: This is a retrospective case study of penile injuries resulting from circumcision complications in neonates and young boys observed in the author’s urological practice. Results: Injuries resulting from circumcision with all devices include death, amputation of excessive skin, amputation of the glans penis, fistula formation, infection, sepsis, meningitis, adhesions, skin bridges, gangrene, and loss of the entire penis. Conclusion: Grievous and crippling injuries and even mortality can occur from routine neonatal circumcision. Adequate information should be provided to new parents of male babies informing them about possible complications. Moreover, doctors should discourage circumcision and inform parents about the many benefits of leaving the infant’s penis intact. Keywords Urology · Circumcision · Complications · Penile injuries · Death · Amputation · Fistula · Sepsis · Meningitis · Adhesions · Skin bridges · Gangrene I have been asked to discuss the complications of circumcision—specifically, the complications of routine male infant circumcision, as I have witnessed it in the United States, during my fairly typical experience as a medical student, intern, surgical resident in urology, and practitioner in urology. It is hoped that this narrative will reveal some of the reasons that non-religious, non-therapeutic male circumcision persists with some tenacity in the United States. As a medical student in pediatric rotation, I was given about two hours of discussion on the benefits of circumcision. At the time, it was generally assumed that circumcision was beneficial because it prevented cancer of the penis in the mature male and prevented cancer of the cervix in his future wife. A corollary of this viewpoint was that, if or when cancer of the penis in a man circumcised at birth was J.L. Snyder (B) American Board of Urology, American College of Surgeons, Virginia Urological Society, Clifton Forge, VA, USA e-mail: [email protected]

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ever observed and reported in the medical literature, the rationale for routine newborn circumcision would cease to exist and that the procedure would cease to be performed. Events would prove otherwise. In the course of time, I was instructed in the performance of the typical newborn circumcision and observed as I performed my first circumcision on a newborn. It should be noted that there was no real choice about whether I would do circumcisions. The most common criticism of my circumcisions was that I left too much skin on, which, I was informed, was not what parents wanted. Eventually, in the tradition of, “See one, do one, teach one,” the day came that I was told to go to the newborn nursery and do the circumcisions, unsupervised, on the boys who has been born the previous night. When I arrived at the nursery, the nurse was ready for me. She had denied the boys a feeding so that they wouldn’t vomit during the circumcision and inhale their vomitus. The boys were lined up for me, and I was instructed to go down the line and circumcise each one in turn. After the circumcisions, I was given the charts to record what I had done. I was surprised to notice that one boy had no written consent form in his chart. I asked the nurse why this child with a Hispanic name had been presented for circumcision with no consent. The response was a shrug and a comment that the circumcision would be good for him. In teaching hospitals that serve the poor and underinsured, and train physicians in their various specialties, the custom was, and tends to be for the rest of a physician’s career, that the obstetrician who delivers a male child would do the circumcision in the delivery room in the absence of strong objections from an exhausted, sedated, post-partum mother. If the circumcision had not been done at birth, it would be done in the morning by the on-call pediatric resident who made rounds. At that time, and perhaps even today, the requirements for informed consent were casually observed. Usually, the admission clerk would present a stack of documents to a mother in labor, among which was a vaguely worded paper with words including the word “circumcision.” This mother was asked to sign these papers with no further discussion. The result was presumed to be “informed consent.” If the newborn nurse found that someone had forgotten to have the mother sign a paper for the circumcision, she would go to the mother after the circumcision was performed and have her sign it after the fact. If parents objected that their son, against their wishes, had been circumcised, they would be subjected to a barrage of persuasion from every level of the medical and nursing staff until they conformed. Only a handful of parents were so bold as to seek legal advice and action against the hospital and trusted medical staff who had so carefully and safely guided them through one of the most significant moments of their lives. Now we come to the current situation, in which doctors and hospitals still persist in customs from a more casual time, when doctors had almost unquestioned authority to guide their patients’ care. However, new regulations are intruding themselves, particularly the notion of “informed consent,” which is required by the Joint Commission on Healthcare Organizations, and by law in many jurisdictions. This requires that the person who actually performs an invasive procedure come to the patient, parent, or guardian, explaining a diagnosis with the benefits, alternatives,

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and risks of the proposed procedure before performing it. This raises the problem of how much information and what information satisfies this requirement, and how it is to be documented. Unfortunately, parents are still given vague statements such as: • • • •

It will be good for the baby. Just a little snip and it will be over. You do want your baby to be circumcised, don’t you? We’re going to do your baby’s circumcision today.

This sort of behavior still persists today because a largely unsuspecting public still perceives circumcision as a benign and vaguely beneficial procedure. Rarely are parents told of the risks of: • • • • • • •

Death Amputation of excessive skin, Amputation of the glans penis, Fistula formation, Infection, sepsis, and meningitis, Adhesions and skin bridges, Gangrene and loss of the entire penis through a surgical misadventure (electrocautery instruments are to blame for more than one sex-change operation in small children).

These complications are almost never mentioned. They are unusual, but they have occurred in the experience of the present practitioner. During my career, I have been called to the crib of two infants who were born with a normal penis but became genital cripples as a result of a misguided circumcision. One was a neonate who had a Gomco clamp circumcision by a fully trained obstetrician, the graduate of a major university hospital training program. This child suffered loss of all the skin of the shaft of his penis. The foreskin was curiously preserved. The shaft skin was discarded, and the child was transferred to another hospital. The other was a seven-month-old child who had diaper rash of his penis, perineum, and thighs. During his circumcision, an electrocautery device was used to control bleeding, resulting in gangrene of the entire penis. The result was a succession of painful procedures to construct a skin graft that resembled the form of a penis. This child is now well into his twenties, and understandably very unhappy. Strangely, in my discussions with physicians who perform or advocate circumcision, the mention of these complications and of the undocumented but significant number of deaths due or related to circumcision is not persuasive of the harm of this procedure. Nor are these people impressed by the lack of informed consent to perform a non-therapeutic, cosmetic procedure on a minor. Often the excuse is the “possible benefits” alluded to in the current statements of the American Academy of Pediatrics. These vague and unspecified benefits often reside in the imagination of the person doing the circumcision and have not the force of an absolute indication

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for routine circumcision of the newborn. My arguments against circumcision before a medical audience have resulted in the most uncharacteristic disbelief and hostility, with a line of otherwise well-intentioned persons at the microphone, each waiting to repeat well-worn myths. I have spoken to the editor of a well-known medical journal, who told me flatly that nothing opposing circumcision would be accepted for publication in his journal. His successor also alleges the importance of doing circumcisions to prevent phimosis, a normal condition in childhood. So, where do we go from here? Persuasion of the medical profession has resulted, perhaps, in a greater awareness of the controversy surrounding circumcision. Some doctors now refuse to perform circumcisions. But, after all, those doctors will not be the ones who come into the newborn nursery looking for circumcisions to perform on their morning rounds. Only physicians who perform circumcisions have access to parents to persuade them to allow their child to be circumcised. Others will not have any opportunity to persuade for the benefit of the child that he be left intact. Major medical organizations, while not yet admitting an absolute medical indication for routine circumcision of the newborn male, continue to teach, and to allow their trainees to learn to perform routine newborn circumcisions. We have learned elsewhere in this symposium to “follow the money.” • It is possible, but expensive, to pursue lawsuits of these organizations. • Information campaigns, such as those on the Internet, will reach those with a sympathetic and inquiring mind. • The future reorganization of the finance of US medical care, placing the financial risk on those who deliver medical services, will drive out of practice those procedures that do not have an immediate and measurable benefit. Circumcision has already responded to these pressures in Britain and New Zealand. The pressure on the pocketbook proved to be one of the deciding factors, with the result of a circumcision rate near zero in those societies. • Finally, I would like to address the often-repeated justification for circumcision that the neighbors did not do it, and now they are having “trouble.” In this case, trouble usually means that well-meaning parents are attempting to retract a child’s foreskin for daily cleansing. The resulting discomfort to child and parents often leads to a visit to an equally ill-informed physician who confirms the “trouble” to be a (physiologically) tight foreskin and recommends a circumcision. Proper teaching and understanding of the physiologic adherence between the glans and prepuce—like the eyelids of newborn puppies and kittens—will allow a generation of physicians and parents to emerge who know that it is not necessary to retract a child’s foreskin to clean it or to insure that it is normal. They will allow a child to naturally pull his foreskin forward, so that separation of the physiologic attachment of the prepuce from the glans will occur in an orderly fashion. We also know that one day, that same child will spontaneously retract his foreskin in search of sexual pleasure, and the “trouble” will resolve without intervention. This may be the end of the complications of circumcision.

Chapter 9

NOCIRC of Italy: Scientific Activities 2006–2009 Franco Viviani, S. Bobbo, S. Malaguti, and D. Paolini

Abstract As the majority of Italians are not circumcised, the knowledge of the various aspects of male circumcision (MC) is lacking. The waves of immigrants from Muslim countries presented various problems concerning ritual MC, among them the fact that an ambiguous legislation enabled fraudulent use of National Health Services (NHS) funding, as ritual MCs were falsely labelled as being “therapeutic” in order to have them performed for free under the NHS. To better understand MC in Italy, during the last three years, different graduation theses supervised by the author permitted the gathering of: (a) epidemiological data to update the first epidemiological survey on the topic, (b) the attitudes of 173 Italian urologists toward MC, that were assessed by means of a questionnaire during a national medical congress. A previous thesis allowed (c) the production of the questionnaire administered to these professionals and, finally, (d) interviews were carried out. They were performed in the 15 health facilities supposed to carry out ritual MC, in order to build a map of these facilities in Italy and to better understand the underlying motivations and implications. Data confirm the fact that MC in Italy exists as a delicate, underground, and multifaceted problem. It appears that, “behind the scenes,” not only unnecessary interventions are performed but also that legal violations are common. Keywords Male circumcision · Ritual circumcision

Introduction Thanks to the effort of various researchers, different aspects of female circumcision are at present quite known in Italy and still open to debate, not only to improve legislation on the topic, but to find a more effective and respectful way to cope F. Viviani (B) Faculty of Psychology, University of Padua, Padua, Italy e-mail: [email protected]

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with the interethnic and bioethic problems rising with immigrants. Knowledge about the various aspects of male circumcision (MC), however, is lacking. This is highlighted by media and observers only when life-threatening injuries occur following ritual surgeries,1–5 when sentences for aggravated frauds toward the National Health System (NHS) are delivered as ritual MCs, which are falsely labeled as “therapeutic” in order to have them performed for free under the NHS,6–12 and when experimental designs to promote immigrants’ integration raise a lot of dust.13–17 Pediatricians and urologists discuss the origin and evolution of MC,18,19 and the immediate- and post-circumcision complications,20–22 with papers that do not cover important aspects such as, for example, the incidence of MC. They just cover topics related to its historical significance, mostly ritual,23–27 and other aspects touched on by the literature produced by NOCIRC (see: www.nocirc.org). For this reason, in the last quadrennium, NOCIRC of Italy resolved to be active in this topic, and only some years ago the first epidemiological survey on the incidence of the phenomenon was undertaken,28 to set the topic against its importance. In fact, recent waves of immigrants from Muslim countries posed several issues, mostly related to ritual MC. Important among them was the fact that an ambiguous legislation enabled fraudulent use of NHS funding. Some NHS hospitals undertook experimental ritual MC projects, whose official aim was to improve immigrants’ integration. As a reaction, professionals directly involved in MC, such as pediatricians and urologists, were divided with respect to this problem.16 Unfortunately, despite the great sensation caused because of the severe and lethal consequences suffered by three children after “homemade” surgical operations,2,3 the problem remains underrated. The present paper reports the scientific activities performed in the last three years, without mentioning the efforts made to blazon the problem in various meetings and in the media.5,29

Materials and Methods To better understand MC-related phenomena, four graduation theses, supervised by the author, permitted the collection of: (a) epidemiological data to update the first epidemiological survey on the phenomenon30 ; (b) the construction of a questionnaire permitting to undertake a descriptive research on the attitudes toward MC (therapeutic, prophylactic, and ritual) of the professionals directly involved in the topic.31 It contained general information on the professionals and openended, closed (with categorical responses), and ranking questions related to various aspects of MC. Later on, (c) it was administered to 173 Italian urologists belonging to all the Italian regions, who were scrutinized during a national medical congress.32 The average age of the professionals was 45.9 years (s.d. = 10.8; min. 26, max. 70), and they were active, on average, from 18.4 years. To gain further insights, they were subdivided into three macro-regions (southern, central, and northern Italy). Differences existing between public, private, and mixed facilities were ascertained as well. Finally, (d) contacts were taken in 15 health facilities where ritual MC was routinely executed (data were extracted from the questionnaires), in order to build a map of the facilities performing ritual MC in Italy

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and to better understand the underlying motivations. Only two urologists answered a semi-structured questionnaire prepared for the survey.33

Results Epidemiology Dismissal forms from Italian health facilities (years 2001–2003) gave an update of previous data, gathered investigating the Diagnosis Related Groups (DRG) on subjects lower and older than 18 years of age. From 1999 to 2003 MC interventions carried out in health facilities increased (+12.3%), but remained quite stable from 2002 to 2003 (+1.4%). The observed trend (increment of MC performed in day hospital vs. decrement of those carried out in regular hospitals) was maintained (e.g. annual increment in day hospital = +19.3%). The two age-peaks in interventions, 5–14 and 25–44, remained stable. The previous trend,28 valid for the years 1999–2001 was thus confirmed.

The Opinions of Italian Urologists Toward MC The professional typology of the interviewed Italian urologists is depicted in Table 9.1. Their opinions can be summarized as follows: 171 out of 172 interviewed urologists performed MC, mostly for therapeutic reasons (99.4%). Eleven percent of them did prophylactic MC and 9.9% performed ritual circumcisions. Regarding the therapeutic motivations for the intervention, 146 out of 173 urologists (84.4%) declared “pathology,” 23 out of 173 (13.3%) prevention, 18 of them psychosexual motivations (10.4%). Only 35.9% of the interviewed urologists declared to offer preintervention alternatives to their patients. Significant differences emerged among the three macro-regions considered (χ 2 = 6.9; df = 2, p < 0.032), as they were offered more often in the central (52.6%) and in the southern Italian regions (36.2%) with respect to the northern ones (27.4%). The main MC post-intervention complications that could arise, according to 85.5% of the urologists, in order of importance, are: hemorrhage, annular scars under the glans, psychological problems, infections, progressive loss of glans sensitivity, glans malformations. Table 9.1 Professional typology Type

Frequencies

University Public hospital Self-employed professionals Other

11 130 7 23

6.4% 76.0% 4.1% 13.5%

Total

171

100%

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F. Viviani et al. Table 9.2 Judgments regarding MC practiced in the USA Regions

Positive

Negative

Total

Southern Central Northern

28 11 41

52.8% 31.4% 62.1%

25 24 25

47.2% 68.6% 37.9%

53 35 66

Total

80

51.9%

74

48.1%

154

34.4% 22.7% 42.9%

χ 2 = 8.7; df = 2; p < 0.013.

When asked for an opinion about prophylactic MC practiced in the USA: 51.6% of them were in favor, while 48.4 judged the practice negatively, with significant differences between the Italian regions (Table 9.2). As far as ritual MC is concerned, 63.6% of the professionals were opposed because it was a practice contrary to their deontological code (36.9%) or because they judged it an unnecessary mutilation (20.4%). Inappropriate (18.4%) and not furnished (21.4%) responses to this question were high. Those in favor of ritual MC declared to be such because of their “respect to religious beliefs” (72.1%) and to avoid the negative effects of a refusal (3.3%). In this case, the improper (16.4%) and not given responses (9.8%) were quite high as well. Table 9.3 depicts the differences found by Italian regions. It must be added that 53.0% of the urologists were opposed to ritual MC carried out inside the NHS, of these, only 9.6% affirmed that this praxis was common in the health facility to which they belonged, with significant differences among the Italian regions (Table 9.4). Of those interviewed, 36.4% was asked to perform ritual MC, mostly by parents of Muslim faith (85.7%). The presence/absence of a Bioethics Committee in the facilities where urologists practiced gave significant differences among the macro-regions considered. The presence declined from north to south (Table 9.5). Differences among public, private, and mixed-health facilities revealed rates for the day-hospital/ordinary regimen chosen for the intervention: higher in the mixed facilities (33.3%), lower in the private facilities (27.3%), and very low in the public ones (9.0%) (χ 2 = 7.7; df = 2; p < 0.023). Even with the presence/absence of a Bioethics Committee, revealed rates were significantly different (χ 2 = 7.9; df = 2; p < 0.019) in 100% of the cases in the mixed facilities, 80.0% of the cases Table 9.3 Ritual MC: sides taken by Italian urologists Regions

In favor

Unfavorable

Southern Central Northern

17 20 22

29.8% 52.6% 33.3%

40 18 44

70.2% 47.4% 66.7%

57 38 66

Total

59

36.6%

102

63.4%

161

χ 2 = 5.6; df = 2; p not sign.

Total 35.4% 23.6% 41.0%

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Table 9.4 Performance of ritual MC in the facility where urologists worked Regions

Yes

No

Total

Southern Central Northern

13 13 37

21.7% 33.3% 50.7%

47 26 36

78.3% 66.7% 49.3%

60 39 73

Total

63

36.6%

109

63.4%

172

34.9% 22.7% 42.4%

χ 2 = 12.2; df = 2; p < 0.002. Table 9.5 Presence of a bioethics committee Italy Southern Central Northern Total

Presence

Absence

Total

38 31 64

64.4% 79.5% 87.7%

21 8 9

35.6% 20.5% 12.3%

59 39 73

133

77.8%

38

22.2%

171

34.5% 22.8% 42.7%

χ 2 = 10.3; df = 2; p < 0.005.

in the public, versus 54.5% of the cases in the private health facilities. No significant differences emerged for the pre-intervention alternatives offered among the facilities.

The Search for Facilities Performing Ritual MC On the basis of the data gathered in the previous study, the 15 sites involved in ritual MC were contacted. They were located mostly in the north (n = 9) and in the center (n = 5), while in the south of Italy (n = 2) they declined. However, a good set of data collection was almost impossible because of the fear of legal repercussions for the professionals involved. This made the context hypocritical and reticent (many professionals actually claimed “conscientious objection”). Therefore, in this context, and for the moment, it is only possible to sketch some major trends that emerged. From the press, it was possible to ascertain that, from 2004 and 2008, in the northern part of Italy, different experimental designs took place in order to limit ritual MCs carried out in unsuitable sites, in situations disrespectful of current hygienic rules, and to avoid a sort of “underground market” for MC. This caused several medical, bioethics committees, and political stands to be taken about the problem. In Turin, for example, only a minority of the doctors involved in the project were in favor of MC, the others declared themselves to be conscientious objectors. Political controversies rose and the local bioethics committees generally admitted that, as ritual MC intervention does not accomplish the function of safeguarding health—typical of the NHS—it has not the ethical justifications to be inserted among the essential services to be performed by the NHS.34,35 When interviewed, those responsible for the activities carried out in Turin, affirmed that the subduing motivations were exclusively

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economic, as it was more advantageous for the hospital to allot funds for ritual MC than to face the damages caused by home- or country-of-origin-made ritual surgeries. However, when the 15 health units were contacted, responses were reticent and contradictory: for example, an health unit in the center of Italy first declared that ritual MCs were currently carried out in its facilities (officially declaring the intervention was for phimosis), later on, when more details were asked, the previous declaration was completely denied. In another hospital, in the south of Italy, clarification on the word “ritual” was asked. In general, the majority of the addressed facilities (except for two) firmly denied performing ritual MC in their facilities (this being clearly the opposite of what the urologists affirmed in their questionnaires). At this point, to supplement the scene, several persons in charge of the Jewish and Muslim communities were contacted. The previous declared that their ritual MC (brit milah), to be fulfilled within the eight day of birth, needed the presence of a rabbi and that it was usually carried out in private facilities. The latter declared that, usually, Muslims do not apply to the NHS services because they prefer to circumcise their children in their home country, during vacations, as their tradition does not require time limitations, as it does for Jews. Substantially, the responses furnished by the only two professionals who it was possible to interview—in strict anonymity—were similar. According to them, as the Italian law does not permit the performance of ritual MC for free, even if some facilities do the operations (officially declaring them as being for phimosis or a sclerotic prepuce), it is impossible to manage to trace them for obvious reasons.

Discussion and Conclusions The update of epidemiologic data substantially confirmed known aspects of MC in Italy in the NHS facilities. It is a practice performed mostly for therapeutic reasons, with interventions concentrated in the age ranges 5–14 and 25–44. In the first case, interventions are carried out in ordinary regimen and they usually follow pediatric follow-ups routinely carried out in the schools. As the number of circumcised appears to be slightly high with respect to the incidence of phimosis as pathology, it cannot be excluded that cases of ritual MC (declared as congenital phimosis) are performed in some facilities. In the second case, operations are carried out mostly in day-hospital regimen and are due to secondary phimosis. The responses furnished by the urologists show a substantial homogeneity for their basic preparation on the topic of MC, the general therapeutic approach, the admission regimen adopted, and the ignorance of the resolution of the National Bioethics Committee.36 Quite non-homogeneous was their knowledge of the different forms of MC and, despite the motley responses given towards alternative to MC, they appeared not to be in line with the current acquisitions of conservative nature regarding the prepuce.37 It must be mentioned that only one professional claimed to furnish non-medical alternatives. The differences that emerged in the three macroregions considered are due to the organizational and structural backwardness of the

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southern NHS, while the fact that, in the private facilities, the day-hospital regimen is less used, which is due to the higher cash audit earned applying the ordinary regimen. The fact that the sample was equally halved in contrary/favorable to prophylactic MC practiced in the USA, in our opinion, is due to the absence of such practice in Italy, therefore, the lack of interest and information. The finding that 22.0% of those who furnished a positive or negative opinion on the topic did not explain their reasoning is significant. Similarly, it is notable that a high number of incongruent and not-given responses to this question were found. Non-significant differences emerged neither on the basis of the age of the subjects nor on their years of practice. More opponents were found in the center of Italy, while those in favor were more concentrated in the north (62.1%), probably for a more marked inclination to innovation (usually belonging to the USA). A curious undertone: the most usual motivation for those who were in favor of the practice was the prevention of penile cancer, a position clearly unsupported by strong epidemiologic data.38–40 Regarding ritual MC, 60% of the interviewed declared their opposition to it, with a macro-areas repartition matching the diversification of the presence of Muslim immigrants, who are settled mostly in the northern regions.41 It is possible that the different sensitivity to ritual MC belongs to a different impact with such immigrants. The performance of ritual MC was required of more than one third of the professionals, but their response should have been negative, as only 9.9% of them admitted to having actively performed such surgery. The performance of this ritual violates the Hippocratic oath (36.9%) and this leads one to formulate a culturallymediated defensive position (Italy is a country with a strong Catholic tradition, and body integrity is a strong value). The diffuse reticence to discuss and explore the aspects of ritual MC is mostly due to religious motivations. According to Aldeeb,14 as the Holy Bible mentions male but not female circumcision, this implies a substantial difference, even in the public resonance of the problem. In addition, he notes that two prominent European Catholic and Jewish representatives recently refused to express an opinion on female circumcision because of the fear that this would open a debate of MC. Clearly, to oppose ritual MC means to object to the sacred, a very difficult task in a country that has been for centuries at the dual heel of the spiritual and temporal power of the Catholic Church, that still exerts a great influence on politics. It is also difficult in a democratic country in which one of the fundamentals is the principle of tolerance, touching both the moral (the respect of the “other” beliefs) and the law (the admission of the existence of “other” manifestations with respect to the dominant culture, in the frame of norms and sanctions). The core problem is a clear conflict between the principle of inviolability of the human body and that of the intervention on the body itself, in the name of the principle of belonging to a particular religious group. Now, the problem rising from the conflict between principles can be solved only by means of the compromise or by means of a scale of priority (in which it would be possible—at least to discern—a “higher” principle that could solve the conflict between principles). As long as ritual MC was confined to a restricted circle (the Jews, a small minority group in Italy), it was not much considered, but when other religious groups started vindicating rights, a subtle ethic conflict rose on religious

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basis. Other morals were superimposed: the laic one (etsi deus non daretur), the liberal one (based on the respect and the defense—even all-out—of individual freedom and free enterprise, a principle whose limit is the others’ damage), and, finally, when MC was medicalized, the utilitarian moral as well. To let our attention dwell on this aspect could be useful. The medicalization of ritual MC was clearly conflicting because the introduction of a new possibility with respect to a practice till that moment was carried out mostly for therapeutic reasons (therefore perfectly matching with the moral rules universally adopted by doctors), compelled a significant part of the physicians to refuse it, even with vehemence (conscientious objection). Now, epistemology teaches that science is able to enter into an agreement every time that unforeseen situations appear on the horizon. Doctors are basing their practice on scientific findings, therefore, every time that a new possibility of intervention breaks through the clouds, this changes the prevailing attitudes, the implicit and explicit evaluations, and the normative compromises. At the end, even those who adhered to an ethic code containing some obligations, try new ways in order to avoid disagreeable consequences with respect to the practices for which it is possible to have recourse. In the sample of urologists, those who were in favor of the medicalization of ritual MC, expressed the idea that the principle of solidarity is stronger than that regarding the intangibility of the human body. In this case, a scale of priority was introduced, together with a vaguely compromising moral: in fact, their detractors affirm that the moral of principles was substituted by the moral of compromise. The compromise—per se—is never enthusiastically accepted, as it often raises the desire to set against it a strict rational procedure attenuating the concession given. Informal discussions with urologists inclined us to believe that the ethical problems are substantially two: the dialectic of the “argumentations” and that of “common sense.” In the first case, it is presupposed that ethics are tied with arguments and that this is the level that the contenders must disembroil. In effect, for ritual MC, the starting point is the religious positions and those in charge to expound them must resort to argumentations, whereas doctors should ascertain facts that are relevant or could become relevant. The problem is that, according to our findings, the facts are not clear for many doctors interviewed, as they see MC as a monolith (i.e., many of them are unable to distinguish among the different MC typologies). As a consequence, when they cannot appeal to facts, they usually face the problems assuming the lay position of “common sense.” This position, not dealing with principles, leads to an appeal to a plausibility of solutions to be found “case by case.” Clearly, this approach has strong limitations, as common sense shows a great impotence towards new or odd problems. The trend that emerged regarding the prophylactic MC is analogous, as the furnished responses show a substantial lack of reflection upon it. We noted a certain confusion between prophylactic and therapeutic. But what is therapeutic is directed by the main rule of consent and requires a previous medical evaluation of the conditions able to justify an intervention, alas, what is prophylactic does not require these premises. However, the responses of the doctors interviewed can be justified by ignorance of the situation in the USA and by the inertial force of a professional tradition based on the therapeutic tradition

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(and not the prophylactic or the ritual) that associate with the reluctance to leave established schemes. In conclusion, while it is not difficult to gather data on therapeutic, epidemiologic, and MC-related views in Italy, it is quite difficult to pierce the shroud of reticence on ritual MC. This is because unnecessary interventions are performed and because legal violations are common. Ritual MC in Italy exists as a delicate, underground and multifaceted problem. Clearly, new types of interventions—not only debates—that are able to awaken the professionals and the public to the problem are required. Acknowledgments The author thanks Dr. S. Busatta, Dr. G.L. Costardi, Prof. G. Mantovani, Prof. G. Martorana, Prof. P. Grassivaro Gallo, Dr. L. Catania, the Italian Urology Society, the participants in the 79th Italian Congress of Italian Urologists, and all the doctors who, anonymously, added insights to this paper.

Notes 1. Europe News. (2008) Nigerian man arrested in Italy for boy’s circumcision death. July 23rd, 2008. 2. La Repubblica, June 6th, 2008. 3. La Repubblica, July 22nd, 2008. 4. Marotta M, Marotta E. (2004) Solo infibulazione? La Gazzetta di Sondrio March 10th, 2004. 5. Viviani F. (2008) Circoncisioni fatte in casa, un rischio per i bambini. La Repubblica, June 7th, 2008, p 28. 6. Andretta E. (2000) Circoncisione, rispetto di una cultura. Il Gazzettino, Inserto salute, 13 Marzo 2000, p 14. 7. Il Mattino di Padova, May 9th, 2007. 8. Il Sole 24 Ore.com, July 22nd, 2008. 9. La Padania. (2000) Circoncisioni a carico del servizio sanitario. July 28th, 2000. 10. La Provincia Pavese, May 9th, 2007. 11. Manconi L, Boraschi A. (2006) Immigrazione. La ballata dei circoncisi. L’Unità, November 5th, 2006. 12. Miazzi L, Vanzan A. (2008) Circoncisione maschile: pratica religiosa o lesione?Diritto, Immigrazione e Cittadinanza. Milan: Franco Angeli. 13. Accossato M. (2006) Via alla circoncisione rituale. Nuova bufera sul Sant’Anna. La Stampa web, October 4th, 2006. http://www.lastampa.it/redazione/cmsSezioni/torino/2006/ 200610articoli/11674girata.asp 14. Aldeeb S. (2004) Dibattito, circoncisione, infibulazione: mutilazione genitale “indolore”? http://www.grillonews.it/modules.php?op=modload&name=News&file=article&sid =1381 15. Domenici D. (2008) Salute: i pediatri italiani contro la circoncisione clandestina. http://www.wikio.it/article/71822198 16. Il Corriere della Sera, October 15th, 2006 (http://archivio.corriere.it/archiveDocumentServelt. jsp?url=/documenti>_globnet/corsera/2006/10/co_9_061013094.xml) 17. Stranieri in Italia. (2008) http://stranieriinitalia.it/attualita-circoncisione_gratis 18. Parigi GB. (2003) Destino del prepuzio tra Corano e DRG. Pediatr Med Chir. 25(2):96–100. 19. Zampieri N, Pianezzola D, Zampieri C. (2008) Male circumcision through the ages: The role of tradition. Acta Pediatr. 97(9):1305–1307. 20. Beniamin F, Castagnetti M, Rigamonti W. (2008) Surgical management of penile amputation in children. J Paediatr Surg. 43(10):1939–1943.

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21. Natali A, Rossetti MA. (2008) Complications of self-circumcision: A case report and proposal. J Sex Med. 5(12):2970–2972. 22. Rossi E, Franchella A. (2006) Amputation neuroma following a circumcision: A case report. Eur J Pediatr Surg. 16(4):288–290. 23. Doyle D. (2005) Ritual male circumcision: A brief history. J R Coll Phys Edinb. 35(3): 279–285. 24. Mattelaer JJ, Schipper RA, Das S. (2007) The circumcision of Jesus Christ. J Urol. 178(1): 31–34. 25. Meijer B, Butzelaar RM. (2000) Circumcision from a historical perspective. Ned Tijdschr Geneeskd. 144(52):2504–2508. 26. Sari N, Büyükünal SN, Zülfikar B. (1996) Circumcision ceremonies at the Ottoman palace. J Pediatr Surg. 31(7):920–924. 27. Waszak SJ. (1978) The historic significance of circumcision. Obstet Gynecol. 51(4):499–501. 28. Viviani F, Costardi GL, Capparotto L, Grassivaro Gallo P. (2006) Male circumcision in Italy. In: Denniston GC, Grassivaro Gallo P, Hodges FM, Milos MF, Viviani F (eds.) Bodily Integrity and the Politics of Circumcision. New York, NY: Springer, pp 141–147. 29. Viviani F. (2009) http://www.psicologisenzafrontiere.org/index.php?page=report-incontri-iiciclo-feb-mar-2009; http://www.psicologisenzafrontiere.org/index.php?page=intervista-aldott-franco-viviani; http://www.psicologisenzafrontiere.org/uploads/Considerazioni%20dina tura%20bioetica.doc 30. Bobbo F. (2006/2007) La circoncisione maschile in Italia: aggiornamento dei dati epidemiologici. Graduation thesis, Faculty of Psychology, University of Padua. 31. Meneghello D. (2005) Elaborazione di un questionario sugli atteggiamenti degli urologi nei confronti della circoncisione maschile in Italia. Graduation thesis, Faculty of Psychology, University of Padua. 32. Malaguti S. (2006/2007) Gli urologi italiani di fronte alla circoncisione maschile. Graduation thesis, Faculty of Psychology, University of Padua. 33. Paolini D. (2006–2007) La circoncisione maschile in Italia: contraddizioni e problemi etici. Graduation thesis, Faculty of Psychology, University of Padua. 34. Nejrotti M. (2006) La circoncisione rituale è una pratica deontologicamente corretta? Response of the OMCEO (Turin), personal communication. 35. OMCO Padova. (2005) Regional Consulting Committee for Bioethics. 36. Comitato Nazionale di Bioetica. (1998) La Circoncisione: Profili Bioetici. Governo Italiano. Presidenza del Consiglio dei Ministri. Rome: September 25th, 1998. 37. Orsola A, Caffarati J, Garat JM. (2000) Conservative treatment of phimosis in children using a topica steroid. Urology. 56(2):307–310. 38. Fleiss PM, Hodges FM. (1996) Neonatal circumcision does not protect against cancer. Br Med J. 312:779–780. 39. Frisch M, Friis S, Kjear SK, Melbye M. (1995) Falling incidence of penis cancer in an uncircumcised population (Denmark 1943–1990). Br Med J. 311:1471–1475. 40. Stancik I, Hölti W. (2003) Penile cancer: Review of the recent literature. Curr Opin Urol. 13(6):462–472. 41. Caritas/Migrantes. (2005) Immigrazione. Dossier Statistico 2005. Rome: IDOS.

Chapter 10

A Project About Male Circumcision in the Veneto M. Gloria de Bernardo

Abstract For the first time in Italy, a strong position has been taken against the practice of male circumcision on therapeutic grounds, at the expense of public health authorities, in a small town, Conegliano, Veneto. The hospital’s training service investigated the reasons for which the local medical authorities had decided to reclassify a request for male circumcision, on therapeutic grounds, from a free procedure to a paid one. For this reason, research was undertaken to show that, in recent years, the request for male circumcision considerably increased among Muslim families. It was impossible to understand the real reason for that because all the families had made a request for therapeutic circumcision through their own doctor. By checking the number of these requests, it was noticed that, after the request for male circumcision was reclassified from a free procedure to a paid one, these requests diminished. We also know that some Muslim families used operators who came from their same geographical area in Africa, but the results sometimes were terrible. As reported by the press, one boy in Veneto and another in Puglia died from hemorrhage, caused when the glans was cut off during circumcision. The echo of such research has had consequences in other public health services, where the possibility of creating a ticket-payment for circumcision began to be considered. Keywords Male circumcision · Ritual circumcision The legislation in Italy regarding the situation of male circumcision (MC) is ambiguous. In some regions, the practice of circumcision is excluded from the basic free medical services (Livello Essenziale Assistenza), in others it is included if requested on the basis of therapeutic need, and in others it is free in all cases. Every local health authority, therefore, establishes very differing rules, thereby further increasing the confusion around this problem, which has revealed itself to be not only medical but also cultural and religious.

M.G. de Bernardo (B) University of Verona, Verona, Italy; University of Padua, Padua, Italy e-mail: [email protected]

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It is a fact that, with the increase in immigration, requests for circumcision have increased from families for whom circumcision is a religious duty. In July 2004, there was a parliamentary question as to why, in the local health authority of Conegliano Veneto, in the province of Treviso (ULSS 7), a “Safe Circumcision Project” had been launched, enabling circumcision to be performed on request at a flat-rate payment of C34–50. Both the Caritas charity and the social service were behind the project, trying to avoid immigrant families ending up in the hands of back-street practitioners who injured the children to be circumcised, sometimes even mortally. On the other hand, other health authorities, such as that of Verona, carry out the same procedure as out-patients on children between the ages of 0 and 6 years old, and to adults making such a request, at a cost of C300. It is not only a question of medical resources, which the government cannot afford, but it has become a cultural problem because ritual circumcision is incompatible with Italian culture, especially now because, since 2006, there is legislation specifically forbidding all bodily mutilations. The Conegliano Veneto case has given rise to a series of requests from various bodies that work and are directly concerned with the problems of immigrants in the Veneto. All wish that circumcision be made available in hospital, even without any therapeutic need being established, and at the cost of only the absolute minimum national health service fee (ticket). The project in Conegliano has raised a problem that must be resolved as soon as possible, both in order to start educating the African communities that are the poorest and least open to dialogue and in order to harmonize the functional status of this surgical procedure in all local Italian Health Authorities.

References Agency for Regional Health Services (ASSR). (2004) Lea, monitoring trials. In: Pellegrini L, Toniolo F. (eds.) ASSR, October 2004. 14th Legislature, Union Inspection Regulation Number 4-07152, published 27 July 2004, Session n. 647, at the Ministry of Health.

Chapter 11

The First Survey on Genital Stretching in Italy Pia Grassivaro Gallo, Annalisa Bertoletti, Ilenia Zanotti, and Lucrezia Catania

Abstract In 2006 and 2007, the first survey of genital stretching (GS) in Italy was implemented in order to evaluate the degree of knowledge of professionals involved in immigration issues who may be faced with such ritual modifications in the future. During the survey, some obstetrician/gynecologists pointed out that they had also encountered the same morphology in Italian non-manipulated patients. We recorded these cases as physiological stretching. In the survey, the data collection was done by means of a questionnaire, administrated to 272 professionals, consisting of items to measure the knowledge about these expansive modifications; moreover, among the latter 272 professionals, 14 specialists were subjected to a detailed interview, and they described 21 cases of stretching, both ritual and physiological. On the whole, the phenomenon of GS is poorly known by Italian health operators: 93% of the interviewees declared they knew little or nothing about it. The women with labial hypertrophy identified in the survey included 20 Africans with ritual stretching and about forty Western women with physiological stretching. The incidence in the latter sample is hypothesized from 8 to 20%. In conclusion: physiological GS is ignored by health professionals, even when it is stressed by the patients bearing this trait with concomitant psychological discomfort, which may develop into real anxiety, especially in teenagers. Ritually “modified” immigrant women, forced to cope with a Western society of intact women, consider themselves “different” also because of this morphological trait, with a consequent worsening of their feelings of discrimination and marginalization in diaspora, although they seldom ask for surgical reduction of the elongated labia. Thus, labial hypertrophy has a different semantic connotation in Africa and in Italy. Keywords Expansive genital modifications · Genital stretching · Labia · Hypertrophy · Immigration

P. Grassivaro Gallo (B) Working Group of FGM, University of Padua, Padua, Italy e-mail: [email protected]

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Introduction The survey’s hypothesis was born by previous research done in Uganda (2002), Malawi (2004), and in the Democratic Republic of Congo (2006), which attest to the current existence of ritual genital stretching in these places of origin. It is a female genital modification of the expansive type that WHO improperly included among the female genital mutilation of the 4th type (1996). We thought it right to first begin with a survey on the same genital morphology in Italy, to evaluate the degree of knowledge and preparation of health operators involved in immigration who may be faced with such ritual modifications without being able to recognize and adequately tackle them on the psycho-medical level. During the survey, some obstetricians pointed out the same morphology— physiological genital stretching—in their patients. We had not taken this event into account; therefore, we decided to extend the survey to include the Italian women.

Method and Studied Subjects A questionnaire was prepared to investigate the general knowledge about ritual GS in African women and physiological GS in Italian patients. The checked sample, the “occasional group,” consisted of 272 operators of both sexes, involved at different levels with immigration socio-medical services, who were examined in 2006. The group had 46% operators working in hospital facilities and in different governmental health structures in Parma and in Bologna; 12% were female students of the Faculty of Medicine (nursing section), 19% of health operators were attached to the Obstetrical Clinic of Padua University, and about 11% of them were contacted during some pertinent scientific events. All in all, they are mostly female subjects (76.8%); operators’ calculated the average age-length of professional activity is 14 years. To complete the questionnaire’s information, some of the involved specialists were interviewed in depth; on the whole, there were 14, “The Referents.” Selection was based on meaningful information and/or relevant signals that appeared in patients with GS; these were indicated as “Cases.” The recognized 21 Cases of GS are children (little girls), teenagers, and women with hypertrophic genital morphology, both congenital and manipulated types.

Referents The sample group consisted of 14 operators from public health facilities, 6 males and 8 females, aged from 24 to 67; with 15–35 years of professional activity (with the exception of a young female student who reported her own physiological GS).

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These included a doctor from Chad, a Congolese pediatrician with knowledge about ritual GS, a psychiatrist, an Italian missionary obstetrician in Congo with experience on genital intervention, and nine Italian doctors (six obstetricians and three pediatricians, with GS experience).

Genital Stretching Cases The 21 GS Cases are represented by children (little girls), teenagers, and women examined in Italian health facilities, with hypertrophic genital morphology. Five Italian children, four of them (6–10 years of age), present with a monolateral physiological GS with hypertrophy on only one of the labia minora; two African children, a 9 year-old Ghanaian child, and a 5-year-old Congolese child, who are respectively described to have “open” external genitals and an enlarged hymen. Two Italian teenagers had physiological GS monolaterally: one a 14-year-old, who was emotionally disturbed because of the mistaken modification and a 19-year-old who, on the contrary, had fully accepted her hypertrophic genitals. Eight women: five Italians (24–55 years of age) with physiological GS, four of which have accepted and one who has not accepted her labial hypertrophy; three African girls with ritual GS, two of whom declare themselves satisfied with the modified morphology. No information exists about the remaining four cases.

Results and Discussion This preliminary survey carried out on GS must be considered the first approach to the problem in order to open the way to more in-depth studies. First of all, the survey will capture the interest of the international organizations that are only concerned with the reductive aspects of FGM, completely disregarding the expansive ones that are also changes implemented on the normal female genital morphology. As a secondary focus, not less important, as mentioned in the introduction, the survey aims to provide updated information to those Italian socio-medical operators who are involved with immigration, in order to make them aware of this morphology. The preliminary result is not numerically significant, so here we thought it appropriate to add some observations. The phenomenon of genital stretching is still little known to the health operators in Italy. In a total of approximately 300 interviewees, only one hundred of them declare that they know about it, but, when investigated with more specific questions, 92% of them claim to know little or nothing. Equally unknown is the culture that underlies this practice in Africa. The identification of the ritual expansive type of genital modification in immigrant patients is the first difficulty expressed by the Ob/Gyns. Only 10% of professionals who

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encountered ritual GS recognized it. The most common trend has been to treat such variations as morphological diversity or unusual racial characteristics. Patients with labial hypertrophy identified in this initial survey are a total of about twenty African women with ritual GS and forty Western patients with physiological GS. Of course, in the first case, it is a matter of culture, which means a ritual that includes the manipulation to accomplish the genital modification. The manipulation was not carried out in Italy, even if, in a previous survey on baganda Ugandan women, it appeared in immigrants in Rome (Grassivaro Gallo and Villa, 2004). For Italian obstetric patients having physiological GS, this is almost always a character that manifests itself spontaneously with birth and/or increases with growth. Therefore, we have indicated it with the term physiological GS to distinguish it from ritual forms present in African women. For the latter, we can also provide a percentage guideline, as it happens in the average obstetric patients in Italy, from 8 to 20%, according to what is reported by the two Ob/Gyns of Parma and Florence, who took part in the survey. Most subjects negatively experience physiological GS (60%), yet, this morphology is not taken into account by specialists, despite the psychological discomfort sometimes reported by the Western patients, carriers of the hypertrophy. Immigrant women who are ritually manipulated share such discomfort. When in the diaspora, they are obliged to confront themselves with the western reality and feel “inadequate and different.” Consequently, their feeling of being excluded from the world in which they live increases. This genital manipulation is experienced positively in Africa, where it is endemic and where it becomes an integral part of cultural identity, identity that we are facing also in the diaspora. The manipulated immigrant only seldom requires or accepts the surgical reduction of the elongated labia. In the African sample, 2 subjects out of 16, and in Italy, 16 out of 40 subjects accepted surgery. Among female immigrants, the elongation of the labia minora usually continues to be regarded with the same purpose as it has in the homeland: to increase sexual enjoyment, therefore, it is regarded as a sign of respect for the partner. Indeed, as shown by studies done in the cultural context in which they originate (Uganda 2002, Grassivaro Gallo and Villa, 2004, 2006; Malawi 2004, Grassivaro Gallo and Moro, 2006; Congo 2006, Tshiala Mbuyin, 2005/2006; Grassivaro Gallo et al., 2007), African women regard their manipulated genitalia as functional, if not essential, to their individual growth and as the fundamental aspect of their belonging to the group and for their social identity. Western women, whose relationships with their genital hypertrophy is a more subjective and private matter, the positive, negative, or indifferent reaction is determined by their personal experiences and individual responses, developed in their intimate relationships with partners. Italian women carrying this trait usually manifest a related discomfort, which becomes a real concern in some cases of teenagers who barely tolerate their diversity, while the Italian partners, not accustomed to this unusual shape, in the case of promiscuous relations with immigrant women, consider it with frank disgust. In relations with Italian women, they may consider it to be an over-growth, preventing

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penetration. Given the results, we believe that adequate psychosocial health information would help to better address the problem associated with these practices and to better understand the woman and the way she deals with herself and with her body.

References Grassivaro Gallo P, Villa E. (2004) Longininfismo rituale tra le Baganda (Uganda). Rapporto Preliminare, Rivista di Sessuologia. 28:17–22. Grassivaro Gallo P, Villa E. (2006) Ritual labia Minora Elongation among the Baganda Women of Uganda. Psychopathologie Africaine. 33:213–236. Grassivaro Gallo P, Moro D. (2006) Modificazioni genitali femminili in Malawi. Primo resoconto di un’indagine sul campo. In: Grassivaro Gallo P, Manganoni M. (a cura di.) Pratiche Tradizionali Nocive alla Salute delle Donne. Padova: Unipress, pp 87–102. Grassivaro Gsllo P, Tshiala Mbuyi N, Mulopo Katende C. (2007) L’opinione maschile sull’Elongation des pètites lévres RDC (Republic Democratic del Congo), Luglio, Scienzaonline.com. Tshiala Mbuyi N. (2005/2006) L’infermiere nel linguaggio del corpo: prima indagine sul longininfismo nella Repubblica Democratica del Congo. Tesi di Laurea in Scienze Infermieristiche. Università di Padova. WHO 1996 Female Genital Mutilation. (1996) Report of a WHO Technical Working Group. Geneva: WHO, July 17–19, 1995.

Chapter 12

Knowledge and Opinions of North Italian Health Operators About Female Genital Mutilation Pia Grassivaro Gallo, Ilenia Zanotti, Annalisa Bertoletti, Lucrezia Catania, and Miriam Manganoni

Abstract Since its creation, the Working Group on Female Genital Mutilation (FGM) has looked at large-scale epidemiologic investigation as the best way to monitor the evolution of FGM in Italy. Obstetricians and gynecologists have been considered the most qualified subjects to be interviewed because they have the first contact with the excised women of Africa. The first investigation, which was made in 1993, found that 50% of professionals had at least one experience with FGM patients (Grassivaro Gallo and Viviani, 1995, Female Genital Mutilation: A Public Health Issue Also in Italy. Padua: Unipress); with the second investigation, dated 1999, it was discovered that female gynecologists were more professionally involved with this problem than their male colleagues (Grassivaro Gallo and Cortesi, 1999, Linee guida per il personale medico di fronte a casi di Mutilazione Genitale Femminile (MGF), Quaderni di Ricerca, n. 5, Osservatorio Regionale Regione Veneto (ORIV), Assessorato Politiche Flussi Migratori, Venice). We now introduce the results of the third investigation. The national congresses of specific associations have been the most valuable scientific occasions to collect the opinions of professionals, coming from all parts of the country; the most recent investigation is limited to Northern Italy, but is strictly connected to a similar one in Tuscany. For this reason, the results of the two investigations give us information about the operators working in the North Italian regions. The focus of the present investigation is to evaluate the knowledge and opinions on FGM of the socio-health workers of Northern Italy (Zanotti et al., 2007, Conoscenza e Opinioni degli operatori socio-sanitari del Nord-Italia sulle Mutilazioni Genitali Femminili (MGF) (Rapporto Preliminare). Relazione all’83◦ Congresso Nazionale SIGO, Naples). Keywords Female genital mutilation · Gynecologists · Obstetricians · Infibulation · Medical education

P. Grassivaro Gallo (B) Working Group on FGM, University of Padua, Padua, Italy e-mail: [email protected]

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Subjects The sample group consisted of 211 subjects of both sexes (78% males, 21% females; average age 39.9; range 19–65 years), who were involved with different qualifications in health or social activities in immigration and were contacted in 2006 at several scientific meetings. The health workers include: 51.1% obstetricians or gynecologists; 7.7% consultants; 19.5% nurses; 6.3% subjects involved with immigration; 14.4% others.

