11 10 240 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Netherlands medical authorities condemn circumcision</h1> In a hard-hitting statement issued on 27 May 2010, the Royal Dutch Medical Association (KNMG) has condemned non-therapeutic circumcision of male minors and urged its members to discourage the practice. The statement points out that prophylactic or preventive circumcision of normal male infants and boys confers no health benefit; carries many risks of harm and damage; has an adverse effect on sexual function and bodily appearance; and is a violation of the child’s right to physical integrity. The press release issued by KNMG and a summary of the policy statement is printed below. <h3>Violation of physical integrity</h3> <h2>Royal Dutch Medical Association (KNMG) to discourage non-therapeutic circumcision of male minors</h2> Utrecht, 27 May 2010 – The official standpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children’s rights to autonomy and physical integrity. KNMG is urging a strong policy of deterrence. The reason for the adoption of an official standpoint regarding this matter is the increasing emphasis on the protection of children’s rights. Contrary to popular belief, circumcision can also cause complications – bleeding, infection, urethral stricture and panic attacks are particularly common. Full or partial penile amputations have also been reported as a consequence of complications. KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications. “The rule is: do not operate on healthy children”, says Arie Nieuwenhuijzen Kruseman, chairman of the KNMG. “It is an unfortunate fact that any surgical procedure can cause complications. Doctors accept this to a certain extent because there are medical reasons for the procedure. However, no complications can be justified that occur as the result of an operation that is medically unnecessary.” <h3>Children’s rights</h3> KNMG regards the non-therapeutic circumcision of male minors as a violation of physical integrity, a constitutional right that protects individuals against unwanted internal or external physical modifications. According to the KNMG, minors should only be subjected to medical procedures in the event of illness or abnormalities, or if a convincing case can be made that the procedure is in the interests of the child (such as vaccination). <h3>Dialogue</h3> The KNMG sees good reasons for the statutory prohibition of non-therapeutic circumcision of male minors, but fears that the procedure will then be driven underground, leading to an increase in the number of complications. The Medical Association is aware that the practice of circumcision of male minors has deep religious, symbolic and cultural meaning for some ethnic and religious groups. The KNMG respects this, and is calling for dialogue among medical associations, experts and the relevant religious groups. <h3>Wide support</h3> The following medical and scientific organisations officially support the standpoint of the KNMG: the Dutch Urological Association (Nederlandse Vereniging voor Urologie), the Dutch College of General Practitioners (Het Nederlands Huisartsengenootschap), the Dutch Paediatric Surgery Association (Nederlandse Vereniging voor Kinderchirurgie), the Dutch Plastic Surgery Association (Nederlandse Vereniging voor Plastische Chirurgie), the Association of Surgeons of the Netherlands (Nederlandse Vereniging voor Heelkunde) and the Dutch Paediatric Association (Nederlandse Vereniging voor Kindergeneeskunde). Royal Dutch Medical Association, Policy statement, May 2010 <h2>Non-therapeutic circumcision of male minors</h2> <h3>Preamble</h3> Non-therapeutic circumcision of male minors is a practice that has been carried out for centuries by a variety of different cultures for a variety of different reasons. It is estimated that 13 million boys around the world are circumcised each year. In the Netherlands, the annual figure is between ten and fifteen thousand. Following on from other medical organisations, the Royal Dutch Medical Association (KNMG) has adopted an official viewpoint with regard to this issue. This viewpoint was formulated following consultation with relevant scientific organisations, who also support this stance. This ensures that this viewpoint has a broad basis of support from the relevant professional associations. The reason for our adoption of an official viewpoint regarding this matter is the increasing emphasis on children’s rights. It is particularly relevant for doctors that children must not be subjected to medical proceedings that have no therapeutic or preventative value. In addition to this, there is growing concern regarding complications, both minor and serious, which can occur as a result of circumcising a child. A third reason for this viewpoint is the growing sentiment that there is a discrepancy between the KNMG’s firm stance with regard to female genital mutilation