|Circumcision and the birth of the therapeutic state|
Routine neonatal circumcision: Symbol of the birth of the therapeutic state
Journal of Medicine and Philosophy, 1996
Knock: It’s a matter of principle with me to regard the entire population as our patients. Ipso facto.
–– Jules Romains (1959)
Part IThere is a vast literature on the medical arguments for and against the practice of routine neonatal circumcision (RNC). My aim here is not to join that debate, but rather to identify the ethical dilemma that a dispassionate examination of RNC forces upon us. I shall show that RNC appears to be a medical-prophylactic procedure only because it is performed by physicians. Actually, it is a religious ritual, rather than a medical-technical intervention. 
At one time, religious rituals and rationalisations imparted meaning to the majority of people’s lives and justified controlling their conduct. Today, medical rituals and rationalisations often performed these functions. When suicide, or example, was viewed as self-murder, the actor’s sin justified imposing priestly sanctions on his corpse. When the desire for it is viewed as a manifestation of mental illness, the actor’s disease justifies imposing psychiatric sanctions on his person. Homosexuality and masturbation are two other common behaviours that were first forbidden on religious grounds and then on medical grounds. In 1963 I proposed he term “Therapeutic state” to identify the political order in which social controls are legitimised by the ideology of health (Szasz 1989, p. 212).
While homosexuality, masturbation and suicide are behaviours, being born a male is not. Accordingly, circumcision is justified not by the subject’s behaviour, but by the significance his parents and society attach to his foreskin. For Jews, the ritual sacrifice of the infant’s foreskin symbolizes his entrance into the community of the Chosen. For educated Americans, its prophylactic removal symbolizes his entrance into the community of the “medically enlightened”. Indeed, Webster’s Dictionary defines circumcision as “the cutting off of the prepuce of males being practised as a religious rite by Jews and Muslims and as a sanitary measure in modern surgery”.
Part IIThe biblical origin of circumcision is the covenant between God and Abraham. “And God said to Abraham … ‘This is my covenant, which you shall keep, between me and you and your descendants after you: Every male among you shall be circumcised. … Any uncircumcised male who is not circumcised in the flesh of his foreskin shall be cut off from his people; he has broken my covenant’ ” (Genesis, 17:9). The ancient Israelites made a bargain with their God: they gave Jehovah their foreskins, in return for which Jehovah gave them preferred nation status. 
The idea that there is a hygienic basis for this biblical rule in inconsistent with the passage depicting the enemy’s severed penile foreskin as a trophy:
Then Saul said, “Thus shall you say to David, ‘The king desires no marriage present except a hundred foreskins of he Philistines, that he may be avenged of the king’s enemies’.” … Before the time had expired, David rose and went, along with his men, and killed two hundred of the Philistines; and David brought their foreskins, which were given in full number to the king, that he might become the king’s son-in-law (I Samuel 18:25).
The powers attributed to manipulating the penile foreskin are further illustrated by the following Talmudic story:
In the hereafter Abraham will sit at the entrance of Gehinnom [Hell] and will not allow any circumcised Israelite to descend into it. As for those who sinned unduly, what does he do to them? He removes the foreskin from children who died before circumcision, places it upon them and sends them down to Gehinnom (Cohen, 1975).
To justify expelling the deviant from the group, he must first be transformed into the other, and before consigning the sinful Jew to hell, he must be restored to his uncircumcised state. In an analogous manner, before committing the sick patient to the mental hospital, he is declared “dangerous to himself and others”. Every social group distinguishes between persons who are members of the group and those who are outsiders. Jews base their distinction on circumcision, symbolizing their covenant with God.  We base it on mental health, symbolizing the individual’s capacity to covenant (contract) with other members of society. 
That the practice of circumcision has its origin in ritual is so incontrovertible that not even the most zealous advocates of the procedure try to deny it. They do, however, try to rationalize it – much as people have tried to rationalize the Jewish dietary laws – as an expression of primitive insight into its hygienic character. However, ritual circumcision flies in the face of the most elementary principles of hygiene. For example, traditional Jewish law requires the circumciser, the mohel, to perform the ritual act of metzitzah, which consists in taking the circumcised penis in his mouth and sucking out the blood, an act that must be repeated three times. Around the turn of the century, concerns over the documented spread of tuberculosis and syphilis from mohel to infant caused American Jews largely to abandon this element of the ritual. As recently as 1962 Charles Weiss, writing in Clinical Pediatrics, felt it necessary to repeat the call to outlaw this practice. In France, legislation enacted in 1854 prohibited the practice of metzitzah and mandated that circumcision “be performed in a rational manner” (Remondino 1974, pp. 147, 157).
