|The riddle of the sands|
Sand: A persistent myth about circumcision
"We are all apt to accept a historical myth where we cannot rely on historical knowledge. Where history is lacking, mythology takes its place, and those who disdain history are among the foremost victims of mythology."
— Owsei Temkin 
Although many nineteenth century misconceptions about the foreskin have been dispelled since Douglas Gairdner showed that infantile phimosis was not a congenital abnormality, other old ideas have proved more persistent. One of the most ubiquitous is the proposition that ritual or religious circumcision arose as a hygiene or sanitary measure; and the related idea that troops serving in the Middle East during the Second World War were subject to such severe epidemics of balanitis that mass circumcision was necessary. Both these myths should be firmly laid to rest.
* * * * * * * *
One of the strangest arguments offered for male circumcision is that amputation of the foreskin protects the penis, and more especially the glans, from irritation by sand. This idea is certainly counter-intuitive. Common sense suggests quite the opposite scenario: that the foreskin guards the penis, particularly the glans and the vulnerable urinary opening, from any such irritation by shielding them from dust, sand and other forms of dirt. This function seems all the more likely in boys before puberty, when the foreskin is usually long, tight and less frequently retracted. Yet the claim appears regularly in serious medical journals, both as an explanation for the ancient origin of ritual circumcision in tribal societies, and as a medical justification for its performance in the twentieth century.
In a recent article on the ethics of circumcising male minors, J.M. Hutson asserted that circumcision was "likely to have arisen as an early public health measure for preventing recurrent balanitis, caused by sand accumulating under the foreskin."  He provided no reference for this suggestion, but it is possible that he was copying a similar claim from the policy statement on circumcision issued by the Royal Australasian College of Physicians in 2002: "Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It probably originated as a hygienic measure in communities living in hot, dusty and dry environments."  Again, no citation was offered, and not surprisingly, for it would be very hard to find reliable evidence that ritual or religious circumcision arose as a health measure.
Mutilating procedures commonMany primitive cultures carried out various mutilating procedures on different parts of the body, including the genitals of both boys and girls, but the origins and rationale of these practices are obscure and contested, as are the environmental conditions prevailing when such customs emerged. Such societies also practised human sacrifice, widow-burial, foot-binding, scarification, tattooing, piercing, infibulation, head or nose shaping, tooth evulsion and many other traditions not seen as health-giving today. The idea that the mutilations carried out by savage cultures must have a utilitarian basis emerged in the eighteenth century, when Enlightenment thinkers sought naturalistic explanations for phenomena formerly regarded as miracles or attributed to the will of the Deity. Denis Diderot embodied this trend when he suggested that infibulation of women in some tribal societies originated as a birth control measure and only later became sanctioned as a divinely ordained precept. 
It is, however, a functionalist delusion which Mary Douglas has called "medical materialism" to assume that traditional rites must have a rational basis; modern anthropology recognises that such customs emerge from the belief structure or cosmology of the cultures which produced them and do not necessarily have utilitarian significance.  Many conflicting theories have been advanced to account for ritual operations on the male and female genitals, among which are the following:
Circumcison seen as risky and dangerous
The only point of agreement among proponents of the numerous theories is that a practical objective such as health had nothing to do with it, and the reason is obvious: in the days before aseptic surgery, any cutting of flesh was about the least hygienic thing anybody could do, carrying a high risk of bleeding, infection and death. Among most of the traditional (tribal) societies that practise it as an initiation or transition ritual, circumcision is regarded as a dangerous business, testing the boy’s courage and manliness, but carrying severe risks. Among the Tiv people of central Nigeria, the father’s role is to protect his son from the numerous spiritual dangers attending the operation and to do what he can to mitigate the threats to his health and well-being. There is an account of one Tiv ceremony in which the father played an active but supporting role, standing beside his son during the operation, urging stoicism during the cutting and reassuring him that he could bear it like a man. Later he asked frantically if somebody could do something to stop the bleeding, since the boy was haemorrhaging seriously and was losing consciousness. Among the Mongo (middle Congo), the father is responsible for washing the post-circumcision wound and caring for the boy after the operation. It is believed that if he does not remain continent until the wound is healed, it is likely to become seriously infected.
sometimes took two months to recover, suffering great pain in the meanwhile. One young man came to me for treatment ten days after his circumcision, and … the stench made me retch. His entire penis, his scrotum and the inside of his thighs were a suppurating mess from which the skin was sloughing away, the pus trickling down his legs. 