and the lack of a stance with regard to the non-therapeutic circumcision of male minors, as the two have a number of similarities. The initial objective of this viewpoint is to initiate public discussion of this issue. The ultimate aim is to minimise non-therapeutic circumcision of male minors. The KNMG realises that this particular practice has deep religious, symbolic and cultural meaning. For this reason, it is unrealistic to expect that this practice can be eradicated, even if it was prohibited by law. However, the KNMG does believe that a powerful policy of deterrence should be established. As long as this practice takes place, the KNMG aims to reduce the number of complications as much as possible. The KNMG therefore emphasises that circumcision is a surgical procedure covered by the Individual Healthcare Professions Act. This means that circumcision may only be performed by qualified professional practitioners, in this case, doctors. Doctors who perform circumcisions must also follow all applicable scientific guidelines. This entails, amongst other matters, that circumcisions can only be carried out under local or general anaesthetic, after thorough and precise advice and information has been given to the child’s parents. The fact that this practice is not medically necessary and entails a genuine risk of complications means that extra-stringent requirements must be established with regard to this type of information and advice. 27 May 2010 Prof. Dr. Arie Nieuwenhuijzen Kruseman, Chairman of KNMG <h3>Summary</h3> There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene. Partly in the light of the complications which can arise during or after circumcision, circumcision is not justifiable except on medical/therapeutic grounds. Insofar as there are medical benefits, such as a possibly reduced risk of HIV infection, it is reasonable to put off circumcision until the age at which such a risk is relevant and the boy himself can decide about the intervention, or can opt for any available alternatives. Contrary to what is often thought, circumcision entails the risk of medical and psychological complications. The most common complications are bleeding, infections, meatus stenosis (narrowing of the urethra) and panic attacks. Partial or complete penis amputations as a result of complications following circumcisions have also been reported, as have psychological problems as a result of the circumcision. Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations. Non-therapeutic circumcision of male minors conflicts with the child’s right to autonomy and physical integrity. The KNMG calls on (referring) doctors to explicitly inform parents/carers who are considering non-therapeutic circumcision for male minors of the risk of complications and the lack of convincing medical benefits. The fact that this is a medically non-essential intervention with a real risk of complications makes the quality of this advice particularly important. The doctor must then record the informed consent in the medical file. The KNMG respects the deep religious, symbolic and cultural feelings that surround the practice of non-therapeutic circumcision. The KNMG calls for a dialogue between doctors’ organisations, experts and the religious groups concerned in order to put the issue of non-therapeutic circumcision of male minors on the agenda and ultimately restrict it as much as possible. There are good reasons for a legal prohibition of non-therapeutic circumcision of male minors, as exists for female genital mutilation. However, the KNMG fears that a legal prohibition would result in the intervention being performed by non-medically qualified individuals in circumstances in which the quality of the intervention could not be sufficiently guaranteed. This could lead to more serious complications than is currently the case. The full policy in English can be downloaded as a PDF from the <a href="http://knmg.artsennet.nl/Diensten/knmgpublicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm">Royal Dutch Medical Society website</a> <h2>British Medical Journal supports Dutch circumcision policy</h2> Dutch medical alliance moves to change thinking on male circumcision by Tony Sheldon A broad alliance of medical organisations in the Netherlands has officially adopted the view that circumcision of underage boys without a medical reason violates children’s human rights and contravenes the Dutch constitution. The Dutch Medical Association has spearheaded the move, arguing that the medical benefits of circumcision are unproved whereas complications are underestimated, and urging “a strong policy of deterrence.” Doctors should "actively and insistently" inform parents seeking to have their child circumcised about the association’s stance. It is estimated that up to15,000 circumcisions of boys under 16 years of age are carried out each year in the Netherlands — largely for religious or