|History of circumcision: A French urologist's perspective|
History and geography of ritual circumcisionGérard TILLES
French Society for the History of Dermatology, Musée de l’Hôpital Saint-Louis, Paris, France
Progrès en Urologie, Vol. 9, No. 6, 1999, pp. 1148-1157
Translated by Dennis Harrison
ABSTRACTRitual circumcisions can be separated into two types, depending on the circumstances in which they are performed:
Spiritual circumstances [sic: read circumcisions] expressing a community identity, usually religious, are wrapped in complex meanings that invoke numerous myths, notably Biblical and African.
The secular model of ritual circumcision exemplified in the USA includes--apart from intensely debated medico-scientific justifications--a real social dimension and also reflects a desire for membership in a community.
Whatever the circumstances, physicians may be asked to perform circumcision and should be aware of the significance of this procedure.
Key word: Circumcision.
Mutilations prescribed for oneself or others are of ancient origin and universal in scope: practically no body part has been spared their impact. Sexual mutilations are the most frequent: noteworthy are subincision, practised by Australian aborigines,[34, 43] Fijians, and Amazon Indians; hemicastration, found in Ethiopia, Egypt, and the islands of Micronesia; castration of harem keepers and choir boys (to preserve high voices); genital mutilations of girls (excision, infibulation, clitoridectomy); and finally circumcision, probably the most common of these practices.
Etymologically, the term “circumcision” denotes excision of all or part of the prepuce and comes from the Latin “circum” (around) and “caedere” (to cut). Semantically, the word bears no direct relation to the prepuce. Sometimes [in French] the terms “posthectomie” or “péritomie” are used.
The historical conditions in which circumcision arose are obscure. The practice probably began around the 4th century B.C. as attested to by statues and paintings depicting circumcision among Sumerians, Ethiopians, Phoenicians, Babylonians, as well as by circumcised Egyptian mummies. However, the frequency of circumcision in these periods and its possible social significance are unclear.
A schematic distinction can be drawn between two major types of circumcision, based on the circumstances in which the operation is performed: therapeutic circumcision, which is beyond the scope of this paper, and ritual circumcision. The latter can be subdivided into religious circumcision, as in a ceremony marking a rite of passage and affirming membership in a group, usually religious, and secular circumcision, in which a religious motive is not invoked presumptively. The routine circumcision practised in the USA for controversial prophylactic reasons is an example of the secular type.
Despite this conceptual distinction, we will see that both religious and secular circumcision are laden with complex meanings heavily impregnated with morality and social identity.
RELIGIOUS CIRCUMCISIONToday this practice encompasses African circumcision and the circumcision of the monotheistic religions: Coptic Christianity, Islam and Judaism.
African circumcisionCircumcision is practised by almost all groups in West Africa. In the countries of sub-Saharan Africa, it usually coexists with excision except in the matriarchal societies forming a band across southern Africa between Angola and Mozambique. These societies practise neither circumcision nor excision. Further south, in the southernmost region of the African continent, circumcision practices are explained partly by the migration of patriarchal Bantu societies from equatorial regions.
African circumcision is performed on older children and involves a relatively stereotyped ritual consisting of the following elements in succession:
• seclusion of the initiate, isolation from women and “unclean” children;
• ablation of the prepuce, closely linked to the notion of blood sacrifice (Figures 1 and 2);
• tests of collective or individual endurance after the circumcision (Figure 3);
• wearing of special costumes (Figure 4);
• and sometimes the adoption of a new name marking the child’s true birth.
Circumcision in monotheistic religionsCoptic Christianity 
During the 3rd century A.D., the Egyptians began writing their language in letters borrowed from the Greek alphabet augmented by a few characters from Demotic (a popular Egyptian script dating from the 2nd century). Beginning in the 7th century, this language, known as Coptic, began to disappear from everyday use, to be supplanted by Arabic. It survives to this day however in the Egyptian church. In Coptic societies, circumcision is performed on boys at ages ranging from one week to several years. It is not obligatory in character but is generally carried out for reasons of social conformity and hygiene.
