Advances in Sexual Medicine
Vol.05 No.02(2015), Article ID:55727,16 pages
10.4236/asm.2015.52004
Circumcision of Infants and Children: Short-Term Trauma and Long-Term Psychosexual Harm
Gregory J. Boyle
Australian Institute of Psychology, Fortitude Valley, Queensland, Australia
Email: greg@aipc.net.au
Copyright © 2015 by author and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/
Received 4 March 2015; accepted 12 April 2015; published 16 April 2015
ABSTRACT
Non-therapeutic infant male circumcision is a permanent surgical alteration to the penis that may cause significant physical, sexual and psychological harm. Physical harms include unintended adverse effects of the surgery itself (e.g., complications such as bleeding, infection, excessive re- moval of foreskin leaving insufficient shaft skin to accommodate erections, etc.), as well as the inherent loss of healthy, functional tissue. Sexual harms that necessarily follow from circumcision include the loss of all sensation in the foreskin itself, and the loss of all sexual functions that involve the physical manipulation of the foreskin. Additional sexual harms that may follow cir- cumcision include reduced sexual sensation in the remaining penile structures, difficulty with masturbation, increased chafing in both the circumcised man and his sexual partner, as well as reduced overall psychosexual/psychological tension relief and subjective satisfaction. Psycho- logical harms include short-term trauma as well as the potential for long-term emotional distur- bances, including sadness, frustration, distress, and anger―akin to post-traumatic stress disorder (PTSD). In this paper, the extent and severity of these various harms are considered and it is argued that they are more serious and more widespread than is commonly believed.
Keywords:
Circumcision, Sexual Reduction Surgery, Circumcision-Related Deaths, Male Genital Mutilation
1. Introduction
Non-therapeutic infant male circumcision is “the most commonly performed surgery in the United States” [1] . It is most often performed for cultural or religious reasons, although it is also frequently performed in hospital settings as a routine procedure, at least in the United States (in contrast to other developed nations) [2] , where it was adopted by the medical establishment in the late 1800s as a “cure” for masturbation, along with other perceived physical and/or spiritual ailments [3] [4] . In recent decades, the circumcision of infants and other young boys in the absence of disease or deformity has increasingly been recognized as being in conflict with well-establish- ed principles of medical ethics [5] -[7] and even human rights [8] -[10] . As Dekkers et al. (p. 180) [11] noted, both male and female circumcision constitute “an invasive intervention in the external genital organs” without valid medical indication.
According to Peterson (2001, p. 285), “no person has the right to surgically inflict their religious, sexual, or cosmetic preferences on another person… Parents have a duty to protect their children from harmful practices, and no tradition should be enforced by the permanent alteration or disfigurement of the body of an individual who is legally incapable of providing informed consent.” [12]
Indeed, as several authors have argued, such an extreme interference with a child’s genitals would ordinarily be viewed as a form of child sexual abuse―Bigelow (1995, p. 97) [13] -[15] . The irreversible cutting and removal of part of a child’s sexual organ is a very serious interference [16] .
2. Physical Complications and Harms
Remarkably, there has been little serious research into the anatomy, physiology, and functions of the penile foreskin―however, see [17] -[19] . As a consequence, the harmful effects of its removal, especially in comparison with female forms of circumcision (or “genital mutilation”), are incompletely known [20] [21] . Instead, re- searchers in circumcising cultures have focused almost entirely on the claimed “health benefits” of circumcision, and on new kinds of circumcision methods. Yet as Alice Dreger, a professor of Clinical Medical Humanities and Bioethics at the Feinberg School of Medicine has noted, “No one seriously thinks [that ‘health benefits’ are] the reason to circumcise infants. This is… latched on to by [those] who are looking for a reason to justify a pre-existing desire to circumcise… baby boys. [The American jurist] Oliver Wendell Holmes pointed out that judges tend to know how they want to rule, and then they go on to figure out how to justify the ruling. Routine neonatal male circumcision seems to be a lot like that. People want to do it, and they fish around for a good reason.” [22]
Nevertheless, several risks and harms of circumcision have been identified, notwithstanding the (relative) lack of research into the question [23] . For example, a recent study in the Canadian Urological Association Journal found (p. 260) that, “Most physicians performing neonatal circumcisions in our community have received informal and unstructured training, [leading to] unsatisfactory results [being] witnessed in our pediatric urology practice. Many practitioners are not aware of the contraindications to neonatal circumcision and most non- surgeons perform the procedure without being able to handle common post-surgical complications.” [24]
Grimes (p. 126) made a similar observation as far back as 1978: “Surgical mishaps continue to occur… A partial inventory of operative accidents and their sequalae includes denuding of the penis shaft; incomplete circumcision with residual deformity; lacerated scrotum; subglanular fistula; bivalved, grooved or amputated glans; concealed penis; and cautery burns.” [25]
Aside from accidental amputation of the glans during neonatal circumcision [26] [27] , included among the wide range of additional complications and harms that have been described in the literature, are bleeding and hemorrhage [28] , skin bridges and adhesions [29] [30] , meatal stenosis (in up to 20% of cases) [31] [32] , keloid formation [33] , painful neuromas [17] , toxicity to anesthetic [34] [35] , botched circumcisions [36] , urethral fistulas [37] , bacterial infections [38] , methicillin-resistant Staphylococcal aureus [39] , STIs [40] , HIV infection [41] , reduced penis size and/or buried penis [42] , post-circumcision penile cancer [43] , ischemia of the glans penis [44] , denudation of the penile shaft [45] , erectile dysfunction and impotence [46] , gastric rupture due to lack of anesthesia [47] , ruptured bladder [48] , tachycardia and heart failure [49] , acute venous stasis and swelling of the abdomen [50] , loss of the whole penis [51] (e.g., tragic David Reimer case),1,2 and even death [54] - [57] . Moreover, as Svoboda and Van Howe (p. 2) recently stated, “circumcision adversely affects the developing infant brain by causing trauma-grade increases in heart rate, blood pressure and stress hormone levels. Some infants do not cry because they go into shock. Mother-infant bonding and feeding is disrupted, as are infant sleep patterns. Circumcised infants become more irritable and less consolable than their intact peers.” [23]
While the risk of the most severe harms is often described as “low”, some scholars and ethicists have argued that our tolerance for risk should be close to zero, since the surgery under consideration would be performed on a healthy child without his consent [58] [59] . Needless to say, all such risk is entirely avoidable if the child is not subjected to medically unnecessary surgery in the first place.
In the case of circumcisions performed on post-pubescent males, as is common in South Africa and elsewhere [60] , tethered erections with insufficient shaft skin remaining to accommodate the full tumescence of the penis (sometimes resulting in painful intercourse with chafing) may also contribute to sexual function difficulties [61] ―also see [62] [63] .
As Williams and Kapila (1993, p. 1231) stated, “The literature abounds with reports of morbidity and even death as a result of circumcision.” [57]
Tragically, as noted above, avoidable deaths do occur following neonatal circumcision. For example, a recent death was reported in 2012 by Robbins [64] .3 According to Bollinger (2010, pp. 87-88), “thousands of boys have died since this practice was first medicalized 160 years ago. These boys died because physicians have been either complicit or duplicitous, and because parents ignorantly said ‘Yes’, or lacked the courage to say ‘No’. Every one of these boys would have had a chance at life had he not been circumcised.” [54]
3. Psychological Considerations
What about psychological considerations? In some circumcised men, lifelong psychological maladjustment may be apparent [65] . Indeed, the trauma resulting from painful circumcision may itself contribute to long-lasting psychological vulnerability in some susceptible individuals [66] -[70] . Perry’s work also demonstrates the vul- nerability of the infant brain to trauma and the potentially long-term adverse effects that may follow [65] [71] . Hammack et al. (p. 565) [72] reported that, “Exposure to traumatic events can increase the risk for major depressive disorder (MDD) as well as post-traumatic stress disorder (PTSD)…” Menage [73] as well as Behrendt and Moritz [74] reported PTSD among women who had undergone genital cutting (female circumcision). Likewise, the trauma associated with the male circumcision experience, particularly when carried out without anesthesia [75] is likely to imprint itself onto the child’s still-developing central nervous system (CNS) [76] . PTSD is a possible complication resulting from unanesthetized circumcision―Rhinehart [77] , as is heightened pain sensitivity at least during the several months following circumcision, which Taddio et al. (p. 602) [78] described as “an infant analogue” of PTSD. In addition, Hermann et al. (p. 278) reported that, “neonatal pain experiences in- duce long-term alterations in pain sensitivity [79] ”―also see [80] [81] .
Gaensbauer (1995, p. 122) reported that trauma experienced by preverbal infants resulted in “symptomatology consistent with typical post-traumatic diagnostic criteria… The [adverse] developmental implications of early trauma, particularly if it is severe, appear to be significant.” [82] Neonates exposed to preverbal trauma (e.g., unanesthetized circumcision) may subsequently benefit from psychotherapeutic counseling [83] [84] .
According to Geisheker (2013, p. 24), “Only 14% of US neonates enduring circumcision received any anesthesia… [often] a topical ointment, ineffective… and contraindicated for neonates or when applied to mucosal tissue.” [85]
According to Taddio et al. (p. 599), “Circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants…” [78]
Unfortunately, as Cold and Taylor (1999, p. 37) reported, “local anesthetic cream (EMLA) does not relieve the pain associated with circumcision because of the complexity of penile innervation and the multiple layers that would have to be penetrated by the topical cream in the newborn penis” [17] ―also see [75] [86] .
Research into the effects of circumcision on subsequent pain sensitivity is urgently needed given the potential adverse consequences both for the child’s psychological wellbeing (e.g., the development of a sense of basic trust versus basic mistrust, the key psychosocial task during infancy―see Erik Erikson [87] ) and the psychosex- ual wellbeing of the man he will later become [85] .