The Torah, Talmud and the body of historical Jewish thought all are very clear about the religious origins and nature of circumcision. The great Jewish philosopher and rabbi, Moses Maimonides (1135-1204) stated the case clearly: “No one, however, should circumcise himself or his son for any other reason but pure faith” (Maimonides 1956, p. 378). Modern efforts to attribute medical rationale to this primitive practice have no basis in scholarship and are disrespectful of Jewish tradition.
Part IIIHow and when did ritual circumcision become prophylactic circumcision, and why did it become especially popular in the United States? For millennia, neither circumcision nor the delivery of the pregnant woman was considered to be a medical procedure. The penile foreskin was regarded as a normal body part, and pregnancy was regarded as a normal event. Women gave birth unassisted or were delivered by female relatives or by informally trained midwives. Much as been written about the conquest of pregnancy and delivery for medicine, male professionals displacing female “amateurs” as the sole, legally authorized providers of so called obstetrical services (Paige and Paige 1981, pp. 263-7). Along with this change, the place of delivery was transferred from the home to the hospital, and normal birth itself came to be seen as a surgical intervention, supposedly facilitated by routine episiotomy. The stage was set for routine surgical circumcision of the normal male infant by the obstetrician – a practice rationalized as prophylaxis. Against what? The answer is masturbation, a plague that could be prevented as well as cured by circumcision.
Virtually all medical texts at the end of the nineteenth century and the beginning of the twentieth prescribed circumcision for a variety of ills, ranging from epilepsy and hydrocephalus to malnutrition and tuberculosis, and confidently asserted that it was a cure for the “disease” of masturbation. The following statement from a standard medical text published in 1887 is typical:
Whether masturbation is a cause of epilepsy is doubted. But there can be no doubt of its injurious effects. … Circumcision should always be practiced. It may be necessary to make the genital so sore by blistering fluids that pain results from attempts to rub the part (Money 1887, p. 421).
Many critics of RNC recognize that beliefs about masturbation played a part in the advent of this practice. They fail to appreciate, however, that the American enthusiasm for preventing masturbation and for promoting circumcision are manifestations of the same Puritanical zeal for health-as-virtue that has fuelled other typically American crowd madnesses, such as Prohibition, the War on Drugs, and the Mental Health Movement (Szasz 1970, 1974). For example, Edward Wallerstein (1980, p. 273), the author of Circumcision: An American health fallacy, writes: “So called health circumcision originated in the nineteenth century. … Within the miasma of myth and ignorance, a theory emerged that masturbation caused many and varied ills.” This statement barely hints at the role of the myth of masturbatory insanity, a genuine crowd madness that began in the eighteenth century (long before RNC appeared), quickly became irresistible dogma in both Europe and the United States, and disappeared only in the middle of this century. Since then, medical hysteria has shifted from masturbation to other health hazards, such as smoking and HIV infection. Today circumcision has even been seriously considered to be a “strategy for AIDS prevention” (Fink 1990).
The significance of the idea of masturbatory insanity lies in the fact that sexual self-stimulation was the first in a long line of religious transgressions that were converted into medical diseases (Szasz 1970, 1980). The roots of both RNC and anti-masturbatory measures lie in Jewish law, which recognises the legitimacy of erotic pleasure associated with sexual intercourse, but only provided that the act is marital-genital congress between a Jewish man and a Jewish woman. Every other act is strictly prohibited. Masturbation is condemned unequivocally both in the Talmud and in extra-Talmudic literature. The Zohar (an authoritative commentary on the Pentateuch) calls masturbation “a sin more serious than all the sins of the Torah” (Feldman 1968, p. 114). Jewish exegetes interpret the act as murder and say that the guilty person deserves death, a hyperbole indicating that the prohibition rests on the view that, by destroying his “generative seed” the masturbator commits an act not unlike murder. Recognizing the obvious connections between touching the penis and sexual arousal, Jewish law “definitely prohibits touching one’s own genitals – the unmarried man never, and the married man only in connection with urination” (Epstein 1967, p. 137). When an Orthodox Jewish father bladder trains his son, he admonishes him: “Without hands! Better a bad aim than a bad habit!” For a male to urinate in this manner is a difficult enough feat if he is circumcised. If he is not, it is impossible. The relevance for RNC of the connection between the prohibition against possessing penile foreskin and against touching the penis while urinating has not received the attention it deserves. This, then, is the background against which we must view the history of the anti-masturbation movement and its corollary, medical circumcision.