The Arabs were circumcised before the advent of the Prophet; Islam merely allowed this practice to continue. In fact, Islam does not prescribe circumcision and the word is not even mentioned in the Quran. Circumcision is nevertheless traditional in Muslim societies where it constitutes a rite of initiation: a transition from childhood to adulthood. It also allows integration into the community of believers. Performed most often in the first few years of life (sometimes the odd-numbered years in certain communities) to minimize psychological trauma, it can be carried out by a Muslim or a Jew.
Judaism [2, 9, 22]
In no culture does circumcision occupy the position it occupies in Judaism.
The first circumcision was that of Abraham, who circumcised himself as a sign of the Covenant at the age of 99, then circumcised his eldest son Ishmael, aged 13, as well as all the males of the household. Isaac, son of Abraham, was born exactly one year after the Covenant and was circumcised by his father on the eighth day.
Since circumcision served as a mark of identity, it was frequently prohibited by enemies of the Jews such as the Ptolemys and Antiochus IV Epiphanes (2nd century B.C.) It was also forbidden during the two centuries of slavery in Egypt. Moses, who was not circumcised, reinstated the practice after the Exodus. It was again banned by Hadrian. With the rise of Christianity, circumcision became the distinguishing feature of Judaism
A number of rationales have been put forward for performing circumcision (“Milah”) on the eighth day. According to some, the period of eight days lets the infant experience at least one Sabbath. Others believe that since Creation took six days and God rested on the seventh, the eighth day symbolizes the beginning of a period that is more human, compared with the preceding seven days of divine prerogative. The eighth day, therefore, marks the true birth of man and circumcision assumes the meaning of new beginning and inauguration.
Any Jew who has been circumcised himself can perform circumcision on another, but usually the task is reserved for an individual specially trained in the act (Mohel). The contraindications to circumcision are many and specifically include a suspicion of hemophilia. The Talmud provides, for instance, that if two sisters have each lost a child to circumcision, then the third sister cannot have her son circumcised. In the same way, if a mother has lost two sons to Brit Milah and circumcision appears to be the cause of death, then circumcision is waived for the third son.
The ceremony is carried out according to well-defined rules and comprises three phases: separation of preputial adhesions, done with a fingernail and called “periah”; cutting off the prepuce; and “metzitzah”, the sucking of blood by the Mohel, indispensible for full compliance with the Covenant.
Circumcision and Christianity 
Circumcision is not mentioned in the New Testament. The practice was not straightway put in question during the early years of Christianity, but Paul, anxious to facilitate conversions, decided to relax certain rules (observance of the Sabbath, dietary laws and circumcision). Circumcision became worthless for Christians as a means of integrating members into the community. It was replaced by baptism, while the blood covenant with God was succeeded by Communion with Christ. It should be noted that the circumcision of Christ, which has inspired numerous paintings, notably from the Renaissance, is celebrated by Christians every year on January 1st. [Figures 5, 6, 7, 8]
Elements of meaningThe Covenant
Jewish circumcision is justified by the Covenant. Genesis prescribes it explicitly: “God said to Abraham: As for you, you shall keep my covenant, you and your offspring after you throughout their generations. This is my covenant, which you shall keep, between me and you and your offspring after you: Every male among you shall be circumcised. You shall circumcise the flesh of your foreskins, and it shall be a sign of the covenant between me and you. Throughout your generations every male among you shall be circumcised when he is eight days old, including the slave born in your house and the one bought with your money from any foreigner who is not of your offspring ... Any uncircumcised male who is not circumcised in the flesh of his foreskin shall be cut off from his people. He has broken my covenant”.
Thus the circumcision of Abraham expresses the divine will to conclude a permanent alliance; it is applied to the organ of procreation--a symbol of eternity.
Myth of androgyny
Under this interpretation, “man was created man and woman; he did not become man until his feminine part was removed”. The extraction of Adam’s rib could also be symbolic of circumcision. Adam called the new creature “woman” and assumed his true identity by giving himself a new name: “man”. An original state of androgyny was also invoked by Plato. The incompatibility of androgyny with the development of a harmonious society could have made circumcision an indispensable tool for reconciling men and women. As a matter of fact, Zeus says in the “Banquet” that he has “a plan that will allow men to exist but will humble their pride. I will diminish their strength by cutting them in two ... but if they continue insolent I will split them again. When man’s nature has been diluted in this way, each half will miss the other half and reunite with it”.
