Psychological impacts of male circumcision

This menu page indexes and links articles relevant to an understanding of the psychological, neurological, and sociological sequelae and effects of male circumcision. The material within each category is arranged in order of publication.

Introduction

In medical circles, neonatal male circumcision was long assumed to be psychologically and emotionally benign. It was believed that newborn infants had "poorly developed" neurologic systems; that newborns could not feel pain; or, if they did feel the pain, they would not remember it. According to that orthodoxy, the experience of neonatal circumcision could never have any lasting effect on a child and could not traumatize a child.

• The belief that infants cannot feel pain is now outmoded and discredited.
• Pain of circumcision and pain control
  

It was also a common belief that the foreskin had no particular structure and no useful function; and that the patient would never later regret its loss.

• The idea that the foreskin is a "useless flap of skin" is contradicted by a modern understanding of anatomy.
• The penis and foreskin: Penile anatomy and sexual function
• The assumption that no patient would ever regret being circumcised was not justified.
• Awakenings (link to NOHARMM website)

Enough evidence now exists to say with confidence that male circumcision causes psychological changes. The trauma of the experience is injurious.^23,46,47 It can have long-term deleterious effects later in life.^{23,46,47,50,55,56} However, the specific neurological, psychological, and behavioural changes resulting from early genital trauma have never been carefully investigated. Much more study is needed to further elaborate these changes.

The study of the psychology of circumcision can be divided into several interrelated areas:

1. The effects of pain and perinatal trauma on the child;
2. Grieving the loss of a body part;
3. Effects of early trauma and loss in the adult;
4. The effects on the parent (parental-infant bonding);
5. The effects on society;
6. Factors influencing parents and doctors to request or perform circumcisions.

Although the literature on the psychological impacts of circumcision is far from complete, some information is available. New material is gradually appearing and will be added to these pages as it becomes available.

Perinatal trauma. Circumcision is a form of perinatal (birth) trauma.³⁴ Cansever tested boys before and after circumcision and found that the trauma causes severe disturbance of normal function.⁵ Taddio and others have documented behavioral changes at six months of age, suggestive of PTSD in circumcised boys.³⁶ Yilmaz et al. have demonstrated PTSD in boys in the phallic period who are undergoing circumcision for phimosis.⁵³ Rhinehart has documented posttraumatic stress disorder resulting from the perinatal trauma of circumcision in middle-aged males.⁴⁷ substantial evidence that perinatal trauma^{15,32,44,45,46,48,51,56} and/or deprivation of pleasure^7,18 contribute to later aggressive, violent, and/or suicidal behaviour. Anand and Scalzo suggest that early trauma predisposes to altered pain sensitivity, stress disorders, ADD/hyperactivity, and self-destructive disorders.⁶⁴ Van der Kolk identified a compulsion in traumatized persons to repeat the trauma.¹⁷ Goldman reports that the performance of circumcision by a circumcised male doctor may be a reenactment of one's own circumcision trauma.⁴⁶

Denial of loss. Persons who have lost body parts must grieve their loss.^40,41,42,44 The first stage of grief is denial of the loss.²⁴ Fitzgerald and Parkes state that "Anything that seriously impairs sensory or cognitive function is bound to have profound psychological effects, not only on the person who is affected but also on family, friends, workmates, and caregivers."⁴¹ The thought of permanent loss of sensory function is so painful that persons deny their loss in order to avoid facing the painful feelings.⁴¹ Denial of loss causes a flight from reality. Parkes et al. state that persons in denial may minimize their loss.^40,41,42 Circumcision causes the loss of a body part and all of its functions including a drastic loss of erogenous sensory function, so denial of loss is not uncommon in circumcised males. Circumcised males may experience the full range of distress and emotional dysfunction resulting from loss. This frequently results in circumcised fathers adamantly insisting that a son be circumcised.^{24,28, 56}

Fathers are frequently unable to vocalize their feelings. They will say that "I want my son to look like me," even though the child may be different in eye color, hair color, and other aspects. In fact, what the father really may be feeling is, "I don't want a son with an intact penis to remind me of what I have lost."

