Children have feelings too
BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7144.1616a (Published 23 May 1998) Cite this as: BMJ 1998;316:1616
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In my fairly recent student years I tried to find unbiased information on circumcision. My conclusion was that there was none published. Articles that I was able to locate always had a clear bias, either pro or con, and never effectively answered the concerns raised by the other side. I was disappointed that the original article was true to form, and am disappointed that the responses herein are too.
Competing interests: No competing interests
Dr.J.Menage Bulkington, Warwickshire
3.6.98
The Editor
BMJ, BMA House
Tavistock Square
London WC1H 9JR
Re: Children have feelings too; BMJ 23.5.98
Dear Sir/Madam
Dr. McFadyen (1) is on the right track but, unfortunately, has missed the main point, which is that the medical profession should not be doing genital reduction surgery on unconsenting minors in the first place. Unless her son was suffering from BXO there was every chance that by the time he was 17 years of age his foreskin would have been retractable(2). The President of the British Association of
Paediatric Surgeons stated to the Health Committee of the House of Commons in March 1997 that two thirds of circumcisions carried out on children in this country are unnecessary, mainly because of the ignorance of the surgeons carrying out the operation(3). Cansever demonstrated,through her research into the psychological effects of circumcision, that forced amputation of part of the penis is perceived as an attack by children and can be associated with developmental regression and a shift
towards female gender identity(4). Freud was clear in his concern about castration anxiety in boys, although he failed to make the connection between anxiety engendered by fantasy and that caused by real-life fear of surgical cutting of the genitals.
In my research into the effects of genital procedures on women(5) it was demonstrated that the risk factors for developing Post-Traumatic Stress Disorder after genital procedures are: lack of clear consent, lack of information, feelings of powerlessness, feelings of physical pain, and perceived lack of sympathy on the part of the doctor. I suggest that all of these factors apply in the situation of a
child coerced into genital surgery, however well-meaning the motives.
It is self-evident that children have feelings. However, it is not enough to pay lip-service to that fact on the one hand whilst riding roughshod over children’s rights to bodily integrity on the other. I doubt that Dr.McFadyen’s son would have agreed to have his foreskin amputated if given the choice. His rightful anger towards those who should have protected his body rather than damaged it may save
him from developing PTSD. However, I have spoken to several men whose relationships with their mothers have been permanently damaged as a result of circumcision.
The message to doctors should be that childen are entitled to keep their genitals intact until adulthood, that antibiotics are an appropriate treatment for infection and local steroids are effective in phimosis. Circumcision of males is psychologically no different from female genital mutilation, which is a sexual assault. It is time to take off the blindfold and appreciate the harm that is being done to the next
generation by our profession.
For those who are interested, The Fifth International Symposium on Sexual Mutilations: Medical, Legal and Ethical Considerations in Paediatric Practice’ takes place at the University of Oxford from 5-7 August 1998. Details from NORM-UK, PO Box 71, Stone, Staffordshire ST15 0SF.
Yours faithfully,
Janet Menage M.A. M.B. Ch.B. General Practitioner, Bulkington, Warwickshire
REFERENCES:
(1) McFadyen,A. (1998) Children have feelings too. BMJ, 316:1616
(2) Oster,J.(1968) Further fate of the foreskin; Arch Dis Child; 43:200-203
(3) Spitz,L.(1997) Fifth Report from the Health Committee, House of Commons; 23.3.97, xxviii-xxix
(4) Cansever,G.(1965) Psychological effects of circumcision.Br J Med Psychol, 38:321-331
(5) Menage,J.(1993) Post-traumatic stress disorder in women who have undergone obstetric and/or gynaecological procudures; Joural of Reproductive and Infant Psychology; Vol.11; p221-228
Competing interests: No competing interests
31 May 1998
The Editors
British Medical Journal
BMA
Tavistock Square
London
WC1H 9JR
Dear Sirs,
SOUNDINGS - CHILDREN HAVE FEELINGS TOO
Anne McFayden asks why she was so shocked by her son's response to circumcision. The answer lies within the strange blend of truth and denial that she presents.