Methods By collecting the information, we preferred the use of a questionnaire for its quickness and simplicity. The instrument that we used has been tuned with the collaboration of two institutions: the Research Center for Preventing and Curing FGM of the Faculty of Medicine and the Department of Health Psychology, both of the University of Florence (Abdulcadir and Catania, 2005). The questionnaire is structured as a series of items based on five-levels, Likert scale; 25 items were created to detect the knowledge level, and 14 items, were to glean the opinions related to FGM. After having analyzed the frequencies obtained by every item, we proceeded with the statistical elaboration through the use of SPSS ver. 14.0 (Statistical Package for the Social Sciences). The first step was to analyze the T test, in order to investigate gender differences among independent samples (males and females). Then, on the basis of the answers given to the specific items, we investigated the knowledge and the opinions related to FGM (qualitative variables); we used the hierarchical analysis with the Ward clustering method, in order to investigate the presence of subgroups within the sample. Through the external validation, we also verified, in the last passage, whether there were important relationships between the clusters and the external variables: for the quantitative variable (age, working years of the subjects), the Student’s T test for independent samples has been applied; for the qualitative variable (job title), the X2 test has been applied.

Results After a first reading of the frequencies of the single variables, 85% of the subjects believe they know what FGM is. This does not surprise us. Instead it surprises us that 9% of the operators today do not know anything about it. In particular, from the examination among these last 20 subjects, five obstetricians and six nurses were included. The professionals point out that direct experience with patients (29%) and the mass media (26%) are the primary source of knowledge on FGM (see Table 12.1).

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Table 12.1 How did you become acquainted with FGM? Subjects Medium

Nr

Percentagea

Professional training Scientific literature Direct experience with mutilated patients/pregnant women Referred from other health figures Mass-media

83 83 160

15.1 15.1 29.1

62

11.3

144

26.2

a We

obtained more than one answer per item.

They also state that they know the classification made by WHO related to the different mutilation practices and the corresponding age at which the practice is executed on little girls. From the investigation emerges sufficient information about the details of these practices (for example: short- and long-term consequences and socio-cultural motivations); the sample is mostly focused on only one value, with the exception of some items that uncover some vague information. The opinions and the general judgment about FGM are all based on a Western viewpoint, and are focused only on negative aspects. According to these opinions, these practices must be discouraged and abolished, since they have been considered a violation of the female, an injury and a crime that is very harmful to women’s health. Moreover, in their opinions, the circumcisers should be prosecuted because they use violence against basic human rights and, although this practice is linked to cultural traditions, it should not be absolutely respected. The whole sample is strongly aligned to this Western vision. Thus far, we have presented the results gleaned from the reading of the single variables. Now, we will introduce the results obtained from a more sophisticated statistical analysis. As for knowledge about FGM, the analysis highlighted that the female group, in respect to the male group, is much more inclined to think that: • Hemorrhage is one of the short-term complications of mutilation • FGM prevents the possibility of having an orgasm In relation to the judgments on FGM, no other gender differences emerged. The clusters analysis of the samples point out two groups that particularly stand out from the others (Dendrogram); they are so defined: • Cluster 1, composed of 84 subjects • Cluster 2, composed of 76 subjects

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Specifically, some differences have been noticed as discriminants in the answers related to the beliefs about FGM. In particular, the items that presented these differences are: • • • • • • • •

FGM is practiced only in Muslim countries (item 1); All FGM implies the mutilation of the clitoris (item 2); FGM reduces sexual desire (item 5); FGM is a religious imposition (item 8); FGM causes problems with getting pregnant (item 9); FGM reduces sexual excitement (item 15); FGM prevents the possibility of having an orgasm (item 21); The practice of FGM is circumscribed to poor and uneducated social groups (item 24);

In these items, Cluster Number 1 is the one that reports a higher and more meaningful average of more probable statements than the answers obtained with Cluster Number 2. In particular, if we examine the contents of these items, we notice that five of them (items 1, 2, 8, 9, and 24) contain some “non-truths,” which have been considered, thanks to a strengthened bibliography. The three items left (items 5, 15, and 21) have been called into question for their contents only in some more recent studies (Catania et al., 2004). With this premise, we distinguish the subjects of Cluster Number 1 as people with a low knowledge of FGM, whereas the people of Cluster Number 2 are subjects with high knowledge of FGM. This second group also reports a higher value on average, even in the answers of items 12 and 13. These items both have a factual content, consequently the subjects consider these statements as the most probable: • FGM is done in order to preserve chastity (item 12). • In the societies where FGM is practiced, an extended belief is that it increases fertility (item 13). In the end, through the external validity (done with variables that were different from the ones used for the cluster creation), we analyzed for meaningful relationships between the clusters and the considered external variable. We obtained the following results: • No differences as discriminants emerged, neither between the two clusters nor in respect to the age (T = 0.684; p = 0.495; p > 0.05) or the working years (T = 0.086; p = 0.931; p > 0.05). • When considering the variable called “professional qualification,” the significance test was 0.054, slightly higher than p = 0.05. We can affirm that the last variable considered relatively influences the level of knowledge of the sociohealth workers on FGM. From the contingency table, it emerges that, in regard to the variable “professional qualification,” a very high percentage (80%) of the

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people working in the field of immigration belong to Cluster Number 2, which has been labeled as a group with a high knowledge about FGM. In regards to the items related to the judgments on FGM, no differences as discriminants emerge on the subjects.

Comments and Conclusions In relation to the goal that we wanted to reach, it seems that the analyzed sample of 221 subjects is sufficiently valid, since it is composed of doctors, specialists, nurses, obstetrician/gynecologists, and workers in the field of immigration. They are all professionals who have contact with the contexts where FGM is developed. Note that Italy is the European country with the highest number of infibulated women. Therefore, in our opinion, these results represent very well the present level of knowledge about FGM, as far as the provinces of Emilia Romagna, Veneto, and Lombardia are concerned, a big part of northern and central Italy. During the previous years, other investigations of FGM have been made: an investigation of 145 socio-health operators from Tuscany, which has been done with the same questionnaire (Abdulcadir and Catania, 2005); two investigations made by the Working Group on FGM of Padua, with six years between the studies, the first one on 318 obstetrician/gynecologists (Grassivaro Gallo and Viviani, 1995) and the second one on 114 gynecologists specializing in colposcopy (Grassivaro Gallo and Cortesi, 1999). We will compare them to our analysis. Thanks to their jobs, a high percentage of these subjects know the phenomenon of FGM, precisely 95.5% in 1993; 97.2% in 2005; 85% in the present investigation. With the high number of infibulated women there, the socio-health operators have the concrete opportunity of being in contact with these patients. These are the primary sources of knowledge that have been pointed out: direct contact with patients and, above all, the mass media. For this reason, we could presume that healthcare professionals are proficient and competent with this problem. In fact, however, they have a very superficial knowledge. Indeed, when asked for more detailed particulars pertaining to this subject (for instance, “At what age FGM is practiced?” or “What are the socio-cultural reasons for FGM?”), they seem to have vague information on many aspects. The reasons for this approximated knowledge seem to be the mass media, which conveys stereotyped and ethnocentric information, and the superficiality of the relationship between socio-health operator and the mutilated patient. As for the first point, the majority of interviewed subjects does not have a clear classification of the different practices of genital mutilation, but often identify them with the most known type—infibulation. Different sources of information about FGM mention only infibulation (justly or not), which is surely the most severe mutilation practice and the most known, as well, but it is not the only one. Moreover, these subjects, both male and female, give to this practice only one interpretation—the Western one. If we consider the data about the knowledge of FGM, a clear division on the sample within two groups emerges—the “high knowledge” one and the “low

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knowledge” one. It seems that those responsible for this division are the staff that work in the field of immigration because, given their answers to the items, they are the ones with a high knowledge of the subject. It is important to note that the same dichotomy has been highlighted in the investigation carried out in Tuscany, which used the same questionnaire (Abdulcadir and Catania, 2005). Once again, we believe that the mass media is indirectly responsible. Only specialists would be able to distinguish themselves from other professionals, after deepening their knowledge about the subject, and this knowledge must be independent of the information supplied by newspapers and magazines, which are characterized by very superficial news items. Therefore, we think the leading reason that explains a part of the obtained results is identified by the role that the mass media plays as a source of information, which is then absorbed by the majority of readers and which is characterized by uninformed opinions, biases, and half-truths. In confirmation of our hypothesis, we made reference to a graduation thesis written in Milan about the “Analysis of the articles regarding FGM published in the last 20 years” (De Vita, 2004/2005). This thesis demonstrated the flimsiness, the mistakes, the half-truths, etc., that are repeatedly spread and absorbed by an unsuspecting public thinking it will learn something but instead is shocked by graphic images that are shown rather than detailed explanations and diffusion maps of the phenomenon. The same images continue to be published in different articles. We comment again upon the obtained results in order to talk about the relationship among socio-health operators and excised patients. The operators know superficially about the phenomenon of FGM, although they have daily and direct contact with these patients. The majority of them listen to the information provided by mass media, have learned about FGM through vocational training, but, at the same time, do not seem to be completely informed and are still confused about some points. It seems that information reaches the people, and there are also opportunities to broaden this information, but the people seem not to gain knowledge or do not make use of it. It is as if they know that the problem exists, but it is put aside and is considered superficially. We cannot say, for certain, that this fact is new, but we can confirm its present existence. The 6th National Congress, “The Immigrants in Lombardy,” organized by ISMU –(Initiatives and Studies on Multi-Ethnicity) (Pasini, 2007), raised some very important questions about the fact that obstetrician/gynecologists, when they have to deal with FGM patients, often do not use these moments to gain information about this subject. It seems that they cannot find enough time and the right way to have a dialogue with these women in order to investigate this problem. The difficulties come from both sides. They are caused by linguistic problems or lack of time, but also because specialists may fear embarrassing their patient. Obstacles are not merely linguistic, but also are psychological. Specialists do not know how to face the subject with these women and they prefer to say nothing about it for fear that they would make their patient feel “different.”

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Another problem that emerges is that the presence of FGM is not notated in the mutilated patients’ case histories. This does not permit the transmission of this information among medical personnel nor does it enable an educational process to occur. The last point we noticed is the negative view of this phenomenon, a biased attitude, and the labeling of FGM as an inhuman practice. This attitude does not increase understanding of the phenomenon (Bianchi, 2007). In conclusion: in order to facilitate cultural understanding, the following could be useful: • A cultural mediator or a psychologist to make communication easier and set up a dialogue also among healthcare professionals. From an investigation done in Padua in 1998 (Grassivaro Gallo and Cortesi, 1999), it emerges that 78% of the subjects say that the presence of a cultural mediator would be useful during a gynecological visit. • Frequent training courses for healthcare professionals. This training must be constant and continuous, so that the staff gains knowledge about these practices. In fact, this phenomenon has become part of our country and it will involve Italy more and more because of the progressive increase of immigration. • Behavior guidelines can facilitate the socio-healthcare professionals’ job in order to prepare them for certain behaviors and give them an enhanced awareness of the complexity of the phenomenon. As for this last point, as far as we know, the first draft of the government guidelines about FGM were published online in June 2007 (www.ministerosalute.it). On the basis of the results obtained in our investigation, we thought it appropriate to present Minister L. Turco with some issues related to these guidelines (www.scienzaonline.com, July 2007). None of our suggestions, however, have been considered in the final draft of these guidelines (Linee, 2008).

References Abdulcadir OH, Catania L. (2005) Mutilazioni dei genitali femminili: conoscenze e opinioni del personale sanitario in Toscana. Atti della Soc Italiana di Ginecologia e Ostetricia, pp 1–2. Bianchi S. (2007) Introduzione metodologica. In: Pasini N. (a cura di) Mutilazioni Genitali Femminili: riflessioni teoriche e pratiche. Milan: Il caso della regione Lombardia, Fondazione ISMU, pp 127–134. Catania L, Baldaro-Verde J, Siringatti S, Casale S, Abdulcadir OH. (2004) Indagine preliminare sulla sessualità di un gruppo di donne con mutilazioni dei genitali femminili in assenza di complicanze a distanza. Rivista di Sessuologia. 28:26–34. De Vita R. (2004/2005) MGF: ritualità sociale o barbarie? Tesi di laurea, Fac. di Scienze della Comunicazione e dello Spettacolo. Univ. di Lingue e Comunicazione (IULM), AA Milano. Grassivaro Gallo P, Viviani F. (1995) Female Genital Mutilation: A Public Health Issue Also in Italy. Padua: Unipress.

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Grassivaro Gallo P, Cortesi C. (1999) Linee guida per il personale medico di fronte a casi di Mutilazione Genitale Femminile (MGF), Quaderni di Ricerca, n. 5, Osservatorio Regionale Regione Veneto (ORIV), Assessorato Politiche Flussi Migratori, Venice. Linee G. (25 Mar 2008) Gazzetta Ufficiale della Repubblica Italiana http://ministerosalute.it/ saluteDonna/paginaInternaMenuSaluteDonna , www.Scienzaonline.com, Luglio, 2007, www. ministerosalute.it Pasini N. (a cura di) (2007) Mutilazioni Genitali Femminili: riflessioni teoriche e pratiche. Milan: Il caso della regione Lombardia, Fondazione ISMU.

Chapter 13

Stretching of the Labia Minora and Other Expansive Interventions of Female Genitals in the Democratic Republic of the Congo (DRC) Pia Grassivaro Gallo, Nancy Tshiala Mbuyi, and Annalisa Bertoletti

Abstract Ritual stretching, classified among the female genital mutilations by the WHO in 1996, has been studied for the first time in the Democratic Republic of Congo (DRC) by the Padua Working Group on FGM in 2006. Data gathering took place indirectly from Italy by means of Italian and Congolese local referents, through structured interviews with traditional operators as well as a focus group of about ten intellectuals (in Kasai) and Italian health workers (in Kiwu). The data have been completed, with answers from two questionnaires sent to affected women and health workers of the Mbuji-Mayi Hospital in Kasai. The results enabled us to outline cultural and naturalistic traits, social meanings, countrywide diffusion, and time evolution of the ritual of labial elongation as it takes place in the two abovementioned regions of the DRC. Other forms of expansive genital modifications have been identified, such as ritual defloration and the widening of the vaginal canal, among very isolated populations in the Kiwu region. Keywords Labia minora · Stretching · Democratic Republic of the Congo · Female genital mutilation · Padua Working Group on Female Genital Mutilation · Traditional operators · Ritual defloration · Vaginal canal

Introduction Genital stretching (GS) (Longininfismo in Italian; èlongation des petites lèvres, in French), the expansive modification of the albia minora (nimphae), is obtained by the means of ritual manipulation. It is a common traditional intervention in the African Great Lakes region, included within the DRC, as indicated previously (De Rachewiltz, 1963; Kashamura, 1973).

P. Grassivaro Gallo (B) Working Group on FGM, University of Padua, Padua, Italy e-mail: [email protected]

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This morphology, in our opinion, is classified inappropriately by the WHO (1996) under Female Genital Mutilation, Type 4. In fact, in these cases, there is no sense of self-mutilation, but rather expansive manipulation of the genitalia. In 2006, the Padua Working Group on FGM organized the first survey of ritual genital stretching in the DRC; but due to the difficult political situation of the country in carrying out its first national election, a direct survey in the field was not advised. Instead, it operated indirectly, through in loco referrals, whether Congolese or Italian, contacted from Italy by Italian and Congolese intermediaries (among whom was the co-author of Luba ethnicity).

Survey Instruments Interviews with adult subjects (women and/or men), Congolese and Italians present in Congo, who, under examination, were aware of the ritual, were carried out through a “track” processed in Padua. The track is composed of 26 inherent items, including cultural aspects, psychosocial importance, distribution within the territory, and evolution over time of GS. Moreover, there were two prepared questionnaires: the first, directed at women who had undergone the ritual; the second, directed at sanitary operators (nurses, obstetricians, doctors) who, throughout their professional activities, had come in contact with women with manipulated genitals (often patients or women who had just given birth).

Contacted Subjects Altogether the “track” was proposed: In Kasai: • to the old Luba grandmother of the co-author (Fig. 13.1), interviewed by a cousin, using the tshiluba dialect exclusively. (The mother of the candidate always refused to speak, even by telephone, to her daughter about the ritual). • to a group of intellectuals, all male, who responded (in French) through a “focus group,” organized by a referred Congolese sociologist, contacted by a Luba pediatrician, who practices in Italy and who made himself available for the collaboration. In Kivu: • to an Italian psychiatrist who worked in Goma, in a center for mental hygiene of missionaries of St. Saverio, who reported information yielded from two of his nurses, of Bafulero and Bashi ethnicity, respectively. • To a nun of St. Saverio, working as a missionary for 23 years in Kivu; an expert of the Bukavu and Uvira region.

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Fig. 13.1 Grandmother Njiba (86 years old) (Kinshasa)

Fig. 13.2 Saint Sauveur Hospital (Mbuji-Mayi, in Kasai)

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The questionnaires, however, were sent to a Congolese obstetrician/gynecologist who worked at the Mbenzola State Hospital of Mbuji-Mayi, in Kasai (Fig. 13.2). Altogether, in this manner, information was collected from 52 women and 52 healthcare professionals (in maternity, pediatric, post-partum, and obstetric/gynecology units) subgroups A and B, respectively—that reported on the culture of that territory.

Results From the interviews and from conversations carried out through the “track” we obtained information about the culture, the social meaning, the involved ethnicities, the role of the plants, and the evolution of the ritual of GS. Moreover, much of this information has been confirmed through the questionnaires distributed to the women and the healthcare professionals. This last data were processed exclusively in terms of simple percentages and have given the following results.

Subgroup A Of the 52 women interviewed, the majority (79%), belong to the Luba ethnic group. They are adults with the mean age of 44.5 years; predominantly married (69%). They were introduced to genital stretching within the atmosphere of daily, familiar life (17%) or through friendships (50%); at the age of pre-menstruation or pre-puberty (75%); the manipulation was obtained through plant extracts (60%), supported by objects/instruments of various typologies (40%). The women confirmed the current vitality of the ritual (83%), from which one grows in beauty (27%) and in consideration taken by the husband (78%); they have the clear consciousness that its function is to “increase sexual pleasure” (92%). The labial elongation does not cause substantial physical consequences (76%), except for some women (19%). Regarding the future of the daughters, the opinions of the mothers are divided and almost equivalent—yes and no—(53 and 43%, respectively). They also added the motivations for passing the traditions to their daughters that we enclose in the table. They refer to a matrimonial stability, to the essence of femininity, to the increment of sexual pleasure, and the possibility for women to conform in the same culture. Other motivations advise against transferring the culture because it is obsolete; the parents cannot speak, for the sake of modesty, conferring the task on elderly people; it will be the partner, not the parents, who decides if the wife should be manipulated because the ritual cannot be a pretext for initiating premarital sexual relations.

Subgroup B The majority (97%) of the 52 healthcare professionals are familiar with female genital manipulation and they have recognized its spread in the regions of Kivu and

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Kasai. In addition, they are aware of its presence in the capitol (Map); especially in the rural region (92%) compared to the urban environment (33%). It is work experience that has been favorable to many professionals (88%) in their encounters with manipulation; they also indicate that the GS is not present in girls before age 13, thus confirming the data obtained from the women.

Map: Genital stretching in Democratic Republic of Congo (present research)

The reasoning that supports the presence of the ritual in a more consistent matter (88%) is that of greater sexual satisfaction. Manipulated women are generally accepted (42%) and are considered normal (94%), but often (42%) the hypertrophic labia minora is not the subject of much interest on the behalf of the healthcare professionals.

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The Ritual We begin by emphasizing the manner in which the ritual in the DRC is not included within any rite of passage ceremony, it simply accompanies the normal growth of adolescents. That is, when the young girl begins to show signs of growing breasts (age 12–16), family members believe that she should also have an elongated labia minora. In the development of the rite, we have recognized that some events follow others chronologically, one after the other, but in some cases they can also be missing materials, according to the availability of the environment or the foundation of the ethnicity; the sequence seems to be confirmed for Kasai, as in the arid district of Eastern Congo, in Kiwu. These are the identified phases: • • • • • • •

the decision of the family and the support of the elders; the selection and preparation of plant extracts; the application of the extracts on the genitals, to make them swollen and evident; the manipulation: first intervention and subsequent learning; stretching and maintaining the elongated labia minora; the assurance of the elongation, using topical substances and potions; the recuperation of the elongation after childbirth.

The ritual is imposed by the suggestion of a grandmother, an aunt, or a wise woman in the village who can initiate the girl personally (Bafulero) or rather, entrust it to another greater (Luba). It is suggested to the girl, having already begun, to concern herself with the neophyte and to teach her what men desire to find in a woman: “You cannot have nothing between your legs, otherwise you will not be esteemed.” For the sake of modesty, it will not be the mother who will speak to the adolescent. Among the Bafulero, the girl was entrusted to an initiator, “old sage,” with whom she would spend evenings and from whom she learned the technique of genital manipulation and also “the movement of love,” that is, the action to be taken during intercourse. Therefore, the plant extracts are prepared in advance. In Kasai, a plant similar to a rose, that grows naturally on the banks of waterways, is used. The flower is peeled and the petals crushed to extract a stinging juice with which to massage the labia; or alternatively the root of the tshifumba (that secretes a liquid similar to that of a wild onion). During the ritual, the juice is stored in containers of wrapped Mangus tree leaves. The swelling of the labia by the already prepared, specific plant juices continues. The self-manipulation (of the labia minora) follows. The older girl accompanies the neophyte to an outdoor area (brousse), where they will not be disturbed; they take a blanket, should it be needed, and they prepare a container made of Mangus leaves, shaped like a funnel in which to store plant extracts. They sit facing each other with their legs open. The initiator takes a root (of tshifumba), cuts it, wets the

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thumb and index fingers with the gelatin and begins to massage the labia minora. Then they begin to pull it. It stops when the irritation takes over. They repeat the action from time to time and so on. The first intervention can also be done reciprocally among neophytes to whom it has been explained how to act. Elders can also intervene, touching the genital region to see the results of manipulation. Among the Bashi and the Bafulero, however, the initiated females, sent outdoors and away from foreign eyes, sat in a circle and each person performed genital manipulation. The latter situation seems not have changed over time (Kashamura, 1973). Instead of roots, as already mentioned, a different plant, dilongu, a species of rose, can be used. If the tshifumba leaves are used, they can serve two purposes. From the leaves, a juice can be drawn that acts to soften the labia minora and foliar veins can be drawn from the sticks. These sticks are cut down along the middle and labia minora are inserted, one in each small stick, to prevent them from withdrawing. This way, each labia hangs down so that it will be lengthened in a way that weights can eventually be attached. During the manipulation, the girl assumes a particular position—that of a woman giving birth; sitting with knees flexed open strongly towards the head, and feet turned inward. Finally, the manipulated genitals are covered with coal dust (to which boiled manioc flour can be added to help the elongation). Everything is covered with soft pieces of plants (even tshifumba). The next day the application is removed and the manipulation begins again. A hot potion is prepared, finally, which serves the purpose of helping the GS (it becomes effective, probably because it causes local vasodilation). The GS continues until the labia minora reaches the length of 2–3 cm. or more; at this point they do not withdraw anymore. The care of the GS is a constant task for the woman, even after she is married, and she will resume manipulation after the birth of a child and the subsequent reduction of the labia minora. An in itinere examination of the length of the stretching is expected, and can be implemented by the friends who accompany the neophyte (Luba) or the grandmother who invites her to come before them in private to assess the progress (Bafulero). (In Rwanda—Utu e Tutsi—where GS is very much considered, it is carried on for longer, in consideration of a specific type of sexual intercourse, produced by the vagina. That is at least what was reported in the past). The manipulation is carried out at puberty when the tissues are still extensible. If it is done later, they do not maintain the same elasticity; if it is done too early the procedure is painful. The manipulated girl keeps her reserve about her own condition that will be known in time only by her new husband. No social presentation is held for the initiated females. Any girl who does not undergo GS is referred to by the term tshimbùla or tshimbumba, that is “one who has nothing;” a name given to a “goat that has no horns.” There is also a song in which makonka is used as a term of mockery. The girl who has been manipulated, however, is referred to as “wa tshichèkù,” ready woman, able, who has prepared her body—literally—“flower garden.”

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The Role of Plants The use of plants in rituals is very distinct in their specific, multiple, and differentiated functions. However, they are not always used in the proper way— “The indiscriminate use of the herbs can cause ulcers,” an interviewed woman said. The functions supported by the plants at the ceremony are as follows: • formation of edema in the genital region as a result of irritation caused by plant extracts, often contained in a funnel made of curled mangus leaves; • application of a plant extract that acts as a mordant on the skin of the genital region and softens it; • covering of the manipulated genital region in powder and pieces of plant marrow, a facilitator of elongation; • application of boiled flour in order to promote the elongation; • use of slotted sticks, made from straw or foliar veins, where the labia are inserted during stretching to prevent a return to the normal morphology; • decoctions and teas, to be taken warm, that are favorable to the elongation, through local vasodilation. The ritual plants, classified from the botanic viewpoint (De Wit 1965) or indicated only by their local name, are the following: • Bauhinia tonningii Shumach (Family: Cesalpinaceae), in the local language it is called tshifumba; has these uses: leaves are obtained from an extract to soften the skin (it is used also to soften the leather in tanneries); ribbing from foliar sticks are obtained to confirm the extension of the labia during manipulation. • Bridelia ferruginea, locally called shinkunku, is a “sacred” tree under which ceremonies of groups are also carried out, for example, when men assemble themselves before the hunt, to have a favorable outcome. • Solanum delangeonsa Dunal (Family: Solanaceae), locally called nkulanyi. The very pungent fruit was used to treat skin disease in goats. It is a ubiquitous plant that has been indicated in the ritual of genital manipulation in Uganda and in Malawi. • Maniot (Family: Euphorbiaceae), the cassava.

A Ritual Defloration In the eastern district, among the Bashi of South Kivu, there were reports of a very particular form of female genital modification, different to the GS, which is a ritual form of defloration. (The reference is not isolated in the DRC because even among

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the Thokwe, a ritual defloration is required during a girl’s preparation for marriage, obtained by placing objects of increasing size into the vagina—sticks, eggs, horns, etc.—until the hymen is eliminated. This ritual does not compromise pre-marital virginity of women). However, this refers specifically to another form of manipulation that is intended to help maintain the elasticity of the membrane of the hymen and simultaneously achieve a progressive enlargement of the vaginal canal. This is done to make the first penetration less painful and then to facilitate birth in the future. The procedure is carried out by the shangàsi, also called “mother mokubua,” traditionally the father’s sister, that is, the oldest woman in the father’s family, the person solely and indisputably responsible for the education of the offspring. It is at the exact time of birth that the child undergoes the first procedure, checking the elasticity of the hymen membrane and if necessary, immediately after, manipulation begins in a gradual and constant manner. This is done to avoid having to consult a doctor for the enlargement of the hymen and the vaginal canal when the membrane is thickened with growth. The shangàsi can continue the practice over time on her niece, at home or elsewhere, taking her niece along with her, for example, during scholastic holidays. Everything is done in absolute confidentiality and often not even the father is aware. Specfically, the shangàsi inserts a finger at the opening of the vagina and moves in a circular motion, gradually widening the narrow entry; it acts delicately on the elastic membrane of the hymen, in order to force the opening without breaking it. Such practice is more widespread among the tribes located in brousse and among the most backward tribes; it tends to disappear in urban environments, where the girls rebel against these customs and practices, as well as with other ritual practices, adopted by the villages. After this first procedure, the shangàsi oversees the social development of the girl until marriage, continuing to exert her own authority over the girl even after. She must make sure that the girl behaves in the manner expected of her to become a good wife, responding appropriately to the tasks before her. In conclusion, she is responsible for the growth, psychosocial, and sexual maturity of the grandchildren, which will be removed from the mother immediately after birth. On the other hand, the intervention on the genitals is reflected in an increase of authority and of consideration for women, especially, where there are no traditional educated workers who can educate the girls for whom they are responsible, through more modern methods (education, setting an example, etc.). Genital manipulation can be translated, lastly, for the shangàsi, as a personal advantage, contributing to putting into motion the hormonal activity of the elderly woman, from which she can draw sexual vigor. We stress again that, when the child/adolescent in the diaspora is the bearer of this ritual vaginal enlargement, during an inspection, she may seem to have been

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the victim of abuse but it is only through a closer look at the absence of concomitant signs of rupture and/or bleeding, usually caused by the forced penetration of a male, it helps the professional to understand how the modification is the result of an intentional act, performed by an expert.

Social Meaning The motivation with which the girls were convinced to undergo the GS was aesthetics; they needed to become more beautiful; a vulva that has not undergone GS is considered ugly, not pleasing, therefore, it would not be possible to marry. Women still have a clear awareness that genital modification serves to increase the pleasure of intercourse for the woman as for the man. For the woman, the modified labia become more irrigated by the blood and, therefore, are more sensitive as erogenous zones (“The man is happier because the woman warms up first”). For the man, who begins rubbing the labia minora, it increases the possibility of exercising “petting” in the premises of mating. At this stage, they have their own reason for being. The man likes to “feel” the woman under his fingers. The more meaty the labia, the more attracted he feels to his partner. So much so that the women of the past (ndumba, literally, “the manipulated prostitutes”) would put a lot more work than current women in continuing the manipulation, to be able to subdue their own men. For example, in the Lubumbashi region, the presence of the migrants could make the availability of possible partners of women more competitive, the most popular because they are “stretched.” During the manipulation, the girl can have an orgasm but traditionally must remain a virgin until marriage. The man of Kasai aspires to be the first for his woman and be able to see the sheet stained with blood after the first night, so masturbation is allowed and even encouraged in the practice of genital manipulation. There are tribes, in particular the Rwandan (Utu and Tutsi) that develop these practices much more than the others, the volume and length of the labia minora reaching 5 or 6 cm. It seems that the manipulation in this case has been accentuated and traditionally handed down to allow for sexual intercourse conducted outside the vagina, by rubbing the penis on the labia minora so that they could respond effectively to the sexual behavior adopted. In women, these practices accompany the development of sexuality; for which they are taught to give and feel pleasure (premise to reproduction), but at the same time are obliged to control (that of remaining a virgin). It is added also that the learning of manipulation is collective, for which they grow together in sexuality; however, that must not be expressed completely except in marriage. This tradition still exists in the DRC, mainly in rural areas. In conclusion, in expansive genital modification, the woman becomes the active protagonist in the relationship itself, not only a spectator, as in female genital modifications of reductive typology. So, if the husband (Luba) finds that his wife (of another ethnic group) has not thought to prepare her body, he will go to a “wise woman” so that she may initiate the wife to sexual manipulation.

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Geographic Distribution and Involved Ethnic Groups: Evolution Over Time Through analysis, we have identified the area of diffusion of GS in the DRC (Map), especially present in the eastern region, limited by lakes, bordering the countries where it is endemic (Uganda, Rwanda, Burundi, Zambia, etc.). The included regions in Kivu comprise western and eastern Kasai and, in part, Katanga. As for the ethnic groups involved, some were taken from bibliographical surveys, others were specified by the local contact during the interviews conducted. These include Bafulero and Bashi in Kivu, any immigrants in the Congo in Rwanda, and ethnic Utu and Tutsi. In the Kasai district, it occurs among the Tshokwe (performing also the defloration ritual, through the insertion of objects of increasing size into the vagina), the Bindi, the Kete, the Tetela, the Sanga (in Katanga: the Ndembo, the Lulakat), the Lulua. Basically it is always the Luba people. The labial manipulation appears to be connected to the ethnic group, in Kasai, as in Katanga and Zambia. In Lumumbashi in particular, the women had accentuated elongation, through packs of dust produced from peels of plants. They feared that the partners were attracted to immigrants of the nearest region, where the elongation was highly regarded. In the current evolution, the ritual was conserved predominantly in rural areas, while in urban areas girls do not consider it necessary anymore, but rather as old fashioned. Particularly in the capital, we were told that the abandonment of the ritual may have occurred either because the mothers have a certain reserve to talk about it to their daughters; or they are afraid to continue with the GS and have the daughters have premarital contact with boys (“youth today are so uninhibited that it is inappropriate to add this incentive”). The presence of the Christian religion and the role that it may have as an inhibitor against a pagan practice that, therefore, is sinful is not underestimated. It is our opinion that, as in other African countries where genital interventions are endemic, it will be predominantly the change of perspective of life in the women that will be the driving force for the soft elimination of traditional practices that interfere with their health, to bring women to a better state of mental well-being.

Comments and Conclusions In previous surveys, conducted in 2002 in Uganda and in 2004 in Malawi, we have shown that the physical damage related to the GS ritual is not severe, however, it results in some non-negligible inconveniences in daily life (difficulty in walking fast, requirement of a certain type of clothing, irritation and genital ulcers; discomfort when remaining seated, etc.) and moreover, their importance is also more consistent in migration (difficulty to maintain a stable relationship with western partners, intrusive and disturbing memories, low self-esteem, severe postpartum depression, etc.). GS, however, is FGM (female genital mutilation of the 4th Type, according to a classification given by WHO, 1996) and, as such, we believe its study should be

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deepened in order to understand the social and cultural environment in which the procedure occurs and the high regard that it receives from the people that put it into effect. That said, we will not comment on the cultural results that we obtained, which practically confirm those already noted in neighboring Uganda. Perhaps we can say that the DRC is characterized by the complex structure of plants in rituals, which are probably attributable to the presence of an equatorial, particularly lush vegetation and a forest cover that stretches over more than half of its territory. Here we would like to give priority to the original data that has emerged from research, which we present below.

GS and Ethnicity In the DRC, the Luba seems to be the ethnic reference of tradition. This is true both for residents and for migrants in the territories within it. So, wherever the Luba are present in high concentration, the women continue with GS. We obtained similar results from the Baganda women in southern Uganda (Grassivaro Gallo and Villa, 2004, 2005/2006; Grassivaro Gallo et al., 2006). This polarization does not seem to apply in Malawi, if not by exclusion, where the yao ethnic group of Muslim religion seems to have the only women who are intact (Grassivaro Gallo and Moro, 2006). In the DRC, genital elongation is present overall in contact with the eastern population that surrounds the Great Lakes, from which the tradition itself probably came into the country. In particular, it is in the east where its social importance is accentuated, for reasons of competitiveness in the selection for marriage, of the presence of immigrants from Rwanda and Burundi. The ritual is unknown in the west (Map). GS is not the only genital modification present in the country; we have found traces, particularly in isolated ethnic groups, of at least two other types: ritual defloration and the enlargement of the vaginal canal. Such a plurality of genital procedures in one country has already been highlighted in Uganda, where expansive and reductive modifications were included (Crozzolin, 2004/2005).

GS and Male Opinion In the DRC, we have been fortunate enough to have information from males on the ritual; normally, it is the women that are interviewed who express what they believe to be the opinion of their partners in this regard. The adolescents of Kasai practically grow up expecting to encounter a manipulated woman and, if this does not occur, it would be a great disappointment. From their words, there comes a clearly positive appraisal of GS. This, for example, does not occur for western adolescents. For them, the encounter with a manipulated African woman is a source of contempt, mixed with a certain fear of an unusual morphology that is culturally unknown.

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The information from the males virtually confirmed what the women said, in the consideration of GS as a tool that encourages sexual activity. From the information obtained, an unexpected element emerges (subsequently confirmed by the women): the evaluation of pre-marital virginity. From research done in Uganda and Malawi, we understood that the ritual of GS necessarily entailed a defloration and was carried out with a clear incentive to sexual promiscuity. This does not occur for the Luba people, where the adolescent learns the ritual with the “theory” of the relationship that can only be implemented in the intimacy of marriage.

Table 13.1 Luba women comment on the transfer of GS to the daughters No because: This culture is being erased I do not see the need Unimportant No, does not apply to current customs Because I cannot see the importance As a matter of modesty Modesty Modesty unless another person does it for me No, for modesty (initiation may be not be carried out by parents) Modesty, she can be initiated by her friends For modesty, but may be initiated by friends or grandparents Modesty (initiation taught by the grandparents) It must follow the desires of her husband They follow the desire of her future husband No, because the time in which we live does not allow it, the morals are corrupt Yes because: To have pleasure in the future sex life To please her husband That’s true femininity This is a symbol of the woman Every woman should have it For the preservation of future marriage For their future marital life To conform to future marriage For compliance in future marital sexuality Because if this doesn’t exist there will be divorce For sexual compliance (erotic zone) Preparation for sexuality For the daughter to be well prepared for future sex life Yes, but not by me, for compliance in sexuality To be like me Because it’s good and should not be abandoned Yes, but with the others who are not family Yes, but through other people for sexual compliance As my mother told me, I too must transmit it my daughters, it is considered as means of stopping sexual promiscuity

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Passing of the Ritual and Urbanization Even for the DRC, a disappearance of the ritual is occurring in the urban environment. The same young co-author of the Luba ethnic group, born and raised for the first 20 years in Kinshasa, only learned about it in Padua at the time of selection of the thesis. The modesty of the mother has always prevented the transmission of information between them and has always been maintained that way, even when her daughter asked for information over the telephone for her research. This sentiment also appears clearly in the comments of the women interviewed (and presented in the Table 13.1). The passing of the ritual occurred, according to African indication, that it is noncoercive and virtually painless. In Kinshasa, it has simply gone into disuse. Whoever considers it useful can still perform it, but is not more socially valued because of it. Changing the destiny of the women who come to live in the city, the mothers simply do not consider it necessary to transfer the practice to their daughters anymore. With the disappearance of the ritual, the function of instruction towards psychophysical maturity of the girl, which occurs traditionally by shangàsi, is entrusted to another female family member, for example, a young aunt who makes herself responsible for the future behavior of the adolescent. In the analysis presented, there remains a point about which it was not possible to survey, that is, how the Congolese behave in respect to the transfer of the ritual “in diaspora,” for example, in Italy. The few subjects with whom we were able to contact were not familiar with the practice. Therefore, we leave this point for future research.

References Crozzolin N. (AA 2004/2005) Il sincretismo nelle modificazioni genitali femminili in un gruppo di sfollati. Uganda: un caso di studio. Tesi di laurea in Psicologia. Università di Padova. De Rachewiltz BEN. (1963) Costumi sessuali in Africa dalla Preistoria a Oggi. Milano: Longanesi e c. De Wit HCD. (1965) Il mondo delle piante. Vol. I. Le Piante Superiori (II). Milano: Mondadori. Grassivaro Gallo P, Villa E. (2004) Longininfismo rituale tra le Baganda (Rapporto Preliminare). Rivista Italiana di Sessuologia. 28:17–22. Grassivaro Gallo P, Villa E. (2005/2006) Ritual Labia Minora Elongation among the Baganda Women of Uganda. Psychopathologie Africaine. 33:213–236. Grassivaro Gallo P, Villa E, Pagani F. (2006) Graphic reproduction of genital stretching in a group of Baganda girls. Their psychological experiences, Chap. 6. In: Denniston GC, Grassivaro Gallo P, Hodges FM, Milos MF, Viviani F. (eds.) Bodily Integrity and the Politics of Circumcision. Culture, Controversy, and Change. New York, NY: Springer, pp 65–84. Grassivaro Gallo P, Moro D. (2006) Modificazioni Genitali Femminili in Malawi. Primo resoconto di un’indagine sul campo. Chap. 6. In: Grassivaro Gallo P Manganoni M. (a cura di) Pratiche Tradizionali Nocive Alla Salute Delle Donne. Padova: Unipress, pp 87–101. Kashamura AF. (1973) Sexualitè et Culture. Essai sur les moeurs sexuelles et les cultures des peuples des Grandes Lacs Africains. Paris: Payot. WHO. (1996) Female genital mutilation. Report of a WHO Technical Working Group. Geneva: WHO, 17–19 July, 1995.

Chapter 14

Preventing Infibulation: Mana Sultan Abdurahman Isse at Merka, Somalia Pia Grassivaro Gallo and Sandra Busatta

Abstract An interesting development of the project of eradication of infibulation at Merka, Somalia, from 1993 to 2007 (The 9th International Symposium, Seattle 2006), implemented by Mana Abdurahman Isse, prematurely deceased, is the use of singing and dance to reinforce a western-style approach to female health by means of traditional methods of learning and sensitization. Although the CD on which we base this presentation has a very poor technical quality, we consider it an exceptional anthropological document on the happy combination of the traditional and the modern, which espouses local ways of emotionally communicating very important notions through singing and dancing and more frigid school-like teaching. We are going to apply the notions of British anthropologists, Victor Turner and Maurice Bloch, about cultural performance to the visual document supplied by Mana Abdurahman Isse, a sultan’s daughter, and thus a charismatic figure whose performance is particularly authoritative, in order to analyze how effective an intervention can be that aims at the eradication of the infibulation that exploits culturally sanctioned means of communication. This culturally loaded intervention can suggest to us new approaches to the prevention as well as the eradication of infibulation, with the help of native operators and cultural mediators, also in a diaspora environment. Keywords Female genital mutilation · Infibulation · Medical education · Ritual circumcision

Mana Sultan Abdurahman Isse: A Charismatic Figure for Your People Mana Sultan (1953–2007) was one of the daughters of the last sultan of Merka, Abdurahman Ali Isse, a legendary figure with about 400 wives, according to rumors, P. Grassivaro Gallo (B) Working Group on FGM, University of Padua, Padua, Italy e-mail: [email protected]

G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9_14,  C Springer Science+Business Media B.V. 2010

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and an enlightened man who freed his Bantu slaves and educated his children. Daughter of the first wife of the sultan, Mana was also a political person, who was actively working to build up a constructive dialogue among the warring factions, in particular between the government and the Islamic Courts. During the Nairobi Conference in 2004, she succeeded in obtaining 12% of the representatives in the provisional parliament who were women. Mana was the force behind the creation of Ayuub, a refugee village founded in 1999 on the outskirts of Merka. Helped by an Italian NGO, Water For Life, Ayuub had grown into a healthy model community of about 600 people, with more than 30 schools, promoting rural development projects all over the area of the Lower Shebelli River. From 1996 to 2007, Mana dedicated a great deal of her efforts to support the attenuation and elimination of infibulation, while maintaining the ritual aspect, hence contributing to the campaign against excision as well as infibulation among many Somali women in the district of Merka. Through projects such as Gudnin Usub (New Rite), Mana tried to convince Somali women, as well as traditional and non-traditional health operators, to progress from the Sunna Gudnin, i.e., clitoris incision, to the Gudnin Usub, which simply involves a puncture of the clitoris, while preserving the ritual aspect of this female rite of passage, i.e., the cultural elements. This compromise had the aim of abolishing infibulation. Currently, this alternative rite has been practiced on 3,000 girls in 32 villages of the Lower Shebelli (Abdurahman Issa and Grassivaro Gallo, 2005; Grassivaro Gallo et al., 2001, 2004). Mana supported her campaign for the alternative rite through a number of initiatives, including sewing courses and traditional work groups where women could speak informally about their experiences with infibulation. More formal meetings (Friday Programs) were held every week, in the bush of Merka town, in open space of the Timàn Càdde (White Hair). Meetings with some umulissa, the traditional midwives, were also promoted. Mana and her helpers always strove to convince women that infibulation is very dangerous for a woman’s health and that a good life is possible without forcing daughters to suffer this terrible ordeal. In the summer of 2007, we know that Mana organized and directed one of the events: a performance by the umulissa, an elderly woman who enjoys command of the audience. She is also known as a poetess and most of the performance relies heavily on poetry and song. Before analyzing the constructed performance itself, we will say some words about the cultural importance of poetry in a Somali context.

Female Somali Poetry Somalia’s poetic tradition differs markedly from the Western one. In 1982, Somali scholar Said Sheikh Samantar remarked that even a casual observer could notice the remarkable influence of poetry in Somali culture. In fact, Somali poetry has been the country’s chief means of mass communication, substituting for history books, broadcasting, and newspapers. Modern communication, such as radio, audio

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cassettes, and transportation, have spread the art more efficiently from one area to another. Poetry is an all-pervasive part of nearly everyone’s daily experience. Historically, Somali bards, both men and women, have mobilized public opinion in support of war or peace (Cerulli, 1964; Andrzejewski and Lewis, 1974; Jama, 1991; Hultman, 1993; Orwin, 2001). In Somalia, poetry is the currency of conversation and it is used as a platform for everything from education and entertainment to politics and debate, disseminated all over the country through the use of cassette tapes and players. With no pervasive written language, Somali culture is indisputably oral, and the Somali population is mostly made up of non-literate nomads. “As Islam provides a way of life and defines a relationship with God, so poetry provides a way of speech and thought and defines a relationship with the things of this world” (Lark, 1988). Four criteria—scansion, melody, topic, and function—act in concert to differentiate one genre from another. As for the form, Somali verse is marked by alliteration (xarafraac or kikaad) and an unwritten practice of meter (miisaan) (Samantar, 1982; Orwin, 2001). Scholars group the various genres (more than fifty) into three basic categories. First, classical poetry (gabay), which deals with politics and serious issues, such as interclan relations, consists of texts composed in private and memorized verbatim for public performance. Second, work poetry (hees), which is specific to particular tasks, such as herding camels or churning milk. Third, recreational or dance poetry (cayaar), composed and recited simultaneously. The poetic forms of expression allotted to women are the buraambur, which is the highest of women’s literary genres, the hobeeyo or lullabay, the hoyal or work song, and the sitaat or religious song. Since the 1940s, the introduction of radio and audio cassettes has contributed incalculably to the popularity and dissemination of poetry, which until then had traveled solely on the nomad’s tongue. Today, from Mogadishu to the inner cities of London and Toronto, Somali shops offer a wide assortment of cassettes and CDs, adorned with images of the latest stars. In more recent times, traditional gender roles, tribalism, female circumcision, and especially the civil war, have been the subject of fiery poetic disputes. In poetry, the use of violent diatribe is entirely acceptable, and poetic license provides the socially marginal with a powerful tool to reclaim their honor and challenge the existing power structure. Somali women, in their own classical poetic genre called buraambur—its memorization and transmission has traditionally been restricted by social convention—is no less socially and politically engaged than the men’s genres. Shifting social norms, the result of war and exile, have now permitted many Somali women to play increasingly active public roles, including the public recitation of their poetry at political and cultural events. At the largest Somali peace initiative yet, the Carta Peace Conference in Djibouti in 2000, women took center stage with the performance of peace-promoting poetry and song. In many diaspora communities, women are spearheading the revival of the Somali cultural heritage and actively participating in debates about the war and their status as refugees (Bavelaar, 2006).

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Given the discrimination against female poets, whose poems are not memorized by professional male reciters because it is considered demeaning and insulting, women do not receive exposure through the traditional network. Instead, their poems have circulated through audiotapes and radio transmissions, as well as public performances to large audiences, made available in the refugee camps (Jama, 1991). While the composition of a poem may vary widely, the content and the message always appeal to ideas and experiences shared by the audience. Poetry remains a preferred medium for the communication of sensitive social messages, while poetic license allows people to address issues that may cause embarrassment when discussed in ordinary conversation.