Effects of denial on medical doctors. Goldman states that some circumcised male medical doctors misuse the medical literature to support, rationalize, and justify their own loss; and to defend the practice of circumcision.⁴⁶ Denniston reports that doctors "who have been cut themselves may be unable to stop cutting others."²⁸ LeBourdais reports that the likelihood of a baby being circumcised is determined by the circumcision status of the a father; the sex, age, and circumcision status of the physician; amongst other factors. Goldman reports that doctors who are older, male, and circumcised are more likely to condone circumcision.⁴⁶ Members of medical societies may have emotional issues that may preclude the objective formulation of policy concerning non-therapeutic male circumcision.⁵⁴

Summary

Parents need to be aware that circumcision is dangerous. It involves traumatic loss of a body part. There is a definite potential for long-lasting psychologic injury. However, children differ unpredictably in their resilience to pain, trauma, and loss. Some individuals will be affected more seriously than others. Much more research is needed before we can fully understand the psychologic and social consequences of this traumatic life event.

Highlights

• In the late 19th and early 20th Century, Sigmund Freud identified castration anxiety resulting from fear of operations on the genitals.¹
• As early as 1929, British analyst Edward Glover reported a case of impotence secondary to castration anxiety caused by a particularly brutal circumcision. Glover also reported the behaviour of a medical doctor with an apparent obsessive-compulsive need to perform circumcisions.²
• In 1945, David M. Levy, M.D., reported a study of many children who had undergone various surgical operations, including circumcisions. He found that many suffered from "combat neurosis", an early name for what is now known as posttraumatic stress disorder.³
• Child psychiatrist Anna Freud discussed the role of bodily illness in the mental life of children in 1952. Freud stated that the combination of pain and anxiety can have devastasting effects on children.⁴
• Child psychologist Gocke Cansever (1965) assessed 12 Turkish boys before and after they were circumcised. Cansever reported severe disturbances with functioning after the circumcision as measured by psychological testing.⁵
• James Prescott (1975) reports on the origins of violence. Prescott believes that the deprivation of body pleasure contributes to the development of violent behaviour. ⁷ Circumcision removes the pleasure sensors in the foreskin and so deprives the individual of body pleasure.
• Richards et al (1976) observed behaviour differences in male children in the US that were not found in male children in Europe. The US male children were circumcised while the European children were not circumcised. Richards suggested that the changes were due to circumcision.⁸
• Grimes, apparently unaware of the work of Freud, Cansever, or Richards, wrote in 1978 that "[t]he application of crushing clamps and excision of penile tissue... probably do little to engender a trusting, congenial relationship with the infant's new surroundings."⁹
• Kennedy reported the case of an adolescent boy traumatized by circumcision.¹² Yorke subsequently reported on the need for additional study of psychic trauma. He cited the trauma of circumcision as an example.¹³
• The Diagnostic Manual of the American Psychiatric Association (DSM III) first identified the conditions that contribute to the development of post-traumatic stress disorder (PTSD) in 1980. The 1987 DSM-III-R reports the conditions described for the pathogenesis of PTSD. These are exactly similar to those experienced by the helpless infant undergoing circumcision.¹⁴
• Perinatal psychologist David Chamberlain (1989) demonstrated that people under hypnosis can remember their birth and traumatic events associated with it.¹⁶
• Van der Kolk (1989) reported that victims of trauma tend to reenact the trauma.¹⁷ These findings apply to many kinds of child abuse, and may help to explain why men and women who were victims of circumcision violence are more likely to perpetuate male and female circumcision violence.