Her son's apparently mild adverse psychological reaction to circumcision should have come as no surprise. The documented consequences of circumcision include decrease in IQ, feelings of insecurity and inferiority, sexual identification disturbances, regressiveness, an increase in self-aggression, and other problems.[1] Nor should her son's post-operative infection have been a surprise since 10% of circumcisions result in some degree of infection.[2]
McFayden observed her son's distress on being wounded by circumcision. She observed that the foreskin was prematurely separated from the glans. She will have seen that his penis is permanently altered and scarred. He has sufferred removal of specialised sensory tissue.[3] Despite this she still considers her son's penis to be "beautiful". She believes that it works effectively but the sole test of function was that he can pee up the bathroom wall. What of sexual function? Impotence has been observed as a complication of circumcision.[4] Should her son complain of erectile dysfunction as an adult no doubt his condition will be dismissed as "psychological" without any consideration that it may be secondary to the circumcision. How will her son react when he learns that intimate details of his personal medical history were disclosed in an international journal?
Once circumcision has been chosen by parents or health care providers they may experience cognitive dissonance on receiving any information to show that circumcision is harmful. This leads them to reject the evidence of harm.[5] Doctors need to understand their own feelings before they can hope to understand those of child patients.
Yours faithfully
John D Dalton
References
1. Cansever G. Psychological effects of circumcision. Br J Med Psychol 1965; 38:321-31.
2. Williams N and Kapila L. Complications of Circumcision. Brit J Surg 1993;80:1231-1236.
3. Taylor JR, Lockwood AP and Taylor AJ; The Prepuce: Specialized Mucosa of the Penis and its Loss to Circumcision. Brit J Urol 1996;77:291-295.
4. Stinson JM. Impotence and adult circumcision. J Nat Med Assoc 1973; 65:161.
5. Goldman R. Circumcision: The Hidden Trauma; Vanguard, 1997, ISBN 0-9644895-3-8.
Competing interests: No competing interests
To the editor:
We should expect better from a person of Dr MacFayden's education and training.
Circumcision is an unnecessarily radical, traumatic, and invasive procedure for a simple problem. Several researchers have found a more conservative approach satisfactory. All that is necessary is the lysing of the adhesions under some type of anaesthesia with application of vaseline to prevent readhesion during the healing period.[1-3]
Even more troublesome is Dr Macfayden's surprise at her son's emotional reactions to his penile surgery. The tramatic nature of genital surgery has been known from the time of Sigmund Freud who coined the term "castration anxiety". There are ample reports in the analytical literature of the traumatic effects of circumcision.[4-6] A thorough airing of the trauma of circumcision has recently appeared in book form.[7] There should have been no surprises.
1 Cooper GB, Thompson GJL, Raine PAM. Therapeutic
retraction of the foreskin in childhood. BMJ
1983;286:186-7.
2 Griffiths DM, Freeman NV. Non-surgical separation of
preputial adhesions. Lancet 1984;2:344-5.
3 MacKinlay GA. Save the prepuce. Painless separation of
preputial adhesions in the outpatient clinic. BMJ
1988;297:590-1.
4 Glover E. Int J Psychoanal 1929;10:90-93.
5 Kennedy H. Trauma in childhood. The Psychoanalytic Study
of the Child. 1986;41:209-219.
6 Cansever G. Psychological effects of circumcision. Brit J
Med Psychol 1965; 38:321-331.
7 Goldman R. Circumcision: The Hidden Trauma. Vanguard,
Boston 1997.
Competing interests: No competing interests
I am pleased that your son's penis now looks beautiful and this cosmetic surgery pleases you. A fully functional penis might please your son more.
There are much kinder and thoughtful ways of caring for a tight foreskin. A change in masturbation technique or a dorsal slit is preferable to cutting off a complex part of the penis. The foreskin is a natural part of the penis, capable of giving owner and lover much pleasure.