The credit for inventing and successfully popularising the idea that masturbation poses a grave hazard to health belongs to an anonymous clergyman-physician who, in 1710, published a treatise entitled Onania, or the Heinous Sin of Self-Pollution.  This was followed in 1758 by the publication of Onania, or a Treatise upon the Disorders produced by Masturbation, by Simon-Andre Tissot, a prominent physician in Lausanne. This work established masturbation as a major etiological factor in countless diseases and transformed the pathogenicity of masturbation from theory into dogma. Benjamin Rush, Philippe Pinel, Henry Maudsley and Sigmund Freud are just a few of the celebrated medical personages who never questioned the harmfulness of self-abuse.
It requires education to see the world through disease-coloured glasses. Thus, members of the upper classes are the most ardent consumers of medical fables, while members of the lower classes tend to be sceptical of health information, both valid and invalid (Schoen 1990a). The role of medical misinformation is humorously mocked in Knock, a masterpiece by Jules Romains that is all but forgotten today. Dr Knock explains his views as follows:
“Get sick” is an old idea. It can’t stand up to modern science. “Health” is a word which we could just as well erase from our vocabularies. For me there are only people more or less sick or more or less numerous diseases progressing at a more or less rapid rate. … A profoundly modern theory, M. Mousquet. If you think it over, you’ll be struck by its relation to the admirable concept of the nation in arms, a concept from which our modern states derive their strength (1959, p. 35).
This parody has become our social reality. We conceptualize every problem in living – from the misbehaviour of children to the melancholy of adults – as a disease. Given this mind-set, it is not surprising that circumcision became medicalized and that RNC proved to be especially popular in the United States. It is worth noting here that at about the same time (in the 1950s) that the British National Health Service stopped paying for RNC, American third-party payers, including welfare programs, began to reimburse for the procedure, and “circumcision became the American standard” (Schoen 1990b). By 1993, the rate of circumcision had dropped to 5 or 6 per cent in Britain, but stood at 80-90 per cent in the United States. Despite this, the incidence of cancer of the penis is higher in the United States than in Denmark and Japan, “where circumcision is done only for clear medical indications” (Minerva, 1993) .
Part IVWhy is RNC legal? Because it is defined as preventive medicine. Why is it defined as preventive medicine? To avoid having to ban it as male genital mutilation. This reciprocal relationship between language and law is intrinsic to our concept of legality. Whether a particular act is legal or illegal depends on what we call it. Killing called “self-defence” is legal; killing called “murder” is a crime. We call the removal of the foreskin of the young male “routine neonatal circumcision”, but the removal of parts of the female genitalia “female genital mutilation”. Language thus prejudges the legitimacy (or illegitimacy) of the practice.
Although female circumcision is not the subject of this essay, and although anatomically it is a more serious mutilation than routine male circumcision, I wish to add a few brief remarks here. First, inasmuch as female genital mutilation (FGM) is banned in many Western countries and is not an accepted medical procedure in the United States,  RNC at home is a more important civil rights issue than FGM abroad. Second, although most Americans refuse to compare the to procedures, the similarities are obvious (and apparent to many Europeans). Both interventions alter the normal anatomy of the genital organs, and the people who practise each attribute health benefits to the practice (Americans to male circumcision, Africans to female circumcision) (Brownlee 1994; Merwine 1993). In Nigeria, 21.2 per cent of female circumcisions are performed by physicians (Olamijulu 1983). 
In 1949 an editorial in the British Medical Journal condemned RNC as an intervention that “savours of the barbaric”, re-emphasised its essentially religious-ritual character by listing some of the bizarre methods that people have used for disposing of the amputated foreskin, and strongly criticized physicians for permitting the practice (Editorial, 1949). In 1976, in an important paper in Pediatrics, William Gee and Julian Ansell refuted the allegedly cancer-protective rationale of RNC.
Circumcision has been justified on the basis that carcinoma of the penis is rare in circumcised males. However, if one compares the incidence of carcinoma of the penis in comparable circumcised and uncircumcised white, male populations in temperate zones in Scandinavia and the United States, there is no significant difference in the incidence of carcinoma of the penis (1/100,000) between those circumcised and those not circumcised.
In 1989 the Task Force on Circumcision of the American Academy of pediatrics (a group reserved about the benefits of RNC) nevertheless still cited the lower incidence of cancer of the penis in circumcise males as justifying the practice. Although it recognized that poor genital hygiene plays a role in the etiology of this disease, the Task Force failed to mention that, even if circumcision did offer protection from penile cancer, this cannot justify its routine use before the age of consent. Cancer of the penis is a rare condition that occurs only in middle age or later, affording young males who fear developing the disease time to submit to prophylactic circumcision if that is what they want. Other pathological conditions associated with the uncircumcised penis, such as phimosis severe enough to interfere with urination and urinary tract fictions, are indications for treating the affected children, not for RNC.