• Prescott (1989) contrasts the pain and trauma of circumcision with the pleasure and peace of avoided circumcision. He identifies the pain and lack of pleasure associated with circumcision with changes in brain development and behaviour. Prescott argues that the early genital pain of circumcision "encodes" the brain for later sadomasochistic tendencies, including violent destructive behaviours.¹⁸
• Alice Miller (1991) discusses the effects of early child abuse and trauma on later violent and self-destructive behaviour.¹⁹
• Walter and Streimer have reported a case of body dysmorphic disorder secondary to circumcision.²⁰ Maguire and Parkes confirm that grief is common in persons who have lost body parts⁴⁰.
• Bigelow (1992,1995) reported that circumcised men who have become fathers in circumcising cultures often exhibit a behaviour described as "adamant father syndrome." The "adamant father" insists that his son be circumcised, even after a rational discussion is provided.²⁴
• Menage (1993) found post-traumatic stress disorder in women who have undergone genital procedures.²⁵
• Williams and Kapila surveyed the complications of circumcision in 1993. This is believed to be the first medical journal article of this type to discuss psychologic complications of circumcision in any detail.²⁶
• George C. Denniston, MD, MPH, (1994) discusses the psychological effects and behavior changes in adult men resulting from of denial of loss by penile circumcision.²⁸
• David Chamberlain, Ph.D. (1995) discusses the perinatal origin of later violent behaviour.³² Dr. Chamberlain argues that babies should not be circumcised.
• Hepper (1996) reviews the literature that shows that fetal memory commences to operate well prior to birth and continues across the birth experience into the newborn period.³³
• Diamond provides a psychosexual follow-up report on the case of "John/Joan," who was "sexually reassigned" and raised as a girl following the total loss of his penis to a circumcision disaster. "John" was circumcised to treat a "fused foreskin"---even though this is a normal developmental condition in newborn boys.³⁵ "John" (David Reimer of Winnipeg, Canada) was the subject of a book, As Nature Made Him, by journalist John Colapinto.
• Taddio (1997) demonstrated that the pain of neonatal circumcision remembered at six months of age. The observed behaviour is suggestive of an infant analogue of post traumatic stress disorder.³⁶
• Psychologist Ronald Goldman reports the effects of the trauma of circumcision on the individual and society in a recent book.³⁷
• Hill (1997) reports the tendency of circumcised doctors and religious officials to cite false medical or religious grounds to justify circumcision.³⁸
• British child psychiatrist McFadyen (1998) reported the psychologic trauma experienced by her son following a circumcision operation.³⁹ McFayden's description of her son's trauma is consistent with the early reports of Anna Freud⁴ and Cansever.⁵
• British psychiatrists Maguire and Parkes (1998) reported on the need to grieve the loss of body parts.⁴⁰ Failure to grieve the loss leaves the individual in a state of denial of loss and disconnected from the reality of the loss and injury.
• Bradley et al. report on the failure of sex reassignment surgery in the management of penile ablation secondary to non-therapeutic circumcision.⁴³
• Menage (1998) reports on the psychological harm of male circumcision.⁴⁴
• Jacobsen and Bygdeman (1998) report that traumatic and/or painful procedures in the perinatal period seem to cause a greater propensity to suicide. The effect is markedly greater in males.⁴⁵
• Ronald Goldman, Ph. D. (1999) discusses the impact of circumcision on the child, on parents, on adults, on medical doctors, and on society.⁴⁶
• Psychiatrist John Rhinehart, MD, (1999) documents four cases of PTSD from his psychiatric practice.⁴⁷
• Boyle & Bensley report a survey of the psychological and sexual effects of male circumcision on men.⁴⁹
• Boyle and colleagues survey the psychological and sexual effects of infant circumcision.⁵¹
• Yilmaz et al. administered psychological test to boys before and after circumcision. They found evidence that circumcision causes anxiety similar to post-traumatic stress disorder.⁵³
• Goldman discusses psychological, cultural, and religious factors that influence circumcision policy.⁵⁴

See also The Birth Scene, a site having an excellent discussion of circumcision in four articles by leading writers.