As Denniston (2013, p. 63) pointed out, “Circumcision is a [wounding] that happens before a baby is capable of understanding the profound pain and [one] that is forced upon him without his consent in the [most] vulnerable first days of life. Circumcision interferes with the maternal/infant bond, disrupts breastfeeding and normal sleep patterns, and undermines a male’s first developmental task of establishing trust… Every sexual experience a male has after circumcision is [based] on a neuronal background of pain, even if the male does not [consciously] remember or recognize it... Hyper-reactivity, defensiveness, or the inability to cope when faced with threatening or frightening situations are evidence of early trauma caused by neonatal circumcision.” [88]
Grimes ([25], p. 127) has offered a similar perspective: “The application of crushing clamps and excision of penile tissue... probably do little to engender a trusting, congenial, relationship with the infant’s new surroundings.” (cf. Leboyer, [89] , Birth Without Violence).
Both Talbert et al. [90] , and Gunnar et al. [91] reported that serum cortisol levels (indicative of stressful phy- siological arousal) increased sharply immediately following infant circumcision and remained elevated for several days―see also [25] . Williamson and Evans [92] compared the adrenal cortical response in infants circum- cised with local dorsal penile block and those circumcised without anesthesia, and reported (p. 412) that, “The adrenal cortisol response to surgery was not significantly reduced by the administration of lidocaine.”
There is also evidence that infant or childhood traumatic events (which would include traumatic circumcision) may be associated with subsequent psychotic breakdown [93] -[97] . Since the worldwide incidence of circum- cision is considerably higher among males than females, and if circumcision is a causal factor in susceptible in- dividuals, a greater proportion of males would be expected to suffer a subsequent schizophrenic episode. Indeed, based on a systematic review of the worldwide incidence of schizophrenia, McGrath [98] reported (p. 4) that, “Males have a significantly higher incidence of schizophrenia compared with females (median male to female risk ratio = 1.4)”, supporting the possibility that traumatic circumcision may be a causal factor in subsequent psychotic breakdown.4
Because of the lack of myelination of nerve fibers and the lack of descending inhibitory tracts in the spinal cord [99] -[101] , the infant nervous system is particularly vulnerable to painful trauma such as unanesthetized infant circumcision [102] -[104] . Although the prefrontal cortex is immature in infants, functional differences associated with positive and negative environmental conditions are observed from the very outset [105] . Thus, infant circumcision may cause adverse changes to brain structure and function in the prefrontal cortex that impact adversely on a child’s subsequent personality development. Likewise, the neurons in the brain’s sexual pleasure center, denied sensory input from the free nerve endings and sensory receptors in the amputated fore- skin during the critical developmental period, may atrophy and die or be reassigned to other functions. Based on Hubel and Wiesel’s experiments at Harvard University into the deprivation of sensory input to the visual cortex of kittens during the critical developmental phase, similarly, neonatal circumcision might lead to an irreversible loss of perception of sexual sensation from the foreskin that would normally be received in the brain’s sensory- receptive area [106] -[107] . Thus, even if sensory input from the amputated foreskin could somehow be restored later on (which it can’t), the brain’s sensory-receptive area could not perceive such sensation due to likely neuronal degeneration and death (and/or reassignment to other tasks).
Psychological research [108] demonstrates that there are wide individual differences in personality structure, constitution and the ability to cope with stress. Thus, a significant proportion of adult males who have a more susceptible personality make-up (i.e., those who are constitutionally predisposed towards higher negative mood states such as anxiety, stress, and depression) may suffer various degrees of debilitating PTSD due to ongoing unresolvable sexual frustration related to their circumcisions. This could lead to chronic elevations in negative moods and circumcision-induced learned helplessness―see Seligman’s work [109] .
According to Stoynov (2014), “The removal of the foreskin causes deficiency of sexual sensation, incomplete sensual gratification during acts and emotional and sexual frustration. No matter what the circumcised do they are unable to achieve direct, complete and adequate natural satisfaction because they lack the receptors for it. The completion of gratification that they perceive is brain-generated. The sensorial deficit induces a psychological transformation or the circumcision complex that simulates the accomplishment of sexual gratification… The nervous tension that inadequate fulfilment accumulates in the psyche is inflammable… The circumcision complex makes up for an erotic insufficiency. Its compensations substitute and mask the lost pleasure.” [110]
Circumcision causes irreversible physical, sexual, and neurological damage [19] [111] [112] , heightened pain sensitivity at six months post-circumcision [78] , and possible future psychosexual dysfunction [77] [113] [114] . Indeed, not only is the sexual satisfaction of the circumcised man likely to be adversely affected by the removal of his erotogenic foreskin, the sexual satisfaction of his female partner may be constrained also [115] -[117] .
As Bensley and Boyle (2003, p. 595) pointed out, “While vaginal dryness is considered an indicator for female sexual arousal disorder, male circumcision may exacerbate female vaginal dryness during intercourse. O’Hara and O’Hara reported that women who had experienced coitus with both intact and circumcised men preferred intact partners by a ratio of 8.6 to one. Most women (85.5%) in that survey reported that they were more likely to experience orgasm with a genitally intact partner… Presence of the movable foreskin makes a difference in foreplay, being more arousing to the female. Women reported they were about twice as likely to experience orgasm if the male partner had a foreskin.” [115]
Why might women with genitally intact partners prefer their sexual experiences? As Johmann (2003) has sug gested, using colloquial language to make the point: “The basic problem for the average [circumcised] Ameri- can man is that his penis has been so desensitized… that normal sexual intercourse with a female does not provide enough stimulation―hence the…man must work at it, banging away, trying to feel something.” [118]
4. Lifelong Harm and Sexual Disability
The foreskin is highly innervated erogenous tissue [17] [19] [111] [112] , which following its removal, can no longer provide sensory input to the brain and/or to the autonomic nervous system [116] . The foreskin also provides cumulative erotogenic sensations via its gliding mechanism to stimulate the glans, and vice versa [120] . Any sexual activity involving the physical manipulation of the foreskin is necessarily lost to circumcision [60] [121] . To claim then, as Morris and Krieger (2013, p. 2644) have, that “male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction” [122] defies logic and lacks common sense. Indeed, such a claim rests upon artificially narrow definitions of each of those terms [123] and contradicts the biological synergy of structure and function.5 In an online survey (N = 1369), Bronselaer et al. (2013, p. 820) reported that, “For the glans penis, circumcised men reported decreased sexual pleasure and lower orgasm intensity [compared to intact men]. They also stated more effort was required to achieve orgasm, and a higher percentage of them experienced unusual sensations (burning, prickling, itching, or tingling and numbness of the glans penis). For the penile shaft a higher percentage of circumcised men described discomfort and pain, numbness and unusual sensations.” [125]
Bronselaer et al. (p. 820) concluded that, “This study confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning. Furthermore, this study shows that a higher percentage of circumcised men experience discomfort or pain and unusual sensations as compared with the uncircumcised population. Before circumcision without medical indication, adult men, and parents considering circumcision of their sons, should be informed of the importance of the foreskin in male sexuality.”6
In an empirical study (N = 163) of fine-touch penile pressure thresholds in circumcised versus genitally intact men, Sorrells et al. (2007, p. 865) reported that, “The fine-touch sensitivity of 19 locations on the penis was measured using Semmes-Weinstein monofilament touch-test sensory evaluators∙∙∙to create a penile sensitivity map.” [126]
Sorrells et al. (p. 869) found that, “circumcision removes the most sensitive parts of the penis and decreases the fine-touch pressure sensitivity of the glans penis. The most sensitive regions in the uncircumcised penis are those parts ablated by circumcision. When compared to the most sensitive area of the circumcised penis, several locations on the uncircumcised penis (the rim of the preputial orifice, dorsal and ventral, the frenulum near the ridged band, and the frenulum at the muco-cutaneous junction) that are missing from the circumcised penis were significantly more sensitive.”7 [126]
Other empirical evidence reveals severe sensory neurological damage from male circumcision. For example, Podnar [131] compared elicitation of the penilo-cavernosus reflex among circumcised and genitally intact men. He reported (2011, p. 582) that, “It is known that foreskin, but not glans penis, contains a high density of fine-touch mechanoreceptors. Clinically the penilo-cavernosus reflex provides information on function of the sacral nerves. The study demonstrated that in the majority of circumicised men this reflex cannot be elicited clinically…” [131]
Podnar [131] found that while the penilo-cavernosus reflex was elicited clinically in 92% of genitally intact men, it could only be elicited clinically in 27% of circumcised men, providing strong evidence of a statistically significant (p < 0.001) diminution in sexual response in circumcised versus genitally intact men. Podnar (p. 584) further commented that, “the penilo-cavernosus reflex is assumed to have the physiological function of... being part of the ejaculation process… [and may account for the] difference in sexual function between these two populations of men”. [131]
Psychosexual difficulties including premature ejaculation (PE) among young men [132] , and lack of sexual sensitivity, delayed ejaculation, and erectile dysfunction among older men [113] [134] [135] , as well as long- lasting PTSD in some cases appear to be pervasive in circumcising cultures [135] -[138] .
Dias et al. (2014, p. 122) reported that following adult circumcision, “there was an increase in frequency of erectile dysfunction (9.7% versus 25.8%, p = 0.002) and delayed orgasm (11.3% versus 48.4%, p < 0.001).”
Also, Kim and Pang (2006, p. 619) have reported (N = 373) that, “There was a decrease in sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings.” [140]
While acknowledging many factors are involved in the etiology of erectile dysfunction (ED) which impacts adversely on the psychosocial health and quality of life (QoL) of sufferers and their sexual partners, it is unlikely to be a coincidence that in circumcising cultures such as the USA, 52% of middle-aged men suffer from varying degrees of erectile dysfunction, whereas in non-circumcising cultures such as Germany, the prevalence is only 19% (see Wespes et al., 2012, p. 4) [141] .