Poetry and Song or the Language of Traditional Authority The idea and practice of performance have a particular import for oral expression (Finnegan, 1992) and one influential approach centers the idea of performance around the concept of “social drama” (Turner, 1982, 1986). Social drama, Turner says, is defined as a harmonic or disharmonic social process, arising in conflict situations (1974, p 37, 1985, p 180). Social drama is defined by Turner (1985, p 196), as “an eruption from the level surface of ongoing social life, with its interactions, transactions, reciprocities, its customs making for regular, orderly sequences of behavior.” Turner’s social drama theory has four phases of public action: breach; crisis, redressive action, reintegration. In the liminality of the ritual, there is also room for the critical. Liminality inverts the reality external to the ritual situation in order to produce alternatives for the everyday world. This frequently gives an impression of chaos for the participants in the ritual. Acts that are prohibited in normal day-to-day living are possible or sometimes even ordained. René Girard (1972) thought that the aim of rituals is to make contact with power in order to control and channel it. Closer research into the liminal phase of rituals (not only sacrificial rituals), however, shows that besides channeling, there is also a free use of powers prohibited outside the ritual, not only to channel these powers, but also to benefit the community with new beneficial dynamics. In this part of the paper, we adapt Turner’s notion of social drama (1974) and his analysis of symbols (1967) to the umulissa’s constructed performance. Every social drama alters, albeit minimally, the structure of the related social field. Hence, its “liminal” or “threshold” character transforms the social drama into a limited area of transparency on the opaque surface of social life. As seen on a DVD, umulissa starts immediately in medias res. Her oral performance, however, can be divided into four parts, made up of recited verses in the opening, sung refrain, spoken verses, sung verses and refrain, recited verses in the closing. On the other hand, the poem/song is made up of a chant and counter chant, where the crude description of the operation of the infibulation is alternated by exclamations, such as “Mom, don’t do the pharaonic cutting to me!” or by the refrain, “Mothers are to be blamed for it.” When the first description of the operation, which starts somewhat

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backwards with the girl’s tied legs, ends in a circular way with the girl sealed by thorns, a song erupts: “We have refused it, we don’t want the pharaonic one. Parents who still do it are to blame.” The song is then sung by the audience as a chorus, the first time even clapping their hands (unfortunately, we cannot know whether it was repeated with different audiences, because of the editing). A group of sung verses follows, which forcefully sums up, for a second time, the girl’s ordeal, each verse alternated with the refrain sung by the women’s chorus. A fourth part of recited verses, interrupted only by the sung question, “Where did we get this practice?” concludes abruptly, with force, “If you find someone doing it, advise her not to do it.” Through recited verse and song, that is, through the formalization of language typical of rituals, which we will deal with later, umulissa has created a space that, if it cannot be properly called “liminal,” is at least “liminoid” in its characteristics (Appendix 2). The performer deals with two main arguments: health and religion. Using the very strong metaphor of syphilis for clitoris, which is one of the traditional arguments in favor of the operation, umulissa counterattacks mentioning tetanus, to which she adds other painful consequences during menstruation, urination, sexual intercourse, and childbirth. Yet, the religious argument is even stronger—the child becomes the kid or the lamb on the butcher’s block, ready to be sacrificed. In Somali culture, listeners enjoy poetry, not only for the message but also for the way it is encoded (Orwin, 2001; Jama, 1991), while poetic license provides the socially marginal with a powerful tool to reclaim their honor and challenge the existing power structure. This is such a case, where the sacrificed animal and the child are both associated and opposed symbolically. On the one hand, they are opposed because the former has its throat slit open, the latter has her genitals slit to be closed, as in the very gory, but detailed descriptions by de Villeneuve (1937) and Lantier (1972). On the other hand, the girl also will be slit open: “Infibulation replaces the vulva with an almost solid wall of flesh that joins the thighs from the pubis nearly to the anus, with the exception of a small orifice at the inferior portion of the vulva. . . No matter how virile the husband, consummation of the marriage is nearly impossible because of the surgically created barrier. Another pastoral people, those of the classic Greek myths and tragedies did not miss the symbolic relationship between female throat and genitals” (Loraux, 1985). Slitting the throat of an animal in the prescribed way (udhya, Arabic) is correct because it conforms to the religious texts, but female circumcision is not. “It’s a sin,” umulissa immediately points out. “The child girl is like an animal to be butchered. The sacred books don’t order it done, neither Christianity nor Islam.” Mothers, who should conform to tradition, on the contrary, are those to blame. Mothers are guilty of putting their girls’ lives at risk. Another layer of symbolic meaning also lies in the relationship between girls and sacrificed animals. At the Festival of Sacrifice (Eid al-Adha, Ciidwayneey in the Somali language), after God tested Ibrahim’s faith, an animal, not a human being, has its throat slit. Hence, the sacrifice of the girls should not occur, according to the sacred texts. This is the theological argument umulissa supports, which puts modern interpretations of Islamic law against customary law and claims the former to be superior. Actually, in Ayuub and other villages, women

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have experimented with the Gudnin Usub, the New Rite of substitution of infibulation with a symbolic feast. Umulissa stresses her words and song by means of sweeping arm movements, which ideally connect the audience with the girl in the poster, and by a hint of swaying dance steps. In his discussion on the “language” of traditional authority, Maurice Bloch (1989, pp 19–45) remarks that formal speech-making, intoning spells, and singing are but different steps in the same process of transformation from secular discursive language. The same linguistic modification occurs in religious as well as political oratory: “In a highly formalized or ritualized political situation, there seems no way whereby authority can be challenged except by a total refusal [of all political conventions]. . . The ceremonial trappings of a highly formalized situation seems to catch the actors so that they are unable to resist the demands made on them” (Bloch, 1989, p 24, original italics). Formalized language, that is, the language of traditional authority, is impoverished language, a kind of restricted code, according to Bloch (1989, p 28), who also notes that, in formalized speech, the features of articulation “have been rendered arthritic, and so the possible answers are dramatically reduced perhaps to one.” The propositional meaning potential of language is lost by formalization, but speech acquires an illocutionary or performative force. Intoning a poem is but a further move in the process of formalization of speech, which is very close to a third linguistic manifestation at the end of a continuum, song. “Song is, therefore, nothing but the end of the process of transformation from ordinary language which began with formalization” (Bloch, 1989, p 35). Singing a song involves an almost total lack of creativity (although it does not completely rule it out). Yet, the fact remains that the propositional force of all songs is less than that of spoken words in an ordinary context, especially when songs are sung by groups of people in unison, which characterizes so much of ritual. In a song, however, the illocutionary or performative force is at its most, because, as Bloch (1989, p 37, original italics) puts it, “You cannot argue with a song.” As with speech, the formalization of body movements implies ever-growing control of sequences of movement and, when this has occurred completely, we have dance (Bloch, 1989, p 38). As a matter of fact, umulissa’s performance created a ritualized, non-ordinary space in the school tent by means of the progression of formalization of speech through poetry and song, as well as a hint of dance. The formalization of language creates a quasi-ritual space, where the propositional meaning of the speech is weak and its performative force is strong. Umulissa actually does not put forward a line of argument, but creates a quasi-ritual context, where the pre-text is represented by the poster. She elicits a typical response from the female audience by means of the progressive formalization of her speech and repetition. As Bloch (1989, p 42) points out, units in ritual do not follow each other logically, but sequentially. A frozen statement cannot be expanded, it can only be made again and again, and by means of repetition, it becomes understandable. Moreover, formalization not only removes what is being said from a particular time and a particular place, but it is also removed from the actual speaker, and it becomes a source of traditional authority. The Turnerian breach at the beginning of the performance is highlighted by

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the crisis described in the first verses intoned by umulissa, a tradition that is contested and felt as harmful by more and more people. The creation of a ritualized space through poetry and song defies arguments to the contrary. The audience is challenged through well-known, traditional cultural forms. The formalized speech leaves only a yes/no option, that is, either utter acceptance or rejection. The female audience replies to the challenging refrain by repeating it and clapping their hands. Each verse in the third part of the performance is sung by umulissa and welcomed by the audience/chorus repeating the refrain because they cannot argue with a song. They can only accept it or not. Hence, the redressive action phase starts going back to the intonation of the poem, which reintegrates the participants into the community reassuring them that, if they refuse pharaonic circumcision, they conform to both the sacred texts and science.

Conclusion The experiments with the Sunna Gudnin Project, as well as later attempts to attenuate female circumcision, such as the Gudnin Usub (New Rite) promoted by Mana Sultan Abdurahman and her collaborators, have been successful in Ayuub and other villages in the area of Merka. The DVD shows that, in order to succeed in attenuating or even eradicating FGM, it is extremely important that the intervention be performed according to the socio-cultural norms of the population involved. Poetry remains the preferred medium for the communication of sensitive social messages in Somalia, while poetic license allows people to address issues that may cause embarrassment when discussed in ordinary conversation. Umulissa’s performance, while constructed in the edited videotape, accords with Somali cultural norms. In this context, however, the contribution of a number of reformist shaykhs cannot be underestimated. The DVD, moreover, shows that Mana found valid collaborators and followers to continue her work and, in addition, went a step further with Gudnin Usub, possibly following today’s trend, which has mostly abandoned any ritual during the operation, where it existed all over the area practicing FGM (Moen, 2008). This step forward, beyond Gudnin Usub, is bolder and points to the prevention of FGM, with Friday Programs. The women in the audience seem to accept this proposal. Whether they will be able to carry it out is yet to be seen. In conclusion, we would like to emphasize the diverse strategies against cutting practices, elaborated and applied by Mana in Merka, compared to those seen recently in Italy. The means used to accomplish the suspension of pharaonic circumcision and its eventual eradication, which we have seen in Merka, are not coercive, rather they exclusively employ psycho-social means, including colloquial speech, persuasion, references to charismatic religious figures and/or local specialists (the umulissa), the presentation of traumatic cases caused by pharaonic circumcisions that happened within the same community, and women with their genitals intact that recount their success in their matrimonial lives and in their work. These experiences, proposed to women who are potential mothers of “at risk” daughters, do not impose another

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option different from pharaonic circumcision. The same women, who were participants of the initiative, were persuaded to put into effect the overcoming of the tradition but were not obligated to do it through coercion. Taking into consideration such directives, in fact, structure the initiative of prevention against the tradition delineated by Mana and presented in the video-clip. The umulissa puts into practice a very effective persuasion on the women present, in reference to the life styles, the culture, and the mentality of that context. The DVD employs traditional recitation and song and depicts an audience wearing the same clothing worn by the women present, inspiring a sense of belonging and a sharing of the same values and culture; it reinforces the message with Western references, already familiar even to rural women. The women that we see in the DVD could one day be present in the Somali diaspora living in Italy. If they had not been reached in Somalia by the preventative actions of Mana, we ask ourselves, how can the Italian government persuade them to abandon infibulations? It specifically has to do with the “Consolo,” Law, n. 7, January 9, 2006, published in the Gazzetta Ufficiale, n. 14, of January 18, 2006, on the “Disposition concerning the prevention and the prohibition of the practices of Female Genital Mutilation” and of the corresponding Guide Lines, delineated for the social-sanitary figures and other professionals that operate in contact with the migrant community, and emanated in performance of Article 4 of the same law; published in Gazzetta Ufficiale della Repubblica Italiana, of November 25, 2008 (with the decree of the Ministers of Health). Note, that it does not grant the right of asylum for excised woman. This is a serious gap. Since the “Consolo” is a penal law, it is structured necessarily in Article 9, written in coercive language (Appendix 1), for which it is evident how diverse the specific instruments previewed in Italy. Nevertheless, some representatives of the women’s groups were consulted for the law “in fieri” and have taken part in the ministerial commissions that have formulated the same guidelines. In substance, it is characterized principally by a fundamental punitivity and coerciveness, inadequate to address a subject that in Merka, Somalia, is dealt with successfully using diverse methodologies. The law presents some proposed aspects, open to dialogue; but, for example, we find that Article 7 is formulated too generally because it does not explicitly say that, in the plans of formation and information directed to discourage genital cutting, the associations of the African women in diaspora must be privileged. We strongly fear that such initiatives will be managed by the Italian facilities that also are represented by competent personnel and, without a doubt, will be less credible in their message of dissuasion of the excision practices because they are strangers to the cultures of the target populations. It is true that the Somali women in diaspora, partially integrated into Italian society, who perhaps live in a big metropolis, the way that Rome or Milan can be, are different than those of Merka (present in the DVD), but it is probable that their cultural roots have not been completely forgotten. One Somali mediator, responsible for an NGO of Somali women in Milan, after having seen the DVD, noted that Mana uses strategies of the village that cannot be

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utilized effectively in a Western metropolis. But now, why does the Association of Somali Women in Italy not invent and propose original strategies in a manner that can be adapted to the women in diaspora in our country? We would hope to be refuted but we have no knowledge of any project by the Somali women in Italy (Rigotti, 2007–2008; Ronchi, 2007/2008) that are even vaguely similar in engagement, determination, and consistency in time as the project put into effect by Mana in Merka.

Appendix 1 Consolo Law: Disposition concerning the prevention and the prohibition of the practices of female genital mutilation (we have highlighted in bold all coercive terms of same articles of the law). Article 1 (aim): omissis “. . . the law dictates the measures necessary in order to prevent, to contrast and to repress the practices of female genital mutilation. . .” Article 2 (occupation of promotion and coordination): omissis “. . . the Presidency of the council of the ministers Department for the pars opportunity acquires data and information on the activities carried out for prevention and repression and on the contrast strategies programmed or realized in other States. . .” Article 6 (Practices of mutilation of female genital organs): omissis “. . . Anyone lacking therapeutic requirements, causing a mutilation of the female genital organs is punished with imprisonment from 4 to 12 years. . . Whoever provokes injuries, with the intention of disabling the sexual functions, to the genital female organs different from those indicated to the illness in the body or the mind, is punished with the imprisonment from 3 to 7 years. The punishment is increased by a third when the practices are committed to damage a minor, that is if the act is committed for means of profit. . .” Article 8: omissis “. . . apply themselves to the entity, in whose structure the crime is committed, the financial sanction from quotas of 300 to700 E and the punitive sanctions expected in Article 9, subsection 2. . .”

Appendix 2 Translations from Somalian to English in the DVD. First, her feet are tied, then they start cutting. . .. She’ll vomit and suffer pain and have trouble to urinate. . ..When menstruating she’ll suffer. . .. After 7 days she recovers. Then, other troubles occur. . .. Beware of damaging the girls. . .. They cut the syphilis (clitoris) with the razor blade. . .. God, why did you make me?. . . When she marries, her husband can’t open her. They use the knife. . .. Mom, don’t do the pharaonic cutting to me!. . . The girl gets pregnant. She may get tetanus. . .. It’s a sin. Mothers are to blame for it. The child girl is like an animal to be butchered. . .. The sacred books don’t order to do it. . .. Neither Christianity nor Islam. . .. Men,

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instead, do it not to get germs. . .. For those women already operated, God forgive us! Don’t do it anymore!. . . Mothers are to blame for it. . .. The girl, she’s stitched with thorns; mothers are guilty for it. . .. We have refused it. . .. We don’t want the pharaonic one. . .. Parents who still do it, they are to blame. . .. The child/girl is shaking (with fear). . .. Which law allows that?! Take a razor blade and sharpen it. . .. Tie it on a piece of cloth. . .. Tetanus and other consequences, mothers are to blame for it. . .. Answer me! Where is it written? In no book. . .. What did you reckon of this picture?. . . Speak, I can see no one replying. . .. Think that this child girl is on the butcher’s block. . .. Four are the injuries. . ..The woman feels no pleasure in intercourse. . .. When she overcomes the pain, her menses arrives. . .. This razor blade cuts everything from A to Z. . .. Where did we get this practice from?. . . When the girl begins to grow, we say, “Let’s make her a Muslim.”. . ..Even Christians say that circumcision is good for health, but they don’t become Muslim as a result!. . . If you find someone doing it, advise her not to do it.

References Abdurahman M, Grassivaro Gallo P. (1996/2005) Dieci anni del rito alternativo di Merka (Somalia): da sunna gudnin a gudnin usub (il rito nuovo). Scienza Online no. 17, anno 2, 17 giugno 2005. http://scienzaonline.org/sessuologia/rito-alternativo-merka.html Andrzejewski BV, Lewis IM. (1974) Somali Poetry: An Introduction. Oxford: Clarendon Press. Bavelaar R. (2006) Somali Oral Verse in Exile. June 26, 2006, Wardheernews.com http://wardheernews.com/Articles_06/june_06/27_Poetics_Rahma.html Bloch M. (1989) Ritual, History and Power. London: Berg Publishers. Cerulli E. (1964) Somalia: Scritti vari editi ed inediti, Vol. 3. La poesia dei Somali. La tribu dei Somali. Lingua Somala in caretteri arabi ed altri saggi. Ministero Affari Esteri. Roma: Instituto Poligrafica di Stato. “Consolo” Law n. 7, January 9, 2007, http://gazzette.comune.jesi.an.it/2006/14/1.htm de Villeneuve A. (1937) Etude sur une Coutume Somalie: les Femmes Cousues. J de la Société des Africanistes. 7:15–32. Finnegan R. (1992) Oral Traditions and Verbal Arts. A Guide to Research Practices. London: Routledge. Girard R. (1972) La Violence et le Sacre. Paris: Grasset (Eng. transl. London 1977). Grassivaro Gallo P, Rabuffetti L, Sunna Gudnin VF. (2001) An alternative ritual to infibulation in merka, Somalia. In Denniston GC, Hodges FM, Milos MF. (eds.) Understanding Circumcision: A Multidisciplinary Approach to a Multi-Dimensional Problem. New York, NY: Kluwer Academic/Plenum Publishers. Grassivaro Gallo P, Livio M, Viviani F. (2004) Changes in infibulation practices in East Africa: Comments on a ritual alternative to infibulation in merka, Somalia. In: Denniston GC, Hodges FM, Milos MF. (eds.) Flesh and Blood: Perspectives on the Problem of Circumcision in Contemporary Society. New York, NY: Kluwer Academic/Plenum Publishers. Guide Lines, March 25, 2008. http://ministerosalute.it/saluteDonna/paginaInternaMenuSalute Donna Hultman T. (1993) A Nation of Poets. ANALYSIS 3 Africa News Service (Durham), January 1993. http://allafrica.com/stories/200101080500.html Jama ZM. (1991) Fighting to be Heard: Somali Women’s Poetry. Afr Lang Cult. 4(1):43–53. Lantier J. (1972) La Cité Magique. Paris: Fayard. Lark EG. (November/December 1988) A Nation of Bards. Houston, TX: printed in Saudi Aremco World, pp 32–36.

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Legge n. 7, January 9, 2006, “Disposizioni concernenti la prevenzione e il divieto delle pratiche di mutilazione genitale femminile,” January 18, 2006, Gazzetta Ufficiale della Repubblica Italiana, n. 14 http://gazzette.comune.jesi.an.it/2006/14/1.htm. cited in: Linee Guida destinate alle figure sanitarie etc. (art. 4-Legge n. 7, 2006), March 25, 2008. Gazzetta Ufficiale della Repubblica Italiana, n. 14, November 2008. http://ministerosalute.it/ saluteDonna/paginaInternaMenuSaluteDonna Loraux N. (1985) Façon tragique de tuer une femme. Paris: Hachette. Moen EW (2008). The Sexual Politics of Female Circumcision. Boulder, CO. Department of Sociology http://www.etext.org/Politics/Progressive.Sociologists/authors/Moen.Elizabeth/Thesexual-politics-of-female-circumcision.EMoen Orvin M. (2001) Islamic Religious Poetry in Africa. J Afr Cult Stud. 14:5–6. Rigotti M. (Academic Year 2007/2008) La legislazione Italiana sulle MGF: osservazioni e commenti ricavati da alcune esperienze personali. Tesi di Laurea in Lettere e Filosofia, Corso di laurea in Storia, Università di Padova. Ronchi E. (Academic Year 2007/2008) Iniziative di prevenzione/eradicazione alle Mutilazioni Genitali Femminili attuate da alcune associazioni di donne africane (in Africa e in Italia). Tesi di Laurea in Psicologia, Università di Padova. Samantar SS. (1982) Oral Poetry and Somali Nationalism: The Case of Sayyd Mohammad Abdille Hassan. Cambridge: Cambridge University Press. Turner VW. (1967) The Forest of Symbols: Aspects of Ndembu Ritual. Ithaca, NY: Cornell University Press. Turner VW. (1974) Dramas, Fields and Metaphors: Symbolic Action in Human Society. Ithaca, NY: Cornell University Press. Turner VW. (1982) From Ritual to Theater: Human Seriousness Play. New York, NY: Performing Arts Journal Publications. Turner VW. (1985) Liminality Kabbalah and the Media. New York, NY: Academic Press. Turner VW. (1986) The Anthropology of Performance. New York, NY: PAJ Publications.

Chapter 15

Writing Rites Gone Wrong: Autobiography, Testimonials, and Their Relevance to the Debate Around Genital Alterations Chantal Zabus

Abstract After briefly examining the discursive asymmetry in writings about excision (as I call it in my book Between Rites and Rights [Stanford UP, 2007]) and circumcision, I discuss four moments in the literary history of autobiographies around male circumcision—the seventeenth-century “confessions” from Conversos in Spain and Portugal; two Kenyan ethnoautobiographies from the 1960s, Mugo Gatheru’s Child of Two Worlds and Karari Najama’s Mau Mau From Within; Jacques Derrida’s Circumfession introduce a necessary subjectivity and redress the wrongs in what was originally a rite. Keywords Male circumcision · Female genital mutilation · Ritual circumcision · Gender · Cognitive dissonance · Excision Why such a big issue over a little bit of tissue? That tissue, whether of the foreskin or the clitoris, has a long history of being just that—long. Indeed, aside from the idea of degree, which makes circumcision and excision shuttle between benign and very severe, the foreskin and the clitoris happen to have similar reputations as being disproportionately long. Across the Sudanic “excision belt,” spanning an east–west axis from Yemen to Senegal, it is common to come across tales of the clitoris being too long, in need of cutting, or endowed with the capacity to grow if not excised or to grow back, if not excised properly. Likewise, the foreskin has been thought to be too long and physicians often diagnose phimosis or foreskin constriction as a medical measure. The nineteenth-century medical label “phimosis” indeed became attached to “any foreskin that appeared too long.” J. Cooper Forster, 1855 deemed it “a pathological condition arising from ‘nature having been too prolific in the supply of skin at the extremity of the penis’” (pp 491–492; quoted in Glick, p 153).

C. Zabus (B) Universities of Paris XIII & III-Sorbonne Nouvelle, Paris, France; Institut Universitaire de France, Paris, France e-mail: [email protected]

G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9_15,  C Springer Science+Business Media B.V. 2010

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P. C. Remondino, in 1891, had vilified the foreskin, at tedious length, as a maligned influence and moral “outlaw” (quoted in Comfort, 1967, pp 106–107). The subsequent rise of circumcision as a preventive, and then routine, procedure, therefore, may be linked with the taboo around masturbation or “self-abuse,” to which such a generous “supply of skin” would inexorably lead. Likewise, the clitoris has been considered a long, tribadic appendage rivaling a man’s penis and threatening to usurp its role as penetrator of females (Zabus, 2007, pp 19–35). In addition to masturbation, female same-sex desire is the threat looming behind the clitoral outlaw appendage. This history of both tissues is indeed long but I would like to address a much shorter history, which is that of autobiography in relation to how these two bits of tissue, when severed, seem to reveal different issues.

Discursive Asymmetry In using “circumcision” and “excision,”1 I bear in mind their Latin etymology, circumcidere (“cut around,” “cut about”) and excidere (“cut out,” “hollow out”) to refer to the procedures involved. The issue of excision, a.k.a., “female circumcision,” female genital mutilation (FGM), or female genital cutting (FGC), has drummed up more attention in all fields—cultural and medical anthropology, human rights, law, media, literature, and the arts—than male circumcision, if only for the 1975–1985 United Nations decade for women, which transformed the ancestral rite into a human rights violation. The implicit flaunting of African women’s excised or sutured bodies may explain the success of the 2007 Engel film, A Walk to Beautiful, about five Ethiopian women seeking treatment in Addis Ababa for obstetric fistulas as a result of infibulation,2 although the link between the ailment and infibulation is not clearly established. It was awarded the Best Feature Documentary of 2007, besting studio-financed productions, like Sicko, Taxi to the Dark Side, Operation Homecoming, and Crazy Love. One can hardly expect a film documentary about male circumcision to run in New York and draw crowds with the same enthusiasm. Nor could one expect a text to refer to the World of Foreskinlessness, the way Moses Isegawa’s Abyssinian Chronicles (2000) mentions the Ogaden war raging in “the Horn of clitoris- and labialessness” (p 286). Indeed, the male circumcision issue is still shrouded in banality, cloaked in obsolete justifications, despite notable efforts from numerous individuals and associations. Apart from the ongoing controversy in the United States around routine neonatal circumcision, practiced currently on large segments of the American male population, there has not been a similar humanitarian impetus nor the same discursive amplification around male circumcision as there has been around excision, despite the work of, for instance, Sami Aldeeb Abu-Sahlieh (1999, 2001). On the one hand, scholars and activists alike have been diffident about making a case for symmetry between excision and circumcision, some of them presumably for fear of being accused of anti-Semitism or for fear that excessive attention to male

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circumcision may distract from female genital alteration in Africa and elsewhere (Glick, p 213). On the other hand, male writers who have denounced excision or participated in its eradication, from Somali Nuruddin Farah’s From a Crooked Rib (1970) to American, then Lagos-based Chuck Mike’s Ikikpo: A Sense of Belonging (2000), have refrained from tackling the issue of male circumcision. The same applies to the (male) movie industry, from Malian Oumar Sissoko’s Finzan (1990) to the late Senegalese Sembène Ousmane’s Molaadé (2004). Ivorian-born, Paris-based playwright and novelist, Koffi Kwahulé, has shown a lot of empathy with the predicament of excised women in his play Bintou (1998). Yet, when he told me in an interview I carried out with him in Paris in 2005, of the circumcision he had elected to undergo when 13 years of age, he denied any symmetry (Zabus, 2005). Conversely, besides Billy Ray Boyd’s TVS or “The Victims Speak” website and others, which contain many harrowing testimonials, a website like Blouch, which records stories from individuals having experienced forcible genital cutting, lists 49 MGC (male genital cutting) stories, mostly emanating from “Caucasian-European” Americans with a Jewish background, but only two FGC stories from white NorthAmerican women, who were subjected to labiadectomy and/or clitoridectomy in the 1950s, to remedy masturbation. None of these stories are from individuals outside of Canada and the United States but they alert us to genital operations similar to those practiced in non-Western countries but for apparently dissimilar motives. Tellingly, the general public is nowadays less familiar with these Euro-American genital procedures than with excision in Africa and elsewhere. This may be due to the fact that, in addition to media coverage, African women autobiographers, who have experienced excision or infibulation in the flesh, have contributed to exposing the physical and psychic damages of such operations to a worldwide readership. Autobiography, that is, writing from the realm of the “myself,” thus introduces a necessary subjectivity. An increasing number of scholars dealing with circumcision have themselves been involved somewhat autobiographically in their own circumcision or that of their sons and relatives. In an interview I carried out with Sami Aldeeb Abu-Sahlieh in Lausanne in 2002, he, as a Christian Palestinian, told me that he had heard the shrill screaming of an infant in the process of being circumcised at a neighbor’s house in the Palestine of his childhood and this prompted him to inquire about the raison d’être of circumcision, which he has probed in many of his works, most notably in his seminal Male and Female Circumcision: Among Jews, Christians and Muslims: Religious, Medical, Social and Legal Debate (2001). Leonard Glick also speaks from memory in his Preface to Marked in Your Flesh (2005) as a cultural anthropologist and a college professor with a medical degree but also as the father of circumcised sons. He concludes: “[my] sons are now mature men. Had I known at their births what I know now, they would never have been circumcised” (p viii). I would like to provide four moments in the history of discursive asymmetry around excision and circumcision, which help shed light on the way we perceive both genital alterations at the turn of the present millennium: the

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seventeenth-century “confessions” from Conversos in Spain and Portugal; Kenyan Mugo Gatheru’s Child of Two Worlds (1964); the late French philosopher Jacques Derrida’s Circumfession (1991); and French, Syrian-born Riad Sattouf’s comic strip, My Circumcision (2004). Last but not least, I provide a coda with Somali top-model-cum-UN ambassador Waris Dirie’s Desert Dawn (2002).

The Conversos: The Early “Confessions” of Cristobal Mendez and Estevan de Ares de Fonseca In the context of the thirteenth-century Christian “reconquest” of Spain, Jews were forcibly converted to Catholicism during the Spanish Inquisition of 1478, instituted by the monarchs Ferdinand and Isabella. For these male converts or Conversos who emigrated outside of Spain, the first requirement for re-admission into the Jewish community was circumcision. In the seventeenth-century, one such Spanish Converso, Cristóbal Méndez, whose story Leonard Glick covers in his book, immigrated to Venice and accepted Judaism. He then returned to Spain to save relatives and upon his return, he was apprehended and tried by the Inquisition, to whom he “confessed” that, when pressed by a rabbi and an uncle, he underwent the operation. Mèndez recalled that the pain was “so great. . . that [he] was barely aware of the benedictions. . .. After a recovery period, [he] was called up to the open ark to recite the traditional blessing for deliverance from peril. [He] had become a Jew” (quoted in Glick, p 79). The second instance of autobiographical voicing of the experience of circumcision concerns a Portuguese Converso, Estevan de Ares de Fonseca, who was arrested by the Spanish Inquisition for “Judaizing” and, in his 1635 trial, described his experience as a newcomer to Amsterdam and how the Jews of the Dutch city, upon his refusal to circumcise, “excommunicated [him] in the synagogues, so that no Jew would speak to or with [him].” After several days of ostracism, de Fonseca “finally consented to be circumcised. And they circumcised [him] and gave [him] the name of David” (Gilitz, 1996, p 235; Bodian, 1997). Were these Conversos or Crypto-Jews rewarded in exchange for their confession? And were such rewards deemed worth (admittedly less than) “a pound of flesh,” after the disturbing line from The Merchant of Venice? One notes that for both Conversos, pressure, either from a relative or a religious authority, elicits a confession, which gives a particular coercive dimension to autobiography or what is, at any rate, a testimony. The link between these Conversos and the African testimonials I here provide may look rather tenuous at first but another edict by the King of Portugal in 1486 ordered the deportation of all the Jews who refused to convert to Christianity on the coast of Guinea, West Africa. The Hebrew influence spread in North Africa and then as far as Sudan and Ethiopia. This does not mean, however, that the origin of all African circumcisions is Hebraic since circumcision on the African continent is also thought to date back to Pharaonic Egypt and the early cults of the

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phallus, themselves part of cosmogonic myths around the creation of the universe (de Rachewiltz, 1993, p 169). As a case in point, Ra was thought to have engendered himself through masturbation or even mutilating his own sexual organs. Indeed, masturbation, thought to be infantile, often precedes circumcision in some African societies (Zabus, 2009).

Kikuyu Irua The phrase “female circumcision” makes most (cultural) sense in societies, such as the Kikuyu one in Kenya, East Africa, where the term irua designates both circumcision and excision. As a purification rite, irua posits an original hermaphroditism in the child in that excision aims at removing the allegedly vestigial masculinity of the clitoris, the way in which circumcision removes the vestigial femininity of the foreskin. Although the Jewish rite is always neonatal as opposed to the African rite, both rites rejoin in their premise of the alleged androgyny of the child, who is male-in-appearance until it is circumcised. Indeed, the Hebrew Yesod to refer to a circumcised phallus, with its exposed corona or “crown,” reveals shekhinah or the feminine emanation of Divine Being. Despite its presupposed equivalency, however, the treatment irua has received from Kenyan writers has been asymmetrical, as in Jomo Kenyatta’s famous treatise, Facing Mount Kenya (1938). This asymmetry between male and female irua is also verifiable in the sanctioning of male circumcision in Protestant belief in the 1930s. Indeed, whereas young Kenyan male converts were encouraged to undergo circumcision in Mission dispensaries, irua for girls was considered a brutal bodily mutilation. What is more, whereas in one Church Missionary Society station (Kigari in Embu District), there was an attempt to introduce a Christian circumcision ceremony, at the other (Kabore in the Kikuyu section), not far off and at the same time, Christians were asked to openly disavow female excision “on pain of excommunication” (Murray, 1976, p 93). Excision, not circumcision, thus became a mobilizing force during the anti-colonial or Mau-Mau insurgency in 1952–1956, when Kenyan women had to choose between Christianity and Kikuyu identity. One woman recounts: “If you were not circumcised [excised], they [the Mau Mau fighters] came for you at night, you [we]re taken to the forest [and] circumcised [read: excised], and you [we]re roasted for what you have circumcised [the clitoris] and you are told to eat it” (quoted in Thomas, 2000, p 141). By accepting the male rite but not its female counterpart, the missionaries drove a symbolic rift between the two practices, which Kenyan novelist Ngugi wa Thiong’o famously explores in The River Between (1965), a novel which, incidentally, provides African American novelist Alice Walker with some plot elements for her novel, Possessing the Secret of Joy (1992). In his autobiography, Child of Two Worlds (1964), Kenyan Mugo Gatheru, who augurs Karari Njama’s in Mau Mau from Within (1966), is eager to locate the irua ceremony in the larger context of ancestral rites: “The Kikuyu do not circumcise at

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birth as do the Jews. They do it at puberty as do many other tribal peoples throughout the world.” (p 56) Indeed, as already argued, circumcision as a puberty rite seems to be quintessentially “African,” very much unlike Muslim circumcision or any religiously sanctioned practice, whereby a people seals a covenant with its god, as in the Jewish rite (Hoffman, 1996). Gatheru recounts his circumcision in 1940, which signals his belonging to the riika ria forty or the “age-grade of 1940,” the age-grade and the circumcision date being so important that they feature in Kenyan men’s e-mail addresses. His circumcision allowed him to participate in exclusive meetings, for which younger men had to pay certain dues. In Kikuyu society at the time, boys undergo the ceremony “between 15 and 19 years of age,” whereas girls are excised earlier “so that they do not menstruate before the circumcision [excision]” (p 57) and, therefore, avert thahu, that is, a type of ceremonial uncleanliness that demands purification. In the chapter, “Becoming a Kikuyu,” Mugo Gatheru describes how, at age sixteen, he decided to undergo the ceremony. Yet, as is often the case, a young man’s decision to get circumcised is predicated on the “harassment”—a word he uses (p 57)—to which his peers subjected him. At the time of the actual ceremony, both girls and boys benefit from “helpers” but the boys are expected to put up a show of bravura whereas the “girls must be supported by two aides since they are considered delicate and may perhaps collapse if they are left alone like boys” (p 57). This autobiographical narrative is very insistent on the “feeling of fear” (repeated several times), which Mugo has to shed, along with behavior coded infantile or feminine, such as crying, before accessing full-fledged manhood. The Kikuyu, Embu, and Meru people of central Kenya prefer to leave “the ‘small skin’ or ngwati hanging under [the] penis” after circumcision. But upon his uncle’s insistence, Mugo is cut a second time, for were it not for that “second cut,” he would have been identified as “a ‘primitive’ Kikuyu boy.” This recircumcision establishes that he is “a grown-up Christian Kikuyu,” circumcised but without ngwati: “I was a man. . .. I was now allowed to look down at the handiwork of the circumciser and see what had been done to me. Blood was streaming” (pp 57–58). “Looking down” signals the inexorable badge of passage. Likewise, among the Teda, the circumciser tells the initiate: “Boy, look up,” and, after cutting the prepuce, “Man, look down” (quoted in de Rachewiltz, p 181). Kenya may look like a far-away place, only tenuously connected to the West, but some of its genital practices, such as, among the semi-hamitic Nandi, the erotogenic transfer from the infantile clitoris to the mature vagina, were to inspire Marie Bonaparte and Sigmund Freud’s theories of female sexuality, which still influence Westerners today (Zabus, 2007, pp 19–35). More to our purpose, the body, which, in the Kenyan anthropological context of the 1940s, was neither object nor subject and open to cultural inscription, is now inscribed in pain and in trauma. Like later writings by women around their excision or infibulation, early accounts, such as Gatheru’s, introduced an unprecedented emotionality and a necessary subjectivity.

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Jacques Derrida’s Circumfession As his book title indicates, Jacques Derrida, the French philosopher and father of the “deconstruction” movement, was speaking around his circumcision, circumventing the issue and, in the process, committing quite a few circumlocutionary acts, yet speaking in the first person about the procedure that he underwent when he was an 8-day-old Jewish infant. In El Biar, Algeria, where Derrida was born in 1930, he reports that one did not use the Hebrew word milah from berit milah (the alliance through cutting or Covenant of the Cut [in Genesis 17:1–14 and Leviticus 12:1–5]) to refer to circumcision but rather “baptism,” a Pauline yet euphemistic word used out of fear, but at the same time, a translation of sorts since Christian baptism was an “alternative rite” to replace circumcision.3 Derrida’s philosophical corpus is so traversed by his own circumcision that he goes as far as stating that desire for literature stems from circumcision, for it links ink and blood: “I write with a sharpened blade, if it doesn’t bleed the book will be a failure” (Derrida, 1993, p 130), thereby setting for himself “the impossible task of writing by excision” (Siegumfeldt, 2005, p 32, my italics). Interestingly, the Egyptian doctor, activist, and novelist Nawal El Saadawi also links excision with the incisive act of writing-as-dissection (quoted in Bdran and Cooke, 1999, p 397). Both El Saadawi and Derrida—Mashreq and Maghreb—have bound their words to their wounds. For Derrida, the circumcision ceremony is linked with the mother figure and, more largely, the feminine, more so than with the mohel. Derrida returns to Moses’s wife, Zipporah, the alleged first circumciser. Deemed one of the most obscure and disquieting in the Torah, Zipporah’s gesture of circumcising her own son when on her way to Egypt with Moses has been variously construed (Levenson, 1993, p 50). Zipporah allegedly touched Moses’s feet (the Biblical euphemism for genitals, raglayim) with their son’s bloody foreskin to avert Yaweh’s anger at her husband’s reluctance to confront Pharaoh (Robinson, 1986, pp 447–461). Because Zipporah circumcised one of her sons in a redemptive but unexplained sacrifice, Derrida assimilates Zipporah to his own mother, whom he implicitly accuses of silent complicity with the mohel’s deed. He claims to remember his circumcision, the “open wound” that he has been flaunting like a badge since “the mohel’s succion” when he was 8 days old: “circumcision, cutting of the circumference; meziza, ‘suction of the blood,’ a practice that was abolished in Paris in 1843” (p 115).4 If Derrida mentions mezizah with so much harrowing trepidation, it is not so much because of the “mohel’s succion” but because of “the possibility that the mother sucked off the blood on the child’s little penis” (Spivak, 1998, p 13). This feminine version of mezizah binds Derrida, Zipporah, and his mother, Esther, in a perverse religio, adding incest to injury. Likewise, many African women autobiographers writing about their excision have often accused the mother of being an “anti-mom,” the very opposite of the caring, nurturing mother (Zabus, 2007, pp 163–202). Derrida’s erasure of his father is significant insofar as circumcision is a “symbol of patrilinearity” and a “guarantee of abundantly fertile male lineages.”

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(Eilberg-Shwartz, quoted in Glick, 1992, p 245). The purpose of circumcision being to symbolically release the male child from his mother’s impure blood or, in Saint Augustine’s words in Marriage and Concupiscence II, “to erase the stain of the original sin” (quoted in Steinberg, 1983, p 50), Derrida practices a reverse circumcision and rehabilitates his mother’s contaminating blood-milk-ink, the source of his writing.

Riad Sattouf’s Anti-circumcision Strip Discursive asymmetry between excision and circumcision can also be observed in the realm of humor. Whereas there is even a genre that could be called “circumcision humor,” there is no such humor around the female excision issue. Indeed, one could not imagine a joke around the severed clitoris or the exciser, the way jokes circulate around the rabbi or mohel. For instance, “why does the rabbi have such a good income? Because he gets all the tips” (quoted in Glick, p 271). Along these lines, the cover of Riad Sattouf’s comic strip book for children exhibits three boys peeing side by side, with their backs turned to the reader, holding sticks that are supposed to be symbolic extensions of their penises. While signaling the book’s glib but caustic humor, it does not stifle the serious anti-circumcision message that the Paris-based cartoonist of Syrian origin, Sattouf, wants to convey to the French and francophone youth. Born in a small village in Syria, the young Riad plays Conan the Barbarian with his cousins and they swear by Crom, the God of the Cimmerians, Conan’s tribe. While peeing side by side one day, one cousin remarks that, unlike them, Riad has not turned the big wheel like Conan the Barbarian, which is a euphemistic way of saying that he has not undergone the circumcision ritual. Accused of being an enemy, that is, an Israeli, Riad is excluded from this group of self-appointed “Cimmerians” and Conan-worshippers. You will remember that, once he is set free, Conan, in the 1982 Milius film (played by Arnold Schwartzenegger), learns that the warlord Thulsa Doom, who initially aimed to solve the riddle of steel, becomes the head of a mysterious snake cult because, in Doom’s own words, “flesh is more precious than steel.” The apt juxtaposition of steel and flesh provides Sattouf’s youths with a powerful reasoning kit to comprehend circumcision while “turning the big wheel” is presented as an inexorable rite of passage, necessary to achieve manhood. One day, Riad’s father tells him of his decision to have him circumcised and to schedule the operation in three months’ time. After many fearful deliberations, the boy agrees if his father offers him a plastic giant puppet, which looks like his idol, Conan the Barbarian. As the day of circumcision approaches, Riad is haunted by the pending loss of his prepuce. Two hours before the ceremony, men fill the living room (women are excluded). He is then grabbed by four men who immobilize his arms and legs. With a razor, the circumciser, who suddenly looks like Conan the

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Barbarian, cuts the prepuce. A spectacular squirt of blood spurts and spatters the white handkerchief. Riad then stays in bed for several days with a bandaged penis. Urinating is excruciatingly painful. As the wound is still bleeding after a month, he goes to the village doctor who decrees that it has not been properly done. Riad becomes introverted and regresses, playing with toys for smaller children. When he brings up in an arduous conversation with his father the long-awaited gift of the plastic action doll in exchange for his circumcision, his father dismisses him with an insult. After 2 months, the bandage is removed by the village doctor who jokingly mimics cutting his penis with a pair of scissors. Riad can now pee but in three streams, which gives an ironic twist to the book cover—the three boys peeing in one stream. He, who was convinced that the Israeli were not circumcised, learns that they are. More significantly, he learns that, without consciously articulating it, these two monotheistic, Abrahamic belief-systems—Judaism and Islam—practice male circumcision. Syria, with its complex history—a centre of Islamic civilization from the seventh century onward, a province of the Ottoman empire in 1516, a country mandated to France in the First World War, then united with Egypt as the United Arab Republic until 1961—practices Muslim (sunnite) circumcision. Sunnah is the Arabic term for “tradition” or the “duty” of Muhammad the Prophet, based on the Qur’an and the Ahadith, that is, the religious obligations or recommended practices emanating from Muhammad’s teachings and deeds; sunnah is recommended (mustahhab) but not obligatory (wajib). In the context of Riad Sattouf’s Syrian childhood, it has become de-ritualized. There is no ceremony, religious or otherwise, Islam is not evoked (at least not in the child’s recollection of the event), and there is no celebration afterwards. Riad Sattouf speaks from memory about an experience, which is traumatic enough to warrant an autobiographical narrative, as in Jacques Derrida’s Circumfession. While emanating from two writers with, respectively, a Jewish and a Muslim background, both circumfictions are imbued with a barely quenched anger against the practice itself and the person who authorized the operation—the father in Sattouf’s account, the mother in Derrida’s “confession”. These autobiographies still constitute a tiny literary corpus, compared to the growing body of autobiographies around excision. As of the late 1980s, these selfwritings, which built on earlier testimonies, such as Nawal El Saadawi’s in The Hidden Face of Eve (1980), added nuance to the excision debate: Guinean Kesso Barry in Kesso, princesse peuhle (1987); Somali Aman in Aman (1998); Waris Dirie in her three autobiographies, Desert Flower (1998), Desert Dawn (2002), and Desert Children (2005); Senegalese, Paris-based Khady (Koïta) in Mutilée (2005); Somali, German-based Nura Abdi in Desert Tears (2005) and Fadumo Korn in Born in the Big Rains (2006). In addition to these, Do They Hear You When You Cry? (1998) by Togolese asylum seeker in the US, Fauziya Kassindja, helped propel the issue of genital excision into the literature of exile and in the US media (Zabus, 2007, pp 221–233).

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Waris Dirie and Circumcision As a Coda of sorts, I would now like to turn briefly to the Somali camel girl-turnedtop model and UN ambassador against “FGM” Waris Dirie’s Desert Flower (1998), where Waris recalls her infibulation. From behind her mother’s legs, straddling her body, Waris peers at the exciser, who spits on the blood that has dried on the jagged edge of the broken razor blade. Then her mother blindfolds her, leaving her other senses to record what she calls the “torture”: “The next thing I felt was my flesh, my genitals, being cut away. I heard the sound of the dull blade sawing back and forth through my skin. . .. I just sat there as if I were made of stone, telling myself the more I moved around, the longer the torture would take. Unfortunately, my legs began to quiver of their own accord, and shake uncontrollably, and I prayed, Please, God, let it be over quickly. Soon it was, because I passed out” (Dirie, 1999, pp 45–46). One would expect Dirie’s recollections of the unspeakable to have deepened her understanding of genital alterations. Yet, in her second autobiography, Desert Dawn (2002), while relaying her experience of infibulation for the second time, Waris Dirie recounts that she had her son circumcised as a 1-day-old infant in a US hospital, claiming that circumcision is very different from excision: “Despite my strong feelings about FGM, I knew it was the right thing to do. My son has a beautiful penis. It looks so good and so clean. The other day he told me he had to go to the bathroom. I said, ‘You can do that alone, you are a big boy now,’ but he wanted me to come and see him. His little penis was sticking up straight and clean. It was lovely to look at!” (p 52). Notwithstanding a mother’s pride in her son’s genitals and her marveling at the first throbbing of sexuality, we cannot help notice that Dirie is juxtaposing Muslim notions of tahara (purity) with US medical justifications for routine male circumcision. Waris Dirie’s vignette about her son’s proud display of his erection also deserves comment. Alphonso Lingis (1984) has somewhat eccentrically reformulated the Freudian penisneid, or “penis-envy”: “[the child] perceives his mother desiring him as a mutilated body craves the part detached, castrated, from it” (p 125). Lingis’s reformulation becomes pregnant with new meaning, however, when the mother as a metaphorically “mutilated body,” that is, a body devoid of the phallus, becomes a body that has been “mutilated” in the flesh through infibulation. A new questioning therefore arises around Dirie’s pride in her son’s “beautiful,” “good” penis and her visual delight at seeing it “sticking up straight and clean,” like a termite hill, which, in Somali lore, is a metaphor for the aroused clitoris. Dirie may be unconsciously expressing nostalgia regarding the castration of her talismanic clitoris and the impossibility of any clitoral erection. Behind this vignette of phallic pride lingers, in filigree, the declitorization of the Somali girl child. Compared to the panoply of experiential writings around excision, there is a tiny corpus about circumcision in the making but it is arguably disproportionate, if we reckon that excision concerns some one hundred and fifty million women whereas circumcision is practiced on five continents by about a billion Muslims,

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three hundred million Christians, sixteen million Jews, and an indeterminate number of “animists” and atheists. A discursive type of asymmetry has set in, not only in first-person accounts but also in cultural anthropology, medicine, and law. It should indeed be acknowledged that both circumcision and excision are irreversible genital alterations and that the issues over that little piece of tissue are basically the same. Literature, more particularly, autobiography, is currently telling the wrongs in the rite.