Sand under his foreskin, assuming it could get in and then prove impossible to remove, would seem far preferable to this fate. Even today, in the age of antibiotics, scores of South African teenagers die in consequence of their traditional bush circumcision ordeal. 
Cultural reasons for circumcisionIt is significant that none of the ancient cultures which practised circumcision have traditionally claimed that the ritual was introduced as a sanitary measure. African tribes, Arabs, Jews, Moslems and Australian Aboriginals explain it different ways, but divine command, tribal identification, social role, family obligation, respect for ancestors and promotion of self control figure prominently. Jewish authorities make no mention of hygiene, let alone sand, but place stress on the religious significance of circumcision: it is an outward sign of the Covenant between God and his people.  In The Jewish Rite of Circumcision (c. 1885), Dr Asher Asher added that there was also a moral and a political dimension, but that these were secondary. Following Philo and Maimonides, Asher stated that the moral purpose of circumcision was "to diminish the carnal appetite of mankind", and remind a Jewish man that to carry out his high mission he must begin by surrendering all sensuality, licentiousness, lasciviousness; it is the first step in the process whereby that which we possess in common with the brute is eliminated. … The seal of the Covenant which God has stamped into our flesh is – chastity.
The political reason was to give Jewish men "some unmistakeable sign whereby to recognise each other; a sign of such a nature that no stranger can … impose himself on them as one of themselves".  Recent research has suggested that circumcision did not become established among the Jewish people until about 500 BC, well into historical times, and that the motives had more to do with the preservation of cultural distinctiveness than promoting physical health; it was only then that the verses on circumcision were added to Genesis. 
It is hard to imagine Jewish men in Victorian London exposing their penis to validate their bona fides as co-religionists, but such a prominent mark would be highly significant in places where people normally go about naked. In these societies circumcision has much the same significance as an age card or driver’s licence. The Kaguru of east-central Tanzania explain circumcision (practised at puberty on both boys and girls) in terms of enhancing gender differentiation and social control. They consider the uncircumcised penis unclean because its moistness makes men resemble women, whose wet and regularly bleeding genitals are considered polluting. At the same time, initiation enables the older men to impress the young with "the need for conformity to traditional values and beliefs, and … the superior knowledge and authority of elder males." The circumcision ritual among the Kaguru and many other east African peoples, writes the anthropologist T.O. Beidelman, is "a cultural cosmetic that expresses the socio-economic reality of power rooted in elders’ ability to monopolize both … information and access to women and property".  Unlike the story about sand, there does seems to be some continuity between the primitive and the modern here: witness the insistence of so many American fathers that their sons’ penises must look like just theirs.
Fantasies of Victorian medical menIt was only in the late nineteenth century, when mass circumcision was being introduced for such vital "health" reasons as control of masturbation, that doctors sought legitimacy for the new procedure by claiming continuity with the distant past and attempting to explain the origins of circumcision in terms of their own hygienic agenda. One of the first English surgeons to make the connection was James Copland, who introduced the idea that "the neglect of circumcision in Christian countries" was a common cause of masturbation, and praised the descendants of Abraham and the "followers of Mahomet" for perpetuating "an enduring and healthy race" as one of the "beneficial results of circumcision". He was convinced that "the abrogation of this rite among Christians has been injurious to them, in religious, in moral, in physical, and in sanitory [sic] and constitutional points of view, – that circumcision is a most salutary rite."  This theme was taken up by the sanitarians in the public health movement, such as W.H. Corfield, who praised "the laws of Moses" for anticipating the sanitary provisions of his own day, and singled out circumcision as one of the most salutary regulations that was ever imposed on a people, especially in an eastern country, where the … necessity of scrupulous personal cleanliness is so much increased. … What wisdom was shown by Moses, and by Mahomet in later times, in retaining this wholesome custom as a religious rite, and thereby securing its perpetuation.
It was to the observance of such practices that many nineteenth century writers on hygiene attributed "the singular immunity of the Jewish race in the midst of fearfully fatal epidemics".  This "immunity" was a major theme of epidemiological debate in the late nineteenth century, prefiguring the attempts in our own day to prove that African tribes which practise (male) circumcision have lower rates of HIV infection than those which do not. 
