|Gollaher's history of circumcision|
More reviewsDavid L. Gollaher. Circumcision: A History of the World’s Most Controversial Surgery. New York: Basic Books, 2000. xiv + 253 pp.
Science, Technology and Human ValuesReviewed by Lawrence Dritsas
David Gollaher’s history offers a much-needed text on the ongoing debate in the United States surrounding routine neonatal circumcision. In this country, 60 to 70 per cent of newborn males are routinely circumcised for unsubstantiated medical reasons. Gollaher has attempted to determine why this practice exists in the United States or, more correctly, how an ancient tradition among many of the world’s cultures became a routinely performed medical procedure in the United States. This book is an expansion of Gollaher’s article in the Journal of Social History, Fall 1994, “From ritual to science: The medical transformation of circumcision in America”.
Gollaher considers two aspects of circumcision: tradition and medicine. The opening chapters describe the ancient practice of circumcision among Jews, Muslims, Christians and other cultures. The earliest account of circumcision is a bas-relief found in Egypt that dates to 2500 BC. Priests of the pharaoh are shown ritualistically circumcising two young noblemen. From these roots in Egypt, the traditions of Judaism are then considered. According to linguistic evidence provided by Torah scholars, circumcision may be older than Judaism itself, but it has always been a mark of the covenant between God and the Israelites. Gollaher provides contemporary comment on the practice from St Paul, Maimonides, and other scholars of the Christian, Jewish and Muslim traditions. His use of biblical scholarship provides a broad but informative overview of the roots of the practice in European society and how the practice disappeared among Christians. Probably the most important question about the history and anthropology of circumcision is posed in the preface, “How did disconnected people in different parts of the world assign meaning to genital cutting?”
By examining Muslim practices of circumcision and other cultures, including African and Australian Aboriginal, Gollaher demonstrates similarities and differences in how the body is marked throughout the world. At the end of this world tour, there is no conclusion. Circumcision will not conform to any universal theory. The ritual can signify a number of events or create a person’s identity. Transition rituals where circumcision may be significant include marriage, adulthood, fertility, enslavement, entrance to a wider community and a covenant with the creator. This practice is as old as human society itself, but is continually changing, infinitely mutable, and assigned many different meanings.
From ritual to science
Chapter 4, “From ritual to science”, takes us to late nineteenth century America, where circumcision was rarely performed outside of the Jewish community. This all changed with the work of Dr Lewis Sayre in the 1870s. Sayre had some success in curing a variety of ailments through circumcision, including some forms of paralysis. The medical profession of the late nineteenth century was informed of the concept of “reflex neurosis” and consequently was ready to a accept the proposition that irritation of the glans and foreskin could cause problems throughout the body. Sayre and his supporters reported heir findings to the American Medical Association, and they were published in the leading medical journals of the day. Important evidence for the pro-circumcision lobby were studies that reported superior health among Jewish communities. Because penile and cervical cancers were unknown among Jews, the obvious conclusion was that the circumcised state provided significant protection against these illnesses. Circumcision was also thought to discourage another Victorian evil, masturbation.
Circumcision was slowly accepted by the American people, especially in the middle to upper class individuals who were increasingly receptive to the authority of physicians and able to afford their services. This growing authority was strengthened by the growing use of aseptic techniques introduced by Joseph Lister and new forms of anaesthesia. Surgeons felt more confident in their abilities to predict an outcome that was beneficial to the patient. The medicalisation of childbirth in the United States thus included routine circumcision of male infants. Through the international distribution of the medical journals, routine circumcision spread throughout the English-speaking world.
After World War II, members of the British medical community evaluated routine circumcision. The new National Health Service (NHS) was interested in the cost-benefit analysis of all the procedures they would be providing. Dr Douglas Gairdner published a landmark paper in the lancet in 1949, which demonstrated that no evidence to support routine circumcision existed. In the light of this argument, the NHS decided that routine circumcision offered no obvious benefits to the patient and should not be provided. Consequently, routine circumcision in the United Kingdom had all but disappeared by the late 1960s. Meanwhile, in the United States, routine circumcision continue to be promoted by military doctors as a prophylactic measure against venereal disease. Other ailments that could be avoided through circumcision were penile cancer, cervical cancer and phimosis (adhesion of the foreskin to the glans). Due to its continued promotion by the American medical community, routine circumcision became more common in the United States, and by the mid-1960s, nearly 90 per cent of boys were circumcised.
