July 19, 1965.

Critical Commentary


Surgical operations fall into three types. First, there are those which are socially acceptable and which can be discussed in public without embarrassment; second, there are those which do not qualify as conversation pieces and generally are mentioned only in whispers; and last, there are those which are actually thought to add to the social status of the incised subject. Those in the latter category pass rapidly in and out of favor. While nephroplexy was in vogue 30 years ago, 10 to 15 years later tonsillectomy was popular, and currently such exotic operations as hiatus hernia repair are the real status symbols. Before an operation can be accepted as likely to add to one's social status, certain criteria have to be fulfilled: the operation must be performed on a U part of the body, preferably the symptoms which it aims to relieve should be vague and supratentorial in origin, and last, but of paramount importance, there should be no valid medical reason for it. (U denotes upper and refers to figures of speech and terms appropriate to, and used by the upper class. Non-U is the reverse and implies lack of social acceptability. Thus, "looking glass" is U while "mirror" is definitely non-U.1)

Routine circumcision completely fills the second and third criteria but whether the operation site is to be classified as U or non-U has not yet been decided by Alan Ross or Nancy Mitford. This ritual, however, has become so widespread in the United States that it is no longer much of a status symbol, and a situation has arisen where any recently delivered mother who is eccentric enough to wish her child to retain his prepuce, would be well advised to maintain permanent guard over it until such time as they both leave the hospital. The nursery staff of most American hospitals have an insatiable urge to remove the foreskin and this instinct often causes great concern among European women who do not subscribe to this practice and through force of circumstances have their baby in the United States.

Why is the operation of circumcision practiced? One might as well attempt to explain the rites of voodoo! Ritual is seldom self- explanatory and still less frequently logical. Nevertheless, at least two origins of circumcision can be traced. First, it is part of an ancient rite practiced by many primitive tribes whereby the young male and less frequently the young female, gives proof of his or her ability to endure pain. If they pass the test with fortitude, they are then accepted into the tribe as fully developed adults with attendant privileges. Thus in this respect the operation is similar to many of the tattoos and scars produced by burning, piercing or incising that are accepted as routine cosmetic procedures by these peoples. Second, in many primitive African tribes circumcision is performed to reduce libido. This mutilating practice is generally performed on women to keep them faithful to their husbands. Male infant circumcision is practiced by all Semitic races, Jew and Arab alike, and has been exported by them to all parts of the world and to most races. It will perhaps be a cause of surprise to those of Semitic origin to find that the Australian aborigine has practiced circumcision for as long, if not longer, and for the same basic reason as his more civilized brethren.

So much for the origin of circumcision. Why does the operation find so much favor in Western society? There are a variety of reasons advanced in favor of circumcision most of which are unconvincing when critically examined. Let us consider the so-called medical (or surgical) reasons first. Those few pediatricians who have practiced in an unmutilated population agree that phimosis is all but unknown in infancy. The prepuce is not retractile at birth and does not become so until the child is between two and three years old. A non-retractile foreskin is not synonymous with phimosis and should not be used as pretext for lopping off an innocent and useful appendage. It has been claimed that the uncircumcised male is more prone to venereal disease. Any US or British physician with experience in North Africa or the Levant knows that the Middle East has a venereal disease rate which is second to none. Foreign aid in this context is superfluous. The argument is also advanced, this time with much greater justification, that cancer of the penis is found almost entirely in the uncircumcised; nevertheless, this is an uncommon form of cancer and generally has a fairly good prognosis. Appendicitis causes many more deaths than does cancer of the penis but nobody yet recommends routine appendectomy. Perhaps the most fatuous reason advanced for the operation is that the uncircumcised penis is less hygienic. Soap and water work wonders with the body's other orifices and appendages and there would seem no reason to doubt their efficacy with respect to the foreskin. The pinnae also collect dirt but removal of the external ears does not find favor as a routine measure of hygiene. A further important indication for circumcision which is seldom mentioned in the surgical textbooks is chronic remunerative balanitis.

How is it that parents accept this procedure with such equanimity and enthusiasm? This can be attributed in part to pressure exerted by their medical adviser and in part due to the fact that the procedure has become customary - one has to lop it off along with the Joneses. Moreover, many mothers will express the opinion that the circumcised phallus is more aesthetic, but in general their experience of the uncircumcised organ is limited to memories of a Michelangelo sculpture which appeared as an illustration in one of their college textbooks. Perhaps not least of the reasons why American mothers seem to endorse the operation with such enthusiasm is the fact that it is one way an intensely matriarchal society can permanently influence the physical characteristics of its males.

So far the reasons usually given for routine circumcision in infants have been examined and found wanting. Now let us consider whether the operation is in any way harmful or contraindicated. The function of the prepuce is to protect the glans, the latter being almost insensitive to most ordinary tactile and thermal stimuli. It has, however, specific receptors for other pleasurable sensations. Removal of the prepuce exposes the glans to foreign stimuli which dull these special receptors. During the act of coitus the uncircumcised phallus penetrates smoothly and without friction, the prepuce gradually retracting as the organ advances. In contrast, when the circumcised organ is introduced during coitus, friction develops between the glans and vaginal mucosa. Penetration in the circumcised man has been compared to thrusting the foot into a sock held open at the top, while, on the other hand, in the intact counterpart it has been likened to slipping the foot into a sock that has been previously rolled up. The comparison is apt and worthy of Osler in one of his Rabelaisian moments.

This commentary must not be construed as a crusade against circumcision. The teaching of the Koran and the Bible, the mistaken beliefs of many of the medical profession, the intuition of woman, and, above all, folklore, tradition, and health insurance agencies support this ritual. Nevertheless, let us remember that 98 times out of 100 there is no valid indication for this mutilation other than religion.

1. Ross, A.S.C.: "U and Non-U: Essay in Sociological Linguistics," reprinted in Nobless Oblige: Enquiry Into Identifiable Characteristics of English Aristocracy, London: Penguin Books 1960, pp 9-32.

From the Division of Pulmonary Diseases, University of Maryland, School of Medicine, Baltimore.

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(file revised 4 October 2005)