Moreover, in a study (N = 300) of alexithymia (a personality trait disorder associated with difficulty in emo- tional identification and expression)―measured via the 20-item Toronto Alexithymia Scale―in circumcised versus genitally intact males [142] , Bollinger and Van Howe (2011, p. 184) reported that circumcised men were, “4.53 times more likely to use an erectile dysfunction drug” than genitally intact men [143] . In addition, Wespes et al. [141] reported (p. 32) that the highest prevalence of PE was found in the USA (31%) where circumcision is common, whereas in France (a non-circumcising culture), the lifetime prevalence was only 15%, suggesting that circumcision itself is a causal determinant of premature ejaculation. As Boyle (2012) commented, “Is it not more likely that it is precisely the lack of neurological control over the timing of ejaculation resulting from the severed neuronal circuitry after circumcision that is a major causal factor in PE?” [132]
Indeed, Bollinger and Van Howe [143] found that young circumcised men were 2.56 times more likely than genitally intact men, to suffer from premature ejaculation―see also [144] . At least 10 studies have been published comparing PE prevalence in genitally intact versus circumcised men [117] [139] [144] -[151] . A meta- analysis based on all 10 studies (Van Howe [152] -Personal communication, 5 July, 2014) found a strong trend that circumcised men were more likely to suffer from premature ejaculation (OR = 1.15; 0.93 to 1.41). In addition, Michetti et al. [153] reported increased alexithymia among men with ED problems.8
5. Post-Traumatic Stress Disorder (PTSD)
According to Boyle et al. (2002, p. 332), “A traumatic experience is defined in DSM-IV as the direct consequence of experiencing or witnessing of serious injury or threat to physical integrity that produces intense fear, helplessness or (in the case of children) agitation (American Psychiatric Association, 1994). The significant pain and distress described earlier is consistent with this definition. Moreover, the disturbance (e.g., physiological arousal, avoidant behavior) qualifies for a diagnosis of acute stress disorder if it lasts at least two days or even a diagnosis of post-traumatic stress disorder (PTSD) if it lasts more than a month. Circumcision without anesthesia constitutes a severely traumatic event in a child’s life.” [135]
In the recently updated DSM-5, the very first criterion listed for a diagnosis of either Acute Stress Disorder (duration less than one month) or longer-lasting PTSD is “Exposure to actual or threatened death, serious injury, or sexual violence...” [155] There are two distinct periods of possible psychological trauma that in some cases may result in prolonged PTSD: the first is in response to the physical trauma of the actual genital cutting itself; and the second during adolescence or adulthood, in response to the cognitive realization on the part of the individual that he has been exposed to a permanent, irreversible alteration in sexual sensation/performance as a result of his non-consented circumcision.
Newly circumcised boys may suffer sleep disturbances with periods of abnormally prolonged NREM sleep, increased wakefulness and inability to sleep, difficulties in feeding, and interference with the mother-infant bonding [20] . Also, in a large scale study (N = 3253) in the Philippines, Ramos and Boyle [156] found that almost 70% of boys subjected to ritual circumcision (“Tuli”) and 51% of boys subjected to medical circumcision satisfied the DSM-IV criteria for a diagnosis of PTSD, as measured via the Watson et al. PTSD-I scale [157] .
According to Menage [158] , circumcised men who have become aware that their sexual dysfunction may be at least partially a consequence of having been circumcised during infancy or childhood, have reported feelings of helplessness, abuse, frustration, and of being violated. Moreover, as Bensley and Boyle (2001, p. 215) re- ported, “Psychological consequences as a result of…surgery are well recognized in the medical literature (McGuire & Parkes [159] ). Potential effects of loss of body parts are: 1. Grief for altered body image or function, or both. 2. Anxiety, depression, and sexual problems. 3. Avoidance of or obsessive preoccupation with the loss.” [113]
While many circumcised men seem to “have no conscious issue” with being circumcised, it is possible that they have suffered a deep psychological trauma that is repressed within the unconscious psyche [20] . Indeed, many women who have undergone even extreme forms of female genital cutting/FGM report being “satisfied” with their sex lives [160] ; however, this may be due in part to the fact that they lack adequate knowledge of the relevant genital anatomy (such as the innervations and functions of the clitoris), and therefore may not know what it is that they are “missing” [121] . A similar phenomenon may occur in the case of circumcised men, who typically know very little about the anatomy and functions of the penile foreskin―for further discussion, see Earp and Darby [123] . Finally, within psychological theory, it is well known that individuals who have been subjected to irreversible harm have a tendency to “rationalize” (or even outright deny) the harm, in an attempt to reduce the discomfort associated with cognitive dissonance (see discussion below).
6. Long-Term Psychosexual Harm: The Importance of Constitutional Predisposition
In their study into alexithymia, a personality construct characterized by the sub-clinical inability to identify and describe one’s own emotions, Bollinger and Van Howe (2011, p. 184) reported that, “circumcised men had age- adjusted alexithymia scores 19.9 percent higher [than] intact men.” [143] This suggests that circumcised men are more likely than genitally intact men to exhibit dysfunction in emotional awareness, impacting adversely on their social attachments and interpersonal relationships. Evidently, circumcision sometimes may result in long- term adverse psychosexual consequences among post-pubescent males [135] [161] .
However, the importance of individual differences in pre-existing psychological profiles must be recognized: circumcision―no matter how traumatic―will not affect all men in precisely the same way. Indeed, empirical psychological research suggests that there are wide individual differences in personality structure, constitution and the ability to cope with stress [108] [162] . Accordingly, those who are constitutionally predisposed to respond to traumatic experiences with heightened negative mood states such as anxiety/neuroticism/depression [163] [164] , may experience more negative psychosexual outcomes than those who are not so constitutionally predisposed.
For example, it is possible that psychologically vulnerable individuals who come to realize that their sexual sensation, function and/or satisfaction may have been permanently diminished as a consequence of their circum- cisions (i.e., unwanted removal of erotogenic tissue) [17] may be more likely to experience elevations in nega- tive moods such as sadness, depression, anxiety, stress, frustration, anger and hostility [108] [165] . In some cases, this distress may result in unrelenting, psychological torment and PTSD throughout a man’s life [166] .
In a survey of the long-term consequences of neonatal circumcision among 313 “circumcised but unhappy” men, Hammond (1997, p. 126) reported that, “96.2% suspected or were confident that circumcision had resulted in a reduction of normal male capacity for sexual response and pleasure. The percentage breakdown of categories of circumcision-caused harm is as follows: Sexual Harm: 84%; Emotional Harm: 83.1%; Physical Harm: 81.5%; Psychological Harm: 75.1%; Low Self-Esteem: 74.4%; Problems with Intimate Relationships: 44.7%; Problems with Addictions/Dependencies: 25.6%. A remaining 13.1% of respondents variously attributed their non-intact state to their problems with masculine identity, self-confidence, and fear of doctors.” [133]
In an expanded survey (N = 546), Hammond (1999, p. 87) subsequently reported that, “Respondents reported profound shifts in how they perceived their genitals, themselves, and the society that imposed such a loss. Some revealed violent attitudes toward their circumciser and/or suicidal/homicidal feelings… Emotional distress, manifesting as intrusive thoughts about one’s circumcision, included feelings of mutilation (60%), low self-esteem/ inferiority to intact men (50%), genital dysmorphia (55%), rage (52%), resentment/depression (59%), violation (46%), or parental betrayal (30%). Many respondents (41%) reported that their physical/emotional suffering impeded emotional intimacy with partner(s), resulting in sexual dysfunction. For some, lack of compassion from parents, siblings or friends fostered bitter interpersonal conflict or alienation. Almost a third of respondents (29%) reported dependence on substances or behaviors to relieve their suffering (tobacco, alcohol, drugs, food and/or sexual compulsivity). Generally, men have no acceptable outlet for serious feelings about circumcision. Predictably, 54% of respondents had not sought help for their suffering. The reasons given included: thinking no recourse was available (43%); embarrassment (19%); fear of ridicule (17%); and mistrust of doctors (11%).” [134]
While these surveys suggest that a substantial cohort of circumcised men may be “suffering in silence” [121] , the fact that a large number of circumcised men have reported no physical or psychosexual harm suggests that some men may have no conscious awareness of problems associated with circumcision (as discussed above). Other men may have insight into their circumcision-induced losses, but may exhibit little, if any, concern about their situation, raising the possibility of alexithymia [143] , or perhaps even resilience [167] .
7. Who Promotes Infant Circumcision? The Possibility of Harm Denial
Circumcised men may ask: “Who are you to tell me that I am damaged? I am just fine and sex couldn’t be better.” However, as highlighted in Freudian psychoanalytic theory, psychically wounded individuals may often use defence mechanisms such as denial and rationalization to justify their wounding [168] [169] , as would be expected from cognitive dissonance theory [170] . Such coping strategies may help to minimize any resultant hedonically unpleasant psychological impact.
Consistent with this view, it has been argued that infant circumcision may be largely promoted by circumcised men who are unconsciously seeking to perpetuate the procedure as a compensatory mechanism for their own unresolvable psychic wounding [171] -[173] . Such men may resort to the psychological defences of denial, rationalization, and projection to justify its continuance [174] . In this regard, Bigelow [13] has discussed the “adamant father syndrome” whereby a particular subset of circumcised fathers, against all rational discussion, vehemently insist that their own newborn sons also be subjected to the sexual-reduction surgery. Moreover, in the USA context, the sheer ubiquity of circumcision suggests that any altered personality and/or behavior of circumcised males may tend to be viewed as “normal” [20] . Accordingly, circumcision practitioners may not have given much thought to the trauma and potential long-term adverse psychosexual consequences of the surgery they are paid to carry out. Instead, they may perform circumcisions as a matter of course, both because of parental/societal demand and the concomitant financial reward.