cultural reasons — among Jewish, Muslim, and African Christian communities. [Or more precisely, on account of the cultural, ethnic or religious adherence of the parents; the boys, now living in a secular and multicultural society, may well have other ideas.] The association thinks there are good reasons to ban the practice — female circumcision was outlawed in 2004 — but fears that this might force it underground, leading to a greater number of complications. Instead, it calls for a dialogue between doctors and religious leaders in recognition of the “deep religious, symbolic, and cultural sensitivity” surrounding circumcision. The Dutch Medical Association’s stance was taken on the basis of the argument that “non-therapeutic circumcision” of underage boys amounts to a violation of a child’s physical integrity, and so contravenes Article 8 of the European Convention on Human Rights and Article 11 of the Dutch constitution. It believes circumcision can lead to complications, including haemorrhage, infection, urethral stricture, and panic attacks. There are also reported cases of amputation of part, or all, of the penis as a result of complications involving necrosis. <h3>50 cases with complications per year at one hospital</h3> Dr Tom de Jong, head of paediatric urology at Wilhelmina Children’s Hospital, Utrecht, sees around 50 cases of complications after circumcision every year. Although there is no systematic registration of complications in the Netherlands, his belief, on the basis of published research, is that long term complications can occur in between 8% to 20% of cases, whereas complications arise in 3% to 5% of cases immediately after surgery The association believes that studies that suggest that circumcision reduces the risk of urinary tract infections or HIV/AIDS are inconclusive. Any preventive benefits should be balanced against less invasive forms of prevention, such as good personal hygiene, antibiotics, condom use, and information on safer sex, it argues. The possible medical advantages are “insufficient to justify circumcision on grounds of prevention.” The Dutch Medical Association’s chair, Dr Arie Nieuwenhuijzen Kruseman, said: “With every surgical procedure there is a risk of complications. The rule is not to operate on a healthy child. Children should only be exposed to medical intervention if there is an illness, abnormality, or it can be shown that it is in the interests of the child, such as vaccination.” A survey by the association, carried out to coincide with the new stance, found that two thirds (65%) of a representative sample of 1500 members believe that non-therapeutic circumcision violates physical integrity. The Dutch associations of paediatric medicine, paediatric surgery, surgery, and the college of general practitioners are backing the Dutch Medical Association’s stance. British Medical Journal, 7 June 2010 <a href="http://www.bmj.com/cgi/content/extract/340/jun07_2/c2987" rel="noopener" target="_blank">BMJ 2010;340:c2987</a> <h3>Response: Non-therapeutic Excision of the Foreskin</h3> Antony D. Lempert, GP Principal and Co-ordinator of the Secular Medical Forum Wylcwm Street Surgery, Knighton, Powys LD7 1AD I welcome the principled statement by the Dutch Medical Association and their colleagues advocating an end to ritual circumcision. Without the caveat of religious privilege, a debate about whether or not to surgically interfere with the normal genitalia of little children would be largely unnecessary. There is no reason for gender discrimination when considering child protection. Clinically unnecessary surgical excision of normal genital skin violates a child's human right to an intact body and to be protected from harm [1] In 2007, Sorrells et al [2] demonstrated that circumcision ablates the most sensitive parts of the male penis. There is a risk of further harm [3] when the operation goes wrong. This is sad enough when the circumcision was considered clinically necessary; it is tragic when the operation was done for reasons of conforming to the parents’ religious or cultural views. Many children do not later share their parents’ beliefs or even their cultural values. The bodies of children must be protected from those who would brand them when they are too young to either consent or object. This protection must extend to their genitalia or it is no protection at all. All intervention carries a degree of risk. This is why surgery should only be contemplated where there is a potential for greater good than harm, particularly on non-consenting infants to whom society owes a duty of care and protection. This basic principle ordinarily guides our day to day practice. Were it not for the demands of traditional religious privilege it would not be up for discussion. In January 2010, The SMF approached the doctors’ regulatory body in the UK, the General Medical Council (GMC), asking for them to reconsider their stated