In short, the medical rationalization for mass circumcision is one of the most obvious and most overlooked illustrations of our acculturation to the Therapeutic State. No longer advocated for the prevention of masturbation, circumcision is now regarded as the standard prophylactic measure against penile cancer and urinary tract infections. Although the cause of penile cancer is unknown, it seems unlikely that it lies in the normal anatomy of the human male.
The claim that RNC is rational prophylaxis against UTIs is inconsistent with the evidence. According to a recent study, 99.8 per cent of circumcised infants and 98.6 per cent of uncircumcised infants never experience this (easily diagnosed and treated) problem (Wiswell and Hachey 1993). Thus, the most that RNC can be credited for is that it reduces the rate of UTI in infants by 1.2 per cent.
The conclusion of two Swedish physicians seems to me to be sound:
With regard to the prevention of diseases in adult men, it is in our opinion more fair to postpone a decision [about circumcision] till the young male can make a choice of his own (Bollgren and Winberg 1991).
Part VI believe the time has come to acknowledge that the practice of RNC rests on the absurd premise that the only mammal in creation born in a condition that requires immediate surgical correction is the human male. If the penile foreskin is not merely non-functional, but a biological disadvantage so severe as to justify its immediate surgical ablation, then, surely, it might have atrophied by now. Accordingly, it is not enough for physicians to conclude –as the author of a comment in the New England Journal of Medicine concludes – that:
The benefits [of circumcision] appear to be uncertain. It therefore seems prudent to consider neonatal circumcision as a procedure to be performed at the discretion of parents, not as a part of routine medical care. Omitting circumcision in the neonatal period should not be considered medical neglect. Parents should be informed of the current state of medical knowledge regarding the risks and benefits of the procedure. The ultimate decision may hinge on non-medical considerations (Poland 1990).
If the parents’ ultimate decision to circumcise their male infant hinges on non-medical considerations, then RNC is a medically unjustified practice. It is relevant to note in this connection that observant Jewish parents still employ mohels to circumcise their male infants, a practice the American Medical Association explicitly endorses. The AMA’s Law Department provides a special “release for ritual circumcision” form for “parents of Jewish faith [who] request the performance of a circumcision by a person other than a physician”. Executed by the infant’s parents, the document authorizes the attending physician and hospital “to permit our son to be circumcised by ––, whom we have selected as a person qualified in the ritual of our faith and by experience to perform this procedure” (AMA 1961, p. 36) .  If RNC is medically necessary, what entitled the parents of a Jewish male infant to authorize a non-physician – who is a religious personage to boot – to perform a surgical procedure? Since practising medicine without a licence is a criminal offence, this practice is (or comes close to)a violation of the separation of church (mohel) and state (physician).
If RNC is medically unjustifiable, does it constitute a from of child abuse? Persons unbounded by Jewish or Islamic religious rules might reach that conclusion (Brigman 1984). Should it therefore be illegal? Therein lies our ethical dilemma. We must balance the (relatively small) harm that RNC does to the individual against the (potentially vast) harm that strengthening the state does to everyone (especially the family). Because the family remains our most secure shield against the encroachments of the Therapeutic State, the dilemma calls for compromise.  Preventing RNC does not warrant enlisting the coercive apparatus of the state against the religious values of parents. It does, however, warrant, enlisting the persuasive powers of physicians and the media in the task of informing parents of newborn males about the medically dubious and morally problematic nature of this ostensibly hygienic procedure.
Notes1. This essay is a revised version of an address originally prepared for the Third International Conference on Circumcision, Baltimore, Maryland, 25 May 1994.
2. It seems likely that the ritual circumcision of the male infant is, inter alia, an attenuated version of child sacrifice.
3. This explains why orthodox Jews circumcise dead infants: the ritual ensures that, when they are resurrected, they will be members of the Chosen People.
4. I ignore the role of citizenship here as a marker of membership of the in-group.
5. For further discussion, see Szasz (1970), pp. 180-206
6. This observation is valid only for the overall incidence of cancer of the penis in these countries. In the United States the incidence of cancer of the penis is higher in men who are not circumcised.
7. See also Williams and Kapila (1993).
8. With increasing westernisation, this percentage may be expected to increase.
9. The same form, without the clause specifying that it is for Jewish parents, is reprinted in the 1991 edition, p. 161.
10. I wish to thank David Solomon for this suggestion.
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SourceThomas Szasz, “Routine neonatal circumcision: Symbol of the birth of the therapeutic state”, Journal of Medicine and Philosophy, Vol. 21, April 1996, pp. 137-48