Careful research has demonstrated that circumcision status plays a major role in whether doctors are in support of circumcisions or not [171] . In a survey of 572 primary care physicians, Muller (2010, p. 227) reported that, “Although most respondents stated that they based their decisions on medical evidence, the circumcision status of, especially, the male respondents played a huge role in whether they were in support of circumcisions or not. Another factor that had an influence was the circumcision status of the respondents’ sons.” [172]
This is consistent with the view that those who have been subjected to circumcision themselves may need to “rationalize” what happened to them by appealing to supposed “health benefits” that may follow from the surgery. Also, parents who had subjected their sons to circumcision were clearly in favour of the procedure. Some circumcised men may also feel the compulsion to repeat the trauma by imposing genital cutting on others, including defenceless babies and children [175] . Disturbingly, as pointed out by Forbes (2015, p. 263), a small proportion of fervent circumcision advocates may well have a psychopathological erotic circumfetishism disorder [176] .9
8. Conclusion
As Bollinger (2014) has pointed out, “No psychological study has ever concluded that circumcision is beneficial to a boy’s psyche [whereas] more than one hundred scientific studies [have] found circumcision [to be] painful, traumatic, or psychologically harmful to men and boys.” [177]
Men who are constitutionally predisposed toward higher levels of emotionality [105] are more likely to suffer various degrees of sadness and unhappiness due to ongoing unresolvable sexual frustration and the realization of irreversible, circumcision-induced sexual deficits (in sensation, performance, and satisfaction), leading to chro- nic elevations in negative mood states. However, it should be noted that the emotional pain that some circum- cised men experience must not be equated with psychological illness. Anger, grief, and resentment are normal emotions, not illnesses, although they are negative states of mind that are aversive and which individuals typi- cally wish to avoid. Thus they can be counted among the psychological harms of circumcision in men who ex- perience them.
With the advent of the internet, men who are “circumcised but unhappy” have the opportunity to communi- cate with thousands of other men who also feel aggrieved about having been subjected to involuntary genital surgery in infancy or childhood. As awareness of the physical and psychosexual harm that may result from circumcision continues to grow, it may become increasingly difficult for US doctors to deny that the non-thera- peutic genital cutting of males is a form of harmful mutilation, as is already recognized in the case of female children [85] [178] . With this changing zeitgeist, it is likely that there will be a growing cohort of circumcised men [133] [134] who may need psychological and psychosocial support to deal with their concerns and the ongoing psychosexual difficulties with which they struggle.
References
- Van Howe, R.S. (1997) Why Does Neonatal Circumcision Persist in the United States? In: Denniston, G.C. and Milos, M.F., Eds., Sexual Mutilations: A Human Tragedy, Plenum, New York, 111-119. http://dx.doi.org/10.1007/978-1-4757-2679-4_9
- Frisch, M., Aigrain, Y., Barauskas, V., et al. (2013) Cultural Bias in the AAP’s 2012 Technical Report and Policy State- ment on Male Circumcision. Pediatrics, 131, 796-800. http://dx.doi.org/10.1542/peds.2012-2896
- Hodges, F. (1997) A Short History of the Institutionalization of Involuntary Sexual Mutilation in the United States. In: Denniston, G.C. and Milos, M.F., Eds., Sexual Mutilations: A Human Tragedy, Plenum, New York, 17-40. http://dx.doi.org/10.1007/978-1-4757-2679-4_2
- Aggleton, P. (2007) Roundtable: “Just a Snip”? A Social History of Male Circumcision. Reproductive Health Matters, 15, 15-21. http://dx.doi.org/10.1016/S0968-8080(07)29303-6
- Darby, R.J. (2013) The Child’s Right to an Open Future: Is the Principle Applicable to Non-Therapeutic Circumcision? Journal of Medical Ethics, 39, 463-468. http://dx.doi.org/10.1136/medethics-2012-101182
- Earp, B.D. (2013) The Ethics of Infant Male Circumcision. Journal of Medical Ethics, 39, 418-420. http://dx.doi.org/10.1136/medethics-2013-101517
- Ben-Yami, H. (2013) Circumcision: What Should Be Done? Journal of Medical Ethics, 39, 459-462. http://dx.doi.org/10.1136/medethics-2012-101274
- Svoboda, J.S. (2013) Circumcision of Male Infants as a Human Rights Violation. Journal of Medical Ethics, 39, 469- 474. http://dx.doi.org/10.1136/medethics-2012-101229
- DeLaet, D.L. (2009) Framing Male Circumcision as a Human Rights Issue? Contributions to the Debate over the Uni- versality of Human Rights. Journal of Human Rights, 8, 405-426. http://dx.doi.org/10.1080/14754830903324795
- Merkel, R. and Putzke, H. (2013) After Cologne: Male Circumcision and the Law. Parental Right, Religious Liberty or Criminal Assault? Journal of Medical Ethics, 39, 444-449. http://dx.doi.org/10.1136/medethics-2012-101284
- Dekkers, W., Hoffer, C. and Wils, J.P. (2005) Scientific Contribution, Bodily Integrity and Male and Female Circumcision. Medicine, Health Care and Philosophy, 8, 179-191. http://dx.doi.org/10.1007/s11019-004-3530-z
- Peterson, S.E. (2001) Assaulted and Mutilated: A Personal Account of Circumcision Trauma. In: Denniston, G.C., Hodges, F.M. and Milos, M.F., Eds., Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, Kluwer Academic/Plenum, New York, 271-289. http://dx.doi.org/10.1007/978-1-4757-3351-8_15
- Bigelow, J. (1995) Psychological Factors Related to Infant Circumcision. In: Bigelow, J., Ed., The Joy of Uncircumcising! Hourglass Book Publishing, Aptos, 89-112.
- Boyle, G.J., Svoboda, J.S., Price, C.P. and Turner, J.N. (2000) Circumcision of Healthy Boys: Criminal Assault? Jour- nal of Law and Medicine, 7, 301-310.
- Travis, J.W. (2001) Circumcision as a Component of the Normative Abuse of Children. In: Denniston, G.C., Hodges, F.M. and Milos, M.F., Eds., Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, Kluwer Academic/Plenum, New York, 367-376. http://dx.doi.org/10.1007/978-1-4757-3351-8_18
- Morgan, W.K.C. (1965) The Rape of the Phallus. Journal of the American Medical Association, 193, 223-224. http://dx.doi.org/10.1001/jama.1965.03090030045013
- Cold, C.J. and Taylor, J.R. (1999) The Prepuce. British Journal of Urology International, 83, 34-44. http://dx.doi.org/10.1046/j.1464-410x.1999.0830s1034.x
- Cold, C.J. and McGrath, K.A. (1999) Anatomy and Histology of the Penile and Clitoral Prepuce in Primates: Evolutionary Perspective of Specialized Sensory Tissue of the External Genitalia. In: Denniston, G.C., Hodges, F.M. and Milos, M.F., Eds., Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice, Kluwer Academic/Plenum, New York, 19-29. http://dx.doi.org/10.1007/978-0-585-39937-9_3
- Taylor, J.R., Lockwood, A.P. and Taylor, A.J. (1996) The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision. British Journal of Urology, 77, 291-295. http://dx.doi.org/10.1046/j.1464-410X.1996.85023.x
- Hill, G. (2012) Circumcision and Human Behavior: The Emotional and Behavioral Effects of Circumcision. http://genitalwholeness.wordpress.com/article/circumcision-and-human-behavior-2y9nanfagw8nr-13/
- Earp, B.D. (2015) Do the Benefits of Male Circumcision Outweigh the Risks? A Critique of the Proposed CDC Guidelines. Frontiers in Pediatrics, 3, 1-6. http://journal.frontiersin.org/article/10.3389/fped.2015.00018/full
- Dreger, A. (2006) Proof That I Like Penises. Bioethics Forum, 10 March. http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=132
- Svoboda, J.S. and Van Howe, R.S. (2013) Out of Step: Fatal Flaws in the Latest AAP Policy Report on Neonatal Circumcision. Journal of Medical Ethics, 39, 434-441. http://dx.doi.org/10.1136/medethics-2013-101346
- DeMaria, J., Abdulla, A., Pemberton, J., Raees, A. and Braga, L.H. (2013) Are Physicians Performing Neonatal Cir- cumcisions Well Trained? Canadian Urological Association Journal, 7, 260-264. http://dx.doi.org/10.5489/cuaj.200
- Grimes, D.A. (1978) Routine Circumcision of the Newborn Infant: A Reappraisal. American Journal of Obstetrics and Gynecology, 130, 125-129.
- Gluckman, G.R., Stoller, M.L., Jacobs, M.M. and Kogan, B.A. (1995) Pediatric Urology: Newborn Penile Glans Amputation during Circumcision and Successful Reattachment. Journal of Urology, 153, 778-779. http://dx.doi.org/10.1016/S0022-5347(01)67718-8
- Neulander, E., Walfisch, S. and Kaneti, J. (1996) Amputation of Distal Penile Glans during Neonatal Ritual Circumcision: A Rare Complication. British Journal of Urology, 77, 924-925. http://dx.doi.org/10.1046/j.1464-410X.1996.06934.x
- Hiss, J., Horowitz, A. and Kahana, T. (2000) Fatal Haemorrhage Following Male Ritual Circumcision. Journal of Clinical Forensic Medicine, 7, 32-34. http://dx.doi.org/10.1054/jcfm.1999.0340
- Ponsky, L.E., Ross, J.H., Knipper, N. and Kay, R. (2000) Penile Adhesions after Neonatal Circumcision. Journal of Urology, 164, 495-496. http://dx.doi.org/10.1016/S0022-5347(05)67410-1
- Ritchie, M.L. and Bloom, D.A. (1991) Skin Bridge―A Complication of Paediatric Circumcision. British Journal of Urology, 68, 331.
- Joudi, M., Fathi, M. and Hiradfar, M. (2011) Incidence of Asymptomatic Meatal Stenosis in Children Following Neonatal Circumcision. Journal of Pediatric Urology, 7, 526-528. http://dx.doi.org/10.1016/j.jpurol.2010.08.005
- Upadhyay, V., Hammodat, H.M. and Pease, P.W. (1998) Post Circumcision Meatal Stenosis: 12 Years’ Experience. New Zealand Medical Journal, 111, 57-58.
- Köksal, T., Kadioglu, A. and Tefekli, A. (2000) Keloid as a Complication after Circumcision. British Journal of Urology, 85, 1-2.