non-position on Ritual male circumcision [4] and [5]. The first principle of GMC guidance is “Make the care of your patient your first concern”. With regard to ritual non-therapeutic circumcision, we were advised by the GMC that they had no immediate plans to amend their current guidance. It is time that both the GMC and the BMA followed the Dutch Medical Association’s excellent example of putting patient welfare ahead of the varied chosen beliefs of their parents. Legislation should accompany this to prevent all non-therapeutic surgery on non-consenting children. And let’s call it what it is: Non-therapeutic excision of the foreskin. [1] <a href="http://www.arclaw.org/arc_human_rights_table/">UN Convention on the Rights of the Child 1989</a> [2] Morris L Sorrells et al, <a href="http://www.cirp.org/library/anatomy/sorrells_2007/">Fine-touch pressure thresholds in the adult penis</a>, BJUI 2007; 99: 864-869. (3) Williams N, Kapila L. <a href="http://www.cirp.org/library/complications/williams-kapila/">Complications of circumcision</a>. Brit J Surg 1993;80:1231-6. [4] <a href="http://www.gmc-uk.org/guidance/ethical_guidance/personal_beliefs.asp">Circumcision of Male Children for Religious or cultural reasons</a> [5] <a href="http://www.secularmedicalforum.org.uk/index.php?subject=resources">Ritual Circumcision</a>, Letter to the GMC March 2010 Competing interests: I co-ordinate the <a href="http://www.secularmedicalforum.org.uk/">Secular Medical Forum</a> (SMF) in the UK. We campaign for equality of care for all patients irrespective of their own or their doctors’ own personal beliefs. <a href="http://www.bmj.com/cgi/eletters/340/jun07_2/c2987#237392" rel="noopener" target="_blank">BMJ, 16 June 2010</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Dutch Medical Association: condemns non-therapeutic circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Muskett and Littlejohn express Victorian foreskin fears</h2> Dr Muskett offers helpful explanations of difficult medical terms, and avoids rude words like "penis", while Dr Littlejohn explains that tongue tie and phimosis are equally serious conditions in a newborn baby, requiring immediate surgery. <h3>Philip Muskett: How the Australian climate demands circumcision (1903)</h3> In the performance of circumcision the foreskin of the male organ is removed. This is the part which is medically known as the prepuce (pree'pews) . It owes its origin to the Latin, praeputium, the foreskin. The prepuce may be described as a kind of fleshy cuff which covers the end of the male organ. When the foreskin is unduly long, it gives rise to the condition having the medical name of phimosis (fi-mo'sis). The significance of this term will be better understood when it is explained that it comes from the Greek, phimosis, a muzzling or closure. As a matter of fact, many of these long foreskins cannot be drawn back so as to show the opening of the water pipe. The derivative meaning of phimosis â€“ a muzzling or closure â€“ is therefore very expressive. [1] The front, rounded end of the male organ, which is covered by the foreskin, is called the glans. It is derived from the Latin, glans, an acorn, because of its fancied acorn shape. Behind the glans itself there is a collection of little cells which manufacture a whitish substance termed smegma (smeg'mah) â€“ from the Greek, smegma, soap. When this material is allowed to remain undisturbed, it acquires a very unpleasant, even markedly offensive, odour. It is, moreover, particularly liable to accumulate under a long foreskin, and frequently produces considerable irritation of the parts. A long foreskin may be troublesome in one of two ways. The internal surface of the foreskin often grows to the top of the glans. When this has occurred, it will sometimes be possible to carefully peel back the prepuce. But the two parts may have so tightly grown together that this cannot be accomplished. In these circumstances the operation of circumcision is necessarily required, as it affords the only means by which the two adherent surfaces can be separated. [2] In other instances, the orifice of the foreskin is exceedingly small. The opening may be so tiny that it will barely admit the end of a hair pin â€“ after it has been made into a straight, long wire. A curious event often happens, when a foreskin has such an unusually small orifice. The urine, as it issues from the water pipe, cannot get away, but accumulates inside and distends the foreskin in a most remarkable manner. This is the so called "ballooning" of the foreskin. [3] A long or tight foreskin is likely to be attended with many serious disadvantages. The parts under the prepuce often become irritated and inflamed from the accumulation of smegma and other retained products. Different disorders of the water pipe and bladder are also disposed to occur. There may be the ailment known as "wetting the bed". The straining in