As the enthusiasm grew, other medical men put forward even more fanciful suggestions. Dr Arthur Dampier-Bennett believed that circumcision was invented as a treatment for epilepsy. There was, he thought, evidence that "in all primitive peoples there is a peculiar tendency to epilepsy", which might be caused by cerebral pressure or "local irritation" such as that generated by a tight foreskin. He had treated "epileptiform convulsions" in a four-year old boy by excising his "remarkably long and adherent" prepuce, and he thus considered it "more than likely that, amongst wild tribes … it has been discovered that a pacifying result follows … the operation".  James Allen argued that circumcision came into existence as a preventive of parasitic infections such as schistosomiasis,  while (Sir) John Bland-Sutton insisted that the main purpose of circumcision was to ensure fertility: "it was to ensure fruitful coitus in order that the seed of Abraham should multiply according to the Covenant. A long foreskin is a recognised hindrance to convenient coitus".  Since Moslems enjoyed less respect at that time, and less was known about them, it was Jewish custom which provided Victorian surgeons with the preferred model. Nobody has ever suggested that circumcision as performed by Australian Aboriginals had a hygienic rationale, nor that their custom of knocking out teeth during initiation ceremonies was a precaution against the inconvenience of tooth decay in adult life.
Female genital mutilationIt is usually forgotten by those who accept the sanitary origins of circumcision that many of the tribal cultures which practised male circumcision also enforced various forms of female genital mutilation. Western doctors today are horrified by this sort of surgery, do not seek evidence that it might be beneficial to women’s health and do not suggest that it originated as a means of preventing sand from getting under the clitoral hood or labia and irritating the vagina or the vulva. It was a different story in the mid-nineteenth century, when many doctors assumed with W.F. Daniell that female circumcision as practised by savage cultures "constituted no unimportant branch of medical hygiene" and that further research would reveal "the use and purport of this singular custom".  In the 1850s and 60s many English doctors believed that clitoridectomy was as valuable as male circumcision in treating nervous diseases like epilepsy, hysteria and masturbation (as well as their sequelae in madness) and pushed the therapy on women with little attempt to gain consent.  Many Egyptian and other Islamic physicians today insist on the hygienic value of female circumcision as a preventive of both organic disease and sexual promiscuity. 
Secrets of World War IIJust-so stories about the ancient past are perhaps of merely academic interest, but the threat of sand has also been advanced as a justification for the circumcision of normal western men in the twentieth century. Professor Hutson further claimed that when Australian soldiers were stationed in the Middle East during the first and second world wars "the incidence of recurrent balanitis caused by sand under the foreskin reached ‘epidemic’ proportions, leading to large numbers of soldiers requiring circumcision". On this occasion there is a reference: to a "personal communication" from A.M. Hutson in 1974.  We are not given details of this, but one assumes it is a wartime anecdote told by his father or an uncle.
Further support could have been obtained from Spencer Beasley, one of the authors of the RACP Policy Statement, who similarly claimed that "the fashion for circumcision [in New Zealand] began in World War II in North Africa where soldiers often went days without showers and inflammation of the foreskin from sand was the most common cause of absenteeism from the front line".  This seems doubtful. At a time when the desert resounded to the din of tank battles such as that fought at El Alamein, it is unlikely that the most common sight in the medics’ tent were men with inflamed penises. Nor does history support Professor Beasley’s statement that neonatal circumcision became routine only after the Second World War. The practice had in fact become common in the 1930s,  following the pattern observed in Australia in the 1910s,  and in Britain in the 1890s, when circumcision of male infants and boys was widely enforced as a preventive of "congenital phimosis", masturbation, syphilis, epilepsy, hip joint disease, bed wetting, pimples and minor disorders too numerous to mention. 
It is time that the "sand myth" was laid firmly to rest. Common sense tells us that in the North African combat theatre surgical resources were limited, and already fully committed to treating, first, the wounded, and secondly serious illnesses; army medics in those desperate times were not scratching around for work. On top of that, the omnipresence of desert dust would dictate that surgical procedures be kept to a minimum, since dust in wounds would have far more serious effects than it could ever have under the foreskin. These intuitions are confirmed by the official war histories. If there had been an "epidemic" of balanitis, one would expect it to have left some sign in the records and to have been noticed by the official historians, yet none of the many medical volumes published by Britain, Australia and New Zealand so much as mentions it.
