Normal versus Cut: Final Psychological Score, 100-0

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By Dan Bollinger, 2014

The thought came to me like the proverbial thunderclap: No psychological study has ever concluded that circumcision is beneficial to a boy’s psyche. But was my sudden hypothesis true? What I discovered after an exhaustive search of the literature was that more than one hundred scientific studies found circumcision painful, traumatic, or psychologically harmful to men and boys, but not one peer-reviewed study has shown it benefits the male psyche.

Included in my comprehensive search were articles dealing with the short- and long-term psycho-sexual consequences of circumcision, early trauma, or early sexual abuse. Also included were articles on neonatal circumcision pain control, and the effect of early pain on the brain and its development.

Background

The pros and cons of other aspects of circumcision are well-discussed in the literature including medicine, ethics, law, religion and ethics. However, in psychology the discussion is decidedly one-sided in favor of avoiding the trauma.

Psychology’s study of circumcision began in earnest in 1965 when Gocke Cansever tested children before and after circumcision with a battery of standard psychological tests and concluded that circumcision is perceived by the child as an assault.i Since then many other studies have researched circumcision. Bertil Jacobson and Marc Bygdeman found circumcised men are more likely to commit suicide.ii My study with co-author Robert Van Howe found circumcised men were more likely to test high for alexithymia (inability to identify and express one’s emotions).iii

Sure there are some op-eds that claim circumcision is the greatest thing since sliced bread. And online discussions are full of comments from people who are staunch believers in the religio/cultural/sexual power of cut penises. But opinion and anecdotes are not science.

A seven-part series in Psychology Today on circumcision did not reveal any improvement to a boy’s psyche. An essay by Kurt Johmann in 2003 listed a plethora of negative consequences, but no positive ones.

The topic often comes up for discussion in online forums such as Yahoo! Answers. For instance, one person asked, “Is circumcision beneficial to men’s health?” The best answer, chosen by readers, was:

“There is also the psychological trauma when teens are rejected because their female partners did not want to engage in sexual activity with an uncircumcised male.” The author did not provide any references for this claim. Of course the opposite could be claimed as well, especially since the U.S. intact-to-cut ratio is nearing 50/50.

A comprehensive online survey of 901 men investigated the psychological consequences of circumcision. The vast majority of the men reported negative consequences with about one-tenth reporting no negative consequences, but no man reported any positive psychological outcomes

Is circumcision beneficial?

Now, back to the count. Like I mentioned, I didn’t know offhand of any studies concluding circumcision is psychologically beneficial, and I have a large library on the topic. However, my claim requires an extraordinary due diligence for proof. A search of online journal indexes including Pubmed, PsycINFO, and Google Scholar found no candidates. So, I searched further afield.

A review of the large bibliography in the pro-circumcision website CircInfo.net found only anecdotal evidence of benefit. They had no peer-reviewed study making the same claim. I suspect that if such an article existed, this site would be sure to include it.

I did find that in 1947 Herman Nunberg espoused his hypothesis that circumcision may have a favorable impact on the psychology of the child.iv However no one, not even Nunberg, followed up to see if his hypothesis was true.

What are the harms?

Negative psychological consequences as a result of amputation and mutilation are well reported in the literature and there is no reason to believe that loss or partial loss of the penis is exempt. Potential effects of loss of body parts are: grief for altered body image or function, anxiety, depression, denial, sexual problems, and obsessive preoccupation with the loss.v vi vii

John Rhinehart reported that adults circumcised in childhood displayed feelings of terror, anger, and dissociation when confronted with dangerous situations in adulthood. He went on to suggest that preventing circumcision in the first place would be ideal.viii

Cultural relativism and norming have an effect upon sociology and societal acceptance, but not necessarily psychology. Three studies found that intact boys raised in a circumcising culture felt more ashamed of their bodies.ix x xi At first glance this might seem to show psychological benefit, but this effect is also likely true of intact girls where female circumcision is practiced, even though it is generally accepted that all forms of female circumcision are detrimental to their psyche. Presumably, the counter- argument holds true, too. Circumcised boys and girls would likely feel uncomfortable if they were raised in a non-circumcising culture. Therefore, it is not circumcision that is the culprit, but living in a dissonant culture.

Other findings

Reading the literature you often come across a statement similar to this one: “Circumcision may be carried out for varying reasons in different societies. The reasons may be classified as: medical- therapeutic, preventive-hygienic, religious and cultural.”xii Conspicuously absent from such statements is any mention of a psychological reason.