trying to pass water, occasioned by a long or tight foreskin, is liable to bring on rupture. The same condition of the prepuce predisposes to various nervous disorders. It is considered, likewise, that bad habits are frequently induced by boys meddling with themselves, in consequence of the irritation produced. Nor is it to be forgotten that an unnaturally tight foreskin may actually interfere with the proper growth and development of the organ. In this semi-tropical Australian climate of ours, it would be infinitely better if circumcision were the rule and not the exception. Beside the Jewish race, many other eastern nations follow the practice. No male with a proper sense of cleanliness can feel that his bath has been complete, in the presence of a long or tight foreskin. Without the slightest exaggeration I may say that hundreds of male patients have told me how much they bitterly regretted that circumcision had not been performed on them, when they were young. But never yet have I met with a single individual who was sorry that he had been circumcised. The operation is almost uniformly successful. It has its failures, at times, but they are, comparatively speaking, rare. Philip Muskett (1903), The illustrated Australian medical guide (2 vols, Sydney: William Brooks, 2nd edn 1909), Vol. 1, pp. 219-20 <h4>NOTES</h4> 1. Philip Muskett is an interesting character who had a lot of sensible things to say about food, clothing and lifestyle generally in the Australian climate, and he has been hailed by Michael Symons as an early prophet of modern Australian cuisine. His most general book, The art of living in Australia (1893), unites an attractive advocacy of outdoor eating, the consumption of fruit and the development of the wine industry, on the one hand, with some pretty bizarre medical advice on the other. He spends over a page discussing whether iced water is injurious to health and reports, in all seriousness, that "ice-water dyspepsia" has become "a definite malady" in the United States. I have not been able to find out much about Muskett, other than that he was senior resident medical officer at Sydney Hospital in the late nineteenth century. Considering his views on the importance of climate on lifestyle and the advisability of circumcision in hot conditions, I should not be surprised if he had been an army doctor in India at some stage. See Michael Symons, One continuous picnic: A history of eating in Australia, 1982, Penguin 1984, pp. 259â€“60; Muskett, The art of living in Australia, reprinted by Kangaroo Press, 1987, p. 77 There is no entry for Muskett in the Australian Dictionary of Biography, nor in the Oxford Companion to Australian Literature, but the University of Adelaide has made his Art of living in Australia available as an e-text. 2. If it is impossible to peel the foreskin from the glans, it is hard to see how it could be isolated for the purpose of amputation. In fact, the only situations in which the foreskin fuses to the glans are when it has been injured by premature forcible retraction, and the bleeding surfaces bind together, and/or when a clumsy circumcision has been performed, also leading to this result. <a href="http://www.circumstitions.com/Botched1.html" rel="noopener" target="_blank">See some ugly visual examples here</a>. 3. Many little boys go through a phase when their foreskin balloons out when they have a leak, and most boys find it very entertaining. In the early eighteenth century Pierre Dionis actually advised men with phimosis to pinch the foreskin shut while urinating and allow the liquid to stretch the foreskin and clean the inner surface. <a href="http://www.cirp.org/library/normal/babu1/" rel="noopener" target="_blank">It has recently been shown</a> that "ballooning" does not imply any obstruction or pathological condition and is certainly not an indication for circumcision. It is also common for boys in the seven to ten year age group to have competitions to see who can piss the furthest: it would be very cruel to deprive them of this harmless and simple entertainment. <h3>Dr Littlejohn: Tongue-tie and phimosis the chief causes of breast-feeding problems (1907)</h3> The nurse should always, in the case of a [newborn] male, examine the penis to see if the child is suffering from phimosis. It is not at all uncommon to find that there is merely a pinhole opening in the prepuce, necessitating an early circumcision. Now I must go into the matter of tongue-tie here, because I find that numbers of babies are sent to the out-patients by nurses, under the supposition that that they are suffering from tongue-tie, when as a mater of fact not one in six of them has any tongue tie at all. Hence he nurse should know how to examine a child's tongue to see if it is tied or not. The best way to do this is to place the child on its back on the bed, or on a table, and then place the tips of the fist and second fingers under