- Couper, R.T.L. (2000) Methaemoglobinaemia Secondary to Topical Lignocaine/Prilocaine in a Circumcised Neonate. Journal of Paediatrics and Child Health, 36, 406-407. http://dx.doi.org/10.1046/j.1440-1754.2000.00508.x
- Özbek, N., Akpek, N.E. and Ersoy, E.T. (2000) Toxic Neonatal Methaemoglobinaemia after Prilocaine Administration for Circumcision. British Journal of Urology International, 85, 1-2.
- Patel, H.I., Moriarty, K.P., Brisson, P.A. and Feirs, N.R. (2001) Genitourinary Injuries in the Newborn. Journal of Pediatric Surgery, 36, 235-239. http://dx.doi.org/10.1053/jpsu.2001.20062
- Baskin, L.S., Canning, D.A., Snyder III, H.M. and Duckett Jr., J.W. (1997) Surgical Repair of Urethral Circumcision Injuries. Journal of Urology, 158, 2269-2271. http://dx.doi.org/10.1016/S0022-5347(01)68233-8
- Braun, D. (1990) Neonatal Bacteremia and Circumcision. Pediatrics, 85, 135-136.
- Van Howe, R.S. and Robson, W.L.M (2007) The Possible Role of Circumcision in Newborn Outbreaks of Community-Associated Methicillin-Resistant Staphylococcus aureus. Clinical Pediatrics, 46, 356-358. http://dx.doi.org/10.1177/0009922806294847
- Gesundheit, B., Grisaru-Soen, G., Greenberg, D., Levtzion-Korach, O., Malkin, D., Petric, M., et al. (2004) Neonatal Genital Herpes Simplex Virus Type 1 Infection after Jewish Ritual Circumcision: Modern Medicine and Religious Tradition. Pediatrics, 114, E259-E263. http://dx.doi.org/10.1542/peds.114.2.e259
- Brewer, D.D., Potterat, J.J., Roberts Jr., J.M. and Brody, S. (2007) Male and Female Circumcision Associated with Prevalent HIV Infection in Virgins and Adolescents in Kenya, Lesotho, and Tanzania. Annals of Epidemiology, 17, 217-226. http://dx.doi.org/10.1016/j.annepidem.2006.10.010
- Kon, M. (1983) A Rare Complication Following Circumcision: The Concealed Penis. Journal of Urology, 130, 573- 574.
- Bissada, N.K., Morcos, R.R. and El-Senoussi, M. (1986) Post-Circumcision Carcinoma of the Penis. I. Clinical Aspects. Journal of Urology, 135, 283-285.
- Aslan, A., Karaguzel, G. and Melikoglu, M. (2005) Severe Ischemia of the Glans Penis Following Circumcision: A Successful Treatment via Pentoxifylline. International Journal of Urology, 12, 705-707. http://dx.doi.org/10.1111/j.1442-2042.2005.01129.x
- Sotolongo Jr., J.R., Hoffman, S. and Gribetz, M.E. (1985) Penile Denudation Injuries after Circumcision. Journal of Urology, 133, 102-103.
- Gerharz, E.W., Ransley, P.G. and Woodhouse, C.R.J. (2005) Urinary Retention, Erectile Dysfunction and Penile Ana- esthesia after Circumcision: A Mixed Dissociative (Conversion) Disorder. International Urology and Nephrology, 37, 525-527. http://dx.doi.org/10.1007/s11255-004-4769-2
- Connelly, D.O., Shropshire, L.C. and Salzberg, A. (1992) Gastric Rupture Associated with Prolonged Crying in a New- born Undergoing Circumcision. Clinical Pediatrics, 31, 560-561. http://dx.doi.org/10.1177/000992289203100910
- Jee, L.D. and Millar, A.J.W. (1990) Ruptured Bladder Following Circumcision Using Plasticbell Device. British Journal of Urology, 65, 216-217. http://dx.doi.org/10.1111/j.1464-410X.1990.tb14709.x
- Mor, A., Eshel, G., Aladjem, M. and Mundel, G. (1987) Tachycardia and Heart Failure after Ritual Circumcision. Archives of Disease in Childhood, 62, 80-81. http://dx.doi.org/10.1136/adc.62.1.80
- Ly, L. and Sankaran, K. (2003) Acute Venous Stasis and Swelling of the Abdomen after Circumcision. Canadian Me- dical Association Journal, 169, 216-217.
- Bradley, S.J., Oliver, G.D. and Chernick, A.B. (1998) Experiment of Nurture: Ablatio Penis at 2 Months, Sex Reas- signment at 7 Months, and a Psychosexual Follow-Up in Young Adulthood. Pediatrics, 102, e9. http://dx.doi.org/10.1542/peds.102.1.e9
- Colapinto, J. (2006) As Nature Made Him: The Boy Who Was Raised as a Girl. Harper/Collins, New York.
- Massie, L. (2013) Male Circumcision and the Potential for Unexplained Male Adolescent Suicide in Northern Ireland. In: Denniston, G.C., Hodges, F.M. and Milos, M.F., Eds., Genital Cutting: Protecting Children from Medical, Cultural, and Religious Infringements, Springer, Dordrecht, 101-106. http://dx.doi.org/10.1007/978-94-007-6407-1_7
- Bollinger, D. (2010) Lost Boys: An Estimate of US Circumcision-Related Infant Deaths. THYMOS: Journal of Boyhood Studies, 4, 78-90. http://dx.doi.org/10.3149/thy.0401.78
- Paediatric Death Review Committee: Office of the Chief Coroner of Ontario (2007) Circumcision: A Minor Procedure? Paediatrics and Child Health, 12, 311-312.
- Thorup, J., Thorup, S.C. and Ifaoui, I.B. (2013) Complication Rate after Circumcision in a Paediatric Surgical Setting Should Not Be Neglected. Danish Medical Journal, 60, A4681. http://www.danmedj.dk/portal/page/portal/danmedj.dk/dmj_forside/PAST_ISSUE/2013/DMJ_2013_08/A4681
- Williams, N. and Kapila, L. (1993) Complications of Circumcision. British Journal of Surgery, 80, 1231-1236. http://dx.doi.org/10.1002/bjs.1800801005
- Hutson, J.M. (2004) Circumcision: A Surgeon’s Perspective. Journal of Medical Ethics, 30, 238-240. http://dx.doi.org/10.1136/jme.2002.001313
- Ungar-Sargon, E. (2015) On the Impermissibility of Infant Male Circumcision: A Response to Mazor (2013). Journal of Medical Ethics, 41, 186-190. http://dx.doi.org/10.1136/medethics-2013-101598
- Earp, B.D. (2015) Sex and Circumcision. American Journal of Bioethics, 15, 43-45. https://www.academia.edu/9404847/Sex_and_circumcision http://dx.doi.org/10.1080/15265161.2014.991000
- Watson, L.R. (2014) Unspeakable Mutilations: Circumcised Men Speak out. Amazon Create Space Publishing. http://www.circinfo.org/Personal_stories.html
- Gonzalez, L. (2014) South Africa: Over Half a Million Initiates Maimed under the Knife. All Africa, 25 June. http://allafrica.com/stories/201406251112.html
- Maseko, N. (2013) When Circumcision Can Mean Death in South Africa. BBC News Africa, 19 July. http://www.bbc.co.uk/news/world-africa-23378694
- Robbins, E. (2012) Baby’s Death Renews Debate over a Circumcision Ritual. New York Times, 7 March. http://www.nytimes.com/2012/03/08/nyregion/infants-death-renews-debate-over-a-circumcision-ritual.html?_r=0
- Gaskill, R.L. and Perry, B.D. (2012) Child Sexual Abuse, Traumatic Experiences and Their Effect on the Developing Brain. In: Goodyear-Brown, P., Ed., Handbook of Child Sexual Abuse: Identification, Assessment and Treatment, Wiley, New York, 29-49.
- Beggs, S., Currie, G., Salter, M.W., Fitzgerald, M. and Walker, S.M. (2003) Priming of Adult Pain Responses by Neo- natal Pain Experience: Maintenance by Central Neuroimmune Activity. Brain, 135, 404-417. http://dx.doi.org/10.1093/brain/awr288
- Cansever, G. (1965) Psychological Effects of Circumcision. British Journal of Medical Psychology, 38, 321-331. http://dx.doi.org/10.1111/j.2044-8341.1965.tb01314.x
- Chamberlain, D.B. (1989) Babies Remember Pain. Pre- and Perinatal Psychology Journal, 3, 297-310.
- Chamberlain, D.B. (1995) Birth and the Origins of Violence. Pre- and Perinatal Psychology Journal, 10, 57-74.
- Paley, J. and Alpert, J. (2003) Memory of Infant Trauma. Psychoanalytic Psychology, 20, 329-347. http://dx.doi.org/10.1037/0736-9735.20.2.329
- Anda, R.F., Felitti, V.J., Bremner, J.D., Walker, J.D., Whitfield, Ch., Perry, B.D., et al. (2006) The Enduring Effects of Childhood Abuse and Related Experiences: A Convergence of Evidence from Neurobiology and Epidemiology. European Archives of Psychiatry and Clinical Neurosciences, 256, 174-186. http://dx.doi.org/10.1007/s00406-005-0624-4
- Hammack, S.E., Cooper, M.A. and Lezak, K.R. (2012) Overlapping Neurobiology of Learned Helplessness and Conditioned Defeat: Implications for PTSD and Mood Disorders. Neuropharmacology, 62, 565-575. http://dx.doi.org/10.1016/j.neuropharm.2011.02.024
- Menage, J. (1993) Post-Traumatic Stress Disorder in Women Who Have Undergone Obstetric and/or Gynaecological Procedures. Journal of Reproductive and Infant Psychology, 11, 221-228. http://dx.doi.org/10.1080/02646839308403222
- Behrendt, A. and Moritz, S. (2005) Posttraumatic Stress Disorder and Memory Problems after Female Genital Mutilation. American Journal of Psychiatry, 162, 1000-1002. http://dx.doi.org/10.1176/appi.ajp.162.5.1000
- Paix, B.R. and Peterson, S.E. (2012) Circumcision of Neonates and Children without Appropriate Anaesthesia Is Unacceptable Practice. Anaesthesia and Intensive Care, 40, 511-516.