Mythologies of Africa 
Circumcision in African societies is the object of various explanatory myths, some of which are similar to the myth of androgyny. Of these myths, some say that the first male and female creatures were rough-hewn in a primordial egg. One of the males emerged prematurely from one half of the egg. In an attempt to take sole possession of the world, he tore out a piece of his placenta. One of his own sexual parts, the prepuce, was cut off by God as a punishment for stealing part of the divine placenta.
In other primitive societies, circumcision takes on a meaning akin to the Oedipus complex. Having been forbidden to approach their mother and sisters, the grown sons of the chief kill their father, then kill one another out of rivalry for the same women. When they become aware of their crimes, they cut off their penises in expiation. This practice is replaced by circumcision. In this interpretation, circumcision is indeed supposed to reduce sexual excitation, a reduction indispensable for subordinating individuals to social systems.
For some groups in West Africa, circumcision assumes a meaning similar to the explanation found in Plato. Every child is born surrounded by an evil force, more specifically an evil force attached to the prepuce (or the clitoris in the case of a girl). This force is capable of causing a disorder that makes it impossible for a man to live with anyone. It is necessary therefore to rid every boy of his prepuce and every girl of her clitoris. The maleficent force then falls on children who have not yet been circumcised.
Hygienic aspect of circumcision
Considerations of hygiene also form part of the significance of ritual circumcision, which may then assume value as a prophylactic. Besides alleviating balanitis, the first circumcisions may have been aimed at preventing sexually transmitted infections (STI). Thus Abraham, living in very precarious conditions of hygiene, may have imposed circumcision as an adjuvant for STI prevention. Later, circumcision was prohibited during the period of Egyptian bondage except among the Levites. After leading his people out of the desert, Moses noticed that only the Levites had increased in number. He concluded that circumcision had protected them from STI, and reinstated the practice. More recently, the anxiety about venereal disease in France at the end of the 19th century brought forth proposals to introduce circumcision as a public health measure: “Of all the surgical methods recommended to protect the public against venereal diseases, circumcision is the surest and least questionable”.
Other elements of meaning 
Other interpretations include the role of the prepuce in fertility. African women who have had only girls are sometimes advised to eat a prepuce in order to have a boy. Elsewhere, circumcision may be practised to increase sexual pleasure. It may also be considered a sign of captivity or a mark of bravery.
ROUTINE SECULAR CIRCUMCISION: The CASE of the USAThe United States is unique among Western countries in its practice of routine circumcision. From 1.2 to 1.8 million little Americans are circumcised annually, representing from 60% to 90% of newborn boys.
The routine, almost compulsory character of this mass circumcision raises multiple questions concerning public health and medical practice. Having originated in particular historical circumstances, this procedure has for decades been the subject of studies aimed at making precise measurements of actual medical benefits, calculating cost/benefit ratios, and attempting to understand the sociocultural implications and ethical issues.
The history of circumcision in the United States can be divided into three periods:
1870-1949: Circumcision as punishmentRoutine circumcision was introduced to the United States in stages beginning in the 1870s for one basic purpose: to deprive the male of a prepuce considered essential for masturbation, a practice thought to be the cause of multiple physical and mental pathologies. From Europe, where masturbation was seen as an indication for circumcision, the fear of masturbation spread to North America, where emphasis was placed on its psychological effects.
Routine circumcision made its initial appearance in the United States on February 9, 1870. Lewis Sayre, first professor of orthopedic surgery in the United States, president of the American Medical Association and founder of J.A.M.A., noticed that a 5-year-old boy with multiple tendon contracture of unknown etiology suffered from very painful phimosis and priapism, which Sayre attributed to excessive masturbation. Believing that masturbation could create a “source of irritation” responsible for tendon pathology, Sayre recommended circumcision. According to Sayre, circumcision caused the tendon contracture to disappear within a few weeks, allowing the boy to resume walking.