the tip of the tongue, one on each side of the fraenum linguae, with the palm of the hand towards the child's face, and raise the tip of the tongue upwards. This procedure puts the fraenum linguae on he stretch, and if it stands out like a white band to any extent and holds down the tie of the tongue, then the child is suffering from tongue-tie to a sufficient extent to interfere with sucking, and it should be taken to a doctor to have it snipped. Having examined the tongue and assured herself that it is not tied, the Nurse should next, if the child is male, examine the penis for phimosis. There is no more frequent cause of all sorts of troubles in young children than phimosis, and it is a very common cause of refusal to take the breast. The child takes a suck or two, then stops and cries, and obstinately refused to take any more; this is apparently because the taking of the breast causes a desire to micturate, and the child knows by experience that micturition causes him pain owing to the contracted orifice in the prepuce and adhesions between the prepuce and the glans, and he therefore refuses to take the breast, and holds his water frequently for 12 or even 24 hours. Hence it is that, what with increasing hunger and the discomfort of a distended bladder, the child cries and screams night and day, and there is no rest for mother or nurse. I have frequently known this state of things to go on for days, until everybody was worn out, and the mother has at last consented to have the baby circumcised, when immediately he takes the breast freely for the first time, empties the bladder and sleeps all night, and so do the mother and the nurse, and all the trouble is at an end. Hence the nurse should always make a point of examining the child's penis, as it is very common to find only a pinhole orifice, and in rare case there may be no opening at all. In either of these cases circumcision should be performed without delay. Then there are cases in which, though the opening appears to be large enough to allow the child to pass water, yet the prepuce is firmly adherent to the glans and cannot be at all retracted, and the retained smegma praeputii becomes inspissated [1] and causes irritation. This condition often causes just as much trouble, and circumcision is just as necessary. Now I do not wish you to suppose that I am an advocate of universal circumcision. There are many cases in which the orifice in the prepuce is satisfactory, the child passes water freely, takes the breast freely, and there are no symptoms of irritation from adhesions or retained and inspissated smegma, and though the prepuce cannot be retracted thoroughly at first, as time goes on it will be possible to retract it more and more until retraction is complete, and the smegma can be cleared away. In these cases circumcision is not necessary. [2] But I do say this, that if the orifice is so small as to prevent the possibility ultimately of complete retraction and clearing away of retained smegma, the child should certainly be circumcised. For even if there is no immediate trouble with regard to passing water and taking the breast, there are various other troubles that frequently result subsequently. In the first place, owing to the adhesions and the contracted orifice, the child has to strain more or less in passing water, and the phimosis thus becomes a frequent cause of inguinal hernia. Many cases of inguinal hernia in young infants can be cured by performing a circumcision. Then again, if the prepuce cannot be retracted, the smegma praeputii accumulates and becomes inspissated, and is a source of constant irritation. Even in young infants I have found large, hard masses of inspissated smegma. The constant irritation results in enuresis and constant erections, and later on in masturbation. Many cases of masturbation in young children have thus originated. In other cases various reflex nervous symptoms are produced, sometimes even epileptiform convulsions, and I have several times seen cases of paresis [paralysis] of the lower extremities so caused. A child of two or three and running about has entirely, to use the mother's expression, "lost the use of his legs", and the trouble has been quite cured by circumcision. Hence there are many strong reasons in favour of circumcision, and I do not know of a single one against it. [3] Dr E.S. Littlejohn, "The management of babies: Lecture delivered to the Australasian Trained Nurses Association", Australasian Nurses Journal, Vol. 5, 16 September 1907, pp. 259-65 NOTES 1. Inspissated was a favourite word of late Victorian and Edwardian medical men, who seem to have have sensed a profound affinity with it. The Shorter Oxford Dictionary defines inspissate as "to make thick or dense; esp. to reduce (a liquid) to a semi-solid consistency". From the Latin, spissus, meaning thick or dense. 