Two common reason parents give for circumcising is that he’ll be teased in the locker room and that he’ll look like his dad (if his dad is circumcised, that is). They both could conceivably have negative psychological factors, too, yet I could find no scientific studies to back up these popular claims.

In a bizarre and ironic twist, a man who attempted to surgically reconstruct his foreskin was initially thought to be psychotic, but upon further examination was deemed mentally healthy.xiii Even with a clean bill of health they called his act “self-mutilation” instead of calling it “self-reconstructive surgery.” This is doubly strange since he was attempting to reverse a previous mutilation. (Note: the American Heritage Medical Dictionary definition of mutilate is: “Disfigurement or injury by removal or destruction of a conspicuous or essential part of the body.” And the McGraw-Hill Concise Dictionary of Modern Medicine gives genital mutilation as an example.)  No thought was given to the psychological status of his circumcisers.

In a similar case history, but with a different result, an Indian man suffering from ED chopped off his penis.xiv This story illustrates the psychological importance men give to their body image (and particularly their penis), their sexuality, and how amputation is sometimes a perceived solution.

Looking over the list I observe that a large amount of research has gone into circumcision pain relief, including an ongoing study in Cincinnati.xv This is a silent acknowledgement that the procedure is overly traumatic for the child. But it begs the question; What if the procedure was pain free? Many of the articles listed below show that even if pain free, circumcision is still traumatic, debilitating, and sexually maiming, and therefore has a detrimental effect on the boy’s psyche.

Conclusion

I stopped looking for articles concluding circumcision was psychologically harmful when they exceeded one hundred. I’m sure the list would have been much longer if I had been as diligent in trying to find even just one article that showed a positive psychological result.