- Anand, K.J. and Scalzo, F. (2000) Can Adverse Neonatal Experiences Alter Brain Development and Subsequent Behavior? Biology of the Neonate, 77, 69-82. http://dx.doi.org/10.1159/000014197
- Rhinehart, J. (1999) Neonatal Circumcision Reconsidered. Transactional Analysis Journal, 29, 215-221.
- Taddio, A., Katz, J., Ilersich, A.L. and Koren, G. (1997) Effect of Neonatal Circumcision on Pain Response during Subsequent Routine Vaccination. The Lancet, 349, 599-603. http://dx.doi.org/10.1016/S0140-6736(96)10316-0 http://www.thelancet.com/pdfs/journals/lancet/PIIS0140673696103160.pdf
- Hermann, C., Hohmeister, J., Demiracka, S., Zohsel, K. and Flor, H. (2006) Long-Term Alteration of Pain Sensitivity in School-Aged Children with Early Pain Experiences. Pain, 125, 278-285. http://dx.doi.org/10.1016/j.pain.2006.08.026
- Grunau, R.E. (2013) Neonatal Pain in Very Preterm Infants: Long-Term Effects on Brain, Neurodevelopment and Pain Reactivity. Rambam Maimonides Medical Journal, 4, e0025.
- Page, G.G. (2004) Are There Long-Term Consequences of Pain in Newborn or Very Young Infants? Journal of Perinatal Education, 13, 10-17. http://dx.doi.org/10.1624/105812404X1725
- Gaensbauer, T.J. (1995) Trauma in the Preverbal Period. Symptoms, Memories, and Developmental Impact. Psychoanalytic Study of the Child, 50, 122-149.
- Green, E.J., Crenshaw, D.A. and Kolos, A.C. (2010) Counseling Children with Preverbal Trauma. International Journal of Play Therapy, 19, 95-105. http://dx.doi.org/10.1037/a0017667
- Jepsen, E.K.K., Langeland, W. and Heir, T. (2013) Impact of Dissociation and Interpersonal Functioning on Inpatient Treatment for Early Sexually Abused Adults. European Journal of Psychotraumatology, 4, 1-8. http://dx.doi.org/10.3402/ejpt.v4i0.22825
- Geisheker, J.V. (2013) The Completely Unregulated Practice of Male Circumcision: Human Rights’ Abuse Enshrined in Law? New Male Studies, 2, 18-45.
- Lander, J., Brady-Fryer, B., Metcalfe, J.B., Nazarali, S. and Muttitt, S. (1997) Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision: A Randomized Controlled Trial. Journal of the American Medical Association, 278, 2157-2162. http://dx.doi.org/10.1001/jama.1997.03550240047032
- Erikson, E.H. (1993) Childhood and Society. Norton, New York.
- Denniston, G.C. (2013) The Harm of Circumcision. In: Denniston, G.C., Hodges, F.M. and Milos, M.F., Eds., Genital Cutting: Protecting Children from Medical, Cultural, and Religious Infringements, Springer, Dordrecht, 59-68. http://dx.doi.org/10.1007/978-94-007-6407-1_4
- Leboyer, F. (2011) Birth without Violence. Pinter & Martin, London.
- Talbert, C.M., Kraybill, E.N. and Potter, H.D. (1976) Adrenal Cortical Response to Circumcision in the Neonate. Obstetrics and Gynecology, 48, 208-210.
- Gunnar, M.R., Fisch, R.O., Korsvik, S. and Donhowe, J.M. (1981) The Effects of Circumcision on Serum Cortisol and Behavior. Psychoneuroendocrinology, 6, 269-275. http://dx.doi.org/10.1016/0306-4530(81)90037-8
- Williamson, P.S. and Evans, N. (1986) Neonatal Cortisol Response to Circumcision with Anesthesia. Clinical Pediatrics, 25, 412-415. http://dx.doi.org/10.1177/000992288602500807
- Le Roux, R., Niehaus, D.J.H., Koen, L., Seller, C., Lochner, C. and Emsley, R.A. (2007) Initiation Rites as a Perceived Stressor for Isixhosa Males with Schizophrenia. Transcultural Psychiatry, 44, 292-299. http://dx.doi.org/10.1177/1363461507077728
- Vivian, L.M.H. (2008) Psychiatric Disorder in Xhosa-Speaking Men Following Circumcision. Ph.D. Thesis, University of Cape Town, Cape Town.
- Vivian, L.M.H. (2011) A Descriptive Study of Psychiatric Disorder in Vulnerable Xhosa-Speaking Individuals Following Male Circumcision. Lambert Academic Publishing, Saarbrücken.
- Bentall, R.P., Wickham, S., Shevlin, M. and Varese, F. (2012) Do Specific Early-Life Adversities Lead to Specific Symptoms of Psychosis? A Study from the 2007 Adult Psychiatric Morbidity Survey. Schizophrenia Bulletin, 38, 734- 740. http://dx.doi.org/10.1093/schbul/sbs049
- Varese, F., Smeets, F., Dukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., et al. (2012) Childhood Adversities Increase the Risk of Psychosis: A Meta-Analysis of Patient-Control, Prospective- and Cross-Sectional Cohort Studies. Schizophrenia Bulletin, 38, 661-771. http://dx.doi.org/10.1093/schbul/sbs050
- McGrath, J.J. (2005) Myths and Plain Truths about Schizophrenia Epidemiology: The NAPE Lecture 2004. Acta Psychiatrica Scandinavica, 111, 4-11. http://dx.doi.org/10.1111/j.1600-0447.2004.00467.x
- Branson, H.M. (2013) Normal Myelination: A Practical Pictorial Review. Neuroimaging Clinics of North America, 23, 183-195. http://dx.doi.org/10.1016/j.nic.2012.12.001
- Dean, D.C., O’Muircheartaigh, J., Dirks, H., Waskiewicz, N., Lehman, K., Walker, L., et al. (2014) Modeling Healthy Male White Matter and Myelin Development: 3 through 60 Months of Age. NeuroImage, 84, 742-752. http://dx.doi.org/10.1016/j.neuroimage.2013.09.058
- Dubois, J., Dehaene-Lambertz, G., Kulikova, S., Poupon, C., Hüppi, P.S. and Hertz-Pannier, L. (2014) The Early Development of Brain White Matter: A Review of Imaging Studies in Fetuses, Newborns and Infants. Neuroscience, 276, 48-71. http://dx.doi.org/10.1016/j.neuroscience.2013.12.044
- Anand, K.J. and Hickey, P.R. (1987) Pain and Its Effects in the Human Neonate and Fetus. New England Journal of Medicine, 317, 1321-1329. http://dx.doi.org/10.1056/NEJM198711193172105
- Fitzgerald, M. (1998) The Birth of Pain. MRC News, Summer 1998, 20-23.
- Fitzgerald, M. and McIntosh, N. (1989) Pain and Analgesia in the Newborn. Archives of Disease in Childhood, 64, 441-443. http://dx.doi.org/10.1136/adc.64.4_Spec_No.441
- Fox, N.A. and Davidson, R.J. (1986) Taste-Elicited Changes in Facial Signs of Emotion and the Asymmetry of Brain Electrical Activity in Human Newborns. Neuropsychologia, 24, 417-422. http://dx.doi.org/10.1016/0028-3932(86)90028-X
- Wiesel, T.N. and Hubel, D.H. (1963) Single Cell Responses in Striate Cortex of Kittens Deprived of Vision in One Eye. Journal of Neurophysiology, 26, 1003-1017.
- Hubel, D.H. and Wiesel, T.N. (1964) Effects of Monocular Deprivation in Kittens. Archives of Experimental Pathology and Pharmacology, 248, 492-497. http://dx.doi.org/10.1007/BF00348878
- Boyle, G.J., Matthews, G. and Saklofske, D., Eds. (2008) The SAGE Handbook of Personality Theory and Assessment: Vol. 1―Personality Theories and Models. Sage Publishers, Los Angeles.
- Peterson, C., Maier, S.F. and Seligman, M.E.P. (1995) Learned Helplessness: A Theory for the Age of Personal Control. Oxford University Press, New York.