Notes 1. 2. 3. 4.

Zabus (2009). Engel (2007). Derrida (1993). Derrida (1993, p. 115).

References Aldeeb Abu-Sahleih S. (1999) Muslims’ genitalia in the hands of the clergy: Religious arguments about male and female circumcision. In: Denniston GC, Hodges FM, Milos MF. (eds.) Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. New York, NY: Kluwer Academic/Plenum Publishers, pp 131–171. Aldeeb Abu-Sahleih S. (2001) Circoncision masculine, circoncision féminine: Débat religieux, médical, social et juridique, Preface by Linda Weil-Curiel. Paris: L’Harmattan, Male and Female Circumcision: Among Jews, Christians and Muslims: Religious, Medical, Social and Legal Debate, Foreword by Marilyn Fayre Milos (Warren Center, PA: Shrangi-La Publications, 2001). Bdran M Cooke M (eds.). (1999) Opening the Gates. A Century of Arab Feminist Writing. London: Virago Press. Bodian M. (1997) Hebrews of the Portuguese Nation: Conversos and Community in Early Modern Amsterdam. Bloomington: Indiana UP. Comfort A. (1967) The Anxiety Makers: Some Curious Preoccupations of the Medical Profession. London: Nelson. Cooper JF. (1855) A few remarks on the surgical diseases of children. Part I: congenital phimosis. Med Times Gazette. November 17:491–492. De Rachewiltz B. (1993) Eros noi. Mœurs sexuelles de l’Afrique noire de la préhistoire à nos jours. Paris: Jean-Jacques Pauvert/Terrain vague. Derrida J. (1993) Jacques Derrida: Circumfession: Fifty-Nine Periods and Periphrases. . . (January 1989–April 1990). Bennington. G (Trans.) Chicago, IL: University of Chicago Press. Dirie W. (1999) with Cathleen Miller. Desert Flower. The Extraordinary Life of a Desert Nomad (1998). London: Virago. Dirie W. (2002) with Jeanne D’Haem. Desert Dawn. London: Virago. Eilberg-Shwartz H. (1992) Why not the earlobe? Moment. 17:28–33, February. Engel S (producer), Smith MO, Bucher A (director) (2007) A Walk to Beautiful, New York: Engle Entertainment. Gatheru M. (1964) Child of Two Worlds. London, Ibadan, Nairobi: Heinemann. Gilitz DM. (1996) Secrecy and Deceit: The Religion of the Crypto-Jews. Philadelphia, PA: Jewish Publication Society. Glick LB. (2005) Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. Oxford/New York, NY: Oxford UP.

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Hoffman LA. (1996) Covenant of Blood: Circumcision and Gender in Rabbinic Judaism. Chicago/London: University of Chicago Press. Isewaga M. (2000) Abyssinian Chronicles. New York, NY/London: Alfred A. Knof/Picador. Originally in Dutch, Abessijnse Kronieken. Amsterdam: De Bezige Bij, 1998. Levenson JD. (1993) The Death and Resurrection of the Beloved Son: The Transformation of Child Sacrifice in Judaism and Christianity. New Haven: Yale UP. Murray J. (1976) The church missionary society and the ‘female circumcision’ issue in Kenya 1929–1932. J Relig Afr. 8(2):92–104. Remondino PC. (1891) History of Circumcision from the Earliest Times to the Present. Philadelphia: F.A. Davis. Robinson BP. (1986) Zipporah to the rescue: A contextual study of exodus IV. Vetus Testamentum. 36(4):447–461. Sattouf R. (2004) Ma Circoncision. Rosny-sous-Bois: Bréal Jeunesse. Siegumfeldt I-B. (2005) Milah: A counter-obituary for Jacques Derrida. Substance. 34(1):32–34. Spivak, GC. (1998) Three women’s texts and circumfession. In: Alfred H, Ernstpeter R. (eds.) Postcolonialism and Autobiography: Michelle Cliff, David Dabydeen, Opal Palmer Adisa. Amsterdam/Atlanta, GA: Rodopi. Steinberg L. (1983) The Sexuality of Christ in Renaissance Art and in Modern Oblivion. New York, NY: Pantheon. Thomas L. (2000) ‘Ngaitana’ (I will circumcize myself): Lessons from colonial campaigns to ban excision in Meru, Kenya. In: Shell-Duncan B, Hernlund Y. (eds.) Female “Circumcision” in Africa: Culture, Controversy and Change. Boulder, CO: Lynne Reiner, pp 128–150. Zabus C. (2005) A Propos de Bintou: excision et circoncision: Interview avec Kofi Kwahulé. Africultures. 4235 (December 9, 2005) at www.africultures.com Zabus C. (2007) Between Rites and Rights: Excision in Women’s Experiential Texts and Human Contexts. Stanford, CA: Stanford University Press. Zabus C (ed.). (2009) Fearful Symmetries: Essays and Testimonies Around Excision and Circumcision. Amsterdam/Atlanta, GA: Rodopi.

Chapter 16

The Impact of Neonatal Circumcision: Implications for Doctors of Men’s Experiences in Regressive Therapy Robert Clover Johnson

Abstract This paper asserts that, although most men circumcised as infants have no conscious recollection of the trauma, the unexpected re-experiencing of the pain and shock of circumcision by men in regressive therapies suggests that the experience is never forgotten by the unconscious mind, the source, as has been understood since Freud, of most psychological problems. The history, aims, and methods of a range of regressive therapies are briefly surveyed. Descriptions of men’s discovery in regressive therapy of the profound impact circumcision has had on their lives are described. The presenter outlines his own reexperiencing of circumcision in primal and bioenergetic therapy over a 30-year span. Repatterning or corrective emotional experience is explained as an effort to enable circumcised men to regain confidence and self-assertion, characteristics damaged by the impact of the infant male’s helpless victimization during circumcision. Restoring is also mentioned as a necessary palliative endeavor for victims (including doctors) of this practice. Keywords Psychotherapy · Trauma · Unconscious mind · Regressive therapy · Foreskin restoration · Shock · Masturbation · Limbic system · Terror · Rate · Dissociation · Arthur Janov · Repatterning · Ridged band · Circumstraint · Erogenous nerves · Shame Many observers of routine medical newborn male circumcision in America have reported being alarmed by the agony of the baby and astonished that the doctors involved seem completely unaffected by the infant’s screams and clear signs of shock (Romberg, 1985; Milos, 1989; O’Mara, 1993; Lewis, 2006). Although the importance of focusing on the technical aspects of this surgery might partially explain doctors’ indifference to baby boys’ protests, literature on reasons commonly cited to justify neonatal circumcision suggests that acceptance of some or all of the following beliefs may also play a role: R.C. Johnson (B) Gallaudet University Press, Washington, DC, USA e-mail: [email protected]

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(1) Having a foreskin greatly increases the likelihood of contracting HIV, cancer of the penis (and of the cervix of a partner via intercourse), or other diseases, so its removal is important for health and longevity. (2) Parents, accustomed to circumcision as the norm in their society, often say “yes” when asked if their sons should be circumcised, and doctors must comply with their wishes. (3) A circumcised penis is just as sensitive and effective for sexual purposes as an uncircumcised penis, so the amputation of the foreskin is no great loss. (4) The procedure has moral benefits in that removal of the foreskin makes masturbation and sexual excess more difficult. (5) The infant mind is incapable of registering pain; or, alternatively, the pain experienced will be forgotten, quickly, completely, and permanently, without causing trauma-related complications.

Diehard beliefs that amputation of the foreskin prevents a range of serious diseases have been widely and seriously challenged (Weiss, 1964; Preston, 1970; Wallerstein, 1980; Boyd, 1998; Sidler et al., 2008). The notion that doctors must be beholden to the wishes of parents overlooks the fact that parents are often ill prepared to make fully informed, wise judgments about whether or not their baby should be circumcised. Such parents may rely on the doctor to help make the decision, even though the doctor stands to profit from performing the surgery and is quite likely to be ill-informed himself about the damaging immediate and long-range effects of circumcision (Goldman, 1997, pp. 29–56). The notion that circumcision brings about no adverse sexual effects later in life has been discredited scientifically as well as anecdotally (Taylor et al., 1996; O’Hara, 2002; Sorrells et al., 2007). Although circumcision does make masturbation and sexual excess more difficult and less pleasurable, the “moral” issues mentioned seem oddly anachronistic in most modern, cosmopolitan cultures. It is therefore important to remember that the primary reason for excising the richly innervated, erogenous tissue of the foreskin has historically been to reduce sexual excitability, thus diminishing instances of masturbation and/or promiscuity (Kellogg, 1888; Maimonides, [tr.] 1963). Those issues, though extremely important, are somewhat outside the scope of this paper, which focuses on the discovery by many men in various forms of regressive psychotherapy that the intense genital pain and terror suffered during circumcision have never been forgotten by the unconscious mind, the source—as has been understood since Freud—of most psychological problems. These men’s unanticipated re-experiencing of that trauma and subsequent awareness of the trauma’s negative impact on their lives suggest that, whether consciously remembered or not, circumcision can have lasting, damaging effects on men’s emotional and psychological, as well as sexual, development. In this paper, based on experiences described in the literature as well as on my own experiences during regressive therapy, I will argue that revisiting infant circumcision and expressing rage at or fight/flight reactions against the perpetrators in a regressed state, combined with efforts to create an ersatz foreskin, can have therapeutic psychological and sexual benefits for circumcised men. I will mention some hazards associated with re-experiencing circumcision in regressive therapy and caveats related to using this approach for resolving circumcision-related emotional and sexual issues. Implications for circumcising doctors will also be discussed.

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Memory in Infancy Since few people have conscious memories of experiences that occurred before the ages of two or three, some readers of the following paper may be skeptical of reports that men in various forms of regressive therapy have remembered or re-experienced aspects of their infant circumcisions. Arthur Janov, author of The Primal Scream (1970) and inventor of Primal Therapy, has written that he similarly was doubtful when many of his clients in the late 1960s began having experiences that looked and reportedly felt like “re-living” their births. When Janov asked neurologists if brain science at that time could substantiate such claims, they replied that they were also doubtful because the hippocampus and prefrontal cortex, known to be primary support systems for the formation of conscious memories, were not sufficiently developed in prenates or newborns to formulate detailed records of experience (Janov, 1983, 2007). Since then, however, the dynamic field of neuroscience has made many discoveries that seem to explain and support the validity of neonatal memories being experienced in regressive therapy. The principal corroborative discovery is that certain parts of the “lower” human brain—most notably the twin amygdala in the limbic system—have the function of recording experiences of intense pain and such emotions as terror and rage, associating these feelings with specific external stimuli. Neuroscientists now theorize that the amygdala evolved among mammals as a warning system capable of provoking fight or flight reactions to stimuli associated with previous experiences of harm. These memories tend to be more visceral and reactive emotionally than the explicit conscious memories we generally experience in a more emotionally detached way, as if watching movies in our minds. Also, memories as recorded in the amygdala appear not to depend on the level of neurological maturity required for the creation of most conscious memories. Contrary to the long-held notion that “babies do not feel pain” (still a frequently cited excuse for performing surgery on babies with no or minimal anesthesia), it appears that extremely painful (i.e. traumatic) experiences are not only felt but are stored in all their intensity within the amygdala (Schore, 1994; Phelps and Anderson, 1997; Siegel, 1999). Although the emotional and sensory memories stored in the amygdala are usually kept out of the reach of consciousness through the protective mechanism of “dissociation” or amnesia, these unconscious memories can nevertheless have a profound, lifelong effect on an individual, damaging his or her ability to respond in an optimally healthful way to sexual and other stimuli. Regressive therapies generally aim to create a safe, supportive setting in which individuals suffering from an overload of repressed or dissociated pain can gain enough access to the traumas involved to be able to diminish their damaging impact. Various techniques, including bioenergetic exercises, hypnosis, massage, breathwork, and focused exploration of the emotions underlying anxiety may be used to help clients break through the conscious mind’s habit of recycling familiar, comfortable thoughts that promote avoidance of pain and detachment from the suffering they wish to alleviate. Persistence in regressive therapy can help clients re-experience enough traumatic or highly charged unconscious, emotional material to assimilate and come to terms with the experiential sources of

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their anxieties. The fact that individuals pursuing regressive therapy for many years often re-experience birth or neonatal circumcision traumas testifies to the validity of the following observation by David Chamberlain (1989): Instead of responding to [baby] cries as authentic communication, birth professionals have proceeded to cause pain with the conviction that the pain is merely reflexive and that owing to the immaturity of the infant brain, the pain could not really matter. From the perspective of present knowledge, these key nineteenth century beliefs are only myths, but tragically, they are mega myths still influencing mainstream psychology and obstetrics today.

Regressive Psychotherapy Regressive psychotherapy is a broad term referring to a variety of therapeutic practices that help individuals discover and come to terms with the traumatic origins of inhibitions, anxieties, depression, projected rage, obsessive-compulsive disorders, substance abuse, suicidal impulses, and other tendencies. In spite of quicker, less painful, more popular approaches that describe such leanings as symptoms of chemical imbalances best treated with medications or as results of self-defeating thought patterns that need to be replaced with more constructive ideas, a number of psychological disciplines have moved in the direction of exploring and releasing deeply repressed pain and gradually integrating the memory and significance of this pain into consciousness. These include Reichian Therapy (Reich, 1949), Bioenergetic Analysis (Lowen, 1967, 1975), Primal Therapy (Janov, 1991), Primal Integration (Rowan, 2000), Deep Feeling Therapy (Vereshack, 2001), Hypnotherapy (Hartman and Zimberoff, 2004), Re-evaluation Co-counseling (Jackins, 1970), Holotropic Breathwork (Holmes et al., 1996), EMDR (Shapiro and Forrest, 1997), Somatic Experiencing (Levine, 1999), and others. This development was presaged by Freud and Breuer who discovered in the 1890s that hysteric symptoms appeared to be associated with early traumas and could be significantly relieved if patients were helped to re-experience painful, formerly repressed memories and react to them with a cathartic discharge of suppressed feeling. Freud later shied away from accepting as real many of the memories of child abuse and other traumas brought forth by his patients.1 He concluded that these individuals were recalling their own troubling childhood fantasies, which should be approached critically through a combination of free association and analysis in what is now often called “the talking cure.” It should be added that although Freud thereby created a framework through which patients could be “talked out of” accepting as literally true some of their emerging memories of abuse as infants or young children, he saw literal rather than fanciful significance in the belief sometimes expressed by circumcised men that they had been in some way emasculated very early in life (Freud, 1916–1917/[tr.] 1933). Perhaps the reason for this was that—for anyone aware of normal male anatomy—the evidence of a physical trauma is unmistakable on the circumcised penis. Freud’s disciple, Wilhelm Reich, and many other psychologists later rejected his verbal-analytical approach and returned to the idea that neurotic symptoms in

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general were results of genuine early traumas and could not be alleviated without re-experiencing the pain, even if not a complete multi-sensory replay, of those events. Regressive re-experiencing of repressed painful memories is described by Arthur Janov, the creator of Primal Therapy, as the essential component of psychological healing (Janov, 1991). Some life-threatening or extremely painful traumas can be so agonizing to re-live, however, that most regressive therapists recommend experiencing small doses intermittently so the client can assimilate the memories gradually while also pursuing countervailing, life-affirming expressions of self. Many regressive therapies, in fact, emphasize the exploration of new patterns of reaction to trauma, such as bioenergetic discharge, primal integration, sublime release of shame, repatterning, somatic redecision, corrective emotional experience, survival (fight/flight) discharge, etc. Some of these new experiences may consist of expressing feelings that were deliberately inhibited during the original traumatic event (or events). Tom Golden (1999), a psychotherapist who uses a variety of regressive techniques to help men deal with grief and other issues, discusses in a website how many of his clients have unexpectedly re-experienced aspects of circumcision: I began to see that one of the experiences that was not uncommon for men to “re-experience” within a cluster of old traumas was the pain and trauma related to being circumcised. When I first noticed this I was amazed and shocked. . . I hadn’t thought of the experience of circumcision as being anything but a routine medical procedure. The men who re-lived these things were usually just as startled. They were expecting other issues to surface and were surprised to see circumcision as one of them. We were. . . shocked at the intensity of the related pain. I started looking into the medical aspects and was completely blown away to find that doctors didn’t use any anesthetic. . . the assumption being that babies don’t feel pain.

In his article, “Neonatal Circumcision Reconsidered,” John Rhinehart (1999) describes several case histories of men who discovered in the course of regressive therapy that circumcision had set in motion various lifelong, self-defeating patterns. These men entered therapy because of such tendencies as avoidance of intimate relationships, feelings of inferiority to other men, fear of authority figures (or doctors), shyness or panic attacks in unfamiliar circumstances, and other related feelings. In the course of regressive explorations of the origins of these tendencies, these men were astonished to find themselves re-experiencing their own neonatal circumcisions. Some of Rhinehart’s clients reported distinct sensations of being cut in the genitals. All described feeling overpowered, helpless, and victimized. Rhinehart reports that, once his clients became deeply aware of the impact circumcision had on their lives, he was able to help them “repattern” their emotional responses to this event and to the challenges of adult life, exchanging feelings of helplessness in the face of overwhelming force, personal violation, and intense pain for new feelings of self-worth, self-confidence, and self-determination. How is such repatterning accomplished? Another term that amounts to the same thing is “corrective emotional experience,” this wording was introduced by Franz Alexander, a disciple of Freud who left Europe during World War II and spent most of his career in Chicago. In the abstract of an article on corrective emotional

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experience, hypnotherapists Hartman and Zimberoff (2004) summarize how regressive recall of traumatic experiences can lead to healing: Healing unresolved traumas from early life requires accessing the events that produced the trauma, re-experiencing them cathartically in the original ego state, and reframing the meaning of the experience through corrective emotional experiences. We identify [numerous] types of corrective experiences and suggest that they all fit into one of three categories: (1) building ego strength through release of shame and reclaiming worthiness; (2) building agency through release of helplessness and reclaiming personal power; and (3) building authenticity through release of dissociation and identification and reclaiming self-reflective identity.

In what follows, I will use terms from the Hartman-Zimberoff abstract to outline a narrative describing my own process of discovering and endeavoring to “heal” the trauma of circumcision.

Re-experiencing the Trauma In my experience, the discovery that circumcision had something to do with anxieties related to intimacy that had bothered me since my teens did not become clear until I was 60 years of age. A year earlier, I had reached a point in my marriage in which I faced the fact that, in spite of decades of self-coaching in an effort to sustain a healthy and sophisticated attitude toward sex, all of my intimate relationships had required a struggle to subdue an inexplicable fear that often interfered with or stopped sexual excitement. I had dealt with this feeling 30 years earlier in an intense group therapy experience built around Reichian, Primal, and Bioenergetic Analysis concepts. At that time, I participated in exercises aimed at releasing muscular tensions that Reich and the co-creator of Bioenergetic Analysis, Alexander Lowen, described as chronic reactions to trauma that had the effect of simultaneously keeping painful memories out of consciousness and inhibiting the free flow of emotional and sexual energy (Reich, 1949; Lowen, 1967, 1975). Leaning backwards over a rolled-up towel strapped to a kitchen stool (a device called “The Rack” by Bioenergetic Analysis therapists [see Fig. 16.1, an exercise

Fig. 16.1 “The Rack” used for emotional release (Lowen, 1967)

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Fig. 16.2 Tantrum (Lowen, 1975)

that forcibly relaxed the ordinarily tense muscles in the solar plexus region, released feelings of fear, much yelling and crying, but no clear indicators of the exact nature of the experience my body/mind was remembering. Shortly after that experience, I was permitted to pursue an unanticipated and, until then, deeply repressed inclination to have a full-blown, wordless temper tantrum (see Fig. 16.2). This tantrum, which took place on a king-sized mattress, my fists, feet, and head moving like pistons, my voice emitting high-pitched baby cries, seemed to be my reaction to some terrible physical offense experienced when I was a baby. Once I was finished, feeling enormous relief and a surge of joy, neither my therapists nor I could guess what these seemingly related episodes were all about except that I must have been terrified of something in infancy and appeared to need to react to that event with explosive rage. Though I knew I was far from having resolved the painful emotional issues that led to that radical therapy experience, my next 30 years were devoted to the pursuit of a conventional life: getting married, getting a good job, having and raising a child, etc. But after my daughter went to college, the old feelings of unease and fear associated with intimacy recaptured my attention. I knew from years of experience with traditional psychotherapy that antidepressant medications and talk therapy did little to unearth or resolve deeply repressed, painful memories. I decided I must return to regressive therapy to find and—if possible—quell the sources of my anxiety. For various reasons, I chose to do this work on my own. I used some techniques recalled from my earlier experience, but also made use of suggestions discovered in certain printed and online documents, especially the work of Paul Vereshack, a Canadian practitioner of Deep Feeling Therapy, who offers detailed practical advice online (free) and in print (Vereshack, 2001). As most individuals pursuing regressive therapy would attest, it is difficult to find physical or interpersonal circumstances in which it feels safe or appropriate to release the powerful feelings associated with early traumatic memories. Not wishing to disturb my wife or neighbors, I most often primalled2 at home when those people were away. (Some primallers play recorded music to obscure sounds of crying; others cry or yell into pillows. Some soundproof a room in their homes or are lucky enough to find an understanding therapist with soundproof facilities. Many join groups of primallers at retreats in remote locations.)

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At home, alone, lying on my back on a mattress, I began by focusing on tensions I sometimes experienced in response to intimate situations, then allowed deeper, related feelings to surface. Exploring the emotions associated with these tensions transported me eventually to painful, extremely early experiences. Beneath my adult persona with its pretense of calm self-assurance, I discovered first a toddler, then an infant, crying in pain for his mother. It might seem that such an experience would be embarrassing, but great relief is usually felt when profound feelings—repressed but continually asserting themselves with troubling, enigmatic effects—finally emerge in sessions of weeping or rage. For me, the effort led to my first prolonged, conscious immersion in what I believe was my state of mind and feeling as an infant and toddler, endlessly seeking comfort and healing from a weary, overwhelmed mother. After several months of exploring mother-related emotions, I began to sense that underlying my cries for her help was some terrifying earlier experience increasingly nudging the edges of consciousness, my long-repressed reactions to that event pressing for release. My father once told a friend of his, in my presence, about an occasion in which he gave me “hell” when I was a baby upon discovering that I had done something inappropriate on the living room floor. I couldn’t remember this event (which still remains buried in my unconscious), but sensing that something frightening like my father’s brief and vague description had indeed occurred and following Vereshack’s theory that in regressive therapy we position ourselves, move, and vocalize in ways that—through trial and error—feel increasingly “congruent” with a painful memory ready to surface, I lay on my back, regressed to my now-familiar, whining-for-mother state, then—imagining her complete absence— kicked and flailed defensively as someone or something very powerful began to wrestle with my arms and legs. While struggling to push the strong being away, I suddenly felt sharp, very distinct cutting pains progressing from right to left over the shaft of my penis. I immediately stopped the regression, at once shocked by the unexpected body memory of being cut in a very sensitive, private part and energized by the realization that I had finally identified the trauma I’d endured on the “rack” and subsequently had a tantrum about 30 years earlier. The word “circumcision” came to mind immediately; a surgery certainly performed by a doctor, not my father. Whatever “hell” my father had given me, as far as my unconscious mind was concerned, clearly paled by comparison with this earlier experience. But like Golden, I had never sought to learn about circumcision, thinking of it (as I assume most American men must) as simply a routine medical procedure performed on baby boys for important reasons understood by doctors—analogous, I’d unthinkingly supposed, to severing the umbilical cord. The surprise of discovering that circumcision had been an excruciating, terrifying experience and that the repressed memory of it, combined with the physical harm it caused, might have played a damaging role throughout my life aroused a strong intellectual curiosity that sent me quickly to a computer. I did an Internet search for the word “circumcision,” half-hoping I would find a reasonable explanation as to why this surgery had been performed and how (if at all) I had benefited from it. I was willing to “take my medicine,” in other words, if it were

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generally agreed and easy to understand how beneficial it is for personal happiness to have one’s foreskin removed in infancy. What I learned instead—from countless reliable websites and eventually from many books and articles on the subject—was that no reputable medical organization in the world currently recommends routine infant circumcision as a prophylactic against disease. I learned that circumcision causes the keratinization and desensitization of the glans, a part of the male body that is normally moist and protected by the foreskin (as the tongue is by cheeks and eyes by eyelids) from the daily abrasions that cause it to lose sensitivity. I learned that the foreskin I lost during circumcision contained some three-fourths of my erogenous nerves (most notably the “ridged band” at the aperture), and that this highly sensitive tissue plays important mechanical as well as sensual functions during normal intercourse. The amputation of my foreskin, in other words, had deprived me of certain joyous and joy-giving aspects of sexual experience well-known by the vast majority of men who are not circumcised. I learned that highly influential doctors such as John Harvey Kellogg (who also invented cornflakes) promoted universal circumcision of newborn boys largely to stamp out masturbation, an activity that more than a century ago was erroneously believed to cause insanity and many diseases. I learned that Kellogg, who trained thousands of doctors concerning circumcision techniques—directly or in books— was extremely squeamish about sexual intercourse and was not dissuaded from his determination to stamp out masturbation by the realization that circumcision would also hamper or prevent sex as nature intended it. I learned, in other words, that my circumcision was one aspect of a larger effort in America and elsewhere to reduce the pleasure in one of life’s most enjoyable and important experiences and to instill feelings of shame and dread about sex into the minds of men.3 More importantly, I learned that, in spite of this wealth of information suggesting that the practice of circumcision should have been outlawed decades ago, approximately 3,000 routine infant circumcisions of baby boys are still performed daily in the United States alone. When a particular trauma has clearly had a major damaging effect on an individual, most regressive therapies advise clients to relive the traumatic experience in digestible portions often enough to “see it for what it is,” to objectify it, and eventually to allow the individual to dilute the impact this formerly repressed memory has had on his or her ability to enjoy new experiences free of the trauma’s dire influence.4 A major difficulty in endeavoring to heal the psychological wound of circumcision, however, is the simple fact that the wound is physical as well as emotional. The impact of circumcision has been to terrify an infant, to subject him to excruciating pain that is not brief, to alter his sexual nature, to reduce his sexual capabilities, and to inject feelings of shame, fear, and self-doubt into his personality. In my case, the discovery of the psychological damage of circumcision coincided with my first keen awareness of the physical and sensory damage this practice had inflicted on me. In America, we call this a “double whammy.” The overall effect of this knowledge, combined with continual regressive immersions in the now very accessible memory of circumcision, was that I experienced about a year of seldom interrupted suffering, followed by a general sense of sadness, resignation to my

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own diminished state, and determination to do what I could to end this practice by persuading doctors and parents of its many harms. During that time and to varying degrees ever since, the agony of circumcision became largely unrepressed for me. In the many primals I had subsequent to that first one, I felt I had opened Pandora’s Box, re-experiencing again and again the pain I first experienced during and after circumcision, relinquishing all possibility of ever completely shutting those feelings away. Part of the price I paid for gaining intimate knowledge of an experience my repressive mechanisms had striven for 60 years to protect me from was that, even when I was not explicitly primaling, I often felt keenly as if I had just been circumcised, my penis the site of intense phantom pain. In addition to re-experiencing circumcision as a traumatic memory, my mind raced as I dealt with feelings of betrayal by the people responsible for my well being during infancy. Why would anyone do such a thing to an innocent baby? Could the doctor who circumcised me in 1945 possibly still be living? (Not likely.) What would I say to him if I were to confront him? More important and puzzling to me personally was the question: What role did my parents play regarding my circumcision? Since both had died by the time of my discovery, there was no way to directly ask them how the decision was made or how they felt about the decision, so my mind has jumped from clue to clue in search of the never-to-be-fully-known story. The only details I had learned about my birth from my parents included that my mother was anesthetized when I was born at 3:45 a.m. and slept for many hours thereafter. She had never forgiven my father for “being away on a business trip” at the time; and neither parent met me face-to-face until my father finally arrived at the hospital sometime that afternoon and a “search” was undertaken in the maternity ward. I have learned that American doctors were not required by law to ask parents’ permission to circumcise in 1945, so I have imagined that the deed was already done by that afternoon meeting, but since my older brother was circumcised in 1941, it seems that my parents must have known that I was likely to undergo the same procedure unless they took steps to prevent it. Could it be that my father, who was not circumcised, wished to be away so he would not be blamed for whatever happened? He had been a first-born son. Could it be that the thought of giving a second-born son an advantage over his own first-born son was unendurable, prompting him to flee rather than intervene on my behalf? I’ll never know. I often imagine and re-imagine how these events might have unfolded and how confusion, blame, recriminations, and guilt all led ultimately to the complete silence concerning my circumcision that is so typical and so very American a way of dealing with irremediable family traumas. Since the storylines I have spun in my mind cannot be verified, they must be relegated to the realm of fiction, but what is pertinent here is that once a man becomes aware that his circumcision was painful and debilitating and someone else’s choice, innocence is permanently lost. Cynicism and an anguished sense of having been a helpless victim may erase for a long time all hope of any sanguine resolution to this personal tragedy.

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Discovering Power Several months after my first distinct circumcision-related primal, it occurred to me that something about my actions during that regression may have made it seem safe or conceivably beneficial for my unconscious mind to release the unmistakable, identifying signal of genital cutting sensations. My physical and mental attitude at that point must have been remarkably similar to that of a newborn baby boy about to be circumcised—except that I was allowing myself to defend my body with my arms and legs, actions that would have been attempted but prevented by restraints during the original event. Although it is seldom described as such, the Circumstraint used in routine infant circumcision provides a striking example of forcibly inhibited defensive reactions to this trauma. The limbs of baby boys are strapped down to prevent them from using their hands, knees, or feet, or their ability to assume a self-protective “cannonball” or “roly-poly” posture to interfere with or thwart the violence being perpetrated (see Fig. 16.3). Defeating the baby’s only defense mechanisms in this way adds to the repressed memory of genital pain, a profound sense of helplessness, and ineffectuality. My unimpeded, baby-like, defensive actions during that regression appear to have been the key that unlocked the somatic memory of my life’s worst experience (see Fig. 16.4).

Fig. 16.3 Forced inhibition of defensive reactions (Goldman, 1997, p. 96)

Fig. 16.4 Release of repressed anger and defensive reactions to circumcision decades after the original, forced inhibition. (Modified from Lowen, 1975)

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Now, with the benefit of three years’ hindsight, I can also see that the defensive actions of my arms and legs during that regression constituted a first step toward dismantling a timid, defeated attitude that had plagued me throughout life, in spite of the calm, confident manner I had developed as a façade to obscure those feelings. To use a term from Transactional Analysis, the feeling of inevitable defeat associated with circumcision may become the entire “lifescript” of a man. However, allowing a grown man in the course of a regression to this buried memory to express his infant self’s rage with the power of his adult male body, can contribute to the rewriting of this script and the emergence of a new pattern of feeling, outlook, and behavior. Hartman and Zimberoff point out that “There is sublime release of shame when one is able to experience in the original regressed ego state overcoming what was inhibited, forbidden, or impossible in the past experience, and expressing it in the present situation” (p 9). By revisiting the source of their chronic, defeated attitudes toward experience and discovering within themselves a new, self-affirming response to the initially agonizing experience, victims of early trauma are able to gain a new sense of power and effectiveness. A word should be said here about the circumstances in which anger can help heal trauma. Many men habitually express anger or aggression as a way of asserting their masculinity and may do so reflexively when hurt—partly to hide from themselves or others their feelings of being a victim or “loser.” This is one form of what psychologists call “dissociation.” When we imagine the feelings most men would naturally have if they faced the facts of what was done to their genitals in infancy, it becomes immediately clear why most men, including circumcised doctors, are in denial about anything “bad” ever having happened down there. They are, in other words, dissociated from their authentic selves. I would go so far as to assert that on some level such men have always been aware that something is wrong—something is missing. In the most blatant sense, of course, what is missing for circumcised men is their foreskins. In a deeper sense, however, what is missing is awareness of any feelings whatever about missing a foreskin. When Hartman and Zimberoff speak of “building authenticity through release of dissociation and identification and reclaiming self-reflective identity” they are pointing out that regressive therapy, though admittedly painful in many respects, is extremely beneficial in that it can introduce people to their true selves. Circumcised men, for instance, can discover that they were “robbed” as infants. This discovery, combined with experiencing the sorrow and grief that go along with it and the expression of reactions “in the original regressed ego state” to the violence perpetrated on their genitals are essential aspects of healing the trauma. It may be true that many men, upon realizing that they lost part of their sexual birthright as a result of surgery by some known or anonymous doctor, can gain momentary satisfaction by expressing rage toward the individual or the medical profession at large that they now perceive as having betrayed them. This anger can have great benefit if it leads to the release—as it often does—of tears of grief. This grief, in turn, once deeply felt and identified with, can eventually enable the authentic individual to pursue regressive therapy and discover the benefits of expressing the

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anger that was repressed at the time of violation. Hartman and Zimberoff state that releasing this repressed anger “fosters an empowering cognitive-emotional shift.” They cite Van Velsor and Cox (2001) who describe how the expression of repressed anger toward a rapist by a female rape victim can lead to healing. For the purposes of this paper, I will exchange “she” for “he” and “her” for “his” in the following quote without changing the basic meaning: When the client experiences the healthy unleashing of repressed anger toward [his] perpetrators. . . [he] claims a boundary, or a piece of personal entitlement to certain rights involving safety and protection, personal integrity, emotional reality, and the outward expression thereof, and reinstitutes feelings of personal efficacy and power.

This is not to say, however, that adult, objective rage, properly channeled, should never be used in the campaign against circumcision. Rage against a system collectively ignorant of the consequences of its routines can be legitimately channeled into peaceful anti-circumcision gatherings, editorials, and demonstrations. Systemwide revolts also can be useful, such as the refusal of nurses to participate in circumcisions in a particular hospital.5 To the victims of this practice, many of whom are themselves medical interns or doctors, I would urge that you seek psychological healing by returning to the state that formed your personality . . . the innocent state of being a newborn baby boy with a foreskin. Recalling then how it felt to be bound, clamped, and circumcised, express your rage as you wish you could have then. Lift your knees until the leg restraints snap! Push away the doctor who approaches you with misleading smiles, scalpels, and a Gomco clamp! Assert your right to be left alone! Say “Leave me alone!” if that helps, but above all, keep those sharp instruments away from your body. Protect yourself! Be victorious! Even if this be fantasy only, exult in this moment of triumph over those intent on damaging you! Trust that you are right and they are wrong! Not everyone is able to access what Goldman (1997) describes as the “hidden trauma” of circumcision, but if anyone reading this—including a male doctor— feels the need to heal his own circumcision-related trauma and is unsure how to proceed, I advise starting by reading some of the therapy-related documents and Internet resources listed at the end of this article.

Restoring a Foreskin There is an additional way that victims of circumcision can regain some of the capability denied them by this surgical procedure: restoring a foreskin. An excellent resource on this subject is a book by Jim Bigelow (1992), called The Joy of Uncircumcising! Exploring Circumcision: History, Myths, Psychology, Restoration, Sexual Pleasure, and Human Rights. This volume discusses the history of circumcision and practices that can facilitate restoration of foreskin. Today, thousands of men around the globe are using one or another technique proven to cause new skin cells to develop in the remaining shaft skin of their circumcised penises. The

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process is slow, but patience and diligence can enable a person to develop a foreskin that will cover the glans, protecting it from further abrasion, enabling it to shed keratinized cells and restore its sensitivity. A restored foreskin lacks the erogenous nerves of the original, lost foreskin, but it greatly facilitates intercourse and, according to many reports, greatly increases sexual pleasure for both the restored man and his partner. In light of the fact that Bigelow’s volume is no longer new, it would also be wise to consult websites for one of the many national branches of NORM (National Organization of Restoring Men) that usually contain contact information for individuals who can provide information over the phone, in emails, or through group or individual meetings. These websites also generally contain links to countless articles, books, and online discussions concerning circumcision and restoring. The papers by Ron Low and Wayne Griffiths in this volume also provide useful historical and current information on restoring devices. I should add that, in my opinion, the best way to overcome a significant amount of the damage of circumcision is to combine regressive therapy with restoration. The more aware a person becomes of the psychological trauma, the more keenly he will be aware of the physical and sexual loss. Restoring augments the psychological healing process with a physical process that may help a person to gain new confidence in the sexual equipment, even if circumcision has dealt a heavy blow.

Words of Caution In case my story inspires anyone to pursue some form of regressive therapy in hopes of resolving emotional issues associated with circumcision, I should add a few cautionary comments. In my view, no amount of re-experiencing, catharsis, corrective emotional experience, or restoring can entirely remove from circumcision its inherently tragic nature. Even if a person were to become one of the few who are able to access feelings experienced in infancy, let alone those feelings associated with circumcision itself, please don’t expect any powerful connection to those feelings to miraculously provide long-term happiness or to quickly eliminate all the problems this surgery has caused. All I can guarantee for those determined to pursue regressive therapy is that this endeavor has the capacity to present, over time, a completely new, more accurate grasp of personal history. If a person happens to be circumcised, the probability is that somewhere in the unconscious mind is the repressed memory of that event. Painful and saddening though it almost certainly would be to re-experience that particular memory (or some other, unanticipated traumatic memory), doing so can be extremely rewarding for truth-seekers, whether or not the truths that emerge bring happiness. Also, many will testify that the cognitive dissonance resulting from the continual sabotage of efforts to enjoy life and love brought on by repressed, unfelt pain begins to resolve itself once a person starts having connected regressions. Feeling and owning those long-dissociated pains can eventually enable the conscious mind to make peace with the unconscious mind, leaving one the sadder but wiser, and freer to chart one’s own future.

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Advice for Doctors If you are convinced that circumcising a baby boy’s penis does no harm, please think again. Read carefully the Taylor et al., study on the anatomy of the foreskin (1996) and the Sorrels et al., study (2007) comparing the sexual sensitivity of the intact versus the circumcised penis. Also, find on the Internet a video of a medical circumcision (e.g., http://www.youtube.com/watch?v=AwBCElbVkuY&feature=related). Watch it carefully, but listen to the sounds produced by the baby. Imagine that you are the baby rather than the surgeon. This exercise, if pursued objectively, should help provide a new perspective. I would like to quote from a personal communication from Gabriela Monasterio, a practitioner of deep feeling therapy in Mexico, who believes that unresolved inner pain is what prevents individuals from feeling the natural joy of being alive. In the following response to a video of a routine medical circumcision of a newborn male, Monasterio offers some additional possible explanations for a circumcising doctor’s apparent indifference to the baby boy’s suffering: Watching this video of a baby boy being circumcised, I wondered how on earth this doctor or anyone who witnessed the circumcision could be deaf to the sound of the baby’s cries and the evident fact that he was in shock. The doctor continued to describe the process as if he were talking about a cooking recipe. I feel that this kind of reaction reveals an emotional numbness and deafness in the doctor that can only come from denying and stuffing up his own pain. . . and possibly from a deep “acting out” of that denied pain evident in the fact that he could circumcise that poor baby as if he were just following instructions in a manual. Torturing babies through circumcision is plain torture and we are not here to sugarcoat, justify, or hide this fact. The younger the victims are the worse they are harmed. Facing this truth is the only way we can change what needs to be changed. All that is needed is that we change the way we treat children. If we would stop needlessly torturing them, we could undoubtedly change the world in profound ways. If children grow up accepted as they are, they will become humane and compassionate. If they are not, then humankind will be condemned to repeat its mistakes over and over, till we destroy ourselves (Monasterio, 2007, personal communication).

Fully realizing that doctors perform miracles of healing daily through the removal of malignant tumors and the mending of broken bodies, my final word of advice is simply that physicians remember the first part of the Hippocratic Oath taken upon entering this profession: “. . .never do harm to anyone.” If there is nothing malignant or broken about a newborn boy’s foreskin, what could be simpler and more wonderful than to let it be? If, on the other hand, you choose to circumcise a baby’s healthy foreskin, please remember: he will never forget and likely will never forgive the harm you have needlessly done.

Notes 1. It has been argued that Freud moved in this direction because of intense criticism by shocked Victorian readers of reports suggesting that childhood sexual abuse may have led to hysterical symptoms of many of his patients. In the 1990s, some regressive therapists caused a scandal

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R.C. Johnson by planting suggestions regarding the possibility of such abuse in their patients’ minds. Responsible regressive therapists are scrupulous about avoiding such suggestions. For simplicity’s sake, I choose to use the word “primal” in this paper to refer to all forms of regressive re-experiencing, not just those that occur specifically within Primal Therapy or Primal Integration contexts. A well-known Kellogg quote supports my assertion: “The operation [circumcision] should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment” (Kellogg, 1888). Peter Levine, the inventor of Somatic Experiencing, reduces the re-experiencing component of regression to tiny “titration” drops of recollection—just enough to provoke a rebounding reaction that can “shake off” the trauma. Levine goes so far as to advise against “reliving the trauma,” asserting that awareness of its symptoms should be sufficient to enable the traumatized individual to shake it off (Levine, 1999). Golden (1999) supplies the following statement by nurses at an American hospital who refused to participate in neonatal circumcisions: “Our medical position was that neonatal circumcision was unjustifiable. Our ethical position was that it violated a newborn’s right to a whole, intact body. As patient advocates and nurse-educators working in maternal-child health, we believed that we had a professional duty to dispel myths and offer parents factual information about circumcision, and that we had a duty not to participate in a procedure that surgically altered the normal genitalia of unconsenting minors.”

References Bigelow J. (1992) The Joy of Uncircumcising: Exploring Circumcision: History, Myths, Psychology, Restoration, Sexual Pleasure, and Human Rights. Lindenhurst, IL: Hourglass Book Publishers. Boyd B. (1998) Circumcision Exposed: Rethinking a Medical and Cultural Tradition. Freedom, CA: The Crossing Press. Chamberlain D. (1989) Babies remember pain. Pre- Peri-Nat Psychol J. 3(4):297–310. Freud S. (1916–1917/1933) New introductory lectures on psychoanalysis (Lecture XXXII), “Anxiety and Instinctual Life.” In: Strachey J (ed. & Translator) The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 22. London: Hogarth Press, pp 81–95 (Original work published 1916–1917). Golden T. (1999) Do men “remember” the trauma of circumcision? Posted on MENWEB (www.menweb.org/circtom.html). Goldman R. (1997) Circumcision: The Hidden Trauma; How an American Cultural Practice Affects Infants and Ultimately Us All. Boston, MA: Vanguard Publications. Hartman D, Zimberoff D. (2004) Corrective emotional experience in the therapeutic process. J Heart Cent Ther. 7(2):3–84. Holmes S, Morris R, Clance P, Putney R. (1996) Holotropic Breathwork: An experiential approach to psychotherapy. Psychother Theory Res Pract Train. 33(1):114–120. Jackins H. (1970) Fundamentals of Co-counseling Manual. Seattle, WA: Rational Island. Janov A. (1970) The Primal Scream. New York, NY: Dell Publishing. Janov A. (1983) Imprints: The Lifelong Effects of the Birth Experience. New York, NY: CowardMcCann, Inc. Janov A. (1991) The New Primal Scream: Primal Therapy 20 Years on. Wilmington, DE: Enterprise Publishing. Janov A. (2007) Primal Healing: Access the Incredible Power of Feelings to Improve Your Health. Franklin Lakes, NJ: New Page Books. Kellogg JH. (1888) Plain Facts for Old and Young: Natural History and Hygiene of Organic Life. Burlington, IA: F. Segner & Co. (Facsimile reprint: New York: Arno Press, 1974).

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Levine P. (1999) Healing Trauma: A Pioneering Program for Restoring the Wisdom of Your Body. Boulder, CO: Sounds True. Lewis V. (2006) A mutilator’s question. In: Bollinger D. (ed.) Project blOUCH! April 28, 2006, available online at: www.genitalintegrity.net/blouch/2006/a_mutilators_question.php Page accessed February 20, 2008. Lowen A. (1967) The Betrayal of the Body. New York, NY: MacMillan Company. Lowen A. (1975) Bioenergetics. New York, NY: Putnam Publishing Group. Maimonides M. (1963) The Guide of the Perplexed. Translation by Shlomo Pines. Chicago, IL: University of Chicago, p 609. Milos M. (1989) Infant circumcision: What I wish I had known. In: Prescott J. (ed.) The Truth Seeker: Crimes of Genital Mutiliation, 1(3):3. NORM: The National Organization of Restoring Men. Website: http://www.norm.org/ (Accessed 1/1/09). O’Hara K. (2002) Sex as Nature Intended It: The Most Important Thing You Need to Know About Making Love, but No One Could Tell You Until Now, 2nd ed. Hudson, MA: Turning Point Publications. O’Mara P (ed.). (1993) Circumcision: The Rest of the Story. Santa Fe, NM: Mothering Magazine. Phelps E, Anderson A. (1997) Emotional memory: What does the amygdala do? Curr Biol. 7(5):311–314. Preston EN. (1970) Whither the foreskin? J Am Med Assoc. 213(11):1853–1858. Reich W. (1949) Character Analysis: Third, Enlarged Edition. New York, NY: Orgone Institute Press. Rhinehart J. (1999) Neonatal circumcision reconsidered. Trans Anal J. 29(3):215–221. Romberg R. (1985) Circumcision: The Painful Dilemma. South Hadley, MA: Bergin & Garvey. Rowan J. (2000) Primal integration counselling and psychotherapy. In: Palmer S (ed.). Introduction to Counselling and Psychotherapy. London: Sage. Schore A. (1994) Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. Mahwah, NJ: Lawrence Erlbaum Associates. Shapiro S, Forrest M. (1997) EMDR: The Breakthrough “Eye Movement” Therapy for Overcoming Anxiety, Stress, and Trauma. New York, NY: Basic Books. Sidler D, Smith J, Rode H. (2008) Neonatal circumcision does not reduce HIV/AIDS infection rates. S Afr Med J. 98(10):762–766. Siegel D. (1999) The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. New York, NY: The Guilford Press. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS. (2007) Finetouch pressure thresholds in the adult penis. BJU Int. 99(April):864–869. Taylor JR, Lockwood AP, Taylor AJ. (1996) The prepuce: Specialized mucosa of the penis and its loss to circumcision. Br J Urol. 77:291–295. Van Velsor P, Cox DL. (Dec 2001) Anger as a vehicle in the treatment of women who are sexual abuse survivors: Re-attributing responsibility and accessing personal power. Prof Psychol Res Pract. 32(6):618–625. Vereshack P. (2001) The Psychotherapy of the Deepest Self, 5th ed. Toronto, ON: Life Perspectives. [Available online as Help Me, I’m Tired of Feeling Bad at www.paulvereshack.com] Wallerstein E. (1980) Circumcision: An American Health Fallacy (Springer Series: Focus on Men Volume One). New York, NY: Springer Publishing Company. Weiss C. (1964) Routine non-ritual circumcision in infancy. Clin Pediatr. 3:560–563.