Chapters 5 and 6 present the anatomy and medical background that readers will need to truly understand routine circumcision. It may have been more prudent to place this information at the beginning of the book, since so much has been said about the foreskin already. These chapters provide necessary information about penile anatomy and its pathologies. Also discussed, and the most debatable, are the illnesses that may or may not be prevented (or at least protected against) by circumcision: urinary tract infections, phimosis, penile cancer and HIV infection. Here we also find the history of these illnesses in respect of their connection with the foreskin.
Confusion in medical literature
As Gollaher shows through a review of the medical literature, routine circumcision in the United States came under scrutiny by the late 1960s. In 1971 the American Academy of Pediatrics released a policy stating that circumcision was not indicated. Subsequent policy reviews and medical studies have resulted in a continuing debate in the literature. Certain physicians, such as Thomas Wiswell and Edgar Schoen, have become fervent promoters of routine circumcision, comparing it to a vaccine. They insist that the benefits of the procedure outweigh the risks. A fact that most pro-circumcision fail to emphasize, however, is that while circumcision does provide protection against certain illnesses, the incidence of these illnesses is extremely low. Routinely circumcising millions of boys to prevent a few cases of illness seems irresponsible to the national health services of Canada, Britain and Australia, while most European countries never even instituted the procedure. As of 1999, after an extensive review of the literature, the AAP feels that it cannot recommend routine circumcision on medical grounds, but that it is a decision best left to parents.
All the confusion surrounding routine male circumcision will bring many readers to question why the medical community does not know more about the foreskin and its pathologies. Gollaher explains that the traditional pathologies of the foreskin were often iatrogenic, especially phimosis, which is a physiologic state in newborns. He also explains that the studies done on circumcision are often challenged due to confounding of variables and lack of control groups. An appendix on “Evaluative Research and the Nature of Medical Evidence” provides further study of the contestability of medical “facts”. It is no wonder that a backlash has occurred, and many activist groups protest strongly against circumcision. Gollaher offers an analysis of this movement and a history of the major organizations in Chapter 7. Also of interest here is the small but noticeable group of men who are seeking to restore their foreskins through surgical or less invasive techniques that stretch the skin.
Surgery out of control
While informative, Circumcision does not challenge the modern paradox of male circumcision with the vigour the evidence would seem to permit. Gollaher is against routine circumcision, but his stance remains muted throughout the book. By acknowledging female circumcision in the final chapter, he draws comparisons between the two practices, but stops short of equating them, despite striking similarities. If we are able to outlaw female circumcision in many states, why not male circumcision? If the medical evidence supporting the benefits of male circumcision is so weak, then why is the practice not stopped until we know more? Gollaher does not answer these questions, but he provides all the information we need to ask them. The power of this text is that it provides in one volume complete summary of the circumcision debate. After reading this text, an individual will be informed about a practice that should be extremely familiar to Americans, but is not. Gollaher has succeeded in his goal “to make the familiar strange”.
Today American doctors an medical organizations cannot provide definite opinions about circumcision; therefore, the decision is left up to the parents. Apparently, parents are to make their decision ‘in the best interests of the child”, but upon what facts they are to base their decision is unknown. The assumption, often presented in the medical literature, is that parents have “non-medical” criteria to consider, although these criteria are not effectively demonstrated. The medical community considers the practice to be a cultural phenomenon, although we learn from Gollaher that the medical community itself introduced the practice to American culture. This presents a problem for Gollaher’s thesis. Because he titles Chapter 4 “From Ritual to Science”, we are led to think that there is some connection between Jewish or Muslim ritual and American medical practice. However, the connections are not well drawn out. Instead, the history would seem to show the rise of circumcision in the United States to be a purely medical phenomenon. It is connected to ritual practices only insofar as male circumcision was known to the Christian west as a curiosity. Contemporary concepts of reflex neurosis and Victorian hysteria about genitalia in general had more impact on the development of routine circumcision than Judaism.
At some point during the twentieth century routine circumcision left the sphere of medical practice and moved beyond the influence of physicians. The population of the united states began to accept it without question, being told that it was a procedure similar to cutting the umbilical cord. What remains to be shown is how this trust in medicine changed into a birth ritual for American society – where parents supposedly choose to have their sons circumcised for non-medical reasons, but are not members of societies that circumcise sons for known cultural reasons. Routine circumcision is then an example of the interconnection between science and society, medicine and culture. But how this connection plays out and to which sphere male circumcision belongs is difficult to discern. We are left wondering not how routine circumcision went from ritual to science, but how it has subsequently moved from science to culture. Gollaher answers the first question well, but the second remains a mystery.