The child could not retract his foreskin properly. It is usually the haste to force this issue and to probe around under the foreskin in the name of hygiene that causes the problems.
Competing interests: No competing interests
There are many instances in which I often reflect on the term "minor" as applied to circumcision. What your son has gone through cannot be described as minor, and it is not an uncommon by any means post operative course. I am convinced that the psychological effects last a lot longer than the physical, which as in your case usually heal with good effect. This is a very forgiving organ, thankfully.
Competing interests: No competing interests
A totally odd article
I read this article and the credentials of the author with interest.
My feelings are that it has been placed inthe public domain to elicit
esponse rather than as a real case study. It may well be that unhappy
serendipity has led to the athor's 7 year old son having been circumcised,
and that this article takes advantage of the poor boy's natural emotions
to form an "interesting read".
In 1998 there was almost never a reason for circumcising a healthy
penis. One respondent has rightly noted BXO as probabaly the sole genuine
medical need for a full circumcision. Nonetheless there are other
reasons, and we do not know the history nor the (interestingly)
circumcised status or religious status of the family general practioner,
nor of the urologist who advised circumcision. While it is a generalism,
those who are themselves circumcised are usually unaware of the
seriousness of the removal of a forsskin both physically and
psychologically, since they were usually circumcised neonatally.
One respondent talks about bias. I suspect no man is unbiased.
Nonetheless I will make the attempt. My bona fides are as a person who
was uncircumcised until 22/23, and then required circumcision because of a
totally intractable phimosis composed of 100% scar tissue, which was
inelastic and did not allow retraction of the foreskin at all.
I was born in 1952. That sets the perspective for the availability
of alternative treatments to circumcision when I genuinely HAD to be cut.
Prior to circumcision I had a gradual onset of phimosis. My belief
is that it was caused (0.7 probability) by maternal insistence on
retraction of foreskin, and (0.3 probability) by the relentless
masturbation of the 11 year old male onwards. Masturbation split the tip
of the forskin and scar tissue grew in its place. I am unable to make any
statements about my foreskin prior to learning to masturbate since it was
not of any real interest to me and I nver observed it.
I want to state clearly that I had no desire to be circumcised.
Equally I did not associate the operation with anything psychologically
damaging. I simply neither wanted surgery nor was I particularly keen on
the aesthetics of a circumcised penis.
I thus contracted (pun intended) the phimosis at around the age of
13/14 and waited until I was 22/23 to have surgery. Drivers in the
surgery were that it wqas imposiosble to use a condom in penetrative sex
with a totally non retractile foreskin, and that I stank because
cleanliness was near impossible.
The surgery itself was embarrassing but non traumatic., It was very
painful, and the urologist was pretty poor in his suturing technique,
leading to a cosmetically unpleasing result with skin bridges and odd
adherences. That led to my feeling that he was less than competent. But
that was all.
Post surgery and post healing the glans became less and less
sensitive, but I was relieved to be free of stink and able to use condoms
for sex. I regretted not the surgery but the necessity for the surgery.
I am content that it was the lack of moderm remedies that led to my
surgery and at no time was antagonistic to the medical profession over it
because they had used the best techniques available to them at the time.
Nonethless I do not like the circumcised penis as much as I liked the
uncircumcised one. That is, to me, a matter of form and function. I
woudl have infinitely preferred not to have required the operation but
have not been damaged psychologically by having it.
I hope this gives an unbioased account to counter the respondent who
sees bias.
I will now show some bias, however. I beleiev that all make children
shoudl stay uncircumcised unless an duntil there is either a genuine
medical need for intervention, or they make an informed choice about body
modification. An adult has the absolute to indulge in cosmetic surgery.
Routine Infant Circumcison, either for cultural or for religious reasons
has no place in a modern world
Competing interests:
None declared
Competing interests: No competing interests