Therapists

NOHARMM maintains a webpage listing therapists in various parts of the United States who are knowledgeable in helping men who have issues resulting from their circumcision.

Organizations

• Circumcision Resource Center, Boston, USA
• Society for the Psychological Study of Men and Masculinity (SPSMM)
  (A Division of the American Psychological Association)

References

The psychology of male circumcision

1. Freud S. (1913) Totem and Taboo. Standard Edition, (13),1-161.
2. Glover E. The `screening' function of traumatic memories. Int J Psychoanal 1929; 10:90-93.
3. Levy DM. Psychic trauma of operations in children and a note on combat neurosis. Am J Dis Child 1945;69(1):7-25.
4. Freud, Anna. The role of bodily illness in the mental life of children. Psychoanalytic Study of the Child 1952; Vol 7: 69-81.
5. Cansever G. Psychological effects of circumcision. Brit J Med Psychol (1965), 38, p 321.
6. Oztürk O. Ritual circumcision and castration anxiety. Psychiatry 1973; 36: 55
7. Prescott JW. Body pleasure and the origins of violence. Bulletin of the Atomic Scientists 1975; November:10-20. (Link to www.violence.de)
8. Richards MPM, Bernal JF, and Brackbill Y. Early behavioural differences: gender or circumcision? Dev Psychobiol 1976;9:89-95.
9. Grimes DA. Routine circumcision of the newborn infant: A reappraisal. Am J Obstet Gynecol 1978; 130(2): 125-129.
10. Carter, Nicholas. Routine circumcision: The tragic myth. London: Londinium Press; Torrance, Calif.: Noontime Press, c1979.
11. Salk L, Lipsitt LP, Sturner WQ, et al. Relationship of maternal and perinatal conditions to eventual adolescent suicide. Lancet 1985;i:624-627.
12. Kennedy H. "Trauma in Childhood." The Psychoanalytic Study of the Child (1986) 41:209-219.
13. Yorke, C (1986). Reflections on the problem of psychic trauma. Psychol Study Child, 41:221-236.
14. American Psychiatric Association. Post-traumatic stress disorder. Diagnostic and Statistical Manual III-R (DSM-III-R), Washington 1987.
15. Jacobson B, Eklund G, Hamberger L, et al. Perinatal origin of adult self-destructive behaviour. Acta Psychiatrica Scandinavia 1987;76:364-371.
16. Chamberlain DB. "Babies Remember Pain." Pre- and Peri-natal Psychology Journal, Summer 1989. (courtesy Primal Psychotherapy Page)
17. van der Kolk, B. The compulsion to repeat the trauma: re-enactment, revictimization, and masochism. Psychiatric Clinics of North America 1989;12: 389-411.
18. Prescott, J. Genital pain vs. genital pleasure: why the one and not the other. The Truth Seeker 1989;1(3):14-21.
19. Miller A. Appendix: The Newly Recognized, Shattering Effects of Child Abuse. In: The Untouched Key: Tracing Childhood Trauma in Creativity and Destructiveness. Anchor Books (Doubleday) New York, 1991.(ISBN 0-385-26764-9) (Originally published as Der gemiedene Schlüssel by Suhrkampt Verlag am Main, 1988).
20. Walter G, Streimer J. Genital self-mutilation: Attempted foreskin reconstruction. Brit J Psych 1990;156:125-7.
21. Chamberlain DB. (1991) Babies Don't Feel Pain: A Century of Denial in Medicine. Presented at The Second International Symposium on Circumcision, San Francisco, California, May 2, 1991 (link to www.nocirc.org).
22. van der Kolk BA, Saporta J. The biological mechanisms and treatment of intrusion and numbing. Anxiety Research 1991;4:199-212.
23. van der Kolk BA, Perry JC, Herman JL. Childhood origins of self-destructive behavior. Am J Psychiatry 1991;148;1665-71.
24. Bigelow, Jim, Ph. D. Chapter 10, Psychological Factors Related to Infant Circumcision, pp.89-112. In:The Joy of Uncircumcising!, Hourglass Book Publishing, Inc., Aptos CA 95001, 1992, 1995. (ISBN 0-934061-22-X)
25. Menage J. Post-traumatic stress disorder in women who have undergone obstetric and/or gynaecological procedures: a consecutive series of 30 cases of PTSD. Journal of Reproductive and Infant Psychology 1993; 11:221-228.
26. Williams N, Kapila L. Complications of circumcision. Brit J Surg 1993;80:1231-1236.