Chapter 17

Circumcision Memory Thomas W. Hennen

Abstract A doctor circumcised me six days after my birth. I vowed just before passing out in extreme pain, cold, rage, and exhaustion that “I will not forget” what happened to me that day. Then, 52 years later, I chanced to regain those long-buried memories. This account describes regaining the memories and, through the memories, my perceptions of my world from birth to ten days. The remarkable memories consist of richly detailed visual images, spoken words and sentences, tactile sensations, extreme pain, intense anger, rage, fear, puzzlement, and sadness. I address the memories from the viewpoint of the child I was, living the memories, and of the adult I am, examining and interpreting the memories in context. The first person account is honestly presented, and is not fiction. Predictably, some will not want to believe this account because it challenges their beliefs of what a newborn infant thinks and experiences. Keywords Memories · Rage · Fear · Anger · Pain · Nightmares · Shock · Foreskin · Mutilation · Disfigurement · Deception · Betrayal

Introduction On July 1, 1997, at the age of 51, I had the unusual and unsettling experience of beginning to recover long-buried memories of my first ten days of life outside the womb. These recollections included graphic memories of my own birth and circumcision. Be forewarned that what follows is not fiction: it is real. Today, I am a 63-year-old lifelong bachelor. Although educated, I am not an academic by profession. I have no formal medical training or religious instruction. This account has been through many drafts and was not originally intended for publication. In the T.W. Hennen (B) Washington and California Bar Associations, Attorney Before the US Patent & Trademark Office, Des Moines, WA, USA e-mail: [email protected]

G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9_17,  C Springer Science+Business Media B.V. 2010

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beginning, I sought only to document what I recalled. Admittedly, my account is anecdotal rather than scientific, and is more data than it is thesis. If this account has a thesis, it is that infants possess a level of awareness far beyond anything normally reported in the medical literature, and that pointless and unwarranted circumcision damages the child far more than legal authorities and medical personnel have been willing to acknowledge. All of my life, I have known I had been born in November 1945, at Tacoma General Hospital, a fairly typical American metropolitan hospital in Tacoma, Washington, USA. As a baby, I remembered the pain of my experience there but, after a year or two, those memories became buried under countless other more recent memories. Still, the buried memories continued to negatively affect my life. When I was about ten, and had long since lost access to the early memories, my mother told me explicitly that, soon after I was born, the doctor had “cut a little flap of skin off the end” of my penis. She tried to reassure me that I didn’t need the flap of skin. She said this as though she believed the doctor had performed a valuable service, and I am sure he had convinced her that he did. I was shocked beyond words to think that my own mother would allow this to happen and not protect me, but my mother, it appeared, had requested it be done. I asked earnestly why she would do such a thing, and she responded that the doctor had recommended it be done to me while an infant because otherwise I would grow up and soon be “too big to handle,” and they would never be able to do it then. The doctor made no medical arguments, or at least none my mother could repeat to me; the unsupported assumption being that there was any reason to do this at all. There wasn’t. That was all she would say to me. Further questions were rebuffed, even though I desperately needed to ask many more. In her defense, I don’t think she had any other answers to give. Looking at these arguments today, their complete lack of logic is self-evident. Many years later, my mother admitted to me that she had been very young, from a rural upbringing, really didn’t know anything about these matters, and placed (or misplaced) far too much trust in the doctors.

Nightmares Passing as Dreams My experience in the hospital had affected me deeply and I believe was the genesis of many irrational fears that have plagued me for years. Irrational fears included my extreme shyness and inhibitions, my lifelong lack of trust in others, and my initial fear of barbers, dentists, doctors, or anyone else with shiny metal instruments and a white coat. My mother told me that, while I was a very small child, I would often have trouble sleeping and would toss and turn constantly; I would get little rest. This matches my recollection of having bad dreams of the circumcision at that age. The pediatrician’s solution was to suggest my mother have me sleep with a stuffed toy animal, but that did not help. My problem was not loneliness, it was medically inflicted terror with no redeeming purpose, but no one cared about that.

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One hospital memory, in particular, served to inspire many nightmares. The memory concerned a strange, dark-colored wooden worktable that I believe was a chemistry lab bench that I saw from time to time as I was carried around the hospital. I remember a nurse once tripping and falling down near such a bench and another nurse helping her back up. The dream this memory inspired usually began by me going through a door and finding myself in a small room dominated by just such a chemistry lab bench. In my dream, a nurse would walk on one side of the chemistry lab bench between the bench and the wall on a wooden lattice or grid that kept her feet about six inches off the floor. There was very little room to move past that chemistry lab bench but the nurses were all drawn to it. I dreamed that nurses were tripping and falling down on the wooden grid work that was unstable and lurched from time to time as they stepped on it. In my dream, the wooden grid was sometimes floating on water. Once nurses fell down, they disappeared down into the floor drain. In one common variation of this dream that recurred many times, the room also held a boiler that was heating up and was about to explode. I had this dream or variations of it too many times to count in my childhood and adolescence and continued to have this dream well into adulthood. These and other dreams, some involving steam locomotives trying to kill me, haunted my sleep for years. I could have finished the rest of my life never knowing what was bothering me, but for a bit of technology, and one very fortunate choice on July 1, 1997.

The Account Begins I was not under the influence of any intoxicating substances the night the memories began to return. I did not drink any alcohol that night, nor take any drugs of any kind. I was fascinated by computers and, in June 1996, had acquired a new, faster Windows 95 computer to supplement my older 1985 computer. Then, on July 1, 1997, in the early evening just after dinner, the thought occurred to me that I now had Internet capability and for the last year had been largely ignoring it. I decided to take some time that evening just to see what I could find on the Internet, not looking for anything in particular and with everything being fair game. I began simply enough looking at various sites, and then clicking links that looked interesting. I went from one subject to another in rapid succession without following any particular theme. Then, as I was beginning to get bored, the thought occurred that I could even explore the pornographic sites I had heard people talk about if I could only find one, and this was a good opportunity to try. It was while clicking on a link on one such site that I was taken to a site on male circumcision. Then, when I clicked on a link, I saw a color photographic image of a circumcision being performed on an infant. It was not a pretty image; the bloody infant was screaming in terror; the photo hit very close to home.

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Suddenly, I felt something very strange happening physically in my head. It literally felt like how I imagined having a stroke might feel. I felt no pain, and experienced no other stroke symptoms, but I felt a part of my brain suddenly flooded with a fast flowing, very warm liquid. I presumed the flow was blood. I could feel the sudden flow of liquid as though an artery had burst deep in my brain. I could feel the turbulence of the flow and could tell the flow rate was high. The flow, at first, seemed uncontrolled, as a burst artery would be. Not knowing what was happening and thinking I might have been injured; I felt for signs of blood in my hair, but found none. My whole head quickly overheated and I began to feel flushed and uncomfortable. I felt this only in my head. I felt the turbulent flow of liquid probably for less than a minute, and the overheating probably only 3–5 min. I had never before felt a sensation quite like this and have not felt one since. This was not simply a red-face or embarrassment; it was something very different and much more; this was some kind of autonomous arterial event that I could neither understand nor control. There were no other physical symptoms, but it felt as though something had caused an artery to dilate and quickly allow a great deal of blood to flow to a particular part of my brain. Then after several seconds it seemed to slow down, the flow rate returning closer to normal. As these sensations came on, I was quickly overcome by an inconsolable rage. It was anger so intense it completely dominated my consciousness. Nothing had happened to make me angry. It was a remembered anger, reincarnated from the point I had passed out on the table 51-and- a-half years earlier. I sat motionless in my chair in stunned silence and slowly began to remember. The first memory to return was the memory of the extreme pain I suffered during the most painful part of my circumcision. Initially, the searing pain was all I remembered, but so vividly, I literally thought for a brief moment I was being circumcised again and quickly glanced down for reassurance. I wasn’t. Then, I remembered a little more, but in a somewhat jumbled order that was difficult to put in a proper chronology. I knew instantly what it was I was remembering and I struggled to get it right. I also knew how fragile memory could be and decided it was important that I immediately try to record these memories and so began to write down what I remembered. I continued to be so consumed with rage during the initial writing that the first several drafts of my writing were so angry they were almost incoherent, like the ravings of a lunatic. It has taken me fully 11 years of working intermittently to filter out most but probably not all of the anger from this writing. Remembering was not easy and required great concentration. I was able to work from memories already recovered toward related memories not yet recovered. I went through several more drafts of my documentation until in about late 2002 I thought I had completed my task, but I soon discovered I was wrong. It wasn’t until, in 2008, the effort to write this account completed my recollections and, for the first time, I was able to tell the complete account.

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Estimated Time Line In reconstructing the time line for the events described, I have relied on knowledge of my birth date, and the fact that I was in the hospital for ten days after birth as my mother told me was customary in 1945.

The Memories Assert Themselves The memories I have accessed consist of short episodes of consciousness, of words spoken, of visual images of people, of places, of things, of warmth, of cold, of my own thoughts and of fear, anger, rage and extreme pain made all the more memorable by my intense emotional reaction to the pain, the fear, and the anger. Interspersed between these memories are long periods of sleep, apparently a favorite pastime of newborns. Everything reported here that I remember from 1945 is as I genuinely remembered between 1997 and 2008.

Zero Hour, Wednesday, November 28, 1945, Time from Birth Records: 4:30 A.M. My Birth My natural state was sleep. My memories begin about two hours prior to my actual birth with the initial wrenching movement that broke me lose from my position in my mother’s womb and carried me a short distance from the womb on my way to the world. I initially awoke when I felt I had been bumped loose from the position I had been occupying for so long. With each contraction I sensed that I moved a short distance. The forces seemed violent, sudden, unpredictable, out of my control, and unnecessarily strong yet gentle at the same time, and of relatively short duration, followed by a relaxing calm. I felt no pain. Before birth, my eyes were tightly closed and I could see nothing. Starting at the time shortly after the initial contractions, and for a prolonged time, including during the height of the birth forces, my field of vision (with eyes shut) did fill with patterns of light and dark a couple of times. I was at first frightened and worried that I was leaving the only world I knew for an unknown world and I didn’t know if I could survive the change or not. With few exceptions, I seemed to have little conscious sense of my physical body, only of my mind. Often the onset of birth forces was accompanied by muffled, unintelligible words from someone outside (presumably the doctor). Each time the forces on me subsided, I tried to return physically to where I had been, to where I knew I could survive, so I could go back to life as usual and sleep. But I had no traction and could not go back. I thought I had done something wrong to cause the contractions to start and didn’t know if I was about to die.

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I also remember in particular during birth two episodes of external force that I felt on my neck vertebrae. Up to that point, I didn’t know I had a neck. On two distinct occasions, my head was forcefully twisted to the limit of its motion, and then it was twisted a little further. The pain in my neck vertebrae was severe. At the time, I was sure my neck was very close to snapping and would snap at any moment if the force did not subside, but I was powerless to protect myself. I can only hope that by now doctors have learned better than to use this dangerous technique. Shortly thereafter, with the aid of someone’s hands, I emerged and was then outside, feeling wet and cold and slightly uncomfortable. I recall shortly after arriving being handled one way then another, then held vertically by my ankles and being slapped on the butt, one time. I recall I didn’t like being held upside down, or being hit, nor did I see the need for it. At this point, I caught a glimpse of the doctor. He was dressed in blue or green surgical clothing, but wore a mask. My birth certificate says he was Dr. David H. Johnson. In a fleeting glimpse, I thought I saw a gray beard or other facial hair under and at the right edge (my left) of the mask. The doctor who circumcised me a few days later did not have a beard, as I recall. I sensed the welcome warmth of the large surgical light illuminating the table, its bright light affecting my sensitive retinas through my tightly closed eyelids. The nurses didn’t understand I needed warmth and left me for a time on the cold metal table. I didn’t know where my mother went. She had to be there at first, but once I was on the table, they couldn’t get her out of there fast enough, apparently. I looked for her and expected to be reunited with her but I was never given to her that I recall. The message this sent to me was that the hospital people thought I was not important enough to be allowed to be near my mother, or perhaps my mother didn’t want me and somehow it was my fault. This did not make me feel good. At one point, a nurse pulled on my leg, right or left I don’t know which, but probably right. Then I felt an intense sharp stabbing, burning pain in my heel (the obligatory blood sample). That pain was intense, but fortunately was of short duration and did no permanent, irreversible damage so far as I know. The biggest effect it had was to make my otherwise pleasant arrival unpleasant and to frighten me and make me wary of people. Before taking the blood sample, the nurse foot printed me. At least that didn’t hurt, but tickled a little when she applied the ink to my feet with a roller, and felt sloppy when she pressed each foot against a sheet of paper. This paper became my Tacoma General Hospital Record of Birth that I still have with my important papers. I eventually went to sleep, thus ending this memory.

Day Two, Thursday, Time Unknown The First Nursery I Remember My next earliest recallable memory is of waking up on my back in a bassinet in a dimly lit nursery, wrapped up tightly and trying to sleep. The lights were dim and

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there were no windows. I think this was deliberate to shield the newborn’s eyes from bright lights as the newborn transitioned from life in the womb to life in the world. I was wrapped so tightly I could not move. I was very warm, too warm really, and constrained by the tight wrap. Most of my time was spent sleeping in a bassinet that had high sides, and that did not afford me much of a view except of the ceiling. I heard two or three nurses moving around, talking to each other, and talking to some of the infants. One of the nurses then peered over the side of my bassinet and talked to me. The nurses frightened me. I didn’t know who they were or what they wanted, and I wanted to avoid them. I think I would only have felt comfortable with my mother, but she and I were deliberately kept apart in the hospital, as was standard hospital practice in 1945, almost as if I was to be put up for adoption. I really didn’t know if it was morning or night. I would guess it was early evening when I awoke.

Day Three, Friday, About 10:00 P.M. The Nurse Takes Me on Her Break I do remember a few times, one probably late on the evening of my third day, when a nurse wearing a starched white uniform (probably an RN, not a nurse’s aide) picked me up from my bassinet. I sensed the time from the darkness and low level of activity in the nursery and hallway, and the hushed voices. This nurse was older, probably 35–45 with dark black hair and a white nurse’s cap. We stood there and the nurse talked with the other people. I was very sleepy, but the nurse and her friends seemed wide-awake. I was scared when the nurse picked me up (almost in panic) because I didn’t know who the nurse was, or where the nurse was taking me, or why, or what she expected of me, or what would happen. Also, my mother was not there to protect me. I knew very well how vulnerable I was. The sounds of the people’s voices talking seemed very loud to me, but after I had heard them talking for a short while, the sound volume became more “normal” as my brain adjusted the volume lower.

My Early Thoughts at Being Taken from My Bassinet I felt safe in my bassinet, even though my mother was not there. As the nurse carried me down the hall, several thoughts began to run through my mind. “Where is my mother? Where could she be? What will these people do to me if she is not here to protect me? Are you taking me to meet her?” These had to be some of the first actual thoughts using English words that I ever had.

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Day Four, Saturday, Early Afternoon The Boston (Baby) Marathon I now think it was Saturday, but at the time it was just another day to me. A young student nurse, probably about 18 or 19 years old, came to me and picked me up from my bassinet to take me for a walk. We walked out of the nursery and down the hall to an open area with a high ceiling. I think now this was the lobby just inside the main public entrance to the hospital, the same place I had gone the night before. It was probably shortly after 12:00 noon or so, because I could see blue sky through a high window in what I believe was the west wall. It was warm indoors, and there were a few other people walking up and down the hallway. We walked up and down that hall about four to six times as if running some sort of baby marathon course.

My Introduction to Numbers We walked past many closed offices, probably doctors’ offices, having golden varnish colored wood grain doors with black numbers painted on them. I saw the numbers mostly as mysterious symbols, not as numbers, but suspected they had some significance in identifying the doors.

Day Five, Sunday, About 7:30 P.M. Tommie’s Big Adventure I believe it was about 7:30 P.M. the next night, my fifth day in the world, Sunday, when something wonderful happened. I shared a memorable adventure with a nurse. I’m fairly certain it was against the rules for nurses to take a baby outside the hospital, even if they remained on the grounds, and likely it was illegal as well; it certainly would be illegal today. In the interest of brevity, rather than report the details of this next memory, I will simply summarize it. A nurse decided to take me from the nursery for a walk down the hall, and in the process one thing lead to another and before I knew it, she had taken me outside through one of the many side by side metal framed glass doors of the main entrance and onto the grass “to show me rain.” Unfortunately, it was no longer raining so we came back inside. This abortive attempt inspired others to organize a full-scale expedition that included my nurse, and about ten of the other nurses. We were to go outside for a walk on the grounds at about 10:00 at night. We exited through the janitor’s workroom through a fireproof door near the hospital incinerator, and walked all over the lawn for about 20 minutes before returning. We avoided detection by the supervisor and entered through the same fireproof door through which we exited.

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Day Six, D-Day, Monday, About 7:00 A.M. A Rude Awakening Early One Morning I remember early the next morning, which was my sixth day in the world, Monday, I was in the hospital nursery. I was sleeping in a bassinet, wrapped in a blanket of some kind. I was very warm and comfortable, and was perspiring heavily from the warmth. I was very sleepy. It felt so good to sleep. I would guess now as an adult it was probably just before 8:00 A.M. All of a sudden there was noise and bustling activity in the nursery as the nurses had begun their morning wakeup routine. After a designated time, probably 8:00 A.M., the nurses stopped trying to be quiet and began speaking loudly to each other, deliberately trying to wake up the babies. I yawned and opened my eyes.

My Journey Through the Hospital Another nurse said something, as if some event involving me was listed on a schedule they needed to follow. After several minutes, my nurse handed me to another nurse who then carried me through a doorway out of the nursery and down a hallway. The doorway had two swinging doors, each with a round glass window at about an adult’s eye level.

The Portable Surgical Light Question People were getting organized and there was some discussion whether they could proceed with their plan because of an equipment problem. Against the wall was a portable surgical light that doctors use to light the operating field. I saw it as I was carried into the room. The nurses questioned whether their plan could proceed because they thought the portable surgical light was not working. One of the nurses said it had not worked earlier and she didn’t know if it had been fixed or not. A little later, one of the other nurses confirmed that the light had been fixed and did work properly or that they had arranged to borrow another identical portable surgical light. The decision was made to go ahead because everything was ready. Other than what I have said here, I had no idea what they were talking about. We then must have moved to a second room.

The Entourage Arrives After some delay, the door opened and I heard a man come into the room. He was wearing a brown suit, a white shirt, and a dark tie. The others treated him with great respect. He said something to the nurses I did not understand, probably something

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like “Are we all ready?” And a nurse responded something like “Yes” and may have said his name. They exchanged some pleasantries. I don’t remember precisely what they said. As I recall, there was a time problem, the doctor was in a hurry, probably trying to keep to a schedule, or the nurses were behind schedule, and it was the nurses’ job to make sure everything was ready. Since I only saw my birth obstetrician one time, and he was wearing surgical clothing when I saw him, I could not say if this man in the brown suit was the same person or not.

Close Encounters, First Contact Finally, the doctor turned to me, put his face very close to mine, and said something to me (really he spoke at me, not to me). At some point during this encounter, I smelled the doctor’s bad breath. I almost threw up. I smelled something strong and very bad smelling, probably a mix of coffee and cigarettes, though I had no idea at the time what caused the stench. When he put his face close to mine to speak to me, he spit little drops of saliva at me that hit my face, and he breathed his awful breath on me. I did not like that. I quote him almost verbatim when he said “Hello there, Buddy Boy. Don’t worry about a thing. We’re going to take good care of you. You’ve got nothing to worry about. We will fix your problem. You’re going to be fine after we take care of it.” He used almost if not exactly these words, and certainly that was the tone and substance of what he said to me. Of course, at the time, I did not know how I could respond. I was listening close for any clue as to what he had in mind. When I heard the word “problem,” and that he would “take care of it,” I became quite concerned, got a bad feeling in the pit of my stomach, and wished for some way I could contradict him, and explain why he was wrong, but of course, there was nothing I could do to communicate my disagreement. I had no way to tell this doctor he was full of crap. What I remember especially was his use of the generic name “Buddy Boy” for male infants. When I finally arrived at my new home, coincidentally I soon was given the nickname “Bud.” Each time I heard that name, it made me think of doctors hurting me, and at first it made me worry I was soon to be subjected to some other terrible, disfiguring procedure for someone else’s amusement. Fortunately, I never was after I came home, but I never liked that nickname. I genuinely believe he meant no harm, but in fact, I think he just didn’t appreciate the extensive level of damage his ignorance, ego, and greed were causing by inflicting an unnecessary and disfiguring medical procedure when nothing was wrong. I think he did not particularly care about me as a person, other than as a biological specimen. I think he was primarily performing for the nurses who interested him. The portable surgical light, if it was the same one I had already seen, had been moved from the first room and was still in the stowed position, not set up for use. One nurse asked how you set the light up and the other nurse demonstrated how that was done. I remember the doctor sitting in a desk chair, like a stenographer’s chair, at the desk several feet in front of me as I lay on the table.

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Time to Go Now When the doctor had finished doing whatever it was he was doing, he got up from the desk, the people spoke as if making some kind of arrangements, and we all walked down the hall through several doors. My nurse was carrying me. People began putting their coats on and assembling as if preparing to go somewhere. We then went outside and some people began getting into automobiles while others walked. My nurse was going to walk, but since my nurse was carrying me, and since one of the people had recently purchased an automobile, the automobile owner insisted she and a few others ride with him. My nurse and I got into the automobile along with several other people, some men, some women. The front seatback folded forward on the passenger side to allow us to enter the back seat. My nurse and I sat in the center of the rear seat with other passengers on either side. One thing I remember from that ride was the constant pitching forward and backward as the driver shifted the transmission gears.

Driving to Our Destination Again, to make a long story short, I will briefly summarize what happened next. We drove probably less than a quarter of a mile to a building where, after waiting for someone to bring a key, we entered. We rode an elevator to about the fourth or fifth floor, exited, and went into a room off a hall. Others were there in what seemed to be a library and conference room. There the people conducted about a 30-minute lecture on some medical topic. We then left and returned to a different part of the hospital. We exited the car and climbed up stairs, walked across a porch, and into the building. We waited a few minutes in the main hallway for someone to find the key to the room off that hallway to the right. I can remember seeing down the hallway a pair of swinging doors with round portholes near the top of each one and when they opened, I saw a black man in a rubber apron and elbow length rubber gloves. Someone arrived with a key and opened the door. They carried me inside. This room was cold and dark, had tables and counters that looked fairly old, and looked like it received little use. At first they couldn’t find the light switch, someone cussed, but someone finally switched on the light as more people arrived. Thinking about it as an adult, I suspect the point of what they were doing was finding a room where they could do the circumcision without taking up a costly operating room, a room where no one would see what they were going to do, and where no one would interfere.

Things Start Getting Serious The nurses were beginning to don surgical masks and gowns, and I could tell something was about to happen. The doctor was still dressed in his shirt, tie, and suit. Then the doctor left the room through a door a nurse held open for him. I was curious

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where he went. He left through a wooden door. I looked through the doorway as the door opened and can remember seeing blue ceramic tiles on the wall through the open door. One nurse said the doctor has something to do and we have to wait now until the doctor returns, and that he wouldn’t be gone long. My adult guess is that he had to leave to change his clothes, perhaps shower, and scrub up for “surgery.” He really took it seriously. When he returned, he was dressed head to toe in a deep blue surgical gown with a matching surgical cap on his head covering his hair, and he wore a surgical mask. The nurses anticipated that I might be uneasy at not seeing his face and not recognizing the doctor and so made a point of introducing him to me and telling me he was the same person only dressed up. I did recognize him, and thought the nurses’ explanation was unnecessary.

Time to Put the Horsie into his Harness As everyone was busy doing their part of this procedure, one nurse, an RN I would guess from her all-white uniform and cap, and her more professional demeanor, had appeared in the room. The RN removed my diaper, and said to me as she picked me up under my arms, “Now its time to put the horsie into his harness.” She used exactly these words, no more and no less. She said it as though I was a horse about to be put in a harness, and I think it was supposed to be cute. I did not really know anything about horses or harnesses and so didn’t know what to think about her comment. I remember she picked me up under my arms and dangled my legs down into some form of a device not unlike a ship’s life preserver (or horse collar?). She then fastened elastic straps or other retention devices below to restrain me. I was propped up in an uncomfortable sitting and slightly reclining position that would have been impossible without the restraining device.

The Visual Barrier The nurses built a barrier in front of me by placing a dark blue cardboard box of paper product (probably Kotex brand sanitary napkins) that was about ten inches square and about two or three inches thick, on its side on the surface of the “life preserver” device directly in front of my face, and then placed a second box on top of the first box, and then I believe a third. They placed a blanket over the boxes to make sure I could not witness their work. I believe the doctor took a seat on a low stool or chair in front of me. I could not see him. Then as the room lights seemed to go down, the portable surgical light was quickly set up, turned on, and positioned to shine on the area where the doctor would be working. It was at this point I felt the welcome warmth from the portable surgical light on my abdomen as the nurses adjusted the angle of the light.

The Torture Begins with Manual Separation of the Foreskin The doctor must have given a signal that he was ready to begin. At this point, the doctor or nurse swabbed my genital area with what must have been an iodine-based

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disinfectant. I do know there was absolutely no anesthetic. I then felt what I thought must be the doctor’s hand in a rubber glove touch my penis. He began a slow examination. Then, he somehow quickly grabbed my penis tightly and pulled or twisted on the foreskin, perhaps using a tool, or perhaps not, but in a few quick jerking or twisting motions, tore it loose where it was naturally attached to the glans penis. I was again frightened at this point. What he was doing made me feel I was being permanently injured. There was a fairly severe level of pain, discomfort, and surprise, but once the foreskin was loose, the pain subsided somewhat. I don’t know if the foreskin or tip bled at this point, but the foreskin certainly did later as its arteries were severed. He continued working until he could stroke the foreskin back to fully expose the tip and shaft. I don’t think he applied any artificial lubricant. I felt cool air on the tip as it slipped forward through the foreskin to become fully exposed for the first time, as he squeezed the penis shaft and pulled and tugged on the foreskin. The tip must have been moist, and the moisture began evaporating into the air, cooling it. I felt the smooth texture of the latex glove and could distinguish between touch by his hand, and touch by metal instruments. I didn’t know what he was doing, or why he was doing it, but assumed this was merely an examination that would soon be over, not the permanently mutilating, and disfiguring surgery that it turned out to be.

The Metal Clamp Soon I felt something else touching my foreskin. It was something that was cold, probably metal, and that did not feel good. I could not see it or tell what it was, but it was uncomfortable. It hurt when it pinched my foreskin as it was attached. It must have been a clamping device of some kind and seemed to be made of light gage sheet metal, perhaps spring steel. I felt the doctor pull on this metal clamping device until my foreskin was stretched tight and my penis itself was stretched and very uncomfortable. It is possible my foreskin was stretched to form a tunnel extending beyond the tip. I had the feeling that if I moved in the wrong direction, I might actually pull my penis off, and so tried to remain still. This frightened me further. Despite this mistreatment, the pain and discomfort was moderate to severe, but not extreme. I was thinking that, when this “examination” was over, I would eventually recover and be back the way I was, unharmed. I was wrong again. Harm, it seems, was the whole point.

The Touch of a Scalpel Everyone in the darkened room became silent. Then, with the blanket and boxes blocking my view, and not being able to see anyone’s face or anything else, and feeling restrained, helpless, all alone, and abandoned in the darkness, I felt on my penis the most extreme searing, burning pain. It was greater pain than any other I have ever experienced. It seared me as if to the core of my soul, without warning, without reason, without explanation, without compassion, without understanding,

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and while I was bound and helpless to struggle, against my will, without my permission or consent. I felt a burning arc of pain stream from the bottom of my penis around the right side to the top surface punctuated by a series of separate individual crescendos of pain as each nerve was severed in rapid succession as the scalpel plowed through my most sensitive tissues. Accompanying this extreme, searing, burning pain was the extreme but dull ache of cut skin. I did not cry out. My breathing stopped momentarily. My whole body tensed in shock and surprise. My head looked up and to the right or left in disbelief. My eyes opened wide and I lost my focus on what I could see in the room as my mind focused tightly on my foreskin and I tried to deal with the unexpected burning, searing pain that overwhelmed me. This was the memory that had first broken through to my conscious mind on July 1, 1997. It was the memory that I think has been subconsciously poisoning me psychologically all my life. Because I stoically bore the pain and didn’t at first cry out, I am sure I confirmed their belief that this procedure was indeed painless, justifying withholding all anesthetic. It wasn’t painless. My first reaction was to think the doctor had made a terrible mistake since I had been given no warning that such a thing might happen, nor any reason why it should. Upon seeing my reaction to the first cut, one of the nurses, watching with rapt attention, said “Ha, there we go, I don’t think he likes it much. What’s the matter, baby? Don’t you like it?” Again these were her exact words. The nurses continued to occasionally make insensitive, clinical comments to the doctor as the mutilation and disfigurement proceeded, though I don’t remember what they said. I think this was really a demonstration for the nurses, many of whom may have been student nurses. I did not want this to happen and I was terrified to think what they might be doing to me or what they might do next. They did not explain. They lied. They deceived me with their silence as much as with their words. They did not ask. They just took advantage of an innocent child. My whole body tensed from the pain and shock and tried to escape, but there was no escape. This was not my fault. I was a victim of their cunning, their stupidity, and their greed. I could feel not only my pain, but also the doctor’s instruments and rubber gloves. I could visualize and actually feel the foreskin being removed from my penis, carefully, efficiently, one small piece at a time, with metal tools. It was being removed permanently; it would not grow back. I could also feel the blood from the tiny severed arteries pulsing and flowing over my penis and belly, making them slippery and wet, and the nurse trying to keep the blood under control by blotting it up with a wiper of some sort, pressing against my abdomen, making me more nauseous. The pieces of foreskin were being stripped away from the tip one small piece at a time, never to touch it again. I tried to move to cancel the doctor’s motion, but it didn’t work. I could not pull free, held in place by the “life preserver.” I absolutely did not want this amputation and disfigurement but was powerless to stop it. The message I was left with was that I was only a worthless infant whose body was theirs to mutilate at their whim. I had no value. There was no telling what other mutilations might come next. That message was received loud and clear and I can only believe it profoundly affected my later psychological development in many negative ways.

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Surgical Technique I did not actually see any of the surgery, and I am not an expert on anatomy, but I think I can describe what must have happened based on my sense of touch and my lifelong ability to visualize. I was placed in some sort of body restraining device that looked like a life preserver. My foreskin had been manually separated from its natural attachment to the glans, and then a light gage metal clamp of some kind was attached to the foreskin and used to pull it past my tip and away from my body. The pulling force on the clamp was so strong, that my penis felt stretched in a roughly horizontal direction and was very uncomfortable. I felt like, if I wasn’t careful about how I moved, my penis was going to be pulled off. The first cut of the foreskin was made with a scalpel and began near the bottom right side of my horizontally stretched penis. The cut seemed to sweep circumferentially upward on my right side in a plane perpendicular to the length of my penis from a point near the bottom to a point near the top of the shaft. This cut allowed the right half of foreskin to remain attached at the sides to the uncut left half while severing the nerves at the base of the foreskin. I believe that destruction of nerve function is the primary goal of circumcision as practiced routinely on newborns, and the removal of skin is simply an associated necessity. Once the first semicircular cut was made, there was a brief pause while the doctor put the scalpel down and picked up the other instruments. Then, the doctor began to use tweezers and surgical scissors to cut the loosened foreskin on my right side. With this first incision, the tension that had been applied by the clamping device was relaxed on the right side, but was still present to some degree on the left. The reduction in tension also meant that now the penis was not quite as stretched as it had been. The doctor used the tweezers to grip the loosened foreskin and hold it steady. The doctor used surgical scissors to trim off the skin in what seemed like one very small triangular piece at a time. The right half of my foreskin was removed in what seemed like about six or more separate triangular pieces. I can’t be sure of the exact number or shape and it could have been much more than six pieces. I could feel each small piece of skin being cut and removed separately. I could tell he was fairly experienced using his hands and dissecting tools on biological specimens. This realization that, even though I did not like what he was doing, at least he was skilled and doing it well calmed some of my fear that he might accidentally injure me further. I found my reassurance in knowing he seemed focused only on my foreskin and had not yet attempted to open my belly or remove either of my legs, even if the medical reason to do so equaled the reason to circumcise. It did nothing to change how I felt about what was happening to me, however, nor did it dull the pain. I think his technique was unusual and that was why he had explained his technique to the nurses earlier at the study group meeting. I think he was demonstrating that, when he severs the nerves with the first scalpel cut, he could then use scissors to make many small cuts to the skin without causing me more pain. The many small cuts may have been his way of fitting the remaining skin to the penis so as not to remove too much. At any rate, I think his ego was heavily invested in whatever he was seeking to accomplish and I think he relished having an audience.

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After he had removed most of the skin on my right side, his scissor cuts were getting close to where the skin was still served by functioning nerves from the left side. He seemed to know when to stop, though the last few cuts began to become very painful again and I flinched. He apologized to me, but he did not apologize for the mutilation. I noticed that, as he removed more of the skin, there was less skin to grab with the tweezers and his job was getting more difficult. Finally, he decided he had removed as much as he could without causing me excessive additional pain and risking blowing the whole point of his performance, and he stopped.

The “Intermission” At about this point, after the first half of foreskin had been removed, there was a delay for some reason. My memory is not very clear about the reason for the delay, but I think the nurses expected a pause and said something about it. Perhaps this pause was to allow the doctor time to rest and refocus. Perhaps it was to allow me time to recover by spreading the trauma out over a longer period of time. Perhaps it was to allow the bleeding to slow down. I don’t know which.

The Second Scalpel Cut After this short break, he returned, and everyone again moved in close to me. At this point, I had almost forgotten there might be a second cut, thinking that since the first part was over and done with, I hoped there wouldn’t be another cut. I was wrong. Soon after the doctor had returned and resumed his work, I felt him readjust the clamp pulling on my foreskin to tighten it on the remaining left side, and then the same excruciating, burning, searing pain, the crescendos of pain as each remaining nerve was severed, and the cutting from the bottom but this time on the left side, sweeping up to the top. Then there was the tweezers, grabbing the partially severed foreskin, and the cutting with scissors. By this time, the tension on my penis was completely relieved and it was no longer being stretched. Apparently, the second cut did not quite join the first cut at the top or bottom but was intended merely to sever the nerves; else the left half of the foreskin would have merely fallen off, spoiling the doctor’s fun. By then, I knew the routine. Next, he used tweezers and scissors to remove small triangular pieces of foreskin and to put a final trim on the skin.

Blood Runs Freely I felt the moist tip being exposed to the cool air as the pieces of healthy, warm, protective foreskin were cut away. I felt the blood running on my penis, dripping, and being smeared on my abdomen. I felt nothing contacting the tip, as had previously been the case with the warm, snug foreskin. I felt the nurse wiping up the blood, smearing it around on my belly with an absorbent cloth. The feeling of blood and

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the pressure on my abdomen from the wiping scared and sickened me further. My emotional reaction was severe because I knew very well the disfiguring mutilation was unnecessary and wrong. I knew it at the time, at six days of age, but could not communicate to stop it. I will forever be disappointed in the doctor that he could not (or would not) see the unnecessary nature of the mutilation. I had trusted these people, but realized they had betrayed that trust and were now dissecting me, alive, for no reason anyone has ever been able to explain to me.

The Merciful End to Torture When my ordeal was over, the nurse in the white RN uniform removed the blanket and boxes blocking my view so I could see again, and unfastened me from the restraining device to which I had been shackled. She lifted me up and laid me on my back on the table. Shortly thereafter she disappeared, leaving it to the other two nurses to clean up. One was a young nurse, perhaps a nurse’s aid, about 18 or 20 years old, perhaps younger. The other one was much older, and very thin, with a gaunt and heavily wrinkled face. She was probably about 45–50 years old or more, looked much older, and probably was a heavy cigarette smoker. I think now the older nurse was as much a janitor as she was a nurse. I thought at the time the older nurse was ugly and mean tempered, and not someone I wanted to have around me. I was glad the one nearest to me was the younger one. Immediately afterward, the doctor disappeared from the room as the nurses worked straightening everything up and preparing the room for its next use. The doctor soon returned fully dressed in his brown suit and said something to me I didn’t completely understand, but that I remembered. As I was lying there in agony from the severed skin, he said, “There you go, Buddy. No need to thank me. I was glad to help you out. Now you’ll be fine and you can thank me later for the wonderful thing I did for you.” These were close to exactly the words he used. I noticed he didn’t say “Buddy Boy” this time, only “Buddy.” He forgot the name he gave me and that was just one more impersonal insult to top off the day. I think it was important to him to convince himself he was doing something good. I think somewhere in the back of his fuzzy thinking, he might have suspected the truth, but had suppressed it. It was good I didn’t have to thank him.

Make Him Stop Crying! Pick Him Up! I cried continuously at this point. It was the only way I could communicate my pain with these people and have any hope they might do something about it. I think I also needed to communicate to them that I had been genuinely injured, pointlessly, and I knew that they were responsible. The older nurse was busy cleaning up the blood-soaked linen and putting things away. She ignored my cries as long as she could, until she could take no more. She shouted rudely and sharply to the young

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nurse, “Make him stop crying or I’ll come over there and give him something to cry about! Pick him up! Pick him up!” Again, these were her exact words, delivered in a very angry, menacing tone. I stopped crying, momentarily, out of fear, but I wish now I hadn’t. I wish I had begun screaming. I think that much if not all of the psychological damage I experienced resulted from being injured in this way for no reason, feeling extreme pain, and being surrounded by people who thought I had no pain and who wouldn’t listen to my cries. I continued to cry from the unremitting pain, the surgical shock, the ache of severed nerves and skin, the nausea, the blood loss, the fear, and the anger.

My Vow to Remember and to Obtain Justice I sensed the nurses wanted me to forget about what had happened. I think they said as much. Before I lost consciousness, however, I vowed to myself that if these people thought these events were something I would forget about, and that was how they were going to get away with them, they were wrong. I would make an extreme effort to remember what they did to me that day so that someday I might obtain justice. What justice was, or how I would do that was still a mystery to me. I do remember thinking in precisely these English words the thought “I will not forget this!” This thought kept running through my mind, over and over. This is not the adult interpretation of my feelings; this was literally the thought in English words that went through my small head, time and again, as I lay there in agony on my sixth day. I think this intentional effort to form a permanent memory is probably why I was successful so many years later in recovering this memory.

Merciful Sleep: The End of that Day for Me I did finally stop crying as exhaustion overcame me. Before I lost consciousness, I remember feeling sick to my stomach. My penis burned and I felt the dull but severe ache of cut or torn skin. The fact that my penis ached so much and that the nurses ignored my cries only contributed to my rage. This was not the gentle sleep of a baby, but was the result of the extreme physical and emotional stress I was put under, coupled with the significant blood loss and effort of screaming and crying, mostly to no avail. At the point I blacked out, no one had dressed my wound or wrapped me in a blanket to keep me warm. Apparently it was more important to clean up the room than to tend to the injured infant. It is here my memory of that event that day ended, as my mind went black and I went to sleep. The terror, anger, rage, deception, betrayal, and pain of that memory were as much as my young mind could handle. My brain immediately buried that memory in the deepest recess it could find. When I next awoke, I did not remember the event clearly, but remembered enough to know I should be scared. The next time this anger surfaced was over 51 years later.

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Day Seven or Eight, Tuesday or Wednesday, About 10:00 A.M. My Reawakening I do remember the next time I was awake. I awoke in a bassinet in a brightly sunlit nursery room. It seemed like late-morning, probably about 11 A.M. or 12 Noon; though I can’t be sure it wasn’t later. The morning rush hour of the nurses was over, and a calm bustle had settled in. I know it wasn’t the same day as the circumcision because if it were it would have been late afternoon or night. The room was very warm and I was very groggy from sleep (remember, I was not given anesthetic), felt very warm, and a little nauseous.

Power Lawn Mower I recall hearing a sound like a power lawn mower, with the clatter rising and falling as it came close to the building and then moved away. A nurse shut the windows to reduce the noise. One nurse heard a car screech its tires and began a lecture about unsafe drivers and the damage they can do. One of the other nurses said to another nurse that she wished the talkative one would shut up. I agreed.

The Intense Itch I remember, some unknown amount of time later that day, being carried from my bassinet in a wicker bassinet insert and placed on my back on a low coffee table or surface of some kind in a hospital public area just outside a ward of beds. I was wearing a loose fitting diaper. Lying on my back, the diaper was pinned at the waist and formed a large gap off my belly at the top in front. I remember that my penis, where my foreskin had been, itched intensely. I tried to look down my belly to see what was causing the itch. With some effort on my part to control my hand, my hand touched the end of my penis and I felt something that seemed dead and that had no feeling. I was immediately frightened that my penis was dying and falling apart. I touched the dead material to try to stop the itch and found to my surprise I could grab it and pull it. I could not see what I was doing and thought I might be tearing more of my dead penis away. Removing it did stop the itch immediately, however, and so I continued. No nurse ever checked on what I was doing. With the removal of the foreskin, they seemed to lose interest in me. When the nurse did return, she didn’t even seem to notice I had removed the dead material. This thought that I was pulling off pieces of dead penis, probably coupled with the pulling of the foreskin clamp during the circumcision, became the subject of yet another dream that I had many times through my childhood and adulthood in which my penis would come loose and could not be reattached.

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A Gauze Strip Saturated with Vaseline Brand Petroleum Jelly The dead material seemed adhered with some sort of sticky salve. It turned out that the dead material was gauze (probably the dressing to protect the wound). It was saturated with a sticky salve (probably Vaseline-brand petroleum jelly). It was probably intended to prevent urine from making its way to the incision and causing pain and diaper rash there before the incision healed. It was some kind of wellpracticed nurse’s trick. With the gauze removed, I could see the edges of the cut skin and bits of bloody scab at the incision line on my penis. The wound seemed recent, but dry, partially healed and somewhat shrunk. There was no fresh bleeding. Seeing the condition of the incision made me think that much time had passed since this condition had been inflicted. I think the physical healing must have been well underway, causing me to believe it was at least 48 hours after I had been cut, and perhaps longer.

A Visit from My Mother and Time to Get Ready to Go Home; Wednesday About 11:30 A.M. I heard the nurse come and go a few times. She began talking to me, saying in an excited voice that I would be going home in a few days, and she wanted to bring my mother to see me. It is revealing that, even though they wanted to show me to my mother, they could not simply carry me in to her, but had to arrange a surreptitious rendezvous in the common area outside the ward, so as not to make the other mothers want their babies, too. Also, it seemed to be hospital policy to prevent mothers bonding with their babies on hospital premises. What were those people thinking? What frightened them so much? After about half an hour, I saw my mother for the first time. She was wearing a pale green robe that was open in front with white pajamas or hospital clothes underneath. She bent down to look. She did not pick me up or touch me but spoke to the nurse for a while and then left. She did not speak to me and acknowledged my presence only to the nurse. If only she had picked me up and held me, I would have felt safe for the first time. I have come to learn in later years that she probably didn’t want to risk hurting me and so chose not to touch me, but I didn’t know this then. The world, indeed, was a cold place for me. I don’t currently remember leaving the hospital, or of arriving home the first time, but I do remember the excitement in the nurse’s voice about getting me ready to go home. I didn’t know anything about “home” or why I should be excited and not terrified. I remember thinking at the time the nurse was being unnecessarily enthusiastic and she was embarrassing me. As my mother left me to go back to her room, my recollections of hospital life ended.

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Epilogue Since completing and documenting the bulk of my recollections, I certainly understand better than I did before what happened to me. I still am affected by my experiences and probably always will be, though I may never know the full extent of damage or what might have been. The anger will always be there but at least the mystery is gone. One improvement I have noticed is that now I sleep more soundly than I have most of my life. I dream pleasant dreams almost every night. This is very unusual for me, but a welcome change. My hope is that anyone who has read this far has found my account interesting, and has perhaps gained some useful insight into the mind and awareness of a newborn. I hope further that anyone contemplating circumcision for someone other than themselves will have second thoughts and stop, realizing that no one has the right to sexually mutilate another person’s body and that medical indications for circumcision are rare. We owe special consideration to those, such as infants and children, who cannot protect themselves, but who, if mutilated when young, will grow in time to be mutilated adults. Laws protect adults. Why don’t the same laws protect children? Why do we continue to sacrifice our children on the altar of the medical gods.

Chapter 18

Foreskin Restoration 1980–2008 R. Wayne Griffiths, J. David Bigelow, and James Loewen

Abstract The goal of foreskin restoration is to cover the glans penis to some extent with a double sheath of retractable tissue. Many men who contact NORM (the National Organization of Restoring Men) want full coverage of the glans, plus overhang, even when fully erect. A realistic goal is important, however, since satisfaction or disappointment is clearly related to expectation. For a tightly cut man, “success” may be just enough loose tissue so that erections are no longer painful. For others, it may be possible to achieve full coverage during erection. Currently, there are both surgical and non-surgical methods to re-cover the glans. The results, however, of most surgical procedures have proven disappointing. This presentation discusses both methods; however, the emphasis is upon various non-surgical tissue expansion techniques and devices. While the moveable sheath that covers the penile shaft is commonly called “skin,” its structure is far more complex. Therefore, expansion of the shaft tissue is more challenging than expanding ordinary skin. Keywords Foreskin restoration · Glans · Foreskin · Non-surgical tissue expansion · Moveable sheath · Dartos muscle · Peripenic muscle · Raphe · Corpus cavernosa · Corpus spongiosum · Tunica albuginea · Nerve supply · Ridged band · Meissner’s corpuscles · Viagra · Surgical reconstruction · Scrotal tissue · Mitosis

Natural Structure Before recounting the history and methods of foreskin restoration, I would like to discuss the structure of the shaft tissue and the effects of tissue expansion upon that structure. I will then describe the most common devices used for tissue expansion. Parenthetically, I will mention surgical reconstruction. I will also show some devices used as protection for the circumcised penis. R.W. Griffiths (B) National Organization of Restoring Men, Concord, CA, USA e-mail: [email protected]

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To understand the process and practical issues associated with restoration, we need to take a detailed look at the structure of the penile shaft tissue. The corpus cavernosa is bound by fascia, which determines the diameter of an erection. As we discuss various aspects of penile structure and foreskin, it is important to bear in mind that the shaft covering is a complicated structure, not just skin (derma) as most people seem to believe. The dartos muscle starts at the perineum, envelops the scrotum, and, as it reaches the shaft, it is sometimes referred to as the peripenic muscle; albeit it is the same muscle. The dartos smooth muscle lies about 1 or 2 mm beneath the outer layers of the shaft tissue, which is skin. Between the dartos muscle and the skin are elastic fibers. The dartos muscle is quite separate from the skin layers, except on the ventral side where they join at the region of the median raphé (Fig. 1).1 The muscle fiber bundles are very slender and made of few cells, but they appear in every direction: transversely, longitudinally, and obliquely. At the prepuce, a great many of the fibers course in the long axis of the organ. They are loosely packed and filled with lax fibrous tissue. One researcher suggests that the dartos muscle fibers run circularly, forming a sheet of muscle of equal thickness for the entire length; however, the muscle lines the inner mucosal layer and doubles as the outer sheath tissue, forming the double layer of the foreskin.2 The layers of the penile shaft covering, from the outside inward, include the epidermis, dermi, and the superficial fascia (loose connective tissue that is connected to the dermis and enables the extraordinary mobility of the penile skin), which is also intimately connected to the dartos fascia layer (peripenic muscle), and to most superficial veins. The next inward structure is the fascia penis, which is condensed connective tissue; it surrounds both the corpora cavernosa and corpora spongiosum. Each corpus cavernosum penis is surrounded by the tunica albuginea, very dense connective tissue and almost pure collagen, providing strength against over-inflation (in the manner of reinforced garden hose). This factor determines maximum penile size.3 The ridged band and frenular delta are the most specialized parts of the penis. They contain more nerve endings than any other part of the penile organ. There are

Fig. 1 Dartos muscle (see endnote 1)

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Fig. 2 Ridged band (see endnote 5)

Fig. 3 Ridged band and frenular delta (John A. Erickson, photographer)

17.9 bundles/mm ventrally, 8.6 bundles/mm laterally, and 6.2 bundles/mm dorsally. As each bundle contains tens of axons, the nerve supply to the prepuce is obviously very substantial (Figs. 2 and 3).4 The majority of the medical community in the USA is apparently unaware of or disregards the fact that this specialized mucosal tissue even exists. They are

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also apparently ignorant of the quantity of Meissner’s corpuscles which, when stretched and rubbed over the corona of the glans, trigger fine touch sensations during sexual activity.5,6 Circumcision removes this erogenous tissue, which cannot be replaced (although questions have been raised about the possibility of cloning a new prepuce). In my opinion, the medical community in the USA would not even consider this issue, and, if they did, it would no doubt be at the bottom of the list of their priorities. Also, the pro-circumcision advocates would not be helped in their cause. One restorer was told by his healthcare professional that the medical community prescribes Viagra-type medicines as an apology for circumcision. The medical community often uses terms, such as “redundant” and “excess” to describe the foreskin; however, a second set of adjectives that intact men know to truly define the foreskin include: “profuse, lavish, bountiful, luxuriant, exuberant.”