The Articles

  1. Anand KJS, for the International Evidence-Based Group for Neonatal Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med. 2001;155:173-80.
  2. Anand KJS, Hickey PR. Pain and its effects in the human neonate and fetus. New Engl J Med. 1987;317(21):1321-9.
  3. Anand KJS, Scalzo FM. Can adverse neonatal experiences alter brain development and subsequent behavior? Biol Neonate. 2000;77(2):69-82.
  4. Aust S, Härtwig EA, Heuser I, Bajbouj The role of early emotional neglect in alexithymia. Psychological Trauma: Theory, Research, Practice, and Policy. 2013;5(3):225-232.
  5. Bensley AG & Boyle Physical, sexual and psychological effects of male infant circumcision: an exploratory survey. In Understanding circumcision: a multidisciplinary approach to a multidimensional problem. Eds: Denniston GC, Hodges FM & Milos MF. New York: Kluwer Academic/Pluwer Publishing. 2000;207-231.
  6. Berenbaum H, James T. Correlates and retrospectively reported antecedents of alexithymia. Psychosom Med. 1994;56:353-359.
  7. Bigelow J, Griffiths Increasing awareness of iatrogenic damage consequent to male circumcision. . In Bodily integrity and the politics of circumcision: Culture, controversy, and change. Eds: Denniston GC, Gallo PG, Hodges FM, Milos MF & Viviani F. New York: Springer. 2006;165-176.
  8. Bigelow The joy of uncircumcising! Exploring circumcision :History, myths, psychology, restoration, sexual pleasure, and human rights. Aptos CA: Hourglass Book Pub., 2nd Edition 1995.
  9. Bollinger D, Van Howe, RS. Alexithymia and circumcision trauma: A preliminary investigation. Int J Men’s Health. 2011;10(2):184-95.
  10. Bronselaer GA, Schober J, Meyer-Bahlburg HF, T’Sjoen G, Vlietinck R, Hoebeke PB. Male circumcision decreases penile sensitivity as measured in a large BJU Int. 2013;111(5):820-827.
  11. Cansever G. Psychological effects of circumcision. Br J Med Psychol,1965;38: 321-331.
  12. Cepeda MS, Carr DB, Lau J, Alvarez H. Music for pain relief. (Review). Cochrane Database Syst Rev 2006: art. no.
  13. Chamberlain DB, Babies remember pain. Pre- and Perinatal Psych. J. 1989;3:297-310.
  14. Chamberlain Delusional psychologies of circumcision and civilization. In Circumcision and Human Rights. Eds: Denniston GC, Hodges FM & Milos MF. New York: Springer. 2009;1-14.
  15. Committee on Fetus and Newborn, Committee on Drugs, Section on Anesthesiology, Section on Surgery, American Academy of Pediatrics. Prevention and management of pain and stress in the neonate. Pediatrics. 2000;105(2):454-61.
  16. Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics; Task Force on Pain in Infants, Children, and Adolescents, American Pain The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793- 7.
  17. Cregin R, Rappaport AS, Montagnino G, Sabogal G, Moreau H, Abularrage Improving pain management for pediatric patients undergoing nonurgent painful procedures. Am J Health Syst Pharm. 2008;65:723-727.
  18. Dekkers W, Hoffer C, Wils Scientific contribution, bodily integrity and male and female circumcision. Med Health Care Philos. 2005;8(2):179-191.
  19. Denniston An analysis of circumcision advocacy. In Male and Female Circumcision, Medical, Legal and Ethical Considerations in Pediatric Practice. Eds: Denniston GC., Hodges FM & Milos MF. New York: Kluwer Academic/Plenum Publishers. 1999;221-240.
  20. Denniston Circumcision and sexual pleasure. In Flesh and Blood: Perspectives on the problem of circumcision in contemporary society. Eds: Denniston GC, Hodges FM & Milos MF. New York: Kluwer Academic/Plenum Publishers. 2004;45-54.
  21. Diamond Sexual identity and sexual orientation in children with traumatized or ambiguous genitalia. J Sex Res. 1997;34(2):199-211.
  22. Diamond, Sexual identity and sexual orientation in children with traumatized or ambiguous genitalia. Journal of Sex Research. 1997;34(2):199-211.
  23. Dias J, Freitas R, Amorim R, Espiridião P, Xambre L, Ferraz Adult circumcision and male sexual health: A retrospective analysis. Andrologia. 2013. [Epub ahead of print]
  24. Emde RN, Harmon RJ, Metcalf D, Koenig KL, Wagonfeld S. Stress and neonatal sleep. Psychosom Med. 1971;33(6):491-7.
  25. Fitzgerald M. The birth of pain. MRC News (London). Summer 1998:20-3.
  26. Friedman RM. The role of the testicles in male psychological development. J Am Psychoanal Assoc. 1996;44(1): 201-253.
  27. Frisch M, Lindholm M, Grønbæk Male circumcision and sexual function in men and women: A survey-based, cross-sectional study in Denmark. Int J Epidemiol, 2011;1–15.
  28. Gaensbauer TJ. Trauma in the preverbal period. Symptoms, memories, and developmental impact. Psychoanal Study Child. 1995;50:122-49.
  29. Gallo PG, Araldi L, Viviani R, Gaddini R. Epidemiological, medical, legal, and psychological aspects of mutilated/at-risk girls in Italy: A bioethical In Male and Female Circumcision, Medical, Legal and Ethical Considerations in Pediatric Practice. Eds: Denniston GC, Hodges FM & Milos MF. New York: Kluwer Academic/Plenum Publishers. 1999;241-258.
  30. Garry DJ, Swoboda E, Elimian A, Figueroa. A video study of pain relief during newborn male circumcision. J Perinatol. 2006; 26:106-110.
  31. Gavranidou M, Rosner R. The weaker sex? Gender and post-traumatic stress disorder. Depress Anxiety. 2003;17:130-139.
  32. Gemmel T, Boyle Neonatal circumcision: Its long-term harmful effects. . In Understanding circumcision: a multidisciplinary approach to a multidimensional problem. Eds: Denniston GC, Hodges FM & Milos MF. New York: Kluwer Academic/Pluwer Publishing. 2000;241-252.
  33. Goldman R. Circumcision policy: A psychosocial perspective. Paediatr Child Health. 2004;9(9):630-633.
  34. Goubet N, Rattaz C, Pierrat V, Bullinger A, Lequien Olfactory experience mediates response to pain in preterm newborns. Dev Psychobiol. 2003;42:171-180.
  35. Goulding FJ. Penile block for postoperative pain relief in penile surgery. J Urol. 1981;126:337.
  36. Green EJ, Crenshaw DA, Kolos. Counseling children with preverbal trauma. International Journal of Play Therapy. 2010;19(2):95-105.
  37. Griffiths. Current practices in foreskin restoration. In Male and Female Circumcision, Medical, Legal and Ethical Considerations in Pediatric Practice. Eds: Denniston GC, Hodges FM & Milos MF. New York: Kluwer Academic/Plenum Publishers. 1999;295-302.
  38. Gunnar MR, Fisch RO, Korsvik S, Donhowe. The effects of circumcision on serum cortisol and behavior. Psychoneuroendocrinology. 1981;6(3):269- 75.
  39. Hammond. Long-term consequences of neonatal circumcision. In Sexual Mutilations: Medical, cultural, psychological, legal and sexual aspects of genital mutilation explored. Eds: Denniston GC & Milos MF. New York: Kluwer Academic/Plenum Publishers. 1997;125-129.