27. Diamond, Jed. The Warrior's Journey Home: Healing Men, Healing the Planet. New Harbinger Publications, Inc., 1994.
28. Denniston GC. An Epidemic of Circumcision. Paper presented at the Third International Symposium on Circumision, University of Maryland, College Park, Maryland, May 22-25, 1994. (link to www.nocirc.org)
29. Posttraumatic Stress Disorder. In: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington: American Psychiatric Association, 1994. (ISBN 0-890420062-9)
30. Gunnar MR, Porter FL, Wolf CM, et al. Neonatal stress receptivity: predictions to later emotional temperament. Child Dev 1995; 66: 1-13.
31. Davis M, Emory E. Sex differences in neonatal stress reactivity. Child Dev 1995; 66:14-27.
32. Chamberlain, David B. Birth and the origins of violence. Pre- and Perinatal Psychology Journal (Winter) 1995; 10(2): 57-74. (Link to www.birthpsychology.com)
33. Hepper PG. Fetal memory: does it exist? What does it do? Acta Paediatr Scand 1996, Suppl 416:16-20.
34. deMause L. Restaging fetal traumas in war and social violence. Pre- & Perinatal Psychology Journal 1996, 10(4), 227-258. (Link to www.primalspirit.com)
35. Diamond M. Sex reassignment at birth: a long term review and clinical implications. Archives of Pediatric & Adolescent Medicine 1997; 151;298-304.
36. Taddio A, Katz J, Ilersich AL. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997; 349 (9052): 599-603.
37. Goldman, Ronald F. Circumcision: The Hidden Trauma. Vanguard Publications, 1997. (ISBN 0-9644895-3-8)
38. Hill G. Abolish circumcision in non-consenting children (letter) . Townsend Letter for Doctors and Patients, May 1997; #166:102.
39. McFadyen A. Children have feelings too. BMJ 1998; 316:1616.
40. Maguire P, Parkes CM. Coping With Loss: Surgery and loss of body Parts. [Part 4/10.] Brit Med J 1998; 316(7137)
41. Fitzgerald RG, Parkes CM. Coping with loss: Blindness and loss of other sensory and cognitive functions..BMJ 1998;316:1160-1163.[Part 5/10]
42. Parkes CM. Coping with loss: Facing loss. BMJ 1998;316:1521-1524. [Part 10/10]
43. Bradley SJ, Oliver GD, Chernick AB. Experiment of Nurture: Ablatio Penis at 2 Months, Sex Reassignment at 7 Months, and a Psychosexual Follow-up in Young Adulthood. Pediatrics 1998;102(1):e9.
44. Menage J. (1998) Circumcision and psychological harm. (Link to www.norm-uk.co.uk)
45. Jacobson B, Bygdeman M. Obstetric care and proneness of offspring to suicide. BMJ 1998; 317:1346-49. (Link to www.bmj.com)
46. Goldman R. The psychological impact of circumcision. BJU International 1999; 83, Suppl. 1:93-102.
47. Rhinehart, John. Neonatal circumcision reconsidered. Transactional Analysis Journal 1999 Jul; Vol 29(3):215-221.
48. Boyle, G. J. (2000). Discurso tonico: El trastorno por estrés postraumático (PTSD) de larga duración como resultado de la cirugía genital de los menores. III Congresso Nacional de Psicología: "Violencia y Salud Mental." San Salvador, El Salvador, 6 y 7 octubre 2000. (en español)
49. Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychological Reports 2001;88:1105-1106.
50. Boyle GJ. Los efectos adversos sobre la salud mental de larga duración como resultado de la circuncisión no terapéutica de los niños. VI Congreso Iberoamericano de Psicología de la Salud. Universidad Maimónides, Buenos Aires, 30 de septiembre al 3 de octubre, 2001. (en español)
51. Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychology 2002;7(3):329-43.
52. Boyle G. J. (2002). La Circuncisión No Terapéutica de los Niños y su Relación con el Estrés Postraumático. 9° Congreso Internacional de Psiquiatría, Buenos Aires, Octubre 22-25, 2002. (en español)
53. Yilmaz E. Batislam E, Basar MM, Basar H. Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids. Int J Urol 2003;10(12):651-6.
54. Goldman R. Circumcision policy: a psychosocial perpective. Paediatr Child Health 2004;9(9):630-3. (Offsite link)
55. Behrendt A, Moritz S. Posttraumatic Stress Disorder and Memory Problems After Female Genital Mutilation. Am J Psychiatry 2005;162:1000-2.
56. Hill G. Circumcision and human behavior. Knol 2008. [Full Text]