Surgical Methods of Reconstruction In order to fully cover the history of restoration, we need to at least mention surgical reconstruction—the chronology of which dates back to biblical times and also includes attempts during WWII to camouflage Jewish circumcision. Although a few modern-day procedures (beginning in approximately 1980) have been reasonably successful, most attempts have not had the desired results. A few types of reconstruction are (1) a skin graft from thigh or buttocks, (2) scrotal implant, or (3) Z- or Y-V plasties. Skin graft methods place hairless tissue from elsewhere on the body, unlike penile/scrotal tissue, into a circumferential cut made around the penile shaft. Both the structure of the grafted tissue and muscle, if any, do not perform in the same manner as the very elastic penile shaft tissue. The transplanted tissue usually has a very different condition, texture, and is quite inflexible and smooth. One man commented that his reconstruction looks great, but has no feeling and is quite numb. He added that his sexual activity has not been enhanced. A scrotal implant graft is a multiple-stage reconstruction, involving circumferentially cutting the shaft tissue at the circumcision scar. A tunnel is created in the front side of the scrotum between two incisions, and the penile shaft is threaded through the tunnel, and stitched at both ends. After about six months, when healed, the penis is surgically removed with the new scrotal tissue cut on either side and wrapped around the shaft and sewn on the ventral side. There is then another healing period. At that point, it is typically necessary to reduce the “overhang” and to enlarge the orifice of the new foreskin. One restorer, who had this procedure done in the mid 1980s, had a “wonderfully” long foreskin; however, it was non-retractable. Later, the plastic surgeon cut a ventral slit to facilitate retraction, leaving a dorsal flap over his glans of considerable length (approximately three inches).

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Non-surgical Methods of Restoration Contrary to surgical methods, tissue expansion uses the current tissue expansion method of producing new tissue. In the case of foreskin restoration, it avoids surgery, nerve loss, or disasters that are more common with surgical methods. The works by Takei et al.,7,8 indicate that cyclical periods of tension are quite successful and a preferred method of producing additional new tissue. This method is well suited to the many and varied functions of the penis. Parenthetically, some men have felt that penile pumping would achieve the desired results of tissue expansion; however, the new cells that form after pumping remain in a bloated state and continue to reproduce bloated cells for life. A couple of men who have pumped for many years have a penis that looks like a bloated sausage. In addition, the penis is soft and spongy to the touch.

A Logical and Successful Restoration Regimen New cells are produced by the process of mitosis, that is, cell division. It has also been shown that excessive tension does more damage than moderate tension. Excessive tension causes scar tissue to form, which takes longer to “heal” and hinders flexibility.9 Since the shaft tissue is both muscle and skin, the model for foreskin restoration is a body-building regimen. In such a regimen, one works on the upper body one day and the lower body the next; this allows each set of muscles to have a day of rest to generate new cells and then to be coaxed again the following day to grow more cells. The same principle is true for the penile shaft tissue, which consists of tensioning for a determined number of hours during the day and then letting it rest at night. Consequently, one must realize that there is no fast or instant restoration. One must work into his daily habits a regimen that will suit his lifestyle and work habits. One colleague has noted that one is “fooling” the penile tissue into “thinking that it has to grow to cover the longest penis in the world.” A suggested regimen (which has worked quite successfully for many restorers) is to apply weights or an elastic tether in the process of getting ready to start one’s day. One wears them from four to eight hours and then removes them later in the afternoon or evening. Actually, it is suggested that one start his restoration regimen with a manual tensioning method to get accustomed to a daily regimen. By so doing, one forms a daily habit of tensioning. During this initial period, one has time to consider the type of device that would suit his lifestyle best before making a purchase or designing a homemade device. It is important that cautions be observed and followed: Don’t cause or endure pain. Don’t be overzealous. Don’t cause constriction of blood flow, which includes pain and/or color changes. It is important to make pressure tests to check blood flow.10 Further, as part of the restoration regimen, no matter what device is being

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used, there must be frequent release of the tension against the sheath tissue and/or pressure against the glans so as to allow for free blood circulation. The restorer will want to keep the glans covered as soon as it becomes more sensitive and the nerves become more responsive. When one achieves some longer tissue, a retainer can be used for the remainder of the evening and night. This will keep the glans covered and protected from rubbing against clothing. It will also help retain the sub-preputial fluids, where they will start the process of dekeratinization (sloughing off of the layers of calloused tissue). The retainer might be a tape ring, crisscross taping, an O ring, or narrow Velcro strap. Such a nighttime rest period will allow the shaft tissue (derma and muscle) to produce additional cells. Some restorers have advocated excessive tension for 24 hours, 7 days a week. This type of regimen does not work well, as most of us have other things to do, which involve our genitals, such as urination, sex, bathing, and rest. As noted above, damage and much longer healing time is required with such a stringent regimen, and constant tension is not necessary to achieve restoration. Experience has also shown that restoration does not happen faster with such a regimen. Some of the tissue and muscle may be torn by such excessive tension and, if so, scar tissue is formed in the muscle fibers; flexibility and mobility are thus reduced. Every male has just one penis and needs to become aware of its structure and its care. Please be careful and be aware of what your own body is telling you about your efforts to restore. There are many devices that have been invented since NORM was founded in 1989. In past centuries, the Pondus Judeaus and thongs were used to lengthen the foreskin or to keep the glans covered. The first modern-day recorded attempt occurred in the early 1980s. It involved implanting a small platinum ring in the remaining shaft tissue, which held the tissue in front of the glans. It was hoped that, eventually, the shaft tissue would lengthen to cover the glans when the ring was removed. The tension proved to be insufficient to lengthen the tissue, and, further, calcification formed a ridge where the ring was implanted. A great many devices have been designed since that early effort. A select few of the current devices have been chosen for discussion, along with an evaluation of the results that each one produces. Various devices produce somewhat different results; all devices will produce new tissue and, thereby, produce a “foreskin.” Many current procedures require the application of tape to the shaft tissue; however, fixed tape does not allow the tissue covered by the tape any tension or growth. Therefore, the less tissue covered by tape or the device, the more sheath tissue is tensioned and coaxed to grow additional cells. As a consequence, the degree to which tape is used in the various procedures should be taken into consideration when choosing a restoration method.

Restoration Devices The following is a brief description of the selected devices in the approximate order in which they were invented and made available to the public. Only a few devices have actually been patented: the PUD, Vac-U-Trac, and the Tug Ahoy. Most others

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are being produced and made available without restriction. At present, NORM is aware of at least 17 devices available, and a more thorough count, no doubt, would yield several more. The FOREBALLS was devised in 1987. The first version was made by “barrel” taping two balls together as is shown in The Joy of Uncircumcising, by Jim Bigelow, PhD, as a homemade device. With ideas from fellow restorers at NORM meetings in San Francisco in the early 1990s, the tape was replaced by a rod welded between the two balls. At one of the meetings, someone suggested the name “FOREBALLS.” The PUD (Penile Uncircumcising Device) was patented by American Body Crafters’ Roland Clark. The device was made in several sizes/weights. Wide tape is required to secure the device to the shaft tissue. Because of the circumference of the device, it holds the new foreskin in a somewhat tube shape. The American Body Crafter web site touts it as, “The most sophisticated foreskin restoration product to date.” The BUFF (Brothers United for Future Foreskins) method was available privately from a source in Arizona. It featured the use of tape strips to secure the foreskin in front of the glans. It was soon discovered that a source of additional tension was needed to produce further results. The use of silicone cones to provide the needed tension was one of the first methods developed. It was published in Mark Waring’s 1988 pamphlet, Foreskin Restoration (uncircumcision). After several months of utilizing the information from BUFF and Waring’s pamphlet, Tim Hammond and R. Wayne Griffiths felt the need for a support group. Together, we founded NORM in February 1990. Shortly after its founding, the NORM group was asked to try on various sizes and shapes of the Second Skin Cones, which we did at a meeting in Concord, CA. The cones were a bit bulky, and we made several recommendations for better shapes and sizes. When the cones were produced, in both weighted and non-weighted forms, men who used them complained that the meatus was pushed into the urinary opening and that long-term use was often uncomfortable. D. Evans, of Arizona, devised the T-Tape System. The T-tape method uses fixed tape to secure the shaft tissue and provides tension with an elastic strap. In this method, the tape is applied around the shaft tissue of an erect penis (to allow for nocturnal erections) and holds the tissue in both directions, extended circumferential as well as longitudinal. D. Evans also made a small number of videos, not only of the device, but also of a NORM meeting, as well as other documents about the benefits of restoration. However, he soon went out of business, and others have since made available the instructions and T-tapes. The RECAP-EZ was devised by Arthur Gibson of Texas. It is a combination device that allows the restorer to vary his regimen. The variations are all based on the cone-and-cup structure, which is a tapeless device system. One of the varieties has a scrotal retainer to hold the scrotum in place against the body and allow the cone/cup to tension only the shaft tissue. Due to their bulkiness, most of the RECAP-EZ devices need to be worn at home. The DTR, Dual Tension Restorer, uses pressure against the glans to provide tension; however, the strength and size of the rubber band determines the exact tension. NORM holds that using pressure against the glans to achieve tension is not the best

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procedure. The glans is being crushed, thereby, compressing nerve endings and cutting off circulation. One must be sure to relieve such pressure/tension often in order to provide relief from the compression and allow for blood circulation.11 The CATIIQ—(Constant Applied Tension II Quick), devised in 2002, is another variation on the pressure-against-the-glans system. It uses a rod with a collet/ferrule that applies whatever tension one puts on the glans. TUG AHOY is made by a physician in southern California, which he touts as the “gold standard of foreskin restoration.” The cup is made from half of a flexible toy-store “egg.” The other half is used as the cone, with a bent coated wire attached to an elastic strap for tensioning. The TLC TUGGER is a very sophisticated tapeless tensioning device made with various sizes of cups and cones to fit the individual shape and size of the glans penis. It is made of food grade silicone and uses an elastic band for tension. THE NATURAL RESTORER is a weighted device of stainless steel with a long rod. A lock screw on the rod governs tension. It is a device that, again, puts pressure on the glans for most of the tension. MYSKINCLAMP is a complex device. The cup puts pressure on the glans and the cone holds the sheath tissue. There is a sturdy spring that has to be adjusted and locked in place with a setscrew on the rod. Should the setscrew loosen, however, the spring would expand to the fullest, and that could possibly cause tearing and pain.

Homemade Devices There are many inventive homemade devices made from the use of pill tubes, 35 mm canisters, and plastic pipe couplers, which are discussed further. One device is made with a baby bottle nipple fitted over a cup with a rod through it to hold a ring. It uses an elastic strap for tension. It has the advantage of pulling away from the glans. Paul’s Foreskin Restoration Kit supplies materials and instructions to make a cup-and-cone tensioning device. Tube devices are made using a pill tube, a PVC pipe coupler, a 35 mm canister, etc. to place over the glans. The sheath tissue is taped to the outside of the tube. It does not have to be removed for urination. While the device does lengthen the new tissue; it also widens it. Therefore, the lengthening tissue will not readily close down over the glans like a normal foreskin. Men have contacted me to get information on surgical closure because they have used such devices/methods that have not given closure to the aperture of the new foreskin. Although such surgical procedures are presented in The Joy of Uncircumcising, later experience with such surgical touchups has not proven successful. They are no longer recommended. O rings have been used in various ways as nighttime retainers or several in a sequence on the foreskin to put tension on the tissue. If the rings are narrow and too small, circulation will be cut off quite quickly and the rings must be removed. ANGUS’ O RINGS are a variation on the use of O rings with a urination tube.

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Foam cones are made in various lengths and widths to be compressed over the glans. The shaft tissue is then taped in place so that the foam expands to put tension on the shaft tissue.12 Such cones, however, expand the tissue in both diameter and length. Tape straps with weights or with an elastic band are made in any number of variations. Single Ball Bearings. Some men have used a single stainless steel ball placed in front of the glans, and the shaft tissue is pulled over it. A Velcro strap or cross tape system is used to hold the bearing in place as a weight to tension the shaft tissue. Velcro straps or tape rings are usually used as a retainer to keep the glans covered when not tensioning. It is similar to the O rings used for the same purpose.

Non-restoring Covers There are a number of products that have been offered since the beginning of this era of restoration, such as: MANHOOD is a rayon sheath that was designed to cover the circumcised penis and to protect it from abrasion and cold especially for bike riders. It was designed by and is available from the maker in Canada. SENSLIP is a latex tube with ridges and is attached to the penis with a fold in it to simulate a functioning foreskin. It is somewhat complicated to apply. The concern is that the glans, mucosal tissue, and shaft tissue are covered with a foreign product rather than natural tissue. The manufacturer says that it is porous and should be used mainly for sexual intercourse. The problem, however, is that, if left in place too long, it produces an anaerobic condition that is not conducive to healthy tissue.

Natural Phimosis Treatment NORM has been the central clearinghouse for information about both restoration and how intact men can lengthen their foreskin, as well as providing help for men with phimosis. For the latter, the following devices are available: GLANSIE, from Japan, is a speculum (an instrument for examination of canals) with narrow tips that can be inserted into a phimotic foreskin. It puts tension in a lateral direction to gently open the foreskin so that it will allow retraction over the glans. With time, new cells are formed and the opening widens. PLATIGO AFS BALLOON, from Australia, is a device using small balloons to put tension on the foreskin to widen the opening. With time, new cells grow in the foreskin tissue. This homemade phimosis treatment device is merely an old-fashioned spring clothespin that has had the finger ends tapered. When used, it is opened and coins or washers are inserted into the opening. As necessary, these coins/washers are removed to open the tapered end to provide tension on the opening of the foreskin.

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Fig. 4 Restored foreskin (James Loewen, photographer)

Results As can been seen, the restorer in Fig. 4, after using tissue expansion for about a year and a half, has full coverage of the glans, with an overhang of about three quarters of an inch. When the body is warm, the foreskin opens and can be easily retracted. It is also noted that, after 20 years of being covered, the foreskin has reduced in its thickness and works quite naturally. It protects the glans.

Notes 1. Jefferson G. (1916) The Peripenic muscle; some observations on the anatomy of phimosis. Surg Gynecol Obstet (Chicago). 23(2):177–178. 2. Ibid. 3. McGrath K. (2001) The frenular delta, a new preputial structure. In: Denniston GC, Hodges FM, Milos MF. (eds.) Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem. New York, NY: Kluwer Academic/Plenum Publishers. 4. Ibid. 5. Taylor JR, Lockwood AP, Taylor AJ. (1996) The prepuce: Specialized mucosa of the penis and its loss to circumcision. Br J Urol. 77:291–295, February. 6. Taylor JR. Private correspondence. 7. Takei T, Mills I, Arai K, Sumpio BE. (1998) Jul.: Molecular basis for tissue expansion: Clinical implications for the surgeon. Plast Reconstr Surg. 102(1):247–258. 8. Takei T, et al. (1997) Oct.: Effect of strain on human keratinocytes in vitro. J Cell Physiol. 173(1):64–72. 9. Ibid. 10. Bigelow J. (2002) The Joy of Uncircumcising! Exploring Circumcision: History, Myths, Psychology, Restoration, Sexual Pleasure and Human Rights, 2nd ed., p 14143. 11. Ibid., pp 172–173. 12. Ibid., pp 174–177.

Chapter 19

Restoration: The Foreskin and the American Dream Ron Low

Abstract The author first heard about intactivism in the “Letters to the Editor” section of a national monthly magazine in 1986, at age 24. A decade later, a seed was planted by something he heard on the radio, and now he markets foreskin restoration devices, with over 10,000 clients served. Being a “professional” intactivist has given him some unique opportunities. He explains why he counts himself among the lucky few—with a life’s work in perfect harmony with his passions. Keywords Foreskin · Penis · Uncircumcising · Jim Bigelow · Glans · Tapeless tugger · Intactivism · Devices · TLC tugger · Circumcision · National Organization of Restoring Men (NORM) · Howard Stern

My Journey Begins When I was an 11-year-old boy, I pedaled up to a group of male friends involved in a lively discussion: “. . . Plotzstein is!” said one. “Is what?” I asked. They were discussing who among us was circumcised. Until that moment, I had never imagined there were kids around with anatomical gifts I didn’t have, but Plotzstein’s Irishheritaged tormentors were intact, probably the only normal boys in my grade. We never got around to my turn to be tormented because a mom stepped outside to render our conversation more polite. Later, I asked my own mom about it, and I got the standard description of an inconsequential flap of skin, without which I would be happier and cleaner. Over the years, I gradually realized the vast majority of my peers were like me. I personally never noticed any problems from my lack of a foreskin. I never even fretted that my dad’s penis was different. Even though we saw each other nude plenty

R. Low (B) Northwestern University, Kellogg Graduate School of Management, Chicago, IL, USA e-mail: [email protected]

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of times, I just hadn’t noticed Dad was intact. By the time I was 24, I had enjoyed plenty of opportunities to make sure my anatomy measured up to the expectations of the opposite sex, and foreskin absolutely had never been mentioned. Then one day in 1986, I was browsing my roommate’s Mensa Bulletin magazine. The letters to the editor included several notes about some article I never saw from the prior month. The first two letters sounded like my mom could have written them; foreskin is a dirty flap, intact men get diseases, cutting infants is easier than having adults endure major surgery, etc. But, then came one from an intact guy saying the only problems he’d ever had were too much sensitivity and women handling him roughly, but that he’d overcome both with practice and communication. Then, one from a circumcised man; he explained all about what he thought he was missing and what his partners were missing, how most of the world was intact, and why only an adult should be allowed to elect his own cosmetic pleasure-reducing surgery. I realized in that moment that my mom had no idea what she was talking about when it came to a penis. She even had told me: “Your father had no end of trouble until they did his.” Her language was so vague, I thought she was describing his circumcision; I didn’t find out for another couple of decades that Dad, to this day, is still intact. My parents divorced when I was a kid, so Dad wasn’t handy to discuss it with when I read the Mensa letters, even if I had been inclined to bring it up. Now I knew. There were enough guys on either side of the issue in that magazine (and in the following month’s issue) that there was no way it made sense to decide this on behalf of an infant when he could just as easily weigh the evidence for himself when he matured. I was a silent intactivist for a decade after that. I didn’t know anyone expecting a baby boy to bring it up with, but I would have said to let him decide for himself, if the subject had come up. I didn’t know restoration existed, so there was no point in interjecting purely bad news about lost sensitivity into discussions with my fellow circumcised young men. Then came Jim Bigelow and his book, The Joy of Uncircumcising! I heard Jim being interviewed about his book in 1995 on Chicago radio, and he said in no uncertain terms that sex was a lot better since he had restored his foreskin. The DJ was as intrigued as I was, but after the interview was over, the DJ said: “I suppose that guy made sense, but I’m not going to hang a weight on it.” The DJ’s sidekick chimed in: “And couldn’t he just wear a. . . a little hat?” I am now selling the little hat. Knowing that sex could be better was not enough yet to move me to start restoring. I didn’t want to “hang a weight on it” either, and besides I didn’t then recall the title of that book about restoring. Plus the taping-my-penis part didn’t sound like too much fun. And sex was fine, I thought; I was able to give my wife, Alice, as much satisfaction as she could stand. But in 2000, Alice surprised me for Fathers Day. We spent the night in a romance hotel. My wonderful wife had worked out all the details. It should have been a fantasy come true. And it was for her, but I was unable to climax until the next morning.

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Restoration After the Fathers Day 2000 sex romp didn’t live up to my expectations, I wanted to ascribe a cause. I decided I lacked sensitivity due to my exposed glans. I began using copious amounts of lotion on my genitals to help me become more supple. Soon enough, I got an infected hair follicle on my scrotum, which I told my doctor might be due to all the lotion I was using to get more “supple and sensitive.” He said I had better stick with “tough and leathery,” never mentioning the possibility of restoring. I’m sure he didn’t know about it. By Christmas, I decided I definitely would restore, and started researching methods on the Internet. I really didn’t want to use tape, but the tapeless methods didn’t make sense to me. There wasn’t enough evidence online to convince me they weren’t an elaborate hoax. And the money for a tapeless device wasn’t trivial either. I decided I could try a simple tape method called the Pill Tube (aka, the Canister) based on a web write-up by Australian Bill Sides and, if it showed promise, I might invest in a fancy device. I still recall muting the TV on the evening of April 1, 2001, and explaining to my wife how I was missing something, and summarizing what I had learned about how to get it back with medical tape and elastic straps. She said: “That’s ridiculous. Is this an April Fool’s joke?” No, I told her, I was serious and that I would need her patience and support because I might have tape on my penis when she wished to employ it. We would need to be a little less spontaneous and more planned in the bedroom. Alice quickly caught on to warning me about when to get untaped, and I was soon taping my penis every morning after my shower before work, and not usually untaping myself until the following morning’s shower. Two months of this taping was enough. I ordered a tapeless device online and waited. It never came. Had his device shown up in my mailbox, I would have started using it and might never have bothered making my own. But, I got most of my money back from PayPal and went back online to discover that a man named Dave Leary had published a “how-to” for crafting a silicone tapeless tugging device at home. I made myself a tapeless tugger, which would become the prototype for today’s TLC Tugger. After months of tinkering with it, I wrote to Dave to discuss some improvements on his concept and he gave me his blessing to offer ready-made devices to restorers. Once I started to see measurable gains in slack skin, I was convinced non-surgical restoration would really let me get a whole foreskin’s worth of slack skin back. I started hanging out in the online forums (none of the ones that were around then survive to this day). My new passion was becoming more than a hobby, it was an obsession. Every night, I would get to bed an hour or two after my wife because I found it so rewarding to help the beginning restorers online with their questions and concerns. I was so delighted with my own progress that I published my explicit monthly status photos and some methodology guides online in hopes they would help and inspire others. I knew that every man who discovered restoring

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and improved his sexual experience would most likely also join us to help shout down those who would advocate cutting an infant. At that time, my intactivism prompted me to write to the VP of Human Resources at my day job and tell him how much money we could save if we dropped coverage for routine circumcision from our health plan. He did not appreciate being told how to do his job and also that his culture’s covenant was needless cosmetic surgery. My boss called me in to yell at me for not working this cost-savings scheme through proper channels. Since my job was Industrial Engineer, anything that saved the company money was legitimately my area, so the dust eventually settled. But then the 9/11 attacks came. Sales volume dropped and the company needed to cut costs. The same VP of Human Resources directed each department on how many people they would have to cut. My department was just my boss and me. We were told we would have a 50% reduction. I suppose my salary was a little more money saved than what they were spending on routine infant circumcision.

You Can Get It on Ebay I got another engineering job in 2002 at a toothbrush factory. My family had gotten by in the meantime by selling things on eBay. We got quite creative, for example, by reproducing our kids’ watercolors as lovely calendars and greeting cards. By March of 2003, I had decided that wearing a tapeless retaining cone to hold the shaft skin over the glans was the easiest thing any circumcised man could do to get a persuasive taste of what he was missing. I had visions of millions of circumcised men picking up a cone at the local drugstore and using this simple painless trick to realize the harm of infant circumcision. I didn’t know how to make or sell cones by the millions, but I could make a few. To test the market, I made an eBay listing and offered cones for a few weeks in an online auction. I announced the availability of the cones in the online forums. Five men found the listing and bought a cone. Then I had to figure out how to make them. I told the five cone buyers I would give them free shipping if they would allow me a few weeks to work out how to make a better product with greater efficiency. The one-at-a-time method involved crude hand-made paper forms, which were destroyed with each casting. I needed something durable and geometrically perfect. I used computer drafting software to design a 2-part plastic mold, and I e-mailed my design to a lab that grows 3D plastic shapes in a process called stereolithography. In a week, I received my new mold in the mail, without having met the man who made it. I feel so lucky to live in an age when the Internet was available to help me research my problem, discover the solution, find the first customers who shared my need, and find the mold maker and a supplier of food-grade silicone so I could go into a new business; all without leaving my house. I coined the name “Your-Skin” Cone for the retainer, because it rhymed with “foreskin.” Then a few months later, I figured out how to efficiently make a Tugger to go with it. I called it the Conical Tapeless Tugger, or CT Tugger for short. I

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announced the CT Tugger in the forums, and soon I was selling a few every week. Lucky for me, a user wrote to suggest I call my device the Tape-Less Conical Tugger, or TLC Tugger, because it had more of a ring to it. In June of 2003, I registered my web site, TLC Tugger.com. I still had my day job as an industrial engineer, and I told a couple of co-workers about restoring and how I was making and selling these devices as a sideline. I was already staying up late to offer help in the forums, and now my evenings were consumed with cooking the devices in my family’s kitchen. Within some months, I really had to become an expert at exploiting every free minute. I would leave the house with a supply of devices and postage stamps, plus pre-printed mailing labels coded with what a customer had ordered. I’d prepare the tugging straps and mailing boxes at every red light while driving to work. Then, at lunch, I’d sit in my car and pack the orders, dropping them in the postal box next to the sandwich shop where I ordered the same thing every day. They would make my sandwich when they saw me pull up, so I never had to wait. My wife, Alice, soon noticed that I was buying myself things on eBay; music CDs, Michael Jordan sneakers, rock-and-roll t-shirts. She asked what was up and I told her these devices were bringing in real money and I deserved some treats because I was working so hard. She said we would have to organize this like a real business and pay taxes and stuff. At that time, she was an MBA/accountant with a job that required only 20 h/week, so she could also be a “full-time” mom. We incorporated TLCTugger.com, Inc., in 2004, as equal partners, and Alice took care of the “business” end of the business, while the kids helped with sub-assemblies.

Growth We had our web site and our eBay listings, and the men who needed help with restoring kept finding us. I continued to enjoy participating in the online support process, even for men using methods we didn’t sell. Since we had a corporation and could write off expenses, I started thinking of ways to promote intactivism that could be legitimate business expenses. We offered free foreskin-friendly bumper stickers at our web site: • • • • • • • • • •

“A Foreskin is NOT a birth defect” “Breastfeeding for all, Circumcision for none” “Bring home your WHOLE baby, say NO to circumcision” “Circumcised? You have no idea what you’re missing” “Circumcision? HIS body, HIS decision” “Circumcision? ‘No’—Moroni 8:8” “Circumcision = Sexual Lobotomy” “Feel the love—End circumcision” “Foreskin feels REALLY good” “Foreskin—Not just the wrapper, it’s the candy”

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“God makes no mistakes—say NO to circumcision” “If God wanted me to have a foreskin, I would have been born with one” “I make milk—What’s YOUR superpower?” “Restore your foreskin—TLCTugger.com” “10 out of 10 babies oppose circumcision” “THOU SHALT NOT STEAL—that includes foreskins, HIS body, HIS decision” “YOU may go sit in the toilet until I’m done nursing”

Some of these slogans are about breastfeeding, another of the issues I’m passionate about. I got to dust off some other old hobbies. Now that I had a business to promote, I could invest time and energy into producing pro-intact Internet radio segments. Radio is where I really thought I was headed back during college. Now that the industry’s imploding, I’m glad to call it just a hobby. I’ve also always loved music, song writing, and home recording, so now TLC Tugger sponsors an annual foreskin-related song-parody contest. I get to seed each year’s entries with some works of my own, while not competing for my own cash prizes, of course. These soft-sell promotional efforts have made us just conspicuous enough to snare some free high-profile promotional opportunities. We’ve appeared in two documentaries. We’ve been interviewed by Chicago radio stations. We’ve been written up in three big-city newspapers, and Details and Time magazines. The Chicago Tribune said for “circumcised men who feel they might be missing something, Ron Low is their savior.” While I thought that job was taken, as long as they spell the web address correctly, they can say what they want. In 2006, I tried out for an inventor’s reality show called Everyday Edisons. I had a nicely polished spiel for the first round judges who were specialists in various aspects of marketing new products. Within the 90-second time limit, I told them how circumcision was unnecessary, pleasure-reducing, cosmetic surgery, which had befallen 80 million US men and another 80 million outside the US, all for nonreligious reasons. What I needed the show to help me with was the graphics and communications expertise to take my little Your-Skin Cone from a niche mail-order item in use by several thousand men worldwide, to a family–friendly commodity available at Wal-Mart. They loved it! I was green lighted by the first-round panel and sent to the green room to await videotaping of my audition in front of the actual TV judges. I sat in that green room knowing it was still a long shot. Sure, I had gotten further than 99.5% of the thousands of people who showed up that day, but this was just one city’s audition. The producers designed the auditions so they would have dozens of finalists to draw from and assemble a slate of just a dozen show participants for the season. With all the confidence I could muster, I sat in that green room going over my next speech in my head. There was an adorable little girl sitting across the room with her mom. They had invented some new board game. Another green-lighted guy had brought a whole couch to show off his ingenious tray table that pops up from beneath it. The door opened. “Ron Low?” said a guy in a suit. “Bring your stuff.”

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Odd, I thought. Why was I getting to go before these others who were waiting before me? We walked out together. “I’m Josh, one of the show producers. Congratulations on being green lighted. That shows your idea had real promise. Listen, the production company doesn’t have the last word here. The network also has lawyers on site today to review the ideas. I’m sorry to tell you the network’s lawyer says your idea is not going to be part of the show. There’s nothing to discuss, we’re bound to their authority. So, I just want to say thanks for coming out and best of luck with your invention.” At this point, I noticed we had been strolling the halls of WTTW Studios straight for the exit. In just under a minute, my hopes had been dashed, and I was neatly shuffled out the door.

Living with Integrity Despite setbacks like Everyday Edisons, somehow TLC Tugger keeps getting just enough publicity to maintain a 20% annual growth rate. In March of 2008, I did some math and decided my family could live on just what the Tugger business was bringing in if we were willing to scale some things back a bit. We really had to change something because I wasn’t sleeping. I was getting four solid hours on a good night. The alarm always went off at 6:30 to get me to the car in time to drop my gifted daughter off at high school. One of the co-workers I had told about my sideline was Angel, the production manager. I had confided in him back in 2005, when we were peers on a project together. By 2007, Angel had been promoted to Director of Engineering, my boss. Like a true humanitarian, he privately declared that he wouldn’t hold the moonlighting I had revealed under different circumstances against me, as long as it didn’t affect the quality of my work. By allowing me to keep my day job and continue to work TLC Tugger on the side, including occasional days off, which he knew were for things like TLC-related radio interviews, Angel really taught me the definition of compassion. In late 2007, when my day-job performance came up at the office, I promised Angel that I would hire someone to help with TLC stuff. Indeed, we found a brilliant high-school student, Dan, who now does a lot of the assembly and handles the free bumper-sticker orders. It turns out, Dan has lived in Israel and speaks perfect Hebrew and Russian, so he also helps with some of the international customer service. Early 2008 marked my fourth consecutive annual physical, where I had to again apologize to my doctor for showing up dog tired from lack of sleep. I again got the “de-stress your life” lecture, which I could mouth along with him from memory. I told Angel that I was going to have to choose TLC Tugger, and leave the toothbrush company eventually. He agreed to let me transition out gently. I agreed to go home and tell Alice. Yes, I quit my job without clearing it with my wife. We had discussed it on and off, but it just seemed like she would never be ready, so I took a huge leap.

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I think what imbued me with the guts to leave, apart from the stream of customers that never seemed to stop finding us, was a “living with integrity” seminar to which my pre-9/11 job had sent me. If that seems like a funny place to learn to keep secrets from your spouse, let me explain.

The American Dream In 1996, the beverage can company I worked for must have wanted us to stop stealing paper clips, or to just work harder, or something. They spent a boatload of money on a man-and-wife team who offered a seminar called “Living with Integrity.” They sent us all to the 2-day extravaganza on a rotating basis. The show turned out to have very little to do with working as selflessly as Mother Theresa or being as honest as George Washington. They played on a very specific definition of integrity. They showed examples of people whose work lives integrated closely with their core personal values. I don’t know if the company expected us to change our core personal values to align with the company’s mission, or what. I left the seminar resolved to find a way to pay my way through this world by pursuing my passion, if only I could figure out what that was. My co-worker Phil seemed to be changed by it as well. He asked me shortly after the seminars: “Ron, do you feel you have a ‘life’s work?’ Is shaving costs for the can business something you’ll brag to your grandkids about?” Of course, he had made his point. He really clinched the message when he quit his job and started medical school at age 31. He is a graduate of University of Chicago today and practices medicine. My own foray into life with integrity has been very fruitful. TLC Tugger now carries product offerings for all the primary restoring methodologies. • • • • • •

Taping: TLC Canister and ReJuveness tape Retaining: Your-Skin Cone Packing: TLC Packer, TLC-X Tugging: TLC Tugger, TLC-X, and ComforTug straps Weights: TLC Stackers Covering: SenSlip prosthetic foreskin undergarment.

In the near future, we hope to offer a device to help men with phimosis to comfortably stretch the preputial sphincter so they can avoid circumcision or other surgery. We have so many clients, we can easily research the nature and make-up of the restoring community. In 2008, we conducted a preliminary survey (only 40 respondents that were limited to our newest customers) and learned some things. We found 25% self-identified as gay. This question has been asked quite often, so it was nice to finally have a ballpark figure. The survey produced 0% identifying as Black or African-American. This certainly highlights a conspicuous failure on our part, and we have work to do to figure out how better to serve all communities and ethnic

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groups. Then, 19% said they would like face-to-face restoring support but had never attended a NORM (National Organization of Restoring Men) meeting, so we’ve been doing all we can to facilitate the formation of local chapters. Our full-scale survey will refine these numbers and answer some additional questions this year. We have enough users at our sponsored-user forum that we can quickly find subjects to volunteer for research into comparing foreskin restoration methods and regimens. We hope to soon finally answer the question, Is tugging half of the time as effective for quick results as tugging 24/7? We can address further questions every six months from now on. This will be an important contribution to restoring. When I quit my job, I wasn’t really sure if, any day, the number of men needing our help would shrivel to nothing. I also didn’t know at the time what the US FDA (Food and Drug Administration) thought about restoring. I was afraid to ask. An eBay user forced my hand. This guy saw our auction listings and wrote to ask me if our “penis stretchers” were FDA approved, because he thought they looked dangerous. I explained that our products really worked, were not dangerous and, unlike other penis stretchers, they helped victims of a senseless mutilation. He managed to waste a lot of my time with repetitive and circular questions, which I worked hard to answer carefully because I hoped he would leave the FDA out of this. He didn’t. I heard from the FDA. They wrote to say there was a complaint, so they had to open a file, investigate, and “close the file.” That sounded like “close our business” to me, so I proceeded very cautiously. It turns out, the FDA people were very nice and were on my side. I told them that our devices really worked but that we had no formal studies to prove it. I explained how restoring involves tissue expansion by application of gentle tension. The FDA said, if I wanted to claim that my devices caused faster cell division or the growth of new skin, then I would definitely be classified as a medical device purveyor. I said: “Yep, that’s me.” They advised me about what would be involved— annual inspections of my production facilities at $5,000 per year, plus a device approval process that could take years, eventually cost hundreds of thousands of dollars, and still possibly fail. And the opportunities to continue offering devices while approval was pending would be very restrictive. We had a sort of bargaining session, where the FDA said I could call my devices stretchers and boast only of stretching skin (the way penis stretchers stretch the penile shaft), and then I could be ignored by the FDA (the way penis stretchers are). I said restorers know they grow new skin and don’t just stretch it. The very kind FDA representatives mentioned the hundreds of thousands of dollars again. We finally came to an understanding. I get to keep calling my devices Tuggers, and now I describe their effects as “restoring slack skin.” The FDA is OK with that, so now we are better than FDA-approved, we’re FDA-ignored, and I have a letter saying so. Now that I can hold my head up high and tout the benefits of restoring slack skin from every mountaintop, there is no stopping me. In 2008, I started looking for more ways to reach out to new audiences. TLC Tugger sponsored a prize for International Mister Leather and we started sponsoring Chicago-NORM’s annual intactivist entry in Chicago’s Pride Parade.

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Then, in August of 2008, the ultimate opportunity arose; one that only a guy like me—with no “day” job—could seize. Howard Stern, who I call the world’s loudest pro-intact celebrity, announced that he would have an on-air “Prettiest Penis Contest” in honor of George Takei, the famous actor from Star Trek. George is intact, and he’s also gay. Howard’s show was eager to have a bachelor party for him in celebration of his then-legal planned marriage in California. Anyone who could get to the Sirius Satellite Radio/Howard TV studios in New York on a Wednesday morning was welcome to enter the contest for a $500 prize. When I called, I was sure they would have more entrants than they could handle, so I tried to distinguish myself: “You should also know I’ve restored my foreskin using constant gentle tension over several years” I told their producer. “Oooh, you’re a. . . real. . . Sicko, aren’t you?” he replied. I explained that I thought what I was doing was a perfectly sane reaction to undo a senseless amputation, and I assured him I would have no trouble getting from Chicago to New York in 5 days, and offered to bring my honor-student daughters along to vouch that I was no Sicko. “That’s OK. You’re in.” he said. When I entered the studio, Howard proved he is the master interviewer, simultaneously witty and sensitive. Howard: Ron: Robin (female newscaster): Ron: George: Howard: Ron: Howard:

Ron: Howard: George: Ron: Robin: George: Howard: Ron: Howard: Ron:

Ron, what brings you here today? You want the title, eh? I have the prettiest penis and you’re going to see it. How do you know you have the prettiest penis? Well, I think it’s the only one that’s going to look like a renaissance painting. A renaissance painting! Who has told you that you have a beautiful penis? Are you into girls or men? My wife loves my penis. And she says you have a great looking penis. Alright, let George see it. This will be great for him and he loves it. This is certainly a gay bachelor par. . . (drops his trunks) . . .WOW! What’s going on with that thing? There’s something ATTACHED to your penis. Yes, what is that? This here is a foreskin restoration tugger. Oh, no. Foreskin restoration. Oh, you’re circumcised? You’re one of those guys who was circumcised and you’re trying to get your foreskin back. I was circumcised at birth; certainly not by choice. Right. And so, for four years, I wore a device similar to this one.

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Robin: Ron:

Howard: Ron: Howard: George: Ron: Robin: Howard: George: Ron:

Howard: Ron:

Howard: Robin: George: Ron:

Howard: Ron: Howard: George: Howard:

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(laughs) Sometimes you wear it strapped to your knee to pull down. At night, you wear it strapped up over your shoulder to pull up, and it just basically applies constant gentle tension. Are you getting your foreskin back? Let’s have a look. All right. Oh, that comes off, does it? (removes Tugger) Ugh. Well, there it is! It actually does work, doesn’t it? And has that been helping the penis itself? I’ll tell you what. Foreskin feels REALLY good. Until you’ve experienced it slinking around, it’s just impossible to even describe. It’s like, you can picture the skin tube as it rolls over on itself, it’s making like a 180 turn. . . It was THAT important to you to get your foreskin back? Oh, it feels so good. And the glans and the skin just below the glans are now covered and protected all the time, so it’s reverted to being more moist and supple, and I just can’t even tell you how much better sex is. Well, Robin, there you go. Here is a man who has restored his penis to its natural state. There’s a lesson for you. And the process gives a good feeling all the time? Yeah, having something attached to your penis does kind of give you an awareness of your penis all day, and so. . . How long did it take before your foreskin came back? You can grow about an inch of new skin a year, and I needed four inches, so it took me four years. Four years you’ve been doing this! Well congratulations to you. What an accomplishment! Good for you. Helping Mother Nature. Yes, I’m glad to see you taking your time, and putting it into something useful! (Everyone laughs)

I didn’t win the prettiest penis contest, which is a shame because that might have won me an invite to the post-show wrap-up show, with more questions about restoration. As it was, I reached Howard Stern’s loyal radio and TV audience of over 7 million. I know the next time circumcision comes up on his show (he often rails against it) he will have restoration on his mind.

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I don’t need to be declared the prettiest penis to know I’ve accomplished something. I hear it every day from the men I help. I get the feedback I need in letters like this one, from a Your-Skin Cone user: First of all, I wish to thank you for making a fine product. I have been using your Restoration Cone for just over a month, and already I am seeing & feeling significant differences in my penis. I am married, and my wife & I are trying to start a family. Before, my penis was so raw & desensitized, it was almost impossible for me to receive enough stimulation to achieve orgasm. In addition, my wife would complain that sex with me would always take so long, & dry her out, making her vagina incredibly sore. Now after a month, things have changed. Sex is much more enjoyable, & we may even be able to conceive naturally. You’ve really helped me out. Thank you again so much for your product. It has changed my life.

Everyone needs to find out in what way they can leave the world a better place than they found it. If you’re Howard Stern, you can earn hundreds of millions of dollars for leaving millions entertained. If you’re like me, you get to pay your way through life by improving one penis at a time, while helping boost the odds that the next boy born won’t ever need restoration services. I’m really living the American Dream. I don’t know if there’s a popular phrase like Australian Dream, Canadian Dream, or English Dream. But I think the American Dream is about finding that way to make your living by providing something people need; doing something you can be proud of. To be able to do this, hand-in-hand with your loving family, well, I think any common phrase would be too trite to describe this kind of satisfaction.

Chapter 20

Genital Autonomy: The Way Forward David Smith

Abstract Genital mutilation has always been a cure for the latest fashionable disease. From curing club foot and epilepsy to ensuring a faithful wife, it has been the universal remedy. Now is the time to break down the barriers, alter perceptions, and broaden the knowledge of the subject to every thinking human in the civilized world. This talk will explore ways of widening the debate to make genital mutilation as acceptable to discuss in polite society as HIV/AIDS has now attained. Keywords Genital mutilation · Genital integrity · Genital autonomy · World Health Organization (WHO) · NORM-UK · FORWARD · Female genital mutilation (FGM) · Commissioner of Children In 2006 at Seattle, the winds of change were beginning to be felt on the whole subject of both male and female genital cutting. At that event, the Ninth International Symposium on Circumcision, Genital Integrity, and Human Rights, the initial concepts for the way forward were formulated. In the intervening two years, much has been achieved and some progress has been made towards a brighter future. This symposium is a staging post on the way to a better-informed society and it is essential that the momentum created both here at Keele University, during the last three days, and with the initial launch of Genital Autonomy is maintained and enhanced. To coincide with this symposium, we chose to hold a press conference, in London, to publicize the official unification of the two aspects of our organizations, male and female, and to launch a new genital autonomy symbol. We were gratified that the press turned up and took notice of the new vision for the groups and we anticipate that this will be the beginning of a significant change in thinking worldwide on the issues of genital cutting and this should be the start of the new way forward. For

D. Smith (B) NORM-UK, Staffordshire, UK e-mail: [email protected]

G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9_20,  C Springer Science+Business Media B.V. 2010

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those of you not able to be present in London, with us, I would like to read to you the press statement released to the world’s media: Genders Unite for Genital Autonomy London, 3 September 2008 NORM-UK, the organization concerned with the male foreskin, and FORWARD, the organization concerned with female genital mutilation (FGM), will unite at the Genital Integrity 2008 symposium on September 4th to launch a new campaign promoting the right of all men and women to say no to unnecessary genital surgery. In the face of a large-scale World Health Organization (WHO) promotion of male circumcision as a means to reduce risk of HIV infection in Africa, the new campaign seeks to redress the balance by making the public aware of the strongly conflicting evidence around the effects of circumcision, and the mixed evidence about its value in HIV prevention, and by promoting the fundamental concept of informed choice in medical treatment. “Subjecting young children to a painful, damaging and humiliating circumcision in an attempt to prevent HIV infection from sexual contact is not only profoundly unethical, it is an insane waste of money. These boys will not be sexually active for many years, by which time properly proven and more reliable prevention strategies may be available,” said John Warren, chairman of NORM-UK. “Boys must be left to make their own decision when they are old enough to understand the full implications.” “When the issue of female genital mutilation was still sensitive and highly politicized, FORWARD played a leading role in putting the issue on the international agenda, breaking down the walls of silence,” said Naana Otoo-Oyortey MBE, Executive Director of FORWARD. “It is time to recognize that the right to genital autonomy belongs to all children, regardless of race, culture or gender.” Unnecessary genital surgery on babies is said to be cheaper and easier than on adults. All abuse of babies is easier. They are powerless and history will judge us by how we protect the powerless, said Paul Mason, children’s commissioner for Tasmania, Australia; a keynote speaker at the Genital Integrity 2008 Symposium at Keele University. “Do we say to children that they have no say in this because statistically when they grow up and practice unsafe sex they might be better off? I say let the children decide for themselves—all in good time.”

This is a powerful statement, which has been made by an eminent man who is not only in a position of authority but is prepared to speak out publicly internationally, as we have all had the privilege of hearing today. Paul Mason has come all the way from Tasmania not only to be with us and share with the symposium his words of wisdom, but he has also taken the opportunity to support and to speak out here in Britain on these issues. When approached, he was most willing and enthusiastic in his support. This is a refreshing change from the attitude of his British equivalent, Sir Al Ainsley-Green who, on being asked to attend and speak at this symposium, declined due to a prior engagement. Initially, I thought this was an excuse but, in fact, he is at a conference in Dublin, where Paul Mason went to meet him—in essence to attack the lion in his den and give him the ear bashing he deserves, which I know he most probably has. You will probably be interested to hear the response we received from Sir Al when, after

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numerous email and snail mail exchanges, we finally got a response to bring to this symposium—perhaps not the words we were expecting or hoping for, he wrote: Thank you for your note and request for a meeting. The Children’s Commissioner is charged with promoting the views and interests of children and young people in England. We have a limited budget and resources, which means that regrettably we are not able to comment on every issue affecting children and young people. We simply do not have the capacity to cover every area. For this reason, we are unable to comment officially on your symposium or arrange to meet to discuss the topic. We all face an uphill battle as you will realize from the British Children’s Commissioner’s comments, but that is nothing in comparison with the constant battle we wage with the very organization that should be helping our cause to prevent cruelty to children, the NSPCC (National Society for the Prevention of Cruelty to Children) the largest organization of its kind in the world. They have the audacity to run a campaign called Full Stop; the by-line for which is: Cruelty to children must stop—full stop.