Science, Technology and Human Values, Vol. 26, Spring 2001, pp. 248-53
British Medical JournalReviewed by Tim Stokes, University of Leicester
Male circumcision is the most commonly performed surgical operation in the United States. Data for 1996 reveal that no less than 60% of all US male infants were circumcised. In contrast, the rest of the industrialised world has much lower rates of circumcision. In Britain circumcision is performed only for religious reasons or to correct defined medical conditions. How, then, are we to account for such a large difference?
The strength of US historian David Gollaher’s approach is that he locates circumcision practices throughout the ages within their social and anthropological context. What emerges is a highly readable account of how circumcision was viewed by such diverse groups as the ancient Greeks and the medieval church. The Greeks abhorred circumcision as it constituted a mutilation of the body, and the medieval church devoted much debate to the vexed question of whether Christ recovered his foreskin on his ascension to heaven.
But the history of circumcision is more than just a collection of slightly ribald stories. What I found most interesting was Gollaher’s account of how in the late 19th century circumcision ceased to be the preserve of Jews and Muslims and was transformed, in the United States at least, into a necessary medical procedure that protected against the development of various diseases in later life. One consequence of the germ theory of disease was to see smegma, produced by the foreskin, as infectious material. What better way to cleanse the male body of disease than removing this harbour of infection. Circumcision also became an important part of the medicalisation of childbirth. For Gentiles, having one’s foreskin removed was a sign of having been delivered by a doctor rather than a midwife, of benefiting from the safe and germ-free confines of the hospital. Doctors also benefited financially, as they could charge for an additional surgical procedure and circumcised infants spent longer in hospital.
As one might expect, Gollaher is strong on the rise of the US anti-circumcision movement from the 1970s onwards and shows quite clearly how the power struggle between the medical lobbies for and against circumcision has resulted in a series of conflicting reports from the American Academy of Pediatrics. He has less to say on the UK situation, and I suspect that a historical study of circumcision in 20th century Britain is in order.
British Medical Journal, Vol. 322, 17 March 2001, p.680
Bulletin of the History of MedicineReviewed by Peter C. English, Duke University
David Gollaher, president and CEO of the California Healthcare Institute, has written a compelling book on circumcision. He records that in 1996 more than 60 percent of boys born in the United States were circumcised, mostly by physicians during the first hours or days of the infant’s life. Regions varied in the practice: Midwest, 81 percent; Northeast, 67 percent; South, 64 percent; and West, 36 percent. The question Gollaher poses is why physicians, who no longer view the procedure as having any significant health benefit, persist in the practice. His book provides a rich historical, religious, anthropological, and medical analysis.
Gollaher starts his story with the practice of circumcision among ancient Egyptians and with its appropriation by enslaved Jews, who recast it as a sign of God’s covenant and a distinctive symbol of community membership, and who transformed the Egyptian practice of adolescent (rite of sexual passage) circumcision into a religious rite on the eighth day of life. In Christian times, Saint Paul argued that circumcision was not a sign of God’s new covenant. Gollaher claims that Paul no longer wished to distinguish Jews from Gentiles; few Christians were routinely circumcised until the end of the nineteenth century. Muslims also practice circumcision, but it is not tied to a particular moment in a boy’s life. Gollaher next discusses the anthropological elements of the practice in diverse societies outside the Western tradition.
For medical historians, the most intriguing aspect of this volume is how physicians, especially Americans, transformed this rare, religiously restricted practice into the nation’s most commonly performed surgery. Gollaher argues for a rich coalition of influences: the view that a tight foreskin contributed to a wide variety of ills, both physical and psychological; a newly articulated public health concern for hygiene (which defines the uncircumcised penis as less clean); the desire for a preventive measure against cervical cancer in women, penile cancer in men, and a deterrent to venereal disease; the shifting of the practice to a group of patients too young to protest; and trivialization of the foreskin as a worthless remnant.
This volume is not as strong in answering why routine, newborn circumcision – once launched by physicians – has been so difficult to derail. Certainly, medicine has had other enthusiasms which have waned. It is here that cultural history may have insights. When I ask prospective parents why they wish to circumcise their baby, most respond that they believe this is how a penis should look, and they often accompany their words with a facial grimace indicating that an uncircumcised penis lacks appeal. Parents go to great lengths to protect newborns from harm – but this does not extend to circumcision. The book deserves a wide readership.
Bulletin of the History of Medicine, Vol. 75, 2001, pp. 623-4