  40. Hepper PG, Fetal memory: Does it exist? What does it do? Acta Pædiatr. (Stockholm) 1996;Suppl.416:16-20.
  41. Hermann C, Hohmeister J, Demirakca S, Zohsel K, Flor. Longterm alteration of pain sensitivity in school-aged children with early pain experiences. Pain. 2006;125:278–285.
  42. Herschel M, Khoshnood B, Ellman C, Maydew N, Mittendorf. Neonatal circumcision. Randomized trial of a sucrose pacifier for pain control. Arch Pediatr Adolesc Med. 1998;152:279-284.
  43. Holman JR, Stuessi K. Adult Circumcision. American Family Physician. 1999;67(6):1514-1520.
  44. Howard C, Howard F, Garfunkel L, de B, Weitzman. Neonatal circumcision and pain relief: Current training practices. Pediatrics. 1998;101:423-8.
  45. Howard CR, Howard FM, and Weitzman. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics. 1994;93(4):641-6.
  46. Howard CR, Howard FM, Fortune K, Generalli P, Zolnoun D, ten Hoopen C, de Blieck. A randomized, controlled trial of a eutectic mixture of local anesthetic cream (lidocaine and prilocaine) versus penile nerve block for pain relief during circircumcision. Am J Obstet Gynecol. 1999;181:1506-1511.
  47. Irwin MG, Cheng. Comparison of subcutaneous ring block of the penis with caudal epidural block for post-circumcision analgesia in children. Anaesth Intensive Care. 1996;24(3):365-7.
  48. Jacobson B, Bygdeman, M. Obstetric care and proneness of offspring to suicide as adults: Case-control study. BMJ. 1998;317:1346-1349.
  49. Jeannine Parvati. Ending circumcision: Where sex and violence first meet. Primal Renaissance: The Journal of Primal Psychology. 1996;2(1):54-58.
  50. Jepsen EKK, Langeland W, Sexton H, Heir. Inpatient treatment for early sexually abused adults: A naturalistic 12-month follow-up study. Psychological Trauma: Theory, Research, Practice, and Policy. 2014;6(2):142-151.
  51. Kass FC, Holman. Oral glucose solution for analgesia in infant circumcision. J Fam Pract. 2001;50(9):785-8.
  52. Kaufman GE, Cimo S, Miller LW, Blass. An evaluation of the effects of sucrose on neonatal pain with 2 commonly used circumcision methods. Am J Obstet Gynecol. 2002;186:564-568.
  53. Kim S, Pang M. The effect of male circumcision on sexuality. BJU Int. 2006; 99(3):619–22.
  54. Kirya C, Werthmann M. Neonatal circumcision and penile dorsal nerve block: a painless procedure. J Pediatr. 1978;92:998-1000.
  55. Kizilhan. Impact of psychological disorders after female genital mutilation among Kurdish girls in Northern Iraq. Eur J Psychiat. 2011;25(2):92–100.
  56. Krugman. Male development and the transformation of shame. In A new psychology of men. Eds: Levant RF & Pollack WS. New York: Basic Books,1995:91•126.
  57. Kurtis PS, DeSilva HN, Bernstein BA, Malakh L, Schechter. A comparison of the Mogen and Gomco clamps in combination with dorsal penile nerve block in minimizing the pain of neonatal circumcision. Pediatrics. 1999;103;e23.
  58. Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA. 1997;278:2158-62.
  59. LaPrairie JL, Murphy. Neonatal injury alters adult pain sensitivity by increasing opioid tone in the periaqueductal gray. Front Behav Neurosci. 2009;3(31):1–11.
  60. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA. 1997;277:1052-7.
  61. Leahy T, Pretty Grace, Tenenbaum Childhood sexual abuse narratives in clinically and nonclinically distressed adult survivors. Professional Psychology: Research and Practice. 2003;34(6):657-665.
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  64. Mancuso T, Burns J. Ethical concerns in the management of pain in the neonate. Paediatr Anaesth. 2009;19:953-957.
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  66. McNally RJ, Perlman CA, Ristuccia CS, Clancy Clinical characteristics of adults reporting repressed, recovered, or continuous memories of childhood sexual abuse. Journal of Consulting and Clinical Psychology. 2006;74(2):237-242.
  67. Meislahn HS, Taylor The importance of the foreskin to male sexual reflexes. In Flesh and Blood: Perspectives on the problem of circumcision in contemporary society. Eds: Denniston GC, Hodges FM & Milos MF. New York: Kluwer Academic/Plenum Publishers. 2004;27-44.
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  69. Mordeniz C, Verit A. Is circumcision a modified ritual of castration? Urol Int. 2009;82(4):399-403. Epub 2009 Jun
  70. O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int. 1999;83 (Suppl.1):79-84.
  71. Odent Neonatal circumcision from a primal health research perspective. In Male and Female Circumcision, Medical, Legal and Ethical Considerations in Pediatric Practice. Eds: Denniston GC, Hodges FM & Milos MFs. New York: Kluwer Academic/Plenum Publishers. 1999;275-278.
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  74. Payne K, Thaler L, Kukkonen T, Carrier S, & Binik Sensation and sexual arousal in circumcised and uncircumcised men. J Sex Med. 2007;4:667–674.
  75. Porter FL, Wolf CM, Miller JP. Procedural pain in newborn infants: The influence of intensity and development. Pediatrics. 1999; 104:
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  77. Rai BP, Qureshi A, Kadi N, Donat How painful is adult circumcision? A prospective, observational cohort study. J Urol. 2013;189(6):2237-42.
  78. Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis Journal. 1999;29(3):215-221.
  79. Richards MPM, Bernal JF, Brackbill Y. Early behavioral differences: gender or circumcision? Dev Psychobiol. 1976;9(1):89–95.
  80. Richters J, Smith AMA, de Visser RO, et Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS. 2006;17:547-54.
  81. Sahin F, Beyazova U, Aktürk Attitudes and practices regarding circumcision in Turkey. Child Care Health Dev. 2003 Jul;29(4):275-80.
  82. Schiavenato M, Butler-O’Hara M, Scovanner Exploring the association between pain intensity and facial display in term newborns. Pain Res Manag. 2011;16(1):10–2.
  83. Schlossberger N, Turne R, Irwin Early adolescent knowledge and attitudes about circumcision: methods and implications for research. J Adolesc Health. 1992;13(4):293-297.
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  86. South MM, Strauss RA, South AP, Boggess JF, Thorp The use of non-nutritive sucking to decrease the physiologic pain response during neonatal circumcision: a randomized controlled trial. Am J Obstet Gynecol. 2005;193:537-542.
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  93. Taddio A, Pollock N, Gilbert-Macleod C, Ohlsson K, Koren Combined analgesia and local anesthesia to minimize pain during circumcision. Arch Pediatr Adolesc Med. 2000;154:620-623.
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References