After ten years of constant attempts at negotiations, countless emails, endless letters, and hours of wasted time on the telephone, we have finally managed to obtain an actual meeting with them, yet, they still refused to send a speaker or even a delegate from the head office in London to attend this conference, although a delegate from a minor regional office did eventually agree to attend this symposium for two days—perhaps this is the first chink in the door against which we have been pushing for so many long years, Let us hope that, with constant pressure and further diligent effort, we can break down this intractable barrier once and for all for the betterment of all children. On a more hopeful and positive note, it is interesting that, in London, some attention is now being paid to genital cutting of both sexes and the Metropolitan Police and the London safeguarding boards are now actively examining cases where evidence of the use of these practices has occurred. Perhaps before long prosecutions will be made and reported widely in the press making our activities easier, but we must be ready and be able to take advantage of the inevitable waves that such public exposure to the procedures will create. The way forward is to be prepared, to have our statements and spokespeople prepared to face the media with positive and reasoned responses when the sadly inevitable tragedy occurs and the true horrors become part of the media frenzy. Perhaps one of the areas that needs to be addressed urgently and where some progress can be made in the relatively near future is engaging with and influencing the current educational system in Great Britain. Sex education for boys is sadly lacking—there is still a reluctance to discuss the topic and more often than not the tone reverts to—read the chapter on the reproductive system of the rabbit—not the most useful or helpful advice! Is it surprising, therefore, that 80% of our enquiries come from boys who have no basic information on the function and working of the foreskin, even to the extent of not realizing that it should retract and that is a normal aspect of its function. This lack of basic information must be addressed; it is essential to get the details out to these young men who face a fearful and worrying time and potentially lifealtering consequences as a direct result of the lack of male sex education in our

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schools today. This information should also be given to every young girl—they are just as likely to be the one of influence and the decision makers of the future—not only can they help their partners but they will keep their future children intact. It is essential that, as an international organization, we start to make waves in this area and beat a path to the Education and Health Ministers’ door to spread the word and, most importantly, to protect our future generations. Where problems occur, the most frequent recourse is to circumcision as a first course of treatment, and it is disconcerting that this is actively supported by the National Institute for Clinical Excellence (NICE). NICE is a powerful government organization in Britain that dictates policy on everything from what drugs may be used to which bedpans can be purchased. They are all-powerful but will not tackle the subject of male circumcision. They openly state they will not consider anything that will not save the NHS a million pounds annually. NORM–UK has submitted a carefully researched paper to them, detailing how restricting the practice of circumcision to those that are medically essential would actually provide significant savings in excess of six million pounds—it is a no-brainer, the essence of which they refuse to examine and embrace. With due reverence to doctors, I feel it important to make reference to the salutary fact that many of the nation’s doctors are both ill-informed about our subject and have no inclination to both adapt to changing attitudes or accept the evidence presented through new research and a change in medical thinking. This, in part, must be attributable to the regrettable practice of financial rewards given to those medics who still persist in circumcision for the betterment of their own pocket. This will be a harder mountain to climb and eventually eradicate, but it is one that must be tackled. The best weapon in our armament will be the threat of legal action. The first case brought will focus their minds and assist our cause considerably. Let us hope that someone, in the very near future, is brave enough to bring that prosecution and open the floodgates to other potential actions. Before this will be successful, it is essential that the diagnostic codes used to disguise circumcision be changed so that they can no longer masquerade as therapeutic operations. Symposia like this are an ideal platform to disseminate information and to assist in the eradication of both erroneous and what we all know is frequently inaccurate information. A classic example of this can be illustrated in the attitudes of the media doctors whose advice is read by millions daily in the more reputable press. It is a well-known fact that two of the most prominent, Thomas Stutterford, in the Times, and Miriam Stoppard, of the Mirror, are pro-circumcision and frequently give what we would all believe is wrong advice to anxious readers in need of more sensible help. Both were invited to attend this symposium, but Stutterford ignored all communications and has similarly ignored all attempts to give him information on our subject. Miriam Stoppard assured the organizers that the date was firmly in her diary and high hopes were raised that she might attend, even for a single day, so that we could enlighten her. Since then, as you probably already have guessed, she has ignored all attempts to contact or communicate with her. Both attitudes are unacceptable and cause a problem that we must attempt to break down. It is a wellknown fact the population will always believe what they read in the press or see on

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television, not what is blatantly obvious truth. The way forward, however, is unpalatable to the recipient, to bombard with literature, letters, and information until, through a war of attrition, we win them over and get the message across. This is something everyone here can assist with. Write to the editors, contact the media, and put the record right. If each and every one is vigilant and you follow your convictions, this situation can and should be reversed. The joint collaborations that have been fostered though the organization of this conference have brought into focus areas of mutual interest that should be developed together. The amalgamation of the female and male campaigns will be a more forceful voice and prevent those, who, in the past, have attempted to divide the two and by doing so weaken the arguments against the practices of both male and female cutting. The most obvious areas of joint working must include efforts to fund collaborative research projects. Similarly, it will be important to work with the communities who practice genital cutting of either sex, at a grassroots level. It will be essential to start speaking and working with the diverse communities whose cultures we need to influence and educate. The quantum-step change in thinking and actions on genital cutting will be enhanced and brought to the attention of a wider public not only by the new symbol but with the launch of a website—Genital Autonomy—which, hopefully, will awaken the world to the problems about which we are actively campaigning and endeavoring to make the subject acceptable in polite society in the same way in which the very word AIDS has gone from the greatest taboo to a subject discussed even around the most polite and formal dinner table. This is where we need to be in the future and preferably making significant inroads into that status by the time of the 2010 symposium. It is up to every one of us to make a difference, to challenge the preconceptions of the public, to wear our badges with pride, and to not be afraid to put our heads over the parapet, as you will realize from the numbers of similarly minded people, not only in this room but those you know on both sides of the Pond who actively support both organizations—NOCIRC and NORM-UK. Without communicating with those who are too afraid to ask but are desperate for help and, more importantly, information, the message of the possibilities for assistance and support will never reach the wider population. The way forward is for everyone to take our message out into the communities where it will do the most good. Two hundred years ago, campaigns were equally important in changing the perceptions of society and radically altering the whole subsequent course of history. This is well illustrated in the movement for the Abolition of Slavery and the production of the first campaigning lapel pin by Josiah Wedgwood. That emotive depiction of a kneeling manacled slave became universally recognized and admired. What was possible in the eighteenth century surely can be improved upon in the twentyfirst century. We should emulate one of the great pioneers of Staffordshire and wear our Genital Autonomy symbol with pride and stand up for what is right, just, and humane.

Chapter 21

Circumcision George Wald

Abstract At the 7th International Symposium on Circumcision, Genital Integrity, and Human Rights, held at Georgetown University in Washington, DC, Van Lewis presented a paper about the amazing work of George Wald (1906–1997), who, in 1967, won the Nobel Prize for his discovery of Vitamin A in the retina of the eye and how it works with light to produce vision. Not only was he a world-class research scientist, Time magazine declared him one of America’s Ten Best Teachers. A child of immigrant New York Jewish parents, beloved Harvard biology professor, and well-known twentieth century activist for peace and justice, George Wald also worked to defend the right of all children, male and female, to genital integrity. Here, thanks to Van Lewis and George Denniston—both students of George Wald—and to his wife for giving us permission to publish this never-before-published paper. This is what Dr. Wald had to say about penile reduction surgery, euphemistically called circumcision. Keywords Myelin sheath · Initiation rite · Maimonides · Jews · Moses · Zipporah · Hygiene · Cancer · Adhesions · Phimosis · Anesthetic · Glans penis · Foreskin · Reform Judaism · Covenant · Violence

George Wald (1975) Every year in early February, after my last lecture at Harvard, I go off into the back country for a while, to put myself together. Last February it was to Mexico, to visit two remote Indian tribes in the Sierra Madre. On the way I stopped off for a lecture at Florida State University in Tallahassee. It was a big public lecture, with a discussion afterward, and a reception. G. Wald (B) Professor of Biology, Harvard University, Cambridge, MA, USA e-mail: [email protected] G. Wald (1906–1997), Nobel Prize recipient, 1967.

G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9_21,  C Springer Science+Business Media B.V. 2010

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Toward the end, a young man came up, bearded, lots of hair, open shirt, jeans.1 He introduced his wife and his mother, a stately woman, carrying the young couple’s 7-month-old infant. “When are you leaving Tallahassee?” he asked. I told him on a seven o’clock flight to Atlanta next morning, to catch the Mexico City plane. “Can I drive you to the airport?” “Yes, thanks,” I said thoughtlessly, “if your car will run.” “We have three,” he said, “and one of them is sure to run.” So at six next morning he came for me and we set out for the airport. A little way along he said, “Have you thought much about circumcision?” “No,” I said, a little surprised, “I haven’t thought about it at all.” “Well, I’ve thought about it a lot,” he said, “I’ve been thinking about it for years. I think it’s a terrible thing to do to a male infant that’s just gone through the struggle of being born, that’s just left the warmth and security of the womb to come out into a cold and strange world, to greet him with the knife, with a mutilation. I’ve never been able to forgive my mother for having that done to me.” (Note: his mother—a recurrent theme) “A few years ago,” he went on, “I realized that to make further progress in my thinking I’d have to go public. So I prepared some carefully lettered signs; and since it was a windy day I asked my younger brother to come along and help carry them. I told my father what we planned to do.” “Well son,” he said, “you know I’ve backed you in almost everything, but I think I’ll pass this one up.” “We drove to the entrance to a big general hospital on a main road, and began to picket. One of the signs read, CIRCUMCISION IS A SEX CRIME. Another read: SEX CRIMINALS FOR HIRE? INQUIRE WITHIN.” Almost every car that drove past would slow up to read our signs. Then something interesting developed. There was a difference in the way men and women reacted. Some of the men were with us. They would lean out, wave, and say things like, ‘You tell them, kid!’ and ‘Right on!’ “But the women were furious. They shook their fists at us, and some of them stopped to curse us out. You’d be surprised at the language they used.” “After awhile the police came and took us in for disorderly conduct. We spent the afternoon in jail, posted bond, and went home.” By that time we had reached the airport. My plane was late, so we sat down and went on talking. Up until then I had been listening, interested, a little amused, not involved. Suddenly he said something that shook me. “It seems to me,” he said, “that the foreskin is the female element in a male. It’s warm flesh enclosing the penis; a kind of male vagina.” “My god!” I said, “That’s wonderful! Because we’ve always been told that the clitoris is the male element in a female!” And I told him about the Dogon.

The Primitive Event: An Initiation Rite The Dogon are a West African people living in Mali south of the great bend in the Niger River. I became interested in them long ago, through their very distinctive wood sculpture. I had hopes to visit them last April; but just before setting out was

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warned that April is the worst month of the year in that region: temperatures near 110◦ and torrential rains that might make the roads impassable. So I had to give it up. The Dogon have an extraordinary creation myth. The primal god, Amma, made the Earth from clay in the shape of a woman lying on her back. Then Amma, being lonely, wanted to copulate with her. Her vagina was an ant hill; but beside it was her clitoris, a termite mound. (These characterizations became clearer to me when I ran across a photograph of a field with termite mounds. They are not broad, rounded eminences like ant hills, but tall, slender, phallic columns.) As Amma approached the Earth to copulate with her, the male element, the termite mound, rose against him. So first he had to destroy it. Suddenly everything fell into place. The Dogon, like many other African peoples, not in early infancy but at or near puberty, as an initiation rite, circumcise the boys, and excise the girls: the clitoris is cut away, in some tribes along with the labia minora. Up to puberty every Dogon child is thought to be to a degree bisexual, a gynandromorph; and that is acceptable, since it has as yet no serious sexual role to fulfill. But then, in preparation for adulthood, the boys are made altogether male by removing the foreskin, their female member; and the girls are made wholly female by excising the clitoris. One does not have to improvise this interpretation. The tribal traditions state it plainly. So, speaking of the creation of man: “each human being from the first was endowed with two souls of different sex. In the man the female soul was located in the prepuce; in the woman the male soul was in the clitoris. . . The dual soul is a danger; a man should be male, a woman female. Circumcision and excision are the remedy.”2 I have no doubt that this is the dominant primitive meaning of circumcision and excision: that, androgynous to a degree in infancy, children have their sex roles established unequivocally at or near puberty by removing the foreskin from boys and the clitoris from girls. These practices are ancient and widespread. They have arisen on every continent. “The bodies of Egyptians exhumed from the earliest prehistoric cemeteries, back of 4000 B.C., have disclosed the evidence of circumcision whenever the body is sufficiently well preserved to make the observation possible. The actual performance of the operation by the Egyptian surgeon is depicted in an Egyptian tomb relief of the twenty-seventh or twenty-eighth centuries B.C. in the cemetery of Memphis.”3 This great Egyptologist believed that the ancient Hebrews, led by Moses, “born in Egypt and bearing an Egyptian name” (Mose = child of, as in the Pharaonic names Ahmose, Thutmose), borrowed from the Egyptians at once the Pharaoh Ikhnaton’s monotheism, the rite of circumcision, and the ban on eating pork. Yet among the ancient Egyptians also, circumcision was a puberty rite, performed at ages 6–14. It is curious that up to relatively modern times, circumcision never set the Jews off from most of the people about them. The custom prevailed not only among the ancient Egyptians, but the Semitic peoples among whom the Jews continued to dwell: Moabites, Edomites, Ammonites, Phoenicians. Circumcision tended much more to divide Semites from non-Semites than Jews from others. To the ancient

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Jews the epitome of the uncircumcised were the Philistines, a non-Semitic sea people, probably from Crete; until the ninth century B.C. they encountered also the Assyrians, Semites yet uncircumcised. With the coming of the Prophet, circumcision became universal among Moslems, accompanied in some groups by female excision. It is practiced ritually by numerous people of central and west Africa including the Ethiopians; many Australian aborigines; Malays, Fijians and Samoans; and Indian tribes in North and South America. (I have a fine pre-Columbian stirrup-bottle from the Vicus area in Peru, the spout of which has the form of an erect, circumcised penis.) The most usual status of circumcision among all these peoples is as an initiation rite, performed at or near puberty, often in direct preparation for mating or marriage. There is some reason to believe that it may have begun that way among the ancient Hebrews. In the Ethiopian (“Coptic”) Christian Church, though boys are circumcised in early infancy, girls are excised at or close to puberty. So far as I know, no other people circumcise as early as the Jews—on the eighth day—except for present-day Americans, who owing to the exigencies of hospital practice, are likely to have their infants circumcised on the third or fourth day.4 Running through all modern discussions of circumcision is the thought that it began, and still operates as an aspect of preventive medicine. Adults who need to be circumcised because of some penile disorder have always uncleanness to blame for their trouble. John Morrison, an Australian physician, observes that in Australia ritual circumcision is practiced only by those tribes that live under desert conditions, in which the combination of sand, wind and shortage of water for washing would have made circumcision frequently necessary later in life, had it not been performed in childhood. He suggests that similar environments may have prevailed wherever else in the world this custom has arisen (Medical Journal of Australia, 1967, p. 125).5 It may well be true that millennia of painful experiences had a part in developing circumcision as a ritualized health measure. That cannot be the whole story, however, or probably even a dominant motif. For one thing it does not touch the parallel practice of female excision, which no one has tried to defend on medical grounds. Nor does it apply to a great variety of other mutilations of the external genitalia practiced by native peoples. But most important of all, such surgery performed under primitive conditions must always have presented a serious hazard. Even under relatively impeccable conditions in a modern hospital, circumcision occasionally causes complications. Done with rude tools in the bush or in the desert, it must often have led to infection, maiming, at times the death of the subject. It is hard to assess what net medical advantage, if any, circumcision might offer under such conditions. It seems to me much to the point that the ancient Jews, far from looking upon circumcision as a health measure, regarded it as a dangerous operation. Thus it was decided early that a Jewish infant whose brother had died as a result of circumcision was to be spared this ritual. In the ceremony of circumcision, the special chair said to be reserved for Elijah is left in place for three days, because these are days of danger for the child. Moses Maimonides, the twelfth century rabbi of Cairo and court physician to Saladin, put the matter plainly: “No one should circumcise

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himself or his son for any other reason than pure faith; for circumcision is not like an incision on the leg or branding on the arm, but a very difficult operation.”6 To regard the Jewish rite of circumcision as primitive prophylaxis is a modern interpolation of medical hindsight on a par with the notion that the ban on eating pork was to prevent trichinosis. As was to be expected, the rite of circumcision has also excited great psychoanalytic interest. Sigmund Freud took it to represent the symbolic castration of sons by jealous fathers.7 There is little anthropological evidence to support this view. It implies a primitive awareness of the male role in procreation that was generally lacking, as well as an interest in castration that so far as we know developed only in relatively sophisticated peoples and in quite other associations. Bruno Bettelheim has suggested an ingenious alternative: that circumcision may represent an attempt on the part of males symbolically to mimic characteristically female roles in reproduction including bleeding at puberty.8 I find it a relief to turn from such baroque interpretations to the simple reasonableness of the traditional view already expressed: that, usually in the form of a puberty ceremony, circumcision is to render boys wholly male, and excision to make girls wholly female. This is, I think, the most widespread view among the peoples themselves who have practiced these rites. I think that this is as close as we shall ever come to rationalizing them. Also I find the concept of the innate bisexuality of the human body not only attractive but well founded anatomically and embryologically. In the human fetus the external genitalia are identical in both sexes until the end of the third month. Then they begin to differentiate. The rudiment that forms the penis with its foreskin in the male becomes the clitoris with its sheath in the female. The folds that become the labia majora in the female become the scrotal sac in males. (There is no male counterpart to the vagina.) Men keep throughout life their vestigial nipples that can be developed into breasts, though never to lactate, by treatment with estrogen. (Have any native people ever excised the male nipples at puberty?) The human body is gynandromorphic in origin, remains so to a degree until puberty, and retains vestiges of this condition throughout life. Anatomically, male and female are variations on the same central theme. That is the reality; what concerns us here are the mutilations practiced to deform that intrinsic reality. These are amazing in their extent and variety. All peoples everywhere have displayed an obsessive preoccupation with the external genitalia (as also with the mouth: witness moustaches, painting the mouth, lip plugs, covering the mouth or veiling the lower part of the face. Eating and reproduction are the two great primal drives). The genitalia tend to be hidden, often when nothing else is hidden. Conversely, males may flaunt them as in the sixteenth century European codpieces; or the gourd sheaths with which Dani tribesmen in west New Guinea hold their members erect and greatly exaggerate their length (R. Gardner and K.G. Heider: Gardens of War, Random House, New York, 1968). Some of the mutilations are cosmetic: the male members are made more attractive by scarifying them and distorting them with swellings and protuberances. In some African tribes the labia minora are purposely lengthened so as to be visible

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externally. Some mutilations have to do with enforcing virginity: Some of the African Arabs practice infibulation: the entrance to the vagina is sewn partly closed so that copulation is impossible until this obstruction is removed. One male mutilation is most remarkable: Some of the Australian tribes that practice circumcision follow it later with so-called sub-incision: The penis is slit below for its entire length, laying open the urethral canal, so that thereafter the man must squat while urinating, like a woman. The member is still capable of erection and copulation; but I should think must be less effective for delivering sperm to the cervix. Could this be a primitive device to limit conception? Or a particularly striking manifestation of Bruno Bettelheim’s mother-envy? It is against this background of endlessly bizarre practices and grotesque explanations that I single out as most reasonable and meaningful the view of circumcision as a puberty rite, along with the parallel excision in girls. Before puberty a degree of gynandromorphy is tolerated in both sexes; but at puberty, when sex begins really to matter, as an initiation into adulthood and preparation for marriage and parenthood, these ceremonial mutilations turn boys into pure males, and girls wholly into females.

The Jewish Rite The Jewish rite of circumcision is something else again, being confined to males and performed in earliest infancy. Yet vestiges remain of its possible source in a puberty rite; so for example the 8-day-old infant is hailed as “chatan”—a bridegroom. The Biblical injunction to circumcise first appears in the weightiest possible form, sealing the covenant between God and Abraham, father of nations: “And God said to Abraham. . .. This is my covenant, which you shall keep, between me and you and your descendants after you: Every male among you shall be circumcised. . .. He that is 8 days old among you shall be circumcised . . . both he that is born in your house and he that is bought with your money. . . So shall my covenant be in your flesh an everlasting covenant. Any uncircumcised male . . . shall be cut off from his people: he has broken my covenant.” (Gen. 17:9–14). Abraham was then ninety-nine. God had no sooner finished speaking than Abraham had himself circumcised, he and his 13-year-old son Ishmael—so a pubescent boy. Also all his male slaves. Did the slaves thereby become Jews? My rabbinic friend, a deep student of such matters, says “Almost.” They became, so to speak, second-class Jews. Any who were freed thereafter were accepted as full Jews. On the other hand, slaves who evaded circumcision had to be sold to Gentiles. Circumcision is one of the holiest and most universal of Jewish rites, and yet it has its limits. One might think the command to circumcise so absolute as to permit no equivocation. It is astonishing to realize that on the contrary any son of a Jewish mother is fully a Jew, circumcised or not. A Jew whose brother has died as the result of circumcision is excused from this obligation. The Bible contains some other interesting vagaries.

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Belated circumcision: When Joshua led the Israelites over the Jordan to claim the Promised Land, God enjoined him among the ceremonies of investiture to “Make flint knives and circumcise the people of Israel.” For though all the Jews who came out of Egypt had been circumcised, that was not true of any born during the 40 years of wandering in the wilderness. So it was done then to all of the males in the nation, some of them 40 years old, at the Hill of the Foreskins. They laid over in camp until healed before moving on (Joshua 5:2–8). Circumcision as a military tactic: When on his wanderings Jacob with his household came to the city-state of Sechem in Canaan, his daughter Dinah went to visit with the women of the city. The prince of Sechem seized and raped her; but also fell in love with her and wanted to marry her. But Jacob’s sons were outraged by the indignity done their family, and wanted revenge. The king interceded for his son, and proposed that Jacob stay at Sechem and that their people intermarry. Jacob’s sons replied, not until all the Sechemite men were circumcised. They agreed, and all underwent the rite. “On the third day, when they were sore, two of Jacob’s sons, Simeon and Levi, Dinah’s brothers, took their swords and came upon the city unawares, and killed all the males.” Then they took everything for their own, including the women and children; and brought back Dinah. Jacob reproached them for this deed, but only because it was impolitic (Gen. 34). Yet he seems to have kept it in mind, for on his deathbed he cursed their ferocity and cruelty, and he left them alone landless among all his sons (Gen. 49:5–7). Circumcision for battle trophies: Saul offered his daughter Michal as wife to David because she loved him, but also because Saul, jealous of David’s popularity, planned by a ruse to have the Philistines rid him of a potential rival. So when David modestly demurred, pleading his insignificance and poverty, Saul sent back word that all he asked as a bride price was one hundred Philistine foreskins. That made David happy. He brought the king two hundred foreskins, and married the princess (I Samuel 18:20–27). Was Moses circumcised? An altogether astonishing passage occurs in Exodus 4:24–26. It will be recalled that Moses, having killed an Egyptian who had mistreated a Hebrew, fled to Sinai and there married Zipporah, daughter of Jethro, a priest of Midian. While Moses was shepherding his father-in-law’s flock, God spoke to him out of the burning bush, and ordered him to return to Egypt. Moses was reluctant to do so, but God insisted; and finally Moses gave in. He gathered up his family and started back to Egypt. Now the amazing passage: “At a night encampment on the way, the Lord met him and sought to kill him. Then Zipporah took a flint and cut off her son’s foreskin,” and smeared the blood on Moses’s genitalia (my translation says “touched his legs with it,” but that is a circumlocution) saying, “You are truly a bridegroom of blood to me!” And when the Lord let him alone she added, “A bridegroom of blood because of the circumcision.” What this seems to mean is that, growing up in Pharaoh’s palace as the ward of an Egyptian princess, Moses had not been circumcised, nor were his sons born in Midian. Zipporah’s quick action saved his life; God was deceived by the blood upon Moses into thinking him circumcised. The Midianites were Semites, but not Jews. Zipporah was not Jewish, hence neither were her children. But she had done

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the right thing; and I like to think that her exultant cry meant, “Now I am fully your Jewish wife. I have circumcised our son, and have saved your life with his blood.” (There is of course a difficulty. Since circumcision was a much more ancient Egyptian than a Jewish rite, Moses should have been circumcised as an Egyptian, if not a Jew. Perhaps this was not done in order to disguise his Jewishness, to make him seem to the Egyptian nobles a more acceptable kind of foreigner. We are never told whether, after Zipporah made Moses appear to have been circumcised, he actually was.) The unique feature of circumcision among the Jews, relative to all the peoples about them who seem to have practiced it as a puberty rite, is its displacement to earliest infancy. No other people have practiced ritual circumcision on infants so young; and those who approach it, the Moslems and Ethiopians, probably did so in imitation of the Jewish custom. Ironically, the Jews are now outdone in this regard by American gentiles—and some Jews—who, having to leave the hospital 3–5 days after a child is born, have non-ritual circumcisions performed as early as the second day.

Why Did the Jews Circumcise So Early in Infancy? Moses Maimonides, the twelfth century codifier of the Talmud, gives “three good reasons:” (1) If it were postponed, the grown boy might not submit to it. (2) The young infant does not feel much pain, “because the skin is tender and the imagination weak;” and (3) the father, who is responsible for carrying out this commandment, hardly knows the infant as yet, whereas later his love for his son might tempt him to spare the boy this mutilation.9 This explanation, for all its practical good sense, I believe is trying to rationalize an ancient practice that must have arisen for other, deeper and more arcane reasons, more closely connected with our earlier discussion.

Male and Female in the Jewish Tradition Let us begin with the ancient belief that the foreskin is the female element in a male. I should like first to suggest that the displacement of circumcision to the eighth day of life, as also the failure to provide any parallel rite for females, were aspects of the obdurately male orientation of Judaism. Then, having dealt with that, I will come back a way. The Jews alone among the Mediterranean peoples worshipped one, militantly male God. This position needed constant defending, both the mono- and the androtheism. It was with good reason that God cautioned Moses, “You shall have no other gods but me . . . for I, the Lord your God am a jealous God” (Exodus 20: 3, 5). Throughout the Mediterranean region the worship of the Great Mother flourished and constantly intruded: Ashtoreth (Astarte), whom Solomon was persuaded

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to worship in his old age (I Kings 11:5); Asherah, mother of the gods, whose worship, attended by both male and female temple prostitutes for the use of the male communicants, persisted for centuries, even invading the Temple in Jerusalem until Josiah, the great reformer, ordered the priests to remove from the Temple “all the vessels made for Baal, for Asherah, and for all the host of heaven . . . and he brought out the Asherah from the house of the Lord. . . And he broke down the houses of the male cult prostitutes which were in the house of the Lord. . .” (II Kings 23:4–7). Not only was the Jewish God male; all about were powerful goddess cults. As Freud put it, Judaism is a Father religion, just as Christianity is a Son religion.10 The only relief from this exclusively male Judeo-Christian theology is in the Roman Catholic cult of Mary. The preoccupation with maleness extends to humankind. Not only was the first human being a male; as the feminist Mary Daly remarks with some bitterness, he preempted the first childbirth under sedation in giving birth to Eve.11 All this ancestral couple’s early children were males. Females were an afterthought. After Seth was born when Adam was 130 years old, we are told that Adam lived another 800 years “and had other sons and daughters” (Genesis 5:3–4). The literal-minded wonder where Adam’s firstborn Cain and his sons in turn found their wives. Where indeed? That was not a pressing problem to the ancient Jews. Once the men were there, women would turn up as needed. I once was told the story of a revivalist preacher who in the course of a sermon used the phrase, “There will be wailing and gnashing of teeth!” “How about me?” asked an old woman sitting up front, “I ain’t got no teeth!” “Teeth?” said the preacher, “Teeth will be provided!” That’s how it was with women in Genesis—they were provided! Could it have been this obsession with maleness that persuaded the ancient Hebrews to make their sons wholly male from earliest infancy by circumcising them on the eighth day? And in the same spirit to do nothing about their daughters, then or later? The Bar-mitzvah for the sons at age thirteen, and nothing for the daughters? One of the ordinances that God gave Moses on the mountain begins: “When a man sells his daughter as a slave. . .” (Exodus 21:7). Men did not sell their sons. In the daily morning prayer, now well over 2,000 years old, Jewish men say: “Blessed art thou, Lord our God, King of the Universe, who hast not made me a woman.” Women say: “. . . who hast made me according to thy will.” Exultation for the men, resignation for the women. In the Judaic scheme the thing to be is male, wholly male, right from the start; and one way to achieve that is by early circumcision. This seems to be a plausible hypothesis; it is not intended to be more, nor can it be. But in defending it I have gone too far. I want now to draw back from it somewhat, for the reality is both more complicated and more interesting. For what I have called the obsessive male-orientation of the Mosaic tradition concealed, and perhaps for that very reason tried to overwhelm, a fundamental ambiguity, a taint of the female, not only in Adam, but reflecting back upon God himself. In the oldest Biblical account of human creation—said to have been written in the ninth century B.C., though presumably the oral tradition goes back much further— “the Lord God formed man from the dust of the Earth” (Genesis 2:7). In Hebrew this

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is to derive man, Adam, from Adamah, the Earth, a feminine form. It is an idea held by innumerable peoples from time immemorial. We keep it still, in our expression Mother Earth. Two other accounts of human creation are assigned by Biblical scholars to the later Priestly version, written in the fifth century B.C. In both of them man and woman are created together, as in the words: “And God created man in his own image; in the image of God created he him; male and female created he them” (Genesis 1:27). Genesis 5:2 begins with almost the same words and then goes on: “. . . and blessed them, and called their name Adam, in the day when they were created.” In both these statements there is the same curious switch of number, from “him” to “them”. The Hebrew is that way too. How get from “him” to “them”? How have a “them” named “Adam”? Does it mean that the first human creature was bisexual? And hence that God, since he shared the same image, is at once male and female? The rabbis who made the Talmud found this a worrisome problem, troubling enough to dispose of early and put behind them. Some ingenuity was expended upon it. Moses Maimonides summed up in the twelfth century as the opinion of “our sages”—the usual expression for a preferred interpretation—that “Adam and Eve were at first created as one being, having their backs united. They were then separated, and one half was removed and brought before Adam as Eve.”12 My rabbinical mentor tells me that this kind of idea—both of a bisexual God and a bisexual first human being made in his image, was in the mainstream of Jewish mystical (Kabbalistic) thought until dismissed in the last century under the influence of German rationalism as sacrilegious or absurd. So Judaism at its source is not as unequivocally male-oriented as at first appeared. There is room in the tradition for God the Parent as well as God the Father; and Eve may not have been born out of Adam, but born with him and sundered from him, the better to “Be fruitful, and multiply, and replenish the Earth. . .” (Genesis 1:28). And infant circumcision? This makes it seem more an act of male assertiveness, perhaps all the more aggressive because the theological ground was a bit shaky. A wholly male priesthood may have insisted very early on masculinizing not only the godhead, but every other aspect of Judaism. It may have been part of that effort to render all males wholly male from earliest infancy by removing the foreskin as a female contaminant. This view of the matter is somewhat reinforced when coupled with the otherwise strange prescription in Deuteronomy 23:1: “He whose testicles are crushed or whose male member is cut off shall not enter the assembly of the Lord.” One can understand that such mutilations might make a Jew unfit to marry, but why should they exclude him from the rituals? Is it that circumcision was regarded as confirming and purifying his maleness, whereas these more drastic mutilations would destroy it, and hence would bar him, as women were barred, from direct participation in religious observances?

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Is Circumcision a Health Measure? I have already given reasons for questioning the origins of circumcision as primitive preventive medicine. In recent times this practice has been taken up widely as a supposed “health measure” by gentiles particularly in the English-speaking United States, Canada and Australia, less in Europe. Many Jews also, religious and otherwise, now defend this practice on grounds of health. Within the last few years many physicians have gone over to the view that infant circumcision, having begun as religious ritual, now survives in Western societies as little more than medical ritual. In that sense it is often grouped with another ritualized operation, tonsillectomy. A few distinctions are needed. Both these operations have a limited role in therapy, in treating specific disorders. What is now being questioned increasingly is their routine performance as prophylaxis, as aspects of preventive medicine. Tonsillectomy, like circumcision, has an ancient history going back some 2,500 years.13 Both operations—excepting circumcision done for religious reasons—have a curious class character. Not only are they restricted largely to developed nations, but within them mainly to the well to do. They are aspects of middle class privilege, evidences of affluence and social status, demonstrations of the special care that middle class parents lavish on their young. Not only do the parents frequently initiate these procedures; they may be performed more for them than for their children, to show that they are as solicitous as the Joneses. A statistic bears out this connection: in England circumcised boys are seven times more likely to have tonsillectomies in early childhood than uncircumcised boys.14 Though routine tonsillectomy is rapidly declining in this country, an American pediatrician could still say in 1969: “It is probably the commonest surgical operation performed today in Western civilization.”15 A physician in good position to know assures me that this is still true. And tonsillectomy is something one can do for daughters as well as sons! Even when the physician is neutral or negative toward these procedures, the parents may still request them. And the physicians’ attitudes— as some of them readily grant—may be colored by the recognition that these rapid, relatively innocuous procedures pay rather handsomely. A circumcision takes about 10 min, and a dozen may be run off any morning. One of our best Boston hospitals at present charges $40 for the use of the room and nurse; and the physician bills his private patients $30–$50 for the operation. It adds up. One of the reasons frequently given for infantile circumcision is that it “will avoid trouble later.” The medical statistics of such later troubles among the uncircumcised also have a strong class orientation. Not only are the sons of the poor less likely to be circumcised, but their lack of circumcision is much more likely to cause later difficulties. The conditions of their lives and the kinds of things they do and are done to them are much more likely to foster uncleanliness of the male member, the only condition that childhood circumcision ameliorates. The statistics of penile pathology among uncircumcised men are overwhelmingly weighted toward workers,

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peasants, and soldiers. What should be blamed upon poverty and squalor is heedlessly ascribed instead to lack of circumcision. As one physician says, “Venereal disease is more prevalent in lower socioeconomic groups and these are the groups that are most likely to be uncircumcised. They are also the groups in which there is a poor standard of personal hygiene. The lower socioeconomic groups are also those with a higher incidence of tuberculosis; but one could be excused for doubting that the retention of the prepuce renders one more susceptible to tuberculosis.”16 One of the most striking things said in support of childhood circumcision is that it practically rules out the development of cancer of the penis. That may be true in the United States; but a study of Javanese men, who are circumcised ritually, found among 78 cases of carcinoma, 7 carcinomas of the penis. Conversely, though almost all of Sweden’s 3.7 million males are uncircumcised, in 1960 only 15 cases were found of cancer of the penis or scrotum. It seems clear that penile cancer is very rare in uncircumcised men with high standards of cleanliness as in Sweden; and that circumcision offers little protection where personal hygiene is not as prevalent. “If the uncircumcised man has a foreskin which he can retract and which he keeps clean, the risk of this cancer is removed.”17 There was a recent flurry in the medical literature owing to the allegation that cancer of the cervix is more prevalent in the wives of uncircumcised men. The initial observation was that Jewish women have lower rates of cervical cancer than gentile women. However gentile women with circumcised husbands seem to develop cervical cancers as frequently as gentile women whose husbands are not circumcised.18 In fact cancer of the cervix seems to follow the same class pattern as penile disorders of all types including penile cancer: “Factors shown to be associated with a high risk of developing cervical cancer include low socioeconomic status, early marriage, multiple marriages, extramarital relations, coitus at an early age, frequent coitus, non-use of contraceptives, syphilis and multiparity.”19 There is no solid basis for believing that circumcision in itself has anything to do with the incidence of cervical cancer. To keep the penis properly clean in the adult demands retracting the foreskin. Many mothers are alarmed because their infants’ foreskins cannot be drawn back. But in fact this is the normal condition in young infants. The foreskin can only rarely be retracted at birth, and ordinarily becomes retractable only at 2–3 years of age. In a careful English study the prepuce was found to be completely retractable in only 4% of newborn boys. In only 54% the tip of the glans (the head of the penis) could just be seen, while in 42% it was completely hidden. Even at 6 months the foreskin could be retracted in only 20% of the infants, whereas at 1, 2 and 3 years this figure rose to 50, 80, and 90%.20 With increasing age the condition improves further. A study in Danish schoolboys, few of whom are circumcised, showed that the foreskin could not be retracted (phimosis) in 8% of 6–7 year olds, but only 1% of 16–17 year olds.21 Clearly the way to deal with unretractable foreskins in boys is not to circumcise, but to wait. Another common complaint is that the foreskin adheres to the glans. Again this seems to be normal in young boys. In Danish schoolboys Oster found the incidence of such “adhesions” to diminish without treatment from 63% in 6–7 year

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olds to 3% in 16–17 year olds. No adhesions were found among ninety-five 17 year olds. Normally the skin of glans and foreskin, which may be fused in infants, separates spontaneously during childhood, a process that may take to age 17 to complete.22 It is also normal for a cheesy sebaceous material called smegma to collect between foreskin and glans. This causes no trouble in young children with unretractable foreskins, since they form little smegma. Oster found smegma in only 1% of 6–7 year olds, increasing at about puberty, and rising to 8% in 16–17 year olds. One can conclude that there is little trouble to expect in the uncircumcised that would not be prevented by simple cleanliness, by older boys and men occasionally drawing back the foreskin and washing gently. As one physician has remarked, the problem is little different from washing behind the ears, yet no one has suggested amputating the ears. Finally, it should be understood that circumcision, like any other surgical procedure, can cause trouble. It produces an appreciable incidence of complications: immediate, such as hemorrhage,23 infection and loss of skin;24 and delayed, such as ulcerations and blocking of the urinary opening. More serious complications are fortunately rare, but they occur. I cite only for its intrinsic interest, not to frighten expectant parents, the wellknown case of a 7-month-old boy, one of a pair of identical twins, who was being circumcised by electrocautery. The current was too strong and burned the penis so badly that it was wholly ablated, flush with the abdomen. The desperate parents finally agreed to have this little boy transformed into a girl, through surgery and hormone treatment.25 It is unlikely that so drastic a mischance will happen again soon.26 A particularly well-considered essay by the pediatrician E. Noel Preston concludes: “Routine circumcision of the newborn is an unnecessary procedure. It provides questionable benefits and is associated with a small but definite incidence of complications and hazards. . . Circumcision of the newborn is a procedure that should no longer be considered routine.”27 Another physician, W.K.C. Morgan, ends an essay in the same journal with the words: “The teaching of the Koran and Bible, the mistaken beliefs of many in the medical profession, the intuition of woman (note: woman), and above all folklore, tradition and health insurance agencies support this ritual. Nevertheless let us remember that 98 times out of 100 there is no valid indication for this mutilation other than religion.”28 It is only fair to note that each such statement in the medical literature inspires letters from other physicians, both of agreement and rebuttal. Having read both sides of the argument carefully, I come out convinced that there can be little wrong with keeping the foreskin that the habit of washing won’t fix. Given a good chance that the genital area will be kept reasonably clean, regarding infant circumcision as a “health measure” is only to rationalize what is in fact a distressing mutilation of young infants. But that is only one of a galaxy of such rationalizations. Specifically for those parents with whom this practice is not traditional and so must decide whether or not to circumcise, that decision involves motivations and repressions that rarely surface,

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perhaps for the very reason that they lie so deep and are potentially so painful. But that brings us back to where this essay began.

The Mothers “I’ve never been able to forgive my mother for having that done to me,” said my young friend in Tallahassee. His mother, not his father. Throughout the current medical discussion of circumcision, it’s all mothers; not a word about fathers. For it’s the mothers who decide, in the hospital, talking with their obstetricians, their pediatricians, about their babies, still wholly their responsibility. Not the Jewish mothers. There no decision is needed, circumcision is taken for granted, and the fathers are ritually responsible. No Jewish boy would dream of blaming his mother for having him circumcised. Why do gentile mothers have their infant sons circumcised? It is strange that one of the commonest reasons they offer is that the penis looks better circumcised. I think that strange because those same mothers are horrified by all kinds of other mutilations practiced by peoples they regard as barbaric, for just such cosmetic reasons: tattooing, scarification, lengthening of the ear lobes—or in some African tribes, of the labia minora—lip plugs, and the like. Why do they condone this mutilation? Why do they think it cosmetic? In part for the curious reason that by now—for here in the US we are in the second and third generation of white middle class circumcision—many mothers have never seen an uncircumcised penis. It would seem strange to them; they are afraid that their little boys would feel strange having one. That is ironic, for Michaelangelo’s David, the epitome of young male beauty, whose pictures adorn innumerable school textbooks—Michaelangelo’s David is uncircumcised. Ostensibly Jewish, yet uncircumcisied. What was in Michelangelo’s mind, making David so big, as big as Goliath; making him so old, no stripling as in the story; making him nude, a sinful state in Biblical times? Was that last just to show that he was uncircumcised? Other changes are rung on this sentiment. A young woman about to have her first child said to me that if it was a boy she would want him circumcised “so that he would look like his father.” And innumerable mothers have their sons circumcised so that they will look like other boys, so that they won’t be embarrassed later when undressing with others “in the locker room.” But there are deeper issues, somewhat harder to come at since they involve in part what are still powerful social taboos. Some years ago the English neurologist Henry Head and his co-workers showed that the glans of the penis lacks the receptors of fine sensory discrimination—light touch, small gradations of warmth or cold—what Head called the epicritic sensations. The glans conveys only protopathic sensations: of deep pressure, extreme heat or cold, and pain. That is, the glans responds only to coarse stimuli, yet with sensations that possess what Head spoke of as great “affective tone,” whether exquisite pleasure or acute discomfort. The foreskin, however, like most other skin, has all

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the apparatus of fine as well as coarse sensory discrimination; and removing it takes away a considerable area of delicately responsive sensory surface. The foreskin also provides a protective sheath for the glans, keeping its skin moist and tender. Its removal exposes the glans to the constant abrasion of clothing and keeps the skin dry. Hence the skin of the glans grows tough and coarse, with a further loss of sensitivity. Through both these effects, circumcision results in an appreciable loss of sensitivity and responsiveness of the male member. There is also a mechanical consideration. “During the act of coitus the uncircumcised phallus penetrates smoothly and without friction, the prepuce gradually retracting as the organ advances”29 An English physician likens penetration by the circumcised organ to thrusting the foot into a sock held open at the top, whereas for its intact counterpart it is like slipping the foot into a sock that has been rolled up.30 Western women are horrified to hear of the practice in other parts of the world of female excision, clitoridectomy, particularly now that it is commonly believed that the clitoris is the main, if not the only source of female pleasure in coitus. Women are indignant that so much more damaging a practice should be taken to be in any way parallel to circumcision. We should realize however that what is done to males by circumcision involves a similar loss of sexual responsivity. Having first encountered such considerations in the current medical literature, I was surprised to learn that this was familiar ground to the ancient rabbis. The great twelfth century Talmudists Judah Halevi, Judah of Barcelona and Moses Maimonides all agreed that the main object of circumcision was to encourage sexual restraint by lowering the sensitivity of the male organ and hence sexual pleasure. Thus Maimonides: “Circumcision simply counteracts excessive lust; for there is no doubt that circumcision weakens the power of sexual excitement, and sometimes lessens the natural enjoyment. . .. Our Sages (Bereshit Rabba, c. 80) say it distinctly: It is hard for a woman with whom an uncircumcised man had sexual intercourse to separate from him. This is, I believe, the best reason for the commandment concerning circumcision.”31 One encounters also the contrary view, that circumcision involves a sexual advantage, directly for women, indirectly for men in making them more pleasing to women. The loss of sensitivity of the male organ can be viewed as a gain, since it increases staying power, the capacity to prolong the sex act. Also I have heard American woman express a preference for the circumcised organ on the grounds that it is neater, less messy and more available. Perhaps for these among other reasons, circumcision is reported to be spreading rapidly in parts of the Congo and Sudan in which it has only recently been introduced and has no ritual significance, because the women insist upon it in their sexual partners. It is almost as though some women saw in the foreskin a competing vagina. And indeed Bryk reports an encounter just after an African circumcision rite, that almost says as much: “His girl comes . . . they talk all through the night. Early in the morning she gives him her hand and in parting says: ‘I’ll return tonight and then I’ll give you my vagina. My dear man. Now I love you truly.’”32 Looking back over the last paragraphs, I see emerging some degree of opposition between man-talk, whether by ancient rabbis or modern physicians, and

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woman-talk, much of it still unrecorded, and the little there is of it still largely filtered through males. It seems to bring out a male impression that circumcision decreases sexual pleasure in men that must compete with a female preference for this condition. It is hard to estimate how much such considerations weigh when mothers decide to circumcise their infants. Whatever their reasons, the mothers do opt for this operation, at present almost universally in our country33 —those who can afford it—yet sometimes with misgivings, knowing that they are handing over their babies for what may seem advisable, yet is surely unnecessary surgery. What makes this decision easier is the widespread conviction that it doesn’t hurt, that the infant feels no pain. The physician is likely to assure the mother that it doesn’t hurt; and she thinks—and sometimes he thinks—that he knows. Here we encounter what I believe in fact to be a deeply planted and passionately defended rationalization. As a biologist I have had to live with that kind of rationalization all my scientific life. We biologists in the course of experimenting sometimes have to decide whether to do things to animals that would hurt people if done to them. The question is whether those operations hurt the animals. Biologists differ in their opinions about this. One must understand that there is no way whatever of finding out. There is no way—not even conceivably—of knowing what another animal feels. There is indeed no way to know what another person feels. The person can tell you; but then you only know what he has said, perhaps inaccurately, perhaps even to deceive you. There is no way at all to check up. A person’s or animal’s sensations are forever their own, forever locked within a private world of consciousness that science cannot penetrate—if indeed one concedes consciousness to another person or animal, since one can know only one’s own. We can do no more than recognize what we take to be signals of pain in certain patterns of behavior—writhing, struggling, squirming, yelping, moaning, and in the case of human beings capable of it, speech—yet with no assurance that the pain is felt. Many biologists, having done some violence to an animal and observed such behavioral signals, prefer to dismiss them as “reflex,” particularly when dealing with a “lower” animal—in invertebrate such as a lobster, or a cold-blooded vertebrate such as a frog or a fish. Such attitudes are not confined to biologists. Few of us hesitate to throw a live lobster into a pot of boiling water, in which it writhes and struggles for a while before dying; or to thread a worm on a hook, however much it writhes; or with that bait to hook a fish, and then work or cut out the barbed hook. Do those animals feel what we are doing to them, do they feel pain? There is no way of knowing; one assumes whatever one likes. As for me, working in the laboratory, I decided long ago that if I did anything to an animal that would hurt if done to me, and the animal reacted much as I would react—except for speech—that I would rather assume that the animal felt pain than that it didn’t. Hence I don’t do such things to animals. Once, not knowing any better, I did something awful to a lobster—though perhaps not as awful as boiling one alive—and I shall never forget how it writhed as it died. So now the only operation I

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perform on an intact, unanesthetized animal is to kill it; and I take a lot of trouble to see that I kill instantly, with one stroke, an animal handled gently up to that moment. So I wonder about those babies. Why does anyone think that circumcision doesn’t hurt them? Well, they can’t say it hurts, not yet having learned to speak; and they don’t seem to remember it later. But then, few persons remember much that happened before they were two or three, and just about no one remembers anything before that; yet who has lived with babies and believes that they are not perfectly aware of all kinds of experiences that they won’t remember later? There is a third, supposedly scientific reason for thinking that very young infants do not feel pain. We are told that the nerve fibers of newborn infants have not yet acquired the myelin sheaths that will later insulate them from one another and help them to conduct excitation more rapidly. It has been suggested that for this reason newborn infants may not feel pain. But as it happens, the sensation of pain, unlike other skin senses, continues throughout life to be conducted, at least in part, by very fine nerve fibers that lack myelin sheaths. So none of these arguments makes much sense.34 I called an old friend, an obstetrician who long ago had taken care of my wife— and circumcised our son. “How do you do the operation?” I asked him. “Do you use a local anesthetic?” “Oh no!” he said. “Then doesn’t it hurt?” I asked. “Well,” he said, falling back upon a common physician-to-patient euphemism, “there’s no doubt that the baby is uncomfortable.” “Doesn’t it squirm and struggle?” I asked. “Well,” he said, “it can’t!” -and then to my surprise, “As a matter of fact it’s rather gruesome. We fasten the baby down in a form that holds him so that he can’t move during the operation. But it takes only about five minutes.” “Five minutes!” I said. “That sounds pretty long to me. I thought it only took a few seconds.” “Would you like to see one done?” he asked. “Sure,” I said. So we made a date. A few mornings later I went to the hospital at the time he had mentioned. When I asked for him at the desk, I was told that he had been delayed. Would I wait over there? When I went over there, I found a young couple, the mother holding a lovely baby boy. “So you’re waiting for Dr. ___, too!” she said with a bright smile; and with that I realized that her baby was going to be the patient. We had about 20 minutes to wait, and chatted together, all happy and relaxed. The parents were very proud of their beautiful son. He had been a little premature, the mother explained, and so had to wait awhile before being circumcised. Now he was six weeks old and doing fine, as I could see. He had already more than doubled his birth weight. Just then, a middle-aged nurse came up to us and asked for the baby. She began to walk off with it. The mother, still all smiles, started along with her; but the nurse stopped and said, kindly but firmly, “Please wait here.” The mother looked distressed. “I thought I could go along!” she cried. “Oh, no!” said the nurse, “but we’ll be back in about ten minutes.” And she went off with the baby. That mother’s face was a study. She sat down again, but now bolt upright, very tense, her face rigid, her eyes straight ahead. Her husband on the other hand was completely relaxed, even making a show of it, chuckling, patting her on her shoulder, telling her jovially that there was nothing to worry about. “Be a man!” he seemed to

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be saying to her; but she wasn’t. She was a very worried woman. I wondered how many mothers had been through that before. Then I was called, and found the doctor in a little surgery. The nurse was still holding the baby, who was quiet and relaxed; and I put on a sterile gown and cap. Then the infant was laid on a plastic form with a depression the shape of a child. His wrists and ankles were clipped into cuffs that held them gently but firmly. With that he began to cry bitterly; the restraint seemed to bother him at least as much as anything that happened later. The surgeon laid a sterile sheet over the child’s middle, with a circular opening exposing the genitals. As already said, the foreskin of such a young infant is usually too tight to be retractable, and often is attached to the glans. So after gently freeing the foreskin all around with a probe, the doctor slit it dorsally with scissors, so that it could be slipped back. There was a little bleeding. Then the shaft of the penis was inserted into the thimble-shaped end of a stainless steel rod, and the slit foreskin pulled forward over the outside of the rod. A circular steel ring was clamped tightly about the foreskin, crushing a narrow band of it between the clamp and the steel rod, just below where the foreskin would be severed. The physician explained that crushing the tissues in this way would cut the bleeding, help the cut ends of the foreskin to heal properly, and numb the nerves. The clamp was left on for five minutes. Then the foreskin was cut through all around, just above the clamp, and slipped off. The steel tool was removed, and the penis wrapped in a Vaseline-gauze dressing. The baby’s wrists and ankles were freed, and the operation was over. “Are you for it or against it?” the surgeon asked me afterward. “I suppose you’re neutral.” “I’m against it,” I said. “So am I,” he replied. Yet nothing about this operation seemed to me horrifying. Clearly the infant was distressed, but seemingly as much by the restraint as anything else. There was no marked response to what I would have judged to be the most painful episodes—the moments of crushing and cutting of tissues. After the first bout of crying on being fastened down, it seemed to me more as though the infant were trying to withdraw into himself. To my astonishment, at one point right in the middle of the operation he seemed to be falling asleep!35 Someone later showed me an interview with the psychiatrist Wilhelm Reich, in which he said: “Circumcision is one of the worst treatments of children. And what happens to them? They can’t talk to you. They just cry. What they do is shrink. They contract, get away into the inside, away from that ugly world.”36 And of course the operation is not the end of it. Barring complications, the circumcised infant is in for 3–5 days of soreness, his glans swollen, inflamed, and blue owing to the disturbed blood circulation. And the mother? Under the usual conditions of a hospital delivery and circumcision, she hardly knows her baby yet. He is brought in to her periodically to nurse; but he is still in the hospital’s care, not hers. She agrees to have him circumcised, or perhaps requests it, quite impersonally. It is a social decision, and remote. She doesn’t know, and no one tells her, when or how it will be done. It all happens far off somewhere, between two feedings.

