Intended for healthcare professionals

Reviews Book

A Surgical Temptation: The Demonisation of the Foreskin and the Rise of Circumcision in Britain

BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7534.183 (Published 19 January 2006) Cite this as: BMJ 2006;332:183
  1. Stefan Bailis, director,
  2. Daniel Halperin (dhalp{at}worldwidedialup.net), assistant professor
  1. Research and Education Association on Circumcision Health Effects, Bloomington, Minnesota
  2. AIDS Research Center, University of California, San Francisco

    Embedded Image

    University of Chicago Press, £24.50/$35, pp 368 ISBN 0 226 13645 0

    www.press.uchicago.edu/

    Rating: Embedded ImageEmbedded ImageEmbedded ImageEmbedded Image

    Robert Darby's stated reason for this book is “an attempt to explain the sudden vogue for male circumcision in Victorian Britain.” He meticulously examines a variety of medical, social, religious, and other factors that led to the popularity of male circumcision in Great Britain in the late 19th century and to its decline in the 20th. Darby's work is largely based on original sources, a daunting task considering that many probably had to be retrieved from deep storage. The book's last sentence summarises its main thesis: “The long careers of spermatorrhea, masturbatory illness, and circumcision itself show just how easy it is for modern medicine to retain irrational elements from its variegated past.”

    The reader, immersed into the zeitgeist of the 18th, 19th, and early 20th centuries, comes to understand many of the moral factors that were intertwined with medical concerns in increasing the popularity of circumcision. For example, nerve force theory and its related disorder, reflex neurosis, were for a time widely accepted theories in medicine. Nerve energy was thought to be transmittable from one system to completely unrelated systems. Irritations in one place, such as between the foreskin and the glans penis, were thought to produce nerve impulses that could affect remote organs, with potentially serious consequences.

    Masturbation was considered to be particularly unhealthy behaviour, not only because it was morally frowned on but also because it was thought to deplete energy. The remarkable success reportedly achieved by circumcision in curing the various disorders that were related to masturbation or irritation of the penis became well known in medical circles, and in turn routine circumcision was adopted by many better educated parents in Britain. Where Darby excels is in his examination of pre-20th century medicine, in particular regarding obscure disorders such as reflex neurosis and spermatorrhoea (excessive semen release such as occurs during nocturnal emissions). However, at times he appears selective in citing sources; for example, he informs the reader of the early church's condemnation of circumcision solely on putative moral grounds, while failing to mention the virulent anti-Semitism that existed, including opposition to some religious practices of Judaism, such as circumcision.


    Embedded Image

    Credit: FOTOMAS/TOPFOTO

    Sadly, Darby's thorough and relatively unbiased treatment of the historical material does not apply to the mid-20th century onwards. When he does discuss more recent medical practices he greatly distorts the research findings, leading one to wonder about Darby's vocational and avocational interests. A Medline search informs us that Darby is not an entirely dispassionate, disinterested historian. His writings show that he is a passionate anti-circumcision activist, who clearly does not concede any valid reason for circumcision as a health measure. All his published documents are naked criticisms of circumcision or effusive defences of the prepuce.

    Knowing of Darby's anti-circumcision activism helps to illuminate the covert message in his book: circumcision is an anti-quated procedure without any valid medical basis. He neglects to differentiate between those medical arguments for circumcision that have been shown to have merit and those that lack it. To Darby, the foreskin is infallible. It may be misunderstood, pathologised, and demonised, but he appears to be completely closed to the possibility that it could have any health risks at all. Darby describes any scholarly concerns over possible medical liabilities of the foreskin as “hostility.” Unlike his use of original sources in discussing pre-20th century medicine, when the author does address current issues surrounding circumcision he relies on secondary sources—usually the work of fellow anti-circumcision activists.

    Most disturbing of all is Darby's consistent failure to acknowledge the validity of a number of the late 19th century and early 20th century claims for circumcision that more recent research has in fact confirmed. For example, there is now ample evidence of a protective effect against penile cancer, syphilis, and some other ulcerative sexually transmitted infections, as well as a variety of dermatological conditions that are more common within the folds of the humid prepuce. The 19th century proponents of circumcision may not have understood the exact mechanisms, but the effectiveness of circumcision against such ailments—along with more recent concerns such as urinary tract infections and cervical cancer—has been confirmed in the medical literature (see Pediatrics 2000;105: 620-3).

    And amazingly, although Darby mentions HIV (in a typically dismissive fashion), he fails to mention the extensive data on the effectiveness of circumcision against HIV infection, now including more than 40 epidemiological studies (Lancet Infectious Diseases 2001;354: 1813-15), or a recent randomised trial of adult men in South Africa that found a risk reduction in circumcised men of 60-75% (PLoS Medicine 2005;2: 1-11). The foreskin contains immune system cells—Langerhans' and other types—that serve as efficient portals of entry for HIV and that are greatly reduced in number by complete circumcision.

    Whether such proven medical reasons are sufficient to justify the routine practice of circumcision is of course a matter of ongoing debate. Although Darby's treatment of the topic before the 20th century is generally informative, he has difficulty suppressing his vehement objection to modern day circumcision, resorting at times to hyperbole, for example when implying that US boys (predominantly circumcised) are “physically disabled” in comparison with (mainly uncircumcised) Dutch boys. (See News p 137.)

    Acknowledgments

    Robert Darby

    Items reviewed are rated on a 4 star scale (4=excellent)

    View Abstract