2. This was also the argument of (Sir) Frederic Truby King, the most influential authority on baby care in the period between the wars, who similarly stated that circumcision was necessary only if the foreskin could not be retracted within a week of the boy's birth. Since most foreskins are not retractable until much later, this policy actually meant a very high rate of circumcision. See discussion in <a href="https://www.darboninstitute.org/a_source_of_mischief_part_3" rel="noopener" target="_blank">A source of serious mischief, Part 3</a>, and in McGrath and Young, <a href="http://www.circumstitions.com/NZ.html" rel="noopener" target="_blank">History of circumcision in New Zealand</a>. 3. Dr Littlejohn's strictures against the evils of the adherent prepuce are drawn straight from Victorian medical dogma, and especially the mythology cooked up by the <a href="http://www.cirp.org/library/history/gollaher/" rel="noopener" target="_blank">American orthopaedic surgeon Lewis Sayre</a>. Further information on phimosis and the evolution of medical myths and knowledge about it <a href="http://www.cirp.org/library/treatment/phimosis/" rel="noopener" target="_blank">available at CIRP</a>. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Edwardian baby care darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Father’s anguish at circumcision of son</h1> <h3>"Consent procedures for circumcision must be tightened"</h3> A New South Wales father was so distressed at the unauthorised circumcision of his baby boy, and by the bland indifference of the authorities to whom he appealed for justice, that he has set up a <a href="http://www.mycircumcisiondisgrace.org/index.html">website to explain his case</a>. The man, Peter – who wishes to remain anonymous to protect the identity of his son – told Circinfo.org that his 6-week old son was circumcised at his partner’s request while he was overseas on a business trip. But he does not blame his partner nearly as much as the doctor who performed the surgery. “She was a victim of the blatant untruths that are spread to justify circumcision – well-meaning but ignorant. She thought that because I was circumcised I would want the boy to be done, or that all boys were circumcised as a matter of routine. I blame the doctor for three unforgivable omissions: failing to tell my partner that circumcision is very much a minority practice these days; failing to give her a copy of the Royal Australasian College of Physicians policy, which states clearly that circumcision is not widely practiced here, and is certainly not recommended; and, most importantly, for failing to obtain my explicit, written, informed consent as the other parent.” The doctor should also have been aware that the Australasian Association of Paediatric Surgeons recommends that if parents insist of circumcision, it should not be done until the boy is at least 6 months old. The doctor’s failure to seek the consent of the other parent is the nub of Peter’s anger. The <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">British Medical Association</a> insists as a matter of policy that doctors who perform circumcision operations on minors must obtain written authorisation from both parents. In Australia there is no such obligation, but an open slather situation that can easily give rise to tragic situations like Peter’s case, or the <a href="https://www.circinfo.org/bundaberg.html">scandalous affair in Bundaberg</a> in 2004. In that incident, an estranged father who did not even have legal custody of the children, then under the care of the mother, took advantage of a permitted access visit to race the boys (aged 5 and 9) off to a compliant surgeon, who circumcised them on the spot, no questions asked. There was a half-hearted attempt to prosecute the man for assault, but the case was dismissed when his barrister (generously provided by Legal Aid) assured the magistrate that he had acted out of sincere religious conviction. (He was of Turkish origin, and claimed to be a practising Muslim.) There was no attempt to prosecute or even discipline the surgeon for performing an unnecessary operation without valid consent. The case attracted some publicity at the time, but apparently not enough to persuade the medical regulatory authorities that this rule-free situation was placing boys at risk of harm. Disappointingly, there was nothing about the need for a defined consent procedure in the RACP policies issued in 2004 and 2010. If there had been, both Peter and his son might have been spared their respective agonies. “You can imagine my shock and despair when I got home and found what had happened: my beautiful boy with a mangled penis. I had been circumcised – as was the fashion back then – but I had always resented that it was done without MY consent. I hated it, and was determined that my son would not be deprived in the same way. I was looking forward to watching him grow up whole and unblemished. To put it mildly, I was pretty