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And yet. . . The infant comes back to her somewhat changed, fretful, withdrawn. One mother said to me, “His crying sounded different to me afterward.” He has been hurt; a violence has been done to him. Many a mother wonders a little, worries a little, then puts it out of her thoughts. After all, everyone else does it, all her friends. And it was done for his sake, for his health, for his peace of mind later when he undresses in that locker room. And yet. . . Suppose it was done for no good reason? Suppose all that was accomplished was the painful mutilation of a helpless infant? The very suggestion is an affront, an attack where the mother is most vulnerable. I shall probably not be forgiven this essay. And to have that attack come from sons! No wonder that those mothers in Tallahassee were upset with my young friend.

The Outcome I have come a long journey since Tallahassee. It is not yet over; I wonder whether it will ever be. There is a lot more to explore. Yet I should like to say where this encounter finds me now. As I write this essay, we are working in the laboratory on the skins of frogs. We use just a small patch of skin in each experiment. The other day the thought occurred to me—I wouldn’t dream of cutting that snippet of skin from a live frog. You couldn’t bring me to do it. As it is, we kill the frog, take a piece of skin to work with, then come back later for another piece. It would probably make a better experiment to take a patch of skin from a live frog, and leave the rest on him until we wanted more. But I couldn’t do that. It would seem to me cruel. Yet frogs can’t talk. Does it feel pain? Does it remember? I don’t know; and there is no way that I can find out. It’s just like those babies. It’s curious—and revealing—how few persons think about circumcision, or indeed about anything involving the genitalia, even their own. What do they even look like? Are they pretty much alike from person to person, or do they vary a little, or a lot? One hardly knows. At one point in writing this essay I looked through the shelves in our Biological Laboratory Library, through books on the senses, on neurophysiology and neuroanatomy, some of them medical textbooks. I was looking for what new information there might be on sensory responses from the glans penis and foreskin. Neither of those words was in the index of any of those books. I hadn’t thought at all about circumcision until that conversation in Tallahassee; but now that I have thought about it—it’s just as with the frogs. I could not bring myself to have another infant of mine circumcised. There is a complication, for I am a Jew, circumcised as is my son. A nonobserving Jew, a non-believer in anything supernatural, yet deeply involved, a Bible reader—of both Testaments—and very much a Jew. For me there are special barriers against deciding not to circumcise; for it is hard to break with a tradition that one’s ancestors have observed for thousands of years, however else one feels.

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So I have looked into what it means for a Jew not to be circumcised. I find the position a little surprising. For one thing, the son of a Jewish mother is wholly a Jew, regardless of circumcision. He can practice his Judaism in any form and to any extent he likes. He may take part in all observances, private and public. A Jewish father is obliged to have his son circumcised; but at thirteen that obligation passes to the son. Not to carry out that obligation is a transgression; the uncircumcised Jew is fully a Jew, but transgressing. Incidentally, Reform Judaism asks circumcision only for born Jews, not for those converted to Judaism. A second discovery will surprise many Jews: the usual hospital circumcision does not fulfill the ritual requirement. It is only an operation, where what is needed is a consecration—a handing over by the Jewish father of his son, to enter the covenant of Abraham, sealed with the shedding of the son’s blood. A hospital circumcision does nothing in this regard. A Jewish child who has already undergone such surgery would still need this ceremony and a token drawing of blood to fulfill the ritual requirement. An added surprise for me has been to realize the relative relaxation with which great talmudists of past centuries viewed circumcision. I have already mentioned that Maimonides, the twelfth century codifier of the Talmud, considered the main point of circumcision to be, by weakening the organ of generation, to foster sexual restraint—an opinion with which other great rabbis of his time concurred.37 Maimonides also allowed for the possibility that a grown boy might refuse to be circumcised, or a father for love of his son might neglect to have it done. After all, said Maimonides, it is “a very difficult operation.” My rabbinic mentors agree that in former times and in other places Jews may have felt more relaxed about circumcision than do orthodox Jews now, perhaps goaded by the existence of reform Judaism, and the disastrous aftermath of a century of relaxed standards in central Europe. It seems to me that a final consideration might bear upon this problem. Child sacrifice (to “Moloch”) was a common rite among the ancient peoples of the Near East, and the Jews were forbidden it in the harshest terms (Leviticus 20:1–2). When God laid claim to all firstborn males, he specified that though those of the domestic animals were to be sacrificed, children were to be redeemed. As Moses, having been instructed by God, explained to the people: “I sacrifice to the Lord all the males that first open the womb; but all the first-born of my sons I redeem” (Exodus 13:15). And one of the ordinances that God gave to Moses along with the Ten Commandments states: “The firstborn of your sons you shall give to me. You shall do likewise with your oxen and your sheep: 7 days it shall be with its dam; on the eighth day you shall give it to me.” (Exodus 22:29). That command, to sacrifice the male firstborn of a domestic animal, taking it from its mother when it is eight days old, makes one wonder whether the prescribed circumcision of sons on the eighth day was once a form of redemption, the token sacrifice of the foreskin to substitute for sacrifice of the child. In any case the principle of redemption runs through these commandments, not only the obligatory redemption of sons, but “every firstling of an ass you shall redeem with a lamb. . .” (Exodus 13:13).

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It is with the greatest hesitation, since I have no right and know so little, that I should like to suggest to my fellow Jews that perhaps the time has come to redeem the foreskin itself, rather than sacrifice it. Surely some substitute might be found for this rite, perhaps even involving a token drawing of blood from an older child, that would be preferable to this assault upon and mutilation of a newborn infant. Since by now I would not circumcise even a Jewish infant, I would not dream of doing this to a gentile child. I would know no medical reason to deprive my sons of their foreskins, being confident that they would share with me habits of cleanliness that would make that unnecessary. If I had my children in grinding poverty and squalor, that might make a difference. I might then even want to have them circumcised, and perhaps would fail, for the usual reason that I could not pay. As with so many other things, those who might need circumcision are least likely to get it, and those who get it are least likely to need it. But even were I poor, if I had cleanly habits and some chance of passing them on to my sons, I would not circumcise them. For it is a barbarous thing to meet a newly born infant with the knife, with a deliberate mutilation. And the part that is removed is not negligible; it has clear and valuable functions to perform. Not circumcising a boy will not only spare him a brutal violence as he enters life; it will promise him a richer existence. And that not only because the possession of a foreskin will increase his genital sensitivity and make possible more satisfactory and pleasurable sexual activity, but also because of the consideration with which this essay began: that the foreskin is the female element in the male. To be sure, that is only a primitive insight, and has no standing in science. Yet that is hardly a criticism. What we consider to be male or female is largely cultural in any case; many of our conventional notions in this regard are now in flux and being challenged. This one has more basis in reality than most. Also unlike many unscientific interpretations of reality that are misleading and dehumanizing, this one can sustain, enrich and illuminate. It offers some redress where it is most needed, in a world increasingly devastated and threatened with destruction by a rampant machismo, a mindless exercise of organized aggressive maleness. Every schoolchild knows that femaleness is determined genetically by the possession of two sex or X chromosomes (XX), and maleness by one together with a relatively empty Y chromosome (XY). Very rarely a male is born with an extra Y chromosome, so XYY. A few years ago, on somewhat questionable grounds, this condition was reported to be correlated with violent behavior. Recently a research project was set up at the Harvard Medical School, to type the chromosomes of a large number of infants and so find a group, which is XYY. The idea was then to tell the parents and follow the behavior of the children, to see whether any special tendencies toward violence emerged. Some other research workers at Harvard Medical School objected strongly to this project, feeling that the study itself might prejudice the children’s behavior and relationship with their parents. A bitter controversy followed, that ended with the director of the project terminating it. While this dispute was at its height, Dr. Michael Mage of the National Cancer Institute wrote a letter to Science magazine to say that all that concern with the

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XYY syndrome provides a fine example of the way research workers in medicine pick strangely peripheral, esoteric topics to study. Our real concern, said Dr. Mage, should be with the XY syndrome, which afflicts half of humanity including himself, and is known to be strongly correlated with war and other forms of criminal violence. Just so. Maleness is our problem, excessive maleness. The circumcised organ is only the beginning of it, and kept hidden. What are displayed, like so much male plumage, are the penis surrogates and aggrandizements: the guns; the cars, named for predatory beasts, driven to and from work as though they were PT boats; the flaunting of power and status; the devastation of the earth and the cultivation of a technology of death and destruction beyond any former imagining, all in the pursuit of an obsessive accumulation of wealth far beyond any possibility of use—all the brutal, gaudy, pretentious and infinitely dangerous panoply of male aggression that now envelops and threatens our lives. This is no time to circumcise males. They need all the female element they can get. For every child is born into the world with much of one sex and a little of the other. The mistake is by a mutilation to take that little of the other sex away. It should be left as nature evolved it, as in the child, so that all our lives we can go on being much of one sex, and always a little of the other.

Notes 1. Ed. Note: This was Van Lewis, who had been a student of Wald’s at Harvard. 2. Griaule M. (1965) Conversations with Ogotemmeli. Oxford University Press, Oxford, pp 22–23. 3. Breasted JH. (1946) The Dawn of Conscience. New York, NY: Scribner, p 353. 4. Ed. Note: An American textbook on obstetrics documents a case where the obstetrician circumcises the breech infant while waiting for the head to be born: Schaffer AJ, Avery MJ. (1977) Diseases of the Newborn, 4th ed. Philadelphia, PA: Saunders, p 420. 5. Note: Urine provides a sterile medium for washing under the foreskin that does not demand retracting it. On the contrary it can be pulled forward and held closed so that the child urinates into it, ballooning it, until released. 6. Guide for the Perplexed, M. Friedlander trans. (1904) London: Routledge and Kegan Paul, p 378. 7. Freud S. (1938) Totem and Taboo. New York, NY: Random House. 8. Symbolic Wounds. (1954) Puberty Rites and the Envious Male. Glencoe, IL: Free Press, p 112. 9. Guide for the Perplexed M. (1904) Friedlander Translation. London: Routledge and Kegan Paul, pp 378–379. 10. Moses and Monotheism. (1939) New York, NY: Alfred A Knopf, p 215. 11. Beyond God the Father. (1973) Boston, MA: Beacon Press, p 195. 12. Guide for the Perplexed M. (1904) Friedlander Translation, 2nd ed. London: Routledge and Kegan Paul, p 216. 13. McNeill RA. (1960) History of tonsillectomy: Two millennia of trauma, hemorrhage and controversy. Ulster Med J. 29:59–63. 14. Illingsworth RS. (1960) Is removal of tonsils and adenoids necessary? Proc Roy Soc Med Lond. 54:393–395.

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15. Bolande RP. (1969) Ritualistic surgery—circumcision and tonsillectomy. N Engl J Med. 280:591–596. 16. Morgan WKC. (1965) The rape of the phallus. J Am Med Assn. 194:309–311. 17. Preston EN. (1970) Whither the foreskin? J Am Med Assn. 213:1853–1858. 18. Boyd JT, Doll R. (1964) Study of the etiology of carcinoma of the cervix uteri. Br J Cancer. 18:419–428. 19. Editorial. (1964) Circumcision and cervical cancer. Br Med J. 2:397–398. 20. Gairdner D. (1949) The fate of the foreskin. Br Med J. 2:1433. 21. Oster J. (1968) Further fate of the foreskin. Arch Dis Childhood. 43:200. 22. Oster, ibid. 23. A 9 pound infant has only 12 oz. of blood. Loss of 20% (only 2.4 oz.) can lead to shock, heart failure and death. 24. Ed. Note: Loss of skin puts the complication rate at 100%. 25. Money J, Ehrhardt AA. (1972) Man and Woman, Boy and Girl. Baltimore, MD: Johns Hopkins University Press, pp 118–123. 26. Ed. Note: An article in 1989 documents four cases. (Gearhart JR, Rock JA. (1989) Total ablation of the penis after circumcision with electrocautery: A method of management and long-term followup. J Urol. 142:799–801). 27. Preston EN. (1970) J Am Med Assn. 213:1858. 28. Morgan WKC. (1965) J Am Med Assn. 193:224. 29. Morgan WKC. (1965) J Am Med Assn. 193:223–224. 30. Whiddon D. (1953) Lancet. 2:337. 31. Guide for the Perplexed M. (1904) Friedlander Translation. London: Routledge and Kegan Paul, p 378. 32. Bryk F. (1928) Neger-Eros. Berlin: Marcus and Weber, p 59; cited in Bettelheim B: Symbolic Wounds, p 163. 33. Ed. Note: Thirty-five years later, the rate is down close to 50%, and in some parts of the country, much lower. 34. Ed. Note: Wald was ahead of his time. In 1987, Anand and Hickey wrote an article in the N Engl J Med (317:1321–1329) that documented cortisol levels with circumcision as high or higher than those in adults with great pain, and now it is generally recognized that infants suffer under the knife. 35. Ed. Note: The crushing has now been documented as excruciating pain, and the infant has just gone into a coma. 36. Reich W. (1967) Reich Speaks of Freud. New York, NY: Farrar, Straus and Giroux, p 29. 37. cf. Philo of Alexandria: The same view, a millennium earlier.

Appendix Resources

Organizations Association Contre la Mutilation des Enfants (A.M.E.). Didier Diers and Xavier Valle, Boite Postale 220, 92108 Boulogne Cedex, France. Attorneys for the Rights of the Child, J. Steven Svoboda, JD, 2961 Ashby Avenue, Berkeley, CA 94705 USA. Tel: 510-464-5430. www.arclaw.org Circumcision Information Australia. www.circinfo.org Circumcision Resource Center. Ronald Goldman, PhD. PO Box 232, Boston, Massachusetts, 02133 USA. Tel: 617-523-0088. www.circumcision.org Doctors Opposing Circumcision (D.O.C.). George Denniston, MD, MPH, President; John Geisheker, JD, Executive Director. www.doctorsopposingcircum cision.org Equality Now. Jessica Neuwirth, President. 250 West 57th Street, New York, NY 10107. Tel: 212-586-0906. Fax: 212-586-1611. www.equalitynow.org Foundation for Women’s Health Research and Development (FORWARD). Naana Otoo-Ovortey, MBE, Executive Director, 765-767 Harrow Road, London NW10 5NY, UK. Tel: +44 (0)20-8960-4000. www.forwarduk.org.uk Inter-African Committee. Berhane Ros-Work, President. 147 rue de Lausanne, CH1202 Geneva, Switzerland. Tel: 22-731-2420. Fax: 22-738-1823. International Centre for Reproductive Health. Els Leye, FGM Project Coordinator. Ghent University, De Pintelaan 185 P3, 9000 Ghent, Belgium. Tel: +32-9 240.35.64. Fax: +32-9 240.38.67. International Coalition for Genital Integrity. Dan Bollinger. Tel: 765-427-7012. www.icgi.org Israeli Association Against Genital Mutilation. Avshalom Zoossmann-Diskin, PO Box 56178, Tel-Aviv 61561 Israel. www.britmilah.org Intact America, Georganne Chapin, Executive Director, PO Box 8516, Tarrytown, NY 10591, USA. 914-372-2331. www.IntactAmerica.org London Black Women’s Health Action Project. Shamis Dirir. Cornwall Avenue Community Centre, First Floor, 1 Cornwall Avenue. ondon E2 0HW United Kingdom. Tel: 181-980-3503. Fax: 181-980-6314.

G.C. Denniston et al. (eds.), Genital Autonomy, DOI 10.1007/978-90-481-9446-9,  C Springer Science+Business Media B.V. 2010

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Medical Ethics Network. John Sawkey, PO Box 578, Yorkton, Saskatchewan, S3N 2W7. Tel: 306-744-2436. med-fraud.org National Organization of Circumcision Information Resource Centers (NOCIRC) [International Headquarters] Marilyn Fayre Milos, RN, Executive Director. PO Box 2512, San Anselmo, CA 94979-2512. USA. Tel: 415-488-9883. Fax: 415488-9660. www.nocirc.org National Organization to Halt the Abuse and Routine Mutilation of Males (NOHARMM). www.noharmm.org National Organization of Restoring Men (NORM) International Headquarters. R. Wayne Griffiths, MS, MEd, 3505 Northwood Drive, Suite 209, Concord, CA 94520-4506 USA. Tel: 510-827-4066. Fax: 510-827-4119. www.norm.org NORM-UK. John P. Warren, MB. Chairman, David Smith, Manager. PO Box 71. Stone, Staffordshire, ST15 0SF, United Kingdom. Tel/Fax: 01785-814-044. www.norm-uk.co.uk QuranicPath.com. Kamil Hussain, [email protected], Mary-Rose Booker, RN. www.cirp.org/nrc Rainb♀. Nahid Toubia, MD. 915 Broadway, Suite 1109, New York, NY, 10010-7108 USA. Tel: 212-477-3318. Fax: 212-477-4154. Terres des Femmes. Petra Schnull, Gritt Richter, Claudia Piccolantonio. Kreuzbergring 10, D-37075 Gttingen, Germany.

Websites Alliance for Transforming the Lives of Children. www.atlc.org/ Association Contre la Mutilation des Enfants (French). pages.pratique.fr/~ame1/ Attorneys for the Rights of the Child. www.arclaw.org/ Birth Psychology. www.birthpsychology.com/birthscene/circ.html/ BoysToo.com (Official Website of NOCIRC of North Dakota). www.boystoo.com/ Circumcision and HIV. www.circumcisionandHIV.com/ Circumcision Information and Resource Pages. www.cirp.org/ Circumcision Information Resource Center (Montreal, Canada). www.infocirc.org/ index-e.htm/ Circumcision Resource Center (Boston, Massachusetts). www.circumcision.org/ D.O.C. (Doctors Opposing Circumcision). www.doctorsopposingcircumcision.org/ Female Genital Mutilation Research Home Page. www.fgmnetwork.org/ In Memory of the Sexually Mutilated Child (John A. Erickson). www.Sexually MutilatedChild.org/ Intact America. www.IntactAmerica.org/ The Intactivism Pages. www.circumstitions.com/ International Coalition for Genital Integrity. www.icgi.org/ Intersex Society of North America Home Page. www.isna.org/, www.dsdguidelines. org/ Jews Against Circumcision. www.JewsAgainstCircumcision.org

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National Organization of Circumcision Information Resource Centers. www.nocirc. org/ Muslims Against Circumcision. www.QuranicPath.com/ National Organization to Halt the Abuse and Routine Mutilation of Males. www.noharmm.org/ National Organization of Restoring Men (NORM). www.norm.org/ NORM-UK (Great Britain). www.norm-uk.org/ Nurses for the Rights of the Child. www.cirp.org/nrc/ Students for Genital Integrity. www.studentsforgenitalintegrity.org/

Books Aldeeb Abu-Sahlieh SA. (2000) Male and Female Circumcision Among Jews, Christians and Muslims: Religious Debate. Beirut: Riad El-Rayyes Books. Aldeeb Abu-Sahlieh SA. (2001) Circoncision Masculine – Circonsion Femine: Debat Religieux, Medical, Social et Juridique. Paris: L’Harmattan. Bigelow J. (1995) The Joy of Uncircumcising! 2nd ed. Aptos, CA: Hourglass [ISBN 0-934061-22-x]. Boyle EH. (2002) Female Genital Cutting: Cultural Conflict in the Global Community. Baltimore, MD: The Johns Hopkins University Press. Darby R. (2005) A Surgical Temptation: The Demonization of the Foreskin & the Rise of Circumcision in Britain. Chicago, IL: The University of Chicago Press. Denniston GC, Milos MF. (eds.) Sexual Mutilations: A Human Tragedy. New York and London: Plenum Publishing Corporation. Denniston GC, Hodges FM, Milos MF. (eds.) (1999) Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. New York, NY: Kluwer Academic/Plenum Publishers. Denniston GC, Hodges FM, Milos MF. (eds.) (2001) Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem. New York, NY: Kluwer Academic/Plenum Publishers. Denniston GC, Hodges FM, Milos MF. (eds.) (2004) Flesh and Blood: Perspectives on the Problem of Circumcision in Contemporary Society. New York, NY: Kluwer Academic/Plenum Publishers. Denniston GC, Gallo PG, Hodges FM, Milos MF, Viviani F. (2006) Bodily Integrity and the Politics of Circumcision: Culture, Controversy, and Change. New York, NY: Springer. Denniston GC, Hodges MF, Milos MF. (eds.) (2009) Circumcision and Human Rights. New York, NY: Springer. Dorkenoo E. (1996) Cutting the Rose: Female Genital Mutilation: The Practice and Its Prevention. London: Paul & Co Pub Consortium. Fleiss PM, Hodges FM. (2001) What Your Doctor May Not Tell You About Circumcision. New York, NY: Warner Books.

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Gallo PG, Viviani F. (eds.) (1995) Female Genital Mutilation: A Public Health Issue Also in Italy. Proceedings of the 1994 International Symposium on Female Genital Mutilation, May 3rd, 1994, Padua, Italy. Padua: UNIPRESS. Glick LB. (2005) Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. New York, NY: Oxford University Press. Goldman R. (1996) Circumcision: The Hidden Trauma. Boston, MA: Vanguard. Goldman R. (1997) Questioning Circumcision: A Jewish Perspective. Boston, MA: Vanguard. Gollaher DL. (2000). Circumcision: A History of the World’s Most Controversial Surgery. New York, NY: Basic Books. Gruenbaum E. (2000) The Female Circumcision Controversy. Philadelphia, PA: University of Pennsylvania Press. Jallow BG. (2004) Dying for My Daughter. Louisville, KY: Wasteland Press. Korn F. (2006) Born in the Big Rains. University of New York: Feminist Press. Lightfoot-Klein H. (1989) Prisoners of Ritual: An Odyssey into Female Genital Circumcision in Africa. New York: Harrington Park Press. Lightfoot-Klein H. (2007) Children’s Genitals Under the Knife: Social Imperatives, Secrecy and Shame. Charleston, SC: BookSurge Publishing. O’Mara P. (ed.) (1993) Circumcision: The Rest of the Story. Santa Fe, NM: Mothering. Omoifo C. (2007) Saving Bekyah: Confronting Female Circumcision, Sexuality, and Womanhood. East Orange, NJ: Sun Rose Publishers. Rahman A, Toubia N. (2000) Female Genital Mutilation: A Guide to Laws and Policies Worldwide. London: Zed Books. Ritter TJ, Denniston GC. (2002) Doctors Re-examine Circumcision. 3rd ed. Seattle, WA: Third Mellinnium Publishing [Available from Amazon.com.]. Robinett P. The Rape of Innocence. Eugene, OR: Aesculapius Press. Skaine R. (2005) Female Genital Mutilation: Legal, Cultural and Medical Issues. Jefferson, NC: McFarland & Company, Inc., Publishers. Somerville M. (2000) The Ethical Canary: Science, Society and the Human Spirit. Toronto, ON: Penguin Books. Wallerstein E. (1980) Circumcision: An American Health Fallacy. New York, NY: Springer. Weiner K, Moon A. (eds.) (1995) Jewish Women Speak Out: Expanding the Boundaries of Psychology. Seattle, WA: Canopy Press.

Videotapes/Films Circumcision? Intact Facts. 18-min. VHS. $44.05. Injoy Productions, 1435 Yarmouth, Suite 102-B, Boulder, CO 80304. Tel: 800-326-2082. Cut: Slicing Through the Myths of Circumcision. Eliyahu Ungar-Sargon. 70-min. DVD. $24.95 plus $4.95 S&H. www.CutTheFilm.com. Cut: Slicing Through the Myths of Circumcision. Eliyahu Ungar-Sargon. DVD. $24.95 plus $4.95 S&H. www.CutTheFilm.com

Appendix

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Facing Circumcision: Eight Physicians Tell Their Stories and Reveal the Ethical Dilemmas of Physicians who Circumcise Newborns. Nurses for the Rights of the Child. 20 minutes. VHS. 1998. Nurses for the Rights of the Child. 369 Montezuma #354, Santa Fe, New Mexico, 87501. 505-989-7377. www. cirp.org/nrc/ Fire Eyes. Soraya Mire. 60 minutes. sale: 16 mm $2,000, video $445, rental: 16 mm $300, video $85. Filmakers Library, Inc., 124 East 40th Street, New York, Y 10016 (212-808-4980). It’s a Boy! Victor Schonfeld. 41 minutes. VHS. $295 institutions, $195 individuals, $65 rental. Filmmakers Library, 124 East 40th Street, New York, NY 10016. el: 212:808-4980. Fax: 212-808-4983. Mother, Why Was I Circumcised? Program for Dutch public broadcast. VPRO, see www.macdocman.com. NOCIRC PSA and Educational DVD, 20 minutes. $5. NOCIRC, POB 2512, San Anselmo, CA 94979-2512. The Prepuce by Steve Scott www.doctorsopposingcir cumcision.org/video/prepuce.html Restoration in Focus: instructional video. 200 min. VHS-PAL tape. www. foreskinrestoration.info. Tahara. Sara Rashad. 18-min. NTSC VHS. $30 ($200 for institutions, schools, libraries). Order at www.taharafilm.com The 8th Day. 53 min. VHS. $30ppd in US, $50ppd outside US. Keren Markuze, POB 361425, Los Angeles, CA 90036. Tel: 323-936-6802. Whose Body, Whose Rights? Lawrence Dillon and Tim Hammond. 1996. 56 minutes. VHS. Home Sales: Video-Finders, 1-800-343-4727. Educational Sales: $195, Rental $70, Catalogue no. 38342, University of California Extension, Center for Media and Independent Learning, 2000 Center Street, Fourth Floor, Berkeley, CA 94704, 510-642-0460

Newsletters Attorneys for the Rights of the Child Newsletter. Albert Fields, Editor. ARC, 2961 Ashby Avenue, Berkeley, CA 94705, USA. Awaken. Faiza Jama Mohamed, Editor. Equality Now, 250 W 57th St #1527, New York, NY 10107, USA. NOCIRC Annual Newsletter. Marilyn Fayre Milos, RN, Editor. NOCIRC. POB 2512. San Anselmo, CA 94979-2512, USA. NOCIRC of Michigan Informant, Norm Cohen, Editor. POB 333, Birmingham, MI 48012, USA. NORM NEWS. David Smith, Editor. NORM-UK, POB 71, Stone, Staffordshire ST15 0SF, England.

Index

A Abraham, 222, 236 Abuse, 40, 57, 120, 138, 152, 212 Adam, 225–226 Adhesions, 25, 83, 228–229 Adolescent autonomy, 22, 26–27 Africa, 4, 9, 49–58, 62–64, 66, 99–100, 139–141, 212, 220 African-American population, 55 Africans, 3, 5–8, 52–53, 55, 57, 62–66, 96, 98–100, 111, 121–122, 124, 132, 138–143, 206, 218–219, 221–222, 230–231 Ahmose, 219 AIDS, 8, 52, 61–66, 69, 215 Aldeeb Abu-Sahlieh, Sami A., 6, 138–139 Alderson, Priscilla, 31 Alexander, Franz, 153–154 American Academy of Pediatrics, 83 American Jewish Committee, 20 American Jewish Congress, 20 Amish, 28 Ammonites, 219 Amputation, 2, 7, 64, 83, 150, 157, 180, 208 Amsterdam, 140 Amygdala, 151 And the Band Played On, 65 Anti-Defamation League, 20 Antisocial Personality Disorder (ASPD), 68, 72 Asherah, 225 Australasian College of Physicians, 42, 46 Australia, 33, 39–40, 43–44, 46, 197, 212, 220, 227 Australian aborigines, 220 Autonomy, 18, 22, 26–27, 32, 46, 211–215 Ayuub, 126, 129, 131

B Beneficence, 46 Berit milah, 143 Best interests, 4, 16–17, 19, 21, 23, 26, 32, 40, 42, 45–46 Bettelheim, Bruno, 2, 221–222 Bible, 91, 222, 229, 235 Bigelow, Jim, 78, 161–162, 189–198, 200 Bioenergetic analysis, 152, 154 Bioethics, 65, 86, 88–90 Boddy, Janice, 5 Bodily integrity, 16–18, 22, 32–33, 43 Boldt v. Boldt, 3–4, 17–18, 21 Bologna, 98 Boston, 174, 227 Brain, 151–152, 170, 173, 184 Breuer, Joseph, 152 British Journal of Urology International, 33 British Medical Association, 16 Bryk, Felix, 231 Burkina Faso, 52 Bush circumcisions, 63 C Cain, 225 Cameroon, 52–53 Canaan, 223 Canada, 139, 197, 227 Cancer, 7, 19, 25, 42, 81, 91, 150, 228, 237 Catholicism, 140 Centers for Disease Control (CDC), 8–9 Chad, 99 Chamberlain, David, 152 Chapin, Georganne, 61 China, 55 Cholera, 50, 56 Christian Church, 220 Christianity, 28–29, 129, 140–141, 225

247

248 Christians, 22, 24, 28, 121, 139–143, 147, 220, 225 Christian Science, 28 Chromosomes, 237 Circumcision, 15–33, 39–46, 49–58, 67–73, 75–79, 81–84, 95–96, 144–147, 149–163, 167–187, 217–238 Circumcision psychopathy, 67–73 Circumcision Psychopathy Checklist (CPCL), 69–73 Circumfession, 140, 143–145 Clinical efficacy, 49–58 Clinical trials, 49–51, 54, 56 Clinton, Bill, 65 Clitoridectomy, 139, 231 Clitoris, 2, 7, 106, 126, 129, 137–138, 141–142, 144, 146, 218–219, 221, 231 Colb, Sherry, 16–17 Comfort, Alex, 138 Common law, 27, 39–41, 43, 45 Competence, 21–24, 27, 31–32 Complications, 42, 63, 79, 81–84, 86–87, 105, 150, 220, 229, 234–235 Conan the Barbarian, 144 Conant, Marcus, 65 Condoms, 8, 52, 56, 62–63, 66 Congo, 52, 55, 98–100, 111–124, 231 Congo Kinshasa, 52, 55 Congolese, 99, 112, 114, 124 Conversos, 140–141 Corona, 141, 192 Côte d’Ivoire, 52 Court of Appeal, 3, 16–18, 20, 23, 31–32 Covenant, 3, 142–143, 202, 222, 236 Cultural/culture, 1–2, 4–10, 17–18, 23, 32–33, 40, 42, 45, 64, 66, 91, 95–96, 99–100, 105, 107, 109, 112, 114, 122–123, 126–127, 129, 131–132, 138–139, 141–142, 147, 150, 212, 215, 237 Customs, 2, 42, 64, 82, 119, 123, 128, 219–220, 224 D Danish, 228 Darby, Robert, 57 Dartos fascia, 77, 190 Dartos muscle, 190 David, Smith, 211–215 Death, 66, 83, 220, 223, 238 Deep feeling therapy, 152, 155, 163 Democratic Republic of Congo, 98, 111–124 Demographic impact, 49–52, 54–57 Derrida, Jacques, 140, 143–145

Index Deuteronomy, 226 Dinah, 223 Dirie, Waris, 140, 145–147 Djibouti, 127 Doctors Opposing Circumcision (DOC), 20, 57, 65, 68 Dogon, 218–219 Dorkenoo, Efua, 8 Dwyer, James, 28–29 E Earth, 163, 219, 225–226, 238 Ecological studies, 55 Edomites, 219 Egypt, 2, 140, 143, 145, 219, 223 Egyptians, 5, 143, 219, 223–224 Electrocautery, 83, 229 Elijah, 220 El Saadawi, Nawal, 143, 145 Embu, 141–142 EMDR, 152 English law, 17–19, 22, 27 English Law Commission, 27 Epidemiology, 87 Ethics, 1–3, 16, 32, 46, 61, 68, 91–92 Ethiopia, 52, 140 Europe, 51, 55, 153, 227, 236 Eve, 145, 225–226 Excision, 5–6, 10, 27, 126, 132, 137–139, 141–147, 219–222, 231 Exodus, 223–225, 236 F Female genital cutting (FGC), 2–3, 5, 6–9, 63–64, 138–139, 211 Female genital mutilation (FGM), 4–5, 41, 98–99, 103–109, 112, 121, 131–132, 138, 146, 212 Fijians, 220 Fistula, 83, 138 Florence, 100, 104 Food and Drug Administration (FDA), 207 Foreskin, 2, 7, 9, 25, 69, 75–79, 83–84, 137–138, 141, 143, 150, 157, 160–163, 178–182, 185, 189–198, 199–210, 212–213, 218–219, 221, 223–224, 226, 228–231, 234–237 Foreskin restoration, 76, 189–198, 207–208 Foreskin retraction, 192, 197 FORWARD, 8, 18, 84, 130–131, 177, 179, 211–215, 234 Freedom of religion, 3, 19, 30 Frenular delta, 190–191

Index Frenulum, 77–78 Freud, Sigmund, 69, 142, 146, 150, 152–153, 221, 225 G Gangrene, 83 Gates Foundation, 61, 64–65 Genital amputation, 64 Genital autonomy, 211–215 Genital cutting, 2–3, 5–6, 8–10, 33, 40, 42, 63–64, 132, 138–139, 159, 211, 213, 215 Genital modifications, 2, 9, 98–100, 118, 120, 122 Genital stretching (GS), 97–101, 111–112, 114–115, 117–118, 120–123 Gentiles, 222, 224, 227–228, 230, 237 Ghana, 52 Gilbert, Howard, 30 Glans, 75–79, 83–84, 87, 157, 162, 179, 181, 192, 194–198, 201–202, 209, 228–231, 234–235 Glick, Leonard, 137, 139–140, 144 Gliding mechanism, 75, 78–79 God, 64, 127, 129, 144, 146, 187, 204, 218, 222–226, 236 Golden, Tom, 153, 156 Grassivaro Gallo, Pia, 97–101, 103–109, 111–124, 125–133 Guinea, 140, 221 Gynecologists, 104, 107–108, 114 Gynecology, 114 H Halevi, Judah, 231 Hartman, D., 152, 154, 160–161 Harvard, 65, 217, 237 Harvard Medical School, 237 Head, Henry, 230 Hebrews, 140–141, 143, 205, 219–220, 223, 225–226 Hellsten, Sirkuu, 5, 9 Hepatitis, 9 Hermaphroditism, 141 Hippocratic Oath, 68, 91, 163 HIV, 7–8, 42, 49–58, 61–66, 150, 212 HIV prevalence, 52–55, 63 Human rights, 1, 3–5, 28, 39–41, 73, 105, 138, 161, 211 Human rights violations, 3, 138 Hutu, 64 Hymen, 99, 119

249 I Immigrants, 6, 86, 91, 96, 99–100, 108, 121–122 Immigration, 96, 98–99, 104, 107–109 Indians, 217, 220 Infection, 8, 19, 25, 42, 50, 56, 62–63, 66, 83, 87, 212, 220, 229 Infibulation, 107, 125–133, 138–139, 142, 146, 222 Informed consent, 4, 6, 44, 46, 65, 82–83 Initiation rite, 9, 62, 218–222 Ishmael, 222 Islam, 45, 55, 126–127, 129, 145 Israel, 205, 223 Israelites, 223 Italy, 85–93, 95, 97–101, 107, 109, 112, 124, 131–133 J Jackson County Circuit Court, 18, 21 Janov, Arthur, 151–153 Japan, 55–56, 197 Jehovah’s Witness, 24, 28 Jethro, 223 Jewish rite, 141–142, 221–224 Jews, 69, 90–91, 139–140, 142, 147, 219–220, 222–227, 235–237 Jong, Erica, 10 Jordan, 203, 223 Joshua, 223 Joy of Uncircumcising!, The, 161, 195–196, 200 Judah of Barcelona, 231 Judah Halevi, 231 Judaism, 19, 28–29, 140, 145, 224–226, 236 Justice, 5, 17, 32, 46, 72, 184 K Kasai, 112–116, 120–122 Kellogg, John Harvey, 150, 157 Kenya, 52–53, 64, 141–142 Keratinization, 76, 79, 157, 194 Kikuyu, 64, 141–142 Kivu, 112, 114, 118, 121 Koran, 229 L Labiadectomy, 139 Labial manipulation, 121 Labia stretching, 111–124 Langerhans cells, 78 Law, 1–10, 16–19, 21–22, 25–27, 29–31, 39–41, 43–46, 82, 90–91, 129, 132, 138, 147, 158, 187

250 Legislation, 27, 39–40, 85–86, 95–96 Lesotho, 52–53, 55 Levi, 223 Liberia, 52, 62 Litigation, 19, 21, 27 London, 8, 127, 211–213 Lower Shebelli River, 126 Lubumbashi, 120 Luo, 64 Lysozyme, 78 M Malawi, 52–54, 98, 100, 118, 121–123 Malays, 220 Male and Female, 5, 8, 57, 64, 107, 139, 141, 211, 215, 221, 224–226 Mana Sultan, 125–133 Marion’s case, 43–44 Mary, 225 Mason, Paul, 39–46, 212 Masturbation, 78–79, 120, 138–139, 141, 150, 157 Mbenzola State Hospital of Mbuji-Mayi, 114 Mbuji-Mayi Hospital, 113–114 Mead, Margaret, 57 Medical ethics, 1, 46, 70 Mediterranean, 224 Meissner’s corpuscles, 77, 192 Memory, 139, 145, 151–152, 156–160, 162, 167–187, 205 Méndez, Cristóbal, 140–141 Meningitis, 83 Mensa Bulletin, 200 Merchant of Venice?, The, 140 Merka, 125–133 Meru, 142 Mexico City, 61–66, 218 Mezizah, 143 Michaelangelo, 230 Michal, 223 Midianites, 223 Milah, 90, 143 Misha, 1–10, 18–28 Moabites, 219 Monasterio, Gabriela, 163 Morgan, W.K.C., 229 Moses, 219, 223–225, 236 Moses Maimonides, 220, 224, 226, 231 Mucosa, 63, 75, 77–78, 190–191, 197 Mucosal loss, 75 Muslims, 17, 31–32, 45, 55, 63, 68–69, 86, 88, 90–91, 106, 122, 142, 145–146

Index Mutilation, 2, 4–5, 7, 27, 41, 57, 88, 96, 98, 103–109, 112, 121, 132, 138, 141, 180, 182–183, 207, 212, 218, 220–222, 224, 226, 229–230, 235, 237–238 Mythology, 1–2 N Nandi, 142 National Cancer Institute, 237 National Health Service, 96 National Institute for Clinical Excellence (NICE), 214 National Organization of Circumcision Information Resource Centers (NOCIRC), 3, 68, 85–93, 215 National Organization of Restoring Men (NORM), 68, 76, 162, 194–195, 197, 207, 212, 214–215 New Guinea, 221 Niger, 52, 218 Non-maleficence, 46 NORM-UK, 68, 76, 212, 214–215 Nuremberg Code of Ethics, 68 O Obstetricians, 69, 82–83, 98–99, 104, 107–108, 112, 114, 176, 230, 233 Obstetrics, 100, 114, 138, 152 O’Donnell, Brian, 61, 63 Oregon, 3–4, 17–21, 23, 25, 28 Oregon Supreme Court (OSC), 3–4, 17, 20–21, 23, 25, 28 Oster, Jakob, 228–229 P Padua, 98, 107, 109, 112, 124 Padua Working Group, 112 Pain, 7, 17, 28, 30, 76, 140–142, 150–153, 156–159, 162–163, 168, 170–172, 179–184, 186, 193, 196, 224, 230, 232–233, 235 Parental rights, 16–18, 20–22, 26, 29–31, 43–44 Parma, 98, 100 Penis, 2, 6–8, 25, 76–79, 81, 83, 120, 137–138, 142–146, 150, 152, 156, 158, 161, 163, 168, 179–182, 184–186, 189–190, 192–197, 199–201, 207–210, 218, 220–222, 228–230, 234–235, 238 PEPFAR, 64–65 Perineum, 83, 190 Peripenic muscle, 190, 198 Pertussis, 50 Peru, 220

Index Pharaoh, 143, 219, 223 Pharaonic infibulations, 131–132 Philistines, 220, 223 Phimosis, 25, 42, 84, 90, 137, 197, 206, 228 Phoenicians, 219 Plants, 114, 116–118, 121–122 Poetry, 126–131 Political power, 57 Population effectiveness, 49–58 Portugal, 140 Power abuse, 57 Prepuce, 2, 77, 84, 90, 142, 144–145, 190–192, 219, 228, 231 Preston, E. Noel, 150, 229 Primal Integration, 152–153 Primal Scream, The, 151 Primal therapy, 151–153 Principles of Ethics, 68 Prophylaxis, 66, 221, 227 Psychopathology, 67–73 Puberty, 32, 114, 117, 142, 219–222, 224, 229 Q Queensland Law Reform Commission, 45 R Rabbis, 226, 231, 236 Randomized controlled trials, 62, 66 Re-evaluation Co-counseling, 152 Regressive psychotherapy, 150, 152–154 Reichian Therapy, 152 Reich, Wilhelm, 152, 154, 234 Religion, 1, 3, 6, 9–10, 17, 19–20, 23, 28–32, 40, 45, 51, 55, 121–122, 129, 225, 229 Religious freedom, 28–31 Religious hierarchy, 57 Remondino, Peter Charles, 138 Restoration, 76, 161–162, 189–198, 199–210 Restoration devices, 194–196 Rhinehart, John, 153 Ridged band, 77–78, 157, 190–191 Risks, 7, 9, 17, 19–21, 23, 25–30, 33, 45, 51, 53, 55–56, 61–63, 65, 72–73, 83–84, 129, 131, 186, 212, 228 Ritual defloration, 118–120, 122 Ritual modifications, 98 Ritual stretching, 98–100 Royal Australasian College of Physicians, 42, 46 Russian Orthodox Church, 19 Rwanda, 52, 117, 120–122

251 S Sacrifice, 2, 129, 143, 187, 236–237 Samoans, 220 Sattouf, Riad, 140, 144–145 Saul, 223 Schwartzenegger, Arnold, 144 Sechem, 223 Semites, 219–220, 223 Sensory nerve endings, 75, 78 Sepsis, 83 Seroprevalence, 52, 54–55 Seth, 225 Sierra Leone, 7 Sierra Madre, 217 Simeon, 223 Skin bridges, 83 Social customs, 2, 42 Social norms, 1, 3, 127 Somalia, 22, 125–133 Somatic Experiencing, 152 Somerville, Margaret, 7, 24, 30 South Africa, 4, 52–54, 63–64 South America, 57, 220 Spain, 140 Spanish Inquisition, 140 Staffordshire, 215 Stern, Howard, 208–210 Stoppard, Miriam, 214 Stutterford, Thomas, 214 Sub-Saharan Africa, 51–52, 63 Sudan, 140, 231 Sunna Gudnin, 126, 131 Sunnah, 145 Supreme Court of Oregon, 18, 20 Surgical Temptation, A, 57 Swaziland, 52, 66 Sweden, 4, 6, 228 Syphilis, 24, 129, 228 T Tacoma, 168, 172 Tacoma General Hospital, 168, 172 Tallahassee, 217–218, 230, 235 Talmud, 224, 226, 236 Tanzania, 45, 52–53 Tasmania, 4, 40–41, 46, 212 Tasmanian Criminal Code, 43 Tasmanian Law Reform Institute, 46 Templeman, Lord, 26 Ten Commandments, 236 Thailand, 56, 66 Thutmose, 219 Tissue expansion, 189, 193, 198, 207

252 Tonsillectomy, 227 Toronto, 65, 127 Tradition, 4, 28–29, 31, 64, 82, 90–92, 105, 114, 120, 122, 126, 129, 131–132, 145, 219, 224–226, 229, 235 Trauma, 69, 142, 150, 152–162, 182 Treaty law, 40 Tshiala Mbuyin, 100 Tutsi, 64, 117, 120–121 U Uganda, 52–53, 56, 64, 66, 98, 100, 118, 121–123 UNAIDS, 8, 51, 61, 65 UN Convention on the Rights of the Child (UNCROC), 3, 22, 40–41 Union of Orthodox Jewish Congregations of America, 20 United Kingdom (UK), 8, 16–19, 21–23, 25–28, 30, 33, 68, 76, 212, 214–215 United Nations (UN), 3, 5, 22, 40–41, 61, 138, 140, 146

Index United States (US), 2–9, 17, 20, 22, 28, 33, 50, 55, 61–65, 68, 81, 84, 138–139, 145–146, 157, 204, 207, 227–228, 230 United Synagogue of Conservative Judaism, 19 University of Padua, 98 USA, 55, 88, 91–92, 168, 191–192 V Vaccines, 8–9, 50–51, 56, 62, 64, 66 Vereshack, Paul, 152, 155–156 W Waldeck, Sarah, 2, 8 Washington, 168 World Health Organization (WHO), 8, 50–51, 61, 64–65, 98, 105, 112, 121, 212 Z Zambia, 52, 121 Zimbabwe, 52 Zimberoff, D., 152, 154, 160–161 Zipporah, 143, 223–224