- Stoynov, V. (2014) Freudian Psychology as a Psychological Projection of Pedocircumcision. In: Stoynov, V., Ed., The Circumcision Complex: Examining the Mental Effects of Circumcision. http://www.circumcisioncomplex.com
- Taylor, J.R. (2007) Fine-Touch Pressure Thresholds in the Adult Penis (Letter). British Journal of Urology International, 100, 218. http://dx.doi.org/10.1111/j.1464-410X.2007.07026_4.x
- Taylor, J.R. (2007) The Forgotten Foreskin and Its Ridged Band. Journal of Sexual Medicine, 4, 1516. http://dx.doi.org/10.1111/j.1743-6109.2007.00588.x
- Bensley, G.A. and Boyle, G.J. (2001) Physical, Sexual, and Psychological Impact of Male Infant Circumcision: An Exploratory Survey. In: Denniston, G.C., Hodges, F.M. and Milos, M.F., Eds., Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, Kluwer Academic/Plenum, New York, 207-239. http://dx.doi.org/10.1007/978-1-4757-3351-8_12
- Gemmel, T. and Boyle, G.J. (2001) Neonatal Circumcision: Its Long-Term Harmful Effects. In: Denniston, G.C., Hodges, F.M., and Milos, M.F., Eds., Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, Kluwer Academic/Plenum, New York, 241-252. http://dx.doi.org/10.1007/978-1-4757-3351-8_13
- Bensley, G.A. and Boyle, G.J. (2003) Effects of Male Circumcision on Female Arousal and Orgasm. New Zealand Medical Journal, 116, 595-596. http://www.nzma.org.nz/__data/assets/pdf_file/0010/17974/Vol-116-No-1181-12-September-2003.pdf
- O’Hara, K. and O’Hara, J. (1999) The Effect of Male Circumcision on the Sexual Enjoyment of the Female Partner. British Journal of Urology International, 83, 79-84. http://dx.doi.org/10.1046/j.1464-410x.1999.0830s1079.x
- Frisch, M., Lindholm, M. and Grønbæk, M. (2011) Male Circumcision and Sexual Function in Men and Women: A Survey-Based, Cross-Sectional Study in Denmark. International Journal of Epidemiology, 40, 1367-1381. http://ije.oxfordjournals.org/content/early/2011/06/13/ije.dyr104.abstract http://dx.doi.org/10.1093/ije/dyr104
- Johmann, K. (2003) The Psychological Harm of Male Circumcision. http://www.johmann.net/essays/psychological-harm-of-circumcision.html
- Boyle, G.J. (2015) Does Male Circumcision Adversely Affect Sexual Sensation, Function, or Satisfaction? Critical comment on Morris and Krieger (2013). Advances in Sexual Medicine, 5, 7-12. http://dx.doi.org/10.4236/asm.2015.52002
- Scott, S. (1999) The Anatomy and Physiology of the Human Prepuce. In: Denniston, G.C., Hodges, F.M. and Milos, M.F., Eds., Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice, Kluwer Academic/Plenum, New York, 9-18. http://dx.doi.org/10.1007/978-0-585-39937-9_2
- Earp, B.D. (2014) Female Genital Mutilation (FGM) and Male Circumcision. Should There Be a Separate Ethical Discourse? Practical Ethics, University of Oxford. https://www.academia.edu/8817976/Female_genital_mutilation_FGM_and_male_circumcision_Should_there_be_a_separate_ethical_discourse
- Morris, B.J. and Krieger, J.N. (2013) Does Male Circumcision Affect Sexual Function, Sensitivity, or Satisfaction? A Systematic Review. Journal of Sexual Medicine, 10, 2644-2657. http://dx.doi.org/10.1111/jsm.12293
- Earp, B.D. and Darby, R. (2014) Does Science Support Infant Circumcision? A Skeptical Reply to Brian Morris. The Skeptic. https://www.academia.edu/9872471/Does_science_support_infant_circumcision
- Bossio, J.A., Pukall, C.F. and Steele, S. (2014) A Review of the Current State of the Male Circumcision Literature. Journal of Sexual Medicine, 11, 2847-2864. http://dx.doi.org/10.1111/jsm.12703
- Bronselaer, G.A., Schober, J.M., Meyer-Bahlburg, H.F.L., T’Sjoen, G., Vlietinck, R. and Hoebeke, P.B. (2013) Male Circumcision Decreases Penile Sensitivity as Measured in a Large Cohort. British Journal of Urology International, 111, 820-827. http://dx.doi.org/10.1111/j.1464-410X.2012.11761.x
- Sorrells, M.L., Snyder, J.L., Reiss, M.D., Eden, C., Milos, M.F., Wilcox, N. and Van Howe, R.S. (2007) Fine-Touch Pressure Thresholds in the Adult Penis. British Journal of Urology International, 99, 864-869. http://dx.doi.org/10.1111/j.1464-410X.2006.06685.x
- Morris, B.J., Krieger, J.N. and Kigozi, G. (2013) Male Circumcision Decreases Penile Sensitivity as Measured in a Large Cohort. British Journal of Urology International, 111, E269-E270. http://dx.doi.org/10.1111/bju.12128_9
- Bronselaer, G. (2013) Reply. British Journal of Urology International, 111, E270-E271. http://dx.doi.org/10.1111/bju.12128_10
- Young, H. (2007) Fine-Touch Pressure Thresholds in the Adult Penis. British Journal of Urology International, 100, 699. http://dx.doi.org/10.1111/j.1464-410X.2007.07072_1.x
- Frisch, M. (2012) Author’s Response to: Does Sexual Function Survey in Denmark Offer Any Support for Male Circumcision Having an Adverse Effect? International Journal of Epidemiology, 41, 312-314. http://dx.doi.org/10.1093/ije/dyr181
- Podnar, S. (2011) Clinical Elicitation of the Penilo-Cavernosus Reflex in Circumcised Men. British Journal of Urology International, 109, 582-585. http://dx.doi.org/10.1111/j.1464-410X.2011.10364.x
- Boyle, G.J. (2012) Clinical Elicitation of the Penilo-Cavernosus Reflex in Circumcised Men. British Journal of Urology International, 110, E160. http://dx.doi.org/10.1111/j.1464-410X.2012.11250.x
- Hammond, T. (1997) Long-Term Consequences of Neonatal Circumcision: A Preliminary Poll of Circumcised Males. In: Denniston, G.C. and Milos, M.F., Eds., Sexual Mutilations: A Human Tragedy, Plenum Press, New York.
- Hammond, T. (1999) A Preliminary Poll of Men Circumcised in Infancy or Childhood. British Journal of Urology International, 83, 85-92. http://dx.doi.org/10.1046/j.1464-410x.1999.0830s1085.x http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410x.1999.0830s1085.x/abstract;jsessionid=41315F127ED7263B953C41E5E41C4686.f03t01
- Boyle, G.J., Goldman, R., Svoboda, J.S. and Fernandez, E. (2002). Male Circumcision: Pain, Trauma and Psychosexual Sequelae. Journal of Health Psychology, 7, 329-343. http://dx.doi.org/10.1177/135910530200700310
- Goldman, R. (1997) Circumcision: The Hidden Trauma. Vanguard Publications, Boston.
- Goldman, R. (1999) The Psychological Impact of Circumcision. British Journal of Urology International, 83, 93-103. http://dx.doi.org/10.1046/j.1464-410x.1999.0830s1093.x
- Goldman, R. (2004) Circumcision Policy: A Psychosocial Perspective. Paediatric Child Health, 9, 630-633.
- Dias, J., Freitas, R., Amorim, R., Espiridião, P., Xambre, L. and Ferraz, L. (2014) Adult Circumcision and Male Sexual Health: A Retrospective Analysis. Andrologia, 46, 459-464. http://dx.doi.org/10.1111/and.12101
- Kim, D. and Pang, M.G. (2006) The Effect of Male Circumcision on Sexuality. British Journal of Urology International, 99, 619-622. http://dx.doi.org/10.1111/j.1464-410X.2006.06646.x
- Wespes, E., Eardley, I., Giuliano, F., Hatzichristou, D., Hatzimouratidis, K., Moncada, I., et al. (2013) Guidelines on male sexual dysfunction: Erectile dysfunction and premature ejaculation. European Association of Urology. http://www.guideline.gov/content.aspx?id=45322
- Taylor, G.J., Bagby, R.M. and Parker, J.D.A. (2003) The 20-Item Toronto Alexithymia Scale: IV: Reliability and Factorial Validity in Different Languages and Cultures. Journal of Psychosomatic Research, 55, 277-283. http://dx.doi.org/10.1016/S0022-3999(02)00601-3
- Bollinger, D. and Van Howe, R.S. (2011) Alexithymia and Circumcision Trauma: A Preliminary Investigation. International Journal of Men’s Health, 10, 184-195. http://dx.doi.org/10.3149/jmh.1002.184
- Tang, W.S. and Khoo, E.M. (2011) Prevalence and Correlates of Premature Ejaculation in a Primary Care Setting: A Preliminary Cross-Sectional Study. Journal of Sexual Medicine, 8, 2071-2078. http://dx.doi.org/10.1111/j.1743-6109.2011.02280.x
- Laumann, E.O., Masi, C.M. and Zuckerman, E.W. (1997) Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice. Journal of the American Medical Association, 277, 1052-1057. http://dx.doi.org/10.1001/jama.1997.03540370042034
- Masood, S., Patel, H.R.H., Himpson, R.C., Palmer, J.H., Mufti, G.R. and Sheriff, M.K.M. (2005) Penile Sensitivity and Sexual Satisfaction after Circumcision: Are We Informing Men Correctly? Urologia Internationalis, 75, 62-66. http://dx.doi.org/10.1159/000085930
- Richters, J., Smith, A.M.A., de Visser, R.O., Grulich, A.E. and Rissel, C.E. (2006) Circumcision in Australia: Prevalence and Effects on Sexual Health. International Journal of STD& AIDS, 17, 547-554. http://dx.doi.org/10.1258/095646206778145730
- Krieger, J.N., Mehta, S.D., Bailey, R.C., Agot, K., Ndinya-Achola, J.O., Parker, C. and Moses, S. (2008) Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya. Journal of Sexual Medicine, 5, 2610-2622. http://dx.doi.org/10.1111/j.1743-6109.2008.00979.x
- Ferris, J.A., Richters, J., Pitts, M.K., Shelley, J.M., Simpson, J.M., Ryall, R. and Smith, A.M.A. (2010) Circumcision in Australia: Further Evidence on Its Effect on Sexual Health and Wellbeing. Australian and New Zealand Journal of Public Health, 34, 160-164. http://dx.doi.org/10.1111/j.1753-6405.2010.00501.x
- Son, H., Song, S.H., Kim, S.W. and Paick, J.S. (2010) Self-Reported Premature Ejaculation Prevalence and Characteristics in Korean Young Males: Community-Based Data from an Internet Survey. Journal of Andrology, 31, 540-546. http://dx.doi.org/10.2164/jandrol.110.010355
- Shaeer, O. (2013) The Global Online Sexuality Survey (GOSS): The United States of America in 2011 Chapter III― Premature Ejaculation among English-Speaking Male Internet Users. The Journal of Sexual Medicine, 10, 1882-1888. http://dx.doi.org/10.1111/jsm.12187
- Van Howe, R.S. (2014) Meta-Analysis of 10 Studies Comparing Premature Ejaculation Prevalence in Genitally Intact versus Circumcised Men. Personal Communication, 5 July 2014.