Official medical histories do not mention circumcisionThe British History of the Second World War identifies the main medical problems in the Middle East and North Africa as hepatitis, diarrhoea, dysentery, tonsillitis, accidental injuries, burns, malaria, sandfly fever and "desert sores". The last sound promising, but no location is specified, and the condition was not treated surgically. [27, 28]
Neither sand nor balanitis are among the "clinical problems of war" discussed by Allan Walker in Australia’s official history, though acne gets a couple of pages, and "desert sores" turn out to be small sores arising from cuts, grazes and insect bites which became infected with either Staph or Streptococcus.  The menace of the foreskin also seems to have escaped his attention in the volume devoted to medical issues in the Middle East and North Africa. As among the British troops, the main health problems encountered were gastric diseases such as diarrhoea, dysentery and hepatitis. These certainly emphasised the need for hygiene, but not specifically of the penis; it referred to the construction of latrines, correct toilet procedures and the control of flies. Interestingly enough, Walker remarks that "conjunctivitis was remarkably uncommon, in spite of dust and glare and paucity of convenience for washing": if the blowing sand was rarely able to inflame the exposed and vulnerable eyeball, it seems highly unlikely that it could do much to harm to the concealed and (in uncircumcised men) well protected glans penis. 
The New Zealand history similarly states that skin inflammations were a hazard of desert warfare, and that they were exacerbated by fine sand, but it makes no mention of the foreskin as a problem site, nor of circumcision as a treatment, and goes on to comment that every effort was made to minimise cuts to the skin, and to avoid surgery unless it was "urgent or else offered the prospect of permanent relief of symptoms sufficient to enable men to be retained in useful employment overseas." [31, 32] In none of the thousands of pages contained in these volumes do the words balanitis, circumcision or foreskin make a single appearance.
An urban mythBecause the sand myth has never been seriously argued for or substantiated, nobody has regarded it as sufficiently important to warrant refutation. As a result it continues to enjoy a subterranean existence as a kind of medical urban myth, popping up in surprising places with odd variations. [33-35] One of the most peculiar is the claim by a correspondent in the Journal of the Royal Society of Medicine that "a German surgeon" had told him that Africa Corps troops had "suffered in the same way", and had similarly been circumcised.  Although the writer conceded that the recommendation was "understandably unofficial", the idea that a German under the rule of Nazism would have submitted to an operation which could have identified him as a Jew, or that anybody in authority would have recommended such a course, is preposterous. To check this point, Mr Hugh Young wrote to Manfred Rommel, son of the German commander, whose courteous reply concluded: "I have never heard that soldiers in the Africa Corps were circumcised. The veterans I could contact have not either". 
Even Aaron Fink, long-time crusader for universal neonatal circumcision, and originator of the idea that circumcision was a "natural condom", and thus the perfect prophylactic against HIV-AIDS,  admitted that protection against desert sand was probably not the main reason for the adoption of circumcision by the Arabs and Jews. But he went on to make the even more extraordinary suggestion that troops serving in the Arctic ought to be compulsorily circumcised so as to avoid frostbite.  One admires the logic, but wonders why Fink regarded frostbite on the glans or penis shaft as preferable to frostbite on the foreskin, which – with its rich blood supply – must provide the definite "health benefit" of insulating the rest of the penis from extremes of cold. Given the frequency with which advocates of routine circumcision appeal to ancient tribal wisdom, one would think that Fink might have noticed that neither the Laplanders, nor the natives of northern Siberia, nor the Eskimos (at least in their original state), who ought to know about such matters, have ever practised circumcision.
A similar error in logic was made by Victorian advocates of circumcision as a preventive of syphilis: observing that the primary chancre was often on the prepuce, they concluded that its amputation in advance would confer a high degree of immunity to the disease, forgetting that the "venereal poison" would then get access to the body through the next layer of skin it encountered.  The fact that these myths, stories and failures of clear thinking crop up so often is a sad indication that the intellectual quality of much of the debate about circumcision is lower than the subject demands.
1. Temkin O. The usefulness of medical history for medicine. The double face of Janus and other essays. Baltimore: Johns Hopkins University Press 1977: 69
2. Hutson JM. Circumcision: A surgeon’s perspective. J Med Ethics 2004; 30: 238
3. Paediatrics & Child Health Division, Royal Australasian College of Physicians, Routine Circumcision of Normal Male Infants and Boys: Policy Statement, Sydney, October 2002.