Sayre’s position at a university gave his first publication an important audience. Sayre led his audience to believe that a simple intervention could cure myriad puzzling diseases thought to be incurable. He encouraged doctors to examine the prepuce every time they encountered unfamiliar pathology. He added a great number of illnesses to the list of indications for circumcision, to the point where many of Sayre’s disciples quite naturally proposed changing over from therapeutic circumcision to preventive circumcision. So great, they said, were the benefits and so innocuous was the operation. Circumcision became progressively established as a simple health precaution, a kind of surgical vaccination.
A few years later, Remondino  enumerated the disorders caused by masturbation (alcoholism, epilepsy, asthma, enuresis, kidney disease, gout, prolapse of the rectum, hernia, cancer, syphilis...), reinforcing the prophylactic benefits of circumcision and contributing greatly to making the procedure acceptable in the eyes of the public. Remondino suggested that insurance companies should treat the foreskin as a special risk factor for men, a suggestion that could only provide additional impetus for circumcision. Some doctors applied themselves to perfecting and simplifying circumcision techniques: in 1910 Kistler invented a device that allowed adults to perform self-circumcision.
In a climate so favourable to preventive circumcision, few publications condemned circumcision as a barbaric practice or advised doctors to stop doing mutilations which lacked a scientific basis.
In fact the practice of circumcision grew, especially as the field of general anesthesia progressed rapidly and the rise in the number of surgeons and hospitals (a 20-fold increase in the last third of the 19th century) motivated surgeons to seek new opportunities for profit. Thus after the First World War neonatal circumcision became almost routine, to the point that in 1929, an editorial in J.A.M.A. called for the circumcision of all newborns, with or without the consent of parents.
The period of evaluationRight into the 1940s, the usefulness of circumcision was taken for granted in the medical birthing culture. Parental approval was almost never requested and the proportion of little Americans circumcised was about 90%--that is, nearly all of them--a situation which explains the first assessment studies.
It was Gairdner’s work that first brought the value of routine infant circumcision into doubt. Drawing up the inventory of indications, which had changed little since the days of Sayre, Gairdner noted that in the West, circumcision was routine only in English-speaking nations and that circumcision was more common in boys from the upper classes.
In 1969, Bolande compared circumcision to tonsillectomy, describing both as ritualistic surgeries having no sound scientific basis. He demanded credible scientific evidence showing that circumcision was useful. In the absence of such evidence, he considered circumcision contrary to the most basic principles of medical ethics, principles also highlighted by Price.
The potential benefits of routine infant circumcision were evaluated in practice guidelines published on several occasions by the American Academy of Pediatrics [38, 44] and the American College of Obstetricians and Gynecologists. The indications assessed by these bodies were prevention of phimosis, facilitation of hygiene, prevention of penile cancer, prevention of cervical cancer (at times considered more frequent in partners of non-circumcised males), and prevention of sexually transmitted infections. Studies showed that:
• usually phimosis in the newborn is physiologically normal and is not an indication for newborn circumcision;
• circumcision could facilitate glans hygiene in conditions of social disadvantage;
• penile cancer can be prevented as effectively by proper hygiene as by circumcision, a procedure whose protective biological mechanism is moreover poorly understood;[4,19,29,30,33]
• absence of circumcision is not by itself a determining factor in the occurrence of cervical cancer.
With regard to the prevention of urinary tract infections in children, the purely retrospective nature of the studies and the limiting of subjects to children treated in hospital did not warrant recommending routine circumcision for this indication.
The question of preventing sexually transmitted infections (STI) was also the subject of numerous studies, notably because of the implications for AIDS prevention. A study of 300 heterosexual men by Donovan, Bassett and Bodsworth  found that circumcision offered no protection against genital herpes, genital warts or non-gonococcal urethritis. Elsewhere, studies conducted in Africa seemed to indicate that heterosexually transmitted HIV was more common in men who had not been circumcised.