- Michetti, P.M., Rossi, R., Bonanno, D., Tiesi, A. and Simonelli, C. (2006) Male Sexuality and Regulation of Emotions: A Study on the Association between Alexithymia and Erectile Dysfunction (ED). International Journal of Impotence Research, 18, 170-174. http://dx.doi.org/10.1038/sj.ijir.3901386
- Reiss, M.D. (2004) My Painful Journey: A Retired Jewish Physician’s Acknowledgement of Circumcision Trauma Leads Him to Activism. In: Denniston, G.C., Hodges, F.M. and Milos, M.F., Eds., Flesh and Blood: Perspectives on the Problem of Circumcision in Contemporary Society, Kluwer Academic/Plenum, New York, 195-206. http://dx.doi.org/10.1007/978-1-4757-4011-0_14
- American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders. 5th Edition, American Psychiatric Publishing, Arlington.
- Ramos, S.M. and Boyle, G.J. (2001) Ritual and Medical Circumcision among Filipino Boys: Evidence of Post-Trau- matic Stress Disorder. In: Denniston, G.C., Hodges, F.M. and Milos, M.F., Eds., Understanding Circumcision: A Multi- Disciplinary Approach to a Multi-Dimensional Problem, Kluwer Academic/Plenum, New York, 253-270. http://dx.doi.org/10.1007/978-1-4757-3351-8_14
- Watson, C.G., Juba, M.P., Manifold, V., Kucala, T. and Anderson, P.E.D. (1991) The PTSD Interview: Rationale, Description, Reliability, and Concurrent Validity of a DSM-III-Based Technique. Journal of Clinical Psychology, 47, 179-189. http://dx.doi.org/10.1002/1097-4679(199103)47:2<179::AID-JCLP2270470202>3.0.CO;2-P
- Menage, J. (1999) Post-Traumatic Stress Disorder after Genital Medical Procedures. In: Denniston, G.C., Hodges, F.M. and Milos, M.F., Eds. Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice, Kluwer Academic/Plenum, New York, 215-219. http://dx.doi.org/10.1007/978-0-585-39937-9_16
- Maguire, P. and Parkes, C.M. (1998) Surgery and Loss of Body Parts. British Medical Journal, 316, 1086-1088. http://dx.doi.org/10.1136/bmj.316.7137.1086
- Abdulcadir, J., Ahmadu, F.S., Catania, L., et al. (2012) Seven Things to Know about Female Genital Surgeries in Africa. The Hastings Center Report, 42, 19-27. http://dx.doi.org/10.1002/hast.81
- Johnson, M. (2010) Male Genital Mutilation: Beyond the Tolerable? Ethnicities, 10, 181-207. http://dx.doi.org/10.1177/1468796810361654
- Boyle, G.J., Saklofske, D.H. and Matthews, G., Eds. (2015) Measures of Personality and Social Psychological Con- structs. Elsevier/Academic Press, Amsterdam. https://www.elsevier.com/books/measures-of-personality-and-social-psychological-constructs/boyle/978-0-12-386915-9
- Eysenck, H.J. (1991) Personality, Stress, and Disease: An Interactionist Perspective. Psychological Inquiry, 2, 221-232. http://dx.doi.org/10.1207/s15327965pli0203_1
- Eysenck, H.J. and Eysenck, M.W. (1985) Personality and Individual Differences: A Natural Science Approach. Plenum, New York. http://dx.doi.org/10.1007/978-1-4613-2413-3
- Zuckerman, M. (2005) Psychobiology of Personality. 2nd Edition, Cambridge University Press, New York. http://dx.doi.org/10.1017/CBO9780511813733
- Miller, A. (1991) The Newly Recognized, Shattering Effects of Child Abuse. In: Miller, A., Ed., The Untouched Key: Tracing Childhood Trauma in Creativity and Destructiveness, Anchor Books (Doubleday), New York.
- Prince-Embury, S., Saklofske, D.H. and Vesely, A.K. (2015) Measures of Resiliency. In: Boyle, G.J., Saklofske, D.H. and Matthews, G., Eds., Measures of Personality and Social Psychological Constructs, Elsevier/Academic Press, Amsterdam, 290-321. http://dx.doi.org/10.1016/B978-0-12-386915-9.00011-5
- Freud, A. (1937) The Ego and the Mechanisms of Defense. Hogarth, London.
- Freud, A. (1952) The Role of Bodily Illnesses in the Mental Life of Children. Psychoanalytic Study of the Child, 7, 69- 81.
- Festinger, L. (1962) Cognitive Dissonance. Scientific American, 207, 93-107. http://dx.doi.org/10.1038/scientificamerican1062-93
- Boyle, G.J. and Hill, G. (2012) Circumcision-Generated Emotions Bias Medical Literature. British Journal of Urology International, 109, E11. http://dx.doi.org/10.1111/j.1464-410X.2012.10917.x
- Muller, A.J. (2010) To Cut or Not to Cut? Personal Factors Influence Primary Care Physicians’ Position on Elective Newborn Circumcision. Journal of Men’s Health, 7, 227-232. http://dx.doi.org/10.1016/j.jomh.2010.04.001
- Spilsbury, K., Semmens, J.B., Wisniewski, Z.S. and Holman, C.D. (2003) Routine Circumcision Practice in Western Australia 1981-1999. Australian and New Zealand Journal of Surgery, 73, 610-614. http://dx.doi.org/10.1046/j.1445-2197.2003.t01-1-02715.x
- Baumeister, R.F., Dale, K. and Sommer, K.L. (1998) Freudian Defense Mechanisms and Empirical Findings in Modern Social Psychology: Reaction Formation, Projection, Displacement, Undoing, Isolation, Sublimation, and Denial. Journal of Personality, 66, 1090-1092. http://dx.doi.org/10.1111/1467-6494.00043
- van der Kolk, B.A. (1989) The Compulsion to Repeat the Trauma: Re-Enactment, Revictimization, and Masochism. Psychiatric Clinics of North America, 12, 389-411.
- Forbes, D. (2015) Circumcision and the Best Interests of the Child. Journal of Paediatrics and Child Health, 51, 263- 265. http://dx.doi.org/10.1111/jpc.12853
- Bollinger, D. (2014) Normal versus Cut: Final Psychological Scores, 100-0. https://www.academia.edu/6504091/Normal_versus_Cut_Final_Psychological_Score_100-0
- Denniston, G.C., Hodges, F.M. and Milos, M.F., Eds. (1999) Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. Kluwer Academic/Plenum, New York.
- Bossio, J.A., Pukall, C.F. and Steele, S. (2015) Response to: The Literature Supports Policies Promoting Neonatal Male Circumcision in N. America. Journal of Sexual Medicine, in Press. http://dx.doi.org/10.1111/jsm.12852
NOTES
1David Reimer committed suicide in Winnipeg on May 4, 2004, by gunshot to the head. Evidently, the destruction of his penis by an unnecessary electrocautery circumcision, his subsequent orchidectomy on the advice of John Money, and resultant unrelenting psychosexual trauma, led to the taking of his own life―see Colapinto [52] .
2Following the attempted suicide of her own teenage son as a result of his circumcision, Massie [53] reported that severe psychological distress following circumcision may be responsible for causing a number of male adolescent suicides: For example, Dontsa Lwane, 19 years, committed suicide after a botched circumcision―died January 8, 2005, Queenstown, South Africa. His brother, Wandile Lwane, 21 years, also committed suicide (after learning of Dontsa’s death)―died January 9, 2005, Queenstown, South Africa. Similarly, Beasley Allen Terrebonne committed suicide as an adult after a botched circumcision and resultant depression―died Dec 23, 2008, Thibodaux, Louisiana, USA.
3The names of several boys who have died following circumcision-related complications are listed online at the following URL: http://www.cirp.org/library/death/ (Retrieved 24 March, 2015)
4If shown to be the case, then logically, it would be instructive to investigate the circumcision status of mass murderers, rapists, child molesters (pedophiles) and other violent sexual offenders, who themselves may be victims of circumcision-induced trauma and resultant mental illness. As many jurisdictions still apply the death penalty for serious crimes, it becomes critically important that any contributory role of circumcision-induced schizophrenia be elucidated.
5See Bossio et al. [124] for further critique of the Morris and Krieger opinion piece. In addition, Bossio et al. [179] stated that “Based on the Statement of Authorship in Morris and Krieger, it appears that the two authors alone composed the group who rated the articles in their review. According to the SIGN criteria that Morris and Krieger utilize, would their entire review in question not warrant a rating of ‘low quality’ based on the ‘high risk of bias’ introduced by the authors’ well documented, unconditional support of the practice of circumcision?”
6In a letter to the editor, Morris et al. [127] sought to criticize this study; however their analysis was subsequently rebutted by the author of the original research; see Bronselaer [128] .
7Likewise, Morris and co-authors attempted to criticize the findings of Sorrells et al. [126] . Again, they were rebutted in a response by Young [129] . As Frisch (2012, p. 313) has noted in response to similar criticism of his own findings regarding adverse sexual effects of circumcision: “[As] in critical letters to the editor following other recent studies that failed to support their agenda, Morris et al. air a series of harsh criticisms against our study. As seen, however, the points raised are not well founded. It seems that the main purpose, as with prior letters, is to be able in future writings to refer to our study as an ‘outlier study’ or one that has been ‘debunked’, ‘rejected by credible researchers’ or ‘shown wrong in subsequent proper statistical analysis’∙∙∙. As these critics repeatedly refer to Morris’s pro-circumcision manifesto as their source of knowledge, their objectivity must be questioned.” [130]
8Even by October 2001, it was estimated that more than 20,000 circumcised men were trying to undo at least some of the damage caused by circumcision, using various “foreskin restoration” methods―Reiss [154] (p. 202) cf. Bigelow [13] . Evidently, many circumcised men feel so distressed about having been subjected to involuntary genital cutting as non-consenting infants or children, thereby depriving them of normal sexual responsivity, that they feel compelled to endure years of difficult and sometimes painful penile skin-expansion “foreskin restoration” efforts. Some passages in the preceding section have been adapted from Boyle [119] .
9See: http://www.croydonadvertiser.co.uk/Croydon-circumcision-campaigner-caught-child-porn/story-15866127-detail/story.html (Retrieved 25 March, 2015); http://www.croydonadvertiser.co.uk/Upper-Norwood-clergyman-die-bars-admitting-string/story-21666915-detail/story.html (Retrieved 25 March, 2015).