The neurology of male circumcision

The study of neurological changes secondary to circumcision is in its infancy. Neurological changes have been demonstrated secondary to pain, stress, and trauma.²² Fitzgerald et al. report experimentation in animals.^59,60 In addition, brain atrophy/dis-organization by sensory deprivation after removal of the pleasure sensors in the prepuce has been hypothesized by Immerman and Mackey.^61,61

57. Goleman D. Early Violence Leaves Its Mark on the Brain. The New York Times, Tuesday, October 3, 1995, Pg. C1.
58. Bower B. Exploring trauma's cerebral side. Science News 1996;149:315.
59. Stein M, Koverola C, Hanna C, et al. Hippocampal volume in women victimized by childhood abuse. Psychol Med 1997;27:951-9.
60. Fitzgerald M. The birth of pain. MRC News 1998; Summer:20-23.
61. Fitzgerald M, Walker S. The role of activity in developing pain pathways. In: Dostovsky JO, Carr DB, Koltzenburg M (eds). Proceedings of the 10th World Congress on Pain. Progress in Pain Research and Management, Vol. 24. Seattle: IASP Press, 2003, pp 185-96.

The next two documents are problematical.^62,63 Immerman & Mackey (1998) set forth an informed hypothesis that removal of the sensors in the prepuce cause brain disorganization/atrophy. Thereafter they seek to justify circumcision by arguing that brain disorganization/atrophy has desirable social effects. This is not consistent with the principles of good medicine. Immerman and Mackey's defense of circumcision's maleficial effect on the brain in these articles may illustrate Goldman's revelation that some medical doctors may use 'Intellectual activity ...as an extremely clever apparatus precisely for the avoidance of facts, as an activity which distracts from reality' when they write about circumcision.⁴⁵ This is a way in which many circumcised men deny the reality of their loss.³⁷ This sometimes manifests itself in the scientific literature.⁴⁵ Anand & Scalzo (2000) hypothesize that early abnormal stimulation of the nervous system (such as the pain of circumcision) affect the development of the nervous system and influence behavior.⁶³

62. Immerman RS, Mackey WC. A biocultural analysis of circumcision: a kinder gentler tumescence. Soc Biol 1998; 44:265-275.
63. Immerman RS, Mackey WC. A proposed relationship between circumcision and neural reorganization. J Genet Psychol 1998; 159(3):367-378.
64. Anand KJ, Scalzo FM. Can adverse neonatal experiences alter brain development and subsequent behavior? Biol Neonate 2000;77(2):69-82.

[See also The Anthropology and Sociology of Circumcision.]