i Cansever G. Psychological effects of circumcision. Br J Med Psychol. 1965;38: 321-331.

ii Jacobson B, Bygdeman, M. Obstetric care and proneness of offspring to suicide as adults: Case-control study. BMJ 1998;317:1346-1349.

iii Bollinger D, Van Howe, RS. Alexithymia and circumcision trauma: A preliminary investigation. Int J Men’s Health. 2011;10(2):184-95.

iv Nunberg H. Circumcision and the problems of bisexuality. Int J PsychoAnal. 1947;145-179.

v Bensley AG. Boyle GJ. Physical, sexual and psychological effects of male infant circumcision: an exploratory survey. In Understanding circumcision: a multidisciplinary approach to a multidimensional problem. Eds: Denniston GC, Hodges FM & Milos MF. New York: Kluwer Academic/Pluwer Publishing. 2000;207-231.

vi Dekkers W, Hoffer C. Wils JP. Scientific contribution, bodily integrity and male and female circumcision. Med Health Care Philos. 2005;8(2):179-191.

vii Maguire P. Parkes CM. Coping with loss: Surgery and loss of body parts. BMJ. 316: 1086-1088.

viii Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis Journal. 1998;29(3): 215-221.

ix Ozturk O. Ritual circumcision and castration anxiety. Psychiatry. 1973;36(1): 49–59.

x Sahin F, Beyazova U. Akturk A. Attitudes and practices regarding circumcision in Turkey. Child Care Health Dev. 2003;29(4): 275-280.

xi Kirimli Y. Yetişkinliğe ilk adım: Sünnet. İğdiş, Sünnet, Bedene Şiddet Kitabı. Eds: Naskali-Gursoy E, Koc A. 2009; 151-163.

xii Yavuz M, Demir T, Dogangun B. The effect of circumcision on the mental health of children: A review. Turkish Journal of Psychiatry, 2012; 23(1): 63-70.

xiii Streimer WG. Genital self-mutilation: attempted foreskin reconstruction. Br J Psychiatry. 1991;56: 125-7.

xiv Sudarshan CY, Nagaraja Rao K, Santosh SV. (2006). Genital self-mutilation in erectile disorder. Indian J Psychiatry. 48(1): 64–65.

xv Available online at: http://clinicaltrials.gov/ct2/show/NCT01726036