In point of fact, most authors note the multiple methodological flaws in the largely retrospective studies, especially the assumption that circumcision is risk-free. The studies depend heavily on the socio-economic status of parents, suggesting that the sexual behaviour of circumcised and non-circumcised men may not be the same. This hypothesis was confirmed by Laumann. Due to the bias inherent in these studies, the results in most cases are difficult or impossible to interpret.
These evaluative studies concluded that there was no absolute indication for routine infant circumcision, bringing into question the justification for a practice affecting nearly all male newborns. Moreover practice guidelines emphasized the need to give parents clear information on the risks of circumcision and non-circumcision, to substitute good hygiene for routine circumcision, and to avoid considering newborn circumcision as a defining element in the overall quality of health.
Notwithstanding these recommendations, the practice of routine circumcision scarcely changed and the frequency of circumcision in the USA today remains the highest in the industrialized world. More than 80% of boys are circumcised at birth  while--for reasons that are not well understood--routine circumcision in economically comparable Anglophone societies (Great Britain, English-speaking Canada, Australia) is either quite uncommon or virtually nonexistent. Against the backdrop of a medical consensus that seems to carry little weight, recent articles underscore the importance of social factors in US circumcision practices and provide some insight into the persistence of this practice.
Circumcision in the USA: A social markerCircumcised men are more likely to be white and socio-economically advantaged. Among blacks, circumcision is half as common. The study conducted by Laumann  on a representative sample of about 1500 Americans aged 18 to 59 found that the circumcision rate is higher among whites than among blacks or Hispanics, a finding that was confirmed by Wilkes and Blum. Of the reasons given by parents to justify a request for circumcision, most are social in character, the parents effectively not wanting their sons to have a physical difference that would set them apart from most Americans and hinder their social integration. Moreover the decision to circumcise or not circumcise a newborn is strongly correlated with the circumcision status of the father, illustrating the attraction of circumcision as a physical mark of social identity.
The circumcision decision also depends to a significant extent on the social status of the mother. The circumcision rate was 2.5 times higher in boys whose mother had a university education. Finally, in contrast to the situation in Europe, circumcision in the United States is not generally correlated with the practice of a religion. Thus circumcision reflects social rather than religious differences. The request for circumcision on the part of parents seems to reflect a desire for membership in an elite, and parents belonging to less favoured classes are not as strongly committed to circumcision.
Besides behaviours linked to the social profiles of parents, the role of circumcising physicians should not be overlooked. Circumcisions are less frequent in public hospitals where physicians are on salary.
Finally, it should be noted that different studies seem to show that masturbation, whose role in introducing routine circumcision to the USA has been previously mentioned, actually appears to be more common in individuals who have been circumcised.
The history of ritual circumcision shows the complexity and intricacy of the meanings attached to this practice. It also illustrates the social importance accorded to circumcision by all the societies that practise it. Finally, it offers physicians abundant raw material for reflection on the history of ideas in medicine and the cultural meanings of certain medical practices; it draws attention to the difficulties inherent in, and the necessity for, proper evaluation of medical practices that have become routine.
CommentaryComments by Vincent Lépinard, Department of Urology, Clinique Saint-Louis, Angers
The practice of circumcision could become one of the great subjects of discussion and controversy of the 21st century.
There are three main categories of circumcision: cultural with religious connotations, cultural with hygienic connotations, and circumcision for medical reasons. The cost of the latter is covered by Social Security.
Limiting the reasons for circumcision to three categories may be instructive but it is simplistic. For many immigrants to the United States, circumcision was synonymous with becoming American. For some years, this practice has diminished and the same motive has been invoked for the opposite reason: in California, where immigration from countries to the south of the United States is very important, immigrants don’t want to get circumcised any more. They assert their identity by refusing to be circumcised and California, where white Caucasians will cease to be a majority in 2010, is the first state in the United States where circumcision is in rapid retreat. In Islam, circumcision is listed in the chapter “Tahara” with personal hygiene, trimming of nails and moustaches.