upset when these dreams were shattered.” Peter’s mood was not improved by the indifference and hostility of the authorities to whom he appealed for help. Politicians thought it was none of their business; the Human Rights Commission did not feel that there had been any infringement of the boy’s human rights, nor of Peter’s rights as a parent; bureaucrats advised him that there was nothing they could do; legal authorities informed him – as though they were imparting great wisdom, known only to the select few – that while any form of female circumcision was illegal in most Australian states, circumcision of male minors was perfectly legal, commonly performed and, really, what was all the fuss about? Peter sent three letters to Senator Bob Brown, that doughty champion of the rights of rivers, whales, trees, refugees etc etc, who of all people might have been expected to have some sort of conscience on this issue. He eventually received a reply from a staffer, informing him that the Greens did not have policies on specific medical procedures. Moral vacuity and intellectual inanity “I was dismayed by the intellectually infantile level of the responses, and their moral vacuity. There was not a hint of sympathy, except perhaps from the NSW Commissioner for Children, who said that she did not agree with medically unnecessary circumcision of male minors. Elsewhere there was no suggestion that there were difficult ethical, moral and legal issues here, that required careful thought, not mere catchphrases.” Considering that fewer than 15% of Australian boys are circumcised these days, Peter thought there might have been a constituency that regarded uncircumcised as normal and circumcision as a misfortune, or at least an aberration. “It seems I was wrong”, he admitted. “All I got was apathy, indifference and a sort of mocking incredulity that I should be so concerned with such a trivial issue. The whole experience left me deeply shaken, with a complete loss of faith in the moral fibre of our guardians (politicians, bureaucrats and medical regulators), and even doubts as to their basic competence.” Peter hopes that <a href="http://www.mycircumcisiondisgrace.org/index.html">his website</a> will alert other parents to the appalling loophole in the child protection safety net that would allow any stranger to kidnap a boy in the street, take him to one of the medical practitioners who perform circumcision operations without medical need, and have him done on the spot. “I think that boys ought to have the same level of legal protection against circumcision as girls currently enjoy against mutilation of their genitals. I don’t expect this to happen any time soon, but while we are waiting for the law to catch up with medical ethics I don’t see why boys should have no protection at all. Even dogs have greater protection these days. At the very least, the rules and procedures for circumcision should be tightened up so that outrages like the one that I and my boy experienced cannot happen again.” <a href="http://www.mycircumcisiondisgrace.org/index.html" rel="noopener" target="_blank">Peter's website, My circumcision disgrace, can be reached here</a> <h2>Comment: Open slather on circumcision of boys must end</h2> At a bare minimum, the rules covering non-therapeutic circumcision of male minors ought to include written consent of both parents; proof of identity and of responsibility for the child; where parents disagree, circumcision not to be performed unless ordered by Family Court; signed declaration by parents that they have read and understood the RACP policy statement and a full statement of all the risks and possible adverse consequences (both physical and psychological) of the operation; requirement to watch a video of (a) the circumcision procedure (b) instructions on after-care and handling of complications and (c) appearance and care of the normal (uncircumcised) penis; a cooling-off period of at least 48 hours; operation performed by a fully trained and competent surgeon, with full anaesthesia and post-operative pain control; no rebate from Medicare unless the operation is clinically necessary <h3>Family Court case of K and H: Circumcision may require consent from both parents</h3> Although the authorities to whom Peter appealed for help seemed confident that a single parent’s consent was sufficient to procure the legal circumcision of a child, there is actually some doubt on this question; their certainty may arise from ignorance of the law rather than knowledge of it. A relevant court decision is a judgement of the Family Court in Adelaide in 2003, in the matter of K and H. The case involved the child of a Tanzanian (Muslim) father and an Australian (Anglican) mother; the father wanted the boy circumcised, the mother did not. Their dispute came before the court because the paediatric surgeon consulted by the parents declined to proceed unless both parents agreed to