4. Diderot D. Supplement to Bougainville’s voyage. Michel Feher (ed.), The libertine reader: Eroticism and the Enlightenment in eighteenth century France. New York: Zone Books 1997: 79
5. Douglas M. Purity and danger: An analysis of the concepts of pollution and taboo. Harmondsworth: Penguin 1970: ch. 3
6. Gollaher D. Circumcision: A history of the world’s most controversial surgery. New York: Basic Books 2000: ch. 3;
7. Thesiger W. The marsh Arabs. London: Longmans 1964: 101-2
8. Editorial. Astonishing indifference to deaths due to botched ritual circumcision. South African Medical Journal 2003; 93: n.p. (No. 8, August)
9. Weiss C. A worldwide survey of the current practice of Milah (ritual circumcision). Jewish Social Studies 1962; 24: 30-48
10. Asher A. The Jewish rite of circumcision. London n.d. [c. 1885]: 1-10
11. Hoffman L. Covenant of blood: Circumcision and gender in rabbinic Judaism. Chicago: Chicago University Press, 1996
12. Beidelman TO. The cool knife: Imagery of gender, sexuality and moral education in Kaguru initiation ritual. Washington: Smithsonian Institution Press, 1997: 117-19
13. Copland J. Pollution. Dictionary of practical medicine. 4 vols. London: Longmans 1844-58: III, 442, 445
14. Corfield WH. Introductory lecture on hygiene and public health. Br Med J 1870; 1: 617-18
15. Darby RJL. Where doctors differ: The debate on circumcision as a protection against syphilis, 1855-1914. Soc Hist Med 2003; 16: 57-78
16. Dampier-Bennett G. The origin of circumcision. Br Med J 1907; 2: 243-4
17. Allen J. Bilharzia haemotoba and circumcision. Lancet 1909; 1: 1317-20
18. Bland-Sutton J. Circumcision as a rite and as a surgical operation. Br Med J 1907; 1: 1409
19. Daniell WF. On the circumcision of females in western Africa. London Medical Gazette 1847; NS 5: 374-8
20. Moscucci O. Clitoridectomy, circumcision and the politics of sexual pleasure in mid-Victorian Britain. Andrew H. Miller and James Eli Adams (eds), Sexualities in Victorian Britain. Bloomington: Indiana University Press 1996
21. Gollaher D. Circumcision: A history of the world’s most controversial surgery. New York: Basic Books 2000: ch. 8
22. Hutson JM. Circumcision: A surgeon’s perspective. J Med Ethics 2004; 30: 238
24. McGrath K. and Young H. A review of circumcision in New Zealand. Denniston GC, Hodges F and Milos M (eds), Understanding circumcision A multi-disciplinary approach to a multi-dimensional problem London and New York: Kluwer Academic and Plenum Press 2001: 129-46
25. Darby RJL. A source of serious mischief: The demonisation of the foreskin and the rise of preventive circumcision in Australia. Denniston GC, Hodges F and Milos M (eds), Understanding circumcision A multi-disciplinary approach to a multi-dimensional problem London and New York: Kluwer Academic and Plenum Press 2001: 153-98
26. Dunsmuir WD and Gordon EM. The history of circumcision. BJU International 1999; 83, Suppl. 1: 1-12
27. Crew FAE. The army medical services. 2 vols. London: HM Stationery Office 1956-7: I, 243-52; II, 251.
28. Cope Z. Surgery. London: HM Stationery Office 1953
29. Walker A. Clinical problems of war. Canberra: Australian War Memorial 1952: 619-23
30. Walker A. Middle East and Far East. Canberra: Australian War Memorial 1953: 384-5; 223
31. Stout TDM. War surgery and medicine. Wellington: Department of Internal Affairs 1954
32. Stout TDM. New Zealand medical services in Middle East and Italy. Wellington: Department of Internal Affairs 1956
33. Speert H. Circumcision of the newborn: An appraisal of its present status. Obstetrics and Gynecology 1953; 2: 164-72; here 165
34. Rosner F. Circumcision: An attempt at a clearer understanding. NY State J Med 1966; 66: 2919-22; here 2920
35. Gardner M. Mind the sand. New Scientist, 22 January 2000: 50-51
36. Gardner AMN. Circumcision and sand. J R Soc Med 1991; 84: 387
38. Fink A. Newborn circumcision as a long-term strategy for AIDS prevention. J R Soc Med 1989; 82: 695
39. Fink A. Circumcision and sand. J R Soc Med 1991; 84: 696
40. Darby RJL. Where doctors differ: The debate on circumcision as a protection against syphilis, 1855-1914. Soc Hist Med 2003; 16: 57-78