It is astonishing that circumcision and excision are not more often put on the same plane. In English, excision is called “female circumcision”, which clearly shows the relationship. A recent legal case in which a woman received a jail sentence for performing excision effectively demonstrated the universal media opposition to these practices, yet failed to spark any debate over circumcision. This is probably due to the fact that excision is more or less limited to African countries automatically considered culturally underdeveloped, the inheritors of barbaric practices. The photos accompanying this article effectively show the inadmissible character of certain practices. But where exactly does the barbarism begin?
One of the main arguments used by those who practise circumcision is that it is not painful. This is found in the declarations of Rabbi Chernomas of Boonton NJ, in a recent interview on ABC (ABC News 17/4/99) and in the advertisements for circumcision on the Internet. Even if the notion of pain in the young child, the newborn and the fetus is of recent vintage, it is more like a dawning awareness in the medical community, than a new discovery. The American Academy of Pediatrics has finally declared that circumcision at birth is not indispensable and most importantly, that if it is to be done, then it should be done with a penile nerve block or EMLA cream. This declaration is the opposite of previous recommendations by the Academy. It marks an important turning point in the thinking of the American pediatric community. But it does not take into account the problem of post-operative pain. Françoise DO LTO, with whom I discussed this subject a couple of decades ago, insisted quite rightly that pain persists throughout the healing period (which is very long) and that this pain is greatly exacerbated by a newborn’s spontaneous erections.
3. Cultural tradition
Respect for tradition is a good thing but must this respect extend to every aberration? The article ably illustrates this problem, particularly with reference to the way circumcision was recommended in the 19th century for prevention of masturbation-induced insanity. No matter how much respect one has for religion, one cannot help being struck by the lack of sober reflection on the subject of circumcision. The justification for this practice has been questioned since Day One. Didn’t Jason, the High Priest, ask Jews to stop circumcising in 175 B.C. so that they could become better integrated into the Hellenistic world? A little later Celsius first described foreskin restoration, intended to allow inhabitants of the Middle East to live in the Roman world.
4. Circumcision for medical reasons
The indications for circumcision in the adult are quite rare (lichen sclerosus, chronic balanitis and phimosis preventing retraction of the prepuce during erection). In children, the indications are even rarer. Lichen sclerosus is the main one. Yet the recommendation for circumcision is usually based on the presence of simple adhesions or a preputial orifice that is a bit narrow. The literature shows that these problems disappear over time and the best thing to do in such cases is to leave well enough alone. I did preputioplasties for many years using Duhamel’s method or two incisions with a result that seemed satisfactory, but found that in the longer term they contributed little to the eventual resolution of the problem.
5. The rights of the child
In the land of the Declaration of the Rights of Man and in accordance with the UN Convention on the Rights of the Child it may be worthwhile remembering that a surgical intervention on a child must be medically necessary, must be done in the best medical interests of the child, and should not expose the child to unnecessary suffering or wounding. Perhaps one day the circumcised will rebel and take legal action against their parents, the doctor and the institution where the act took place. The informed consent of the parents and religious reasons are worthless in the eyes of the law.
One hopes that the information on the Web will bring home to parents the risks associated with circumcision. At the present time, however, it seems to me that the Internet has been taken over by business interests, and that they are promoting their services under the pretext of “informed consent”. Tradition and ignorance can find no better ally than the pursuit of profit.
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References to the commentary
1. HINMAN S. Circumcision. B.J.U. Int., 1999, 84, 543.
2. GHALEN A.P. Religious circumcision : a moslem view. B.J.U. Int., 1999, 84, 543.
3. A. ZOOSSMANN-DISKIN. Circumcision. BJU Int., 1999, 84, 748.
NOTEThe original version in French, with illustrations, can be found here.
I am most grateful to Dennis Harrison for his translation.
Further discussion of circumcision in the United States as a cultural desire (rather than a medico-scientific precaution) can be found in the articles by Geoffrey Miller, Circumcision: Cultural-legal analysis, and Sarah E. Waldeck, Using Male Circumcision to Understand Social Norms as Multipliers. They make the important point that, in a scientific age, is necessary to find medico-scientific justifications for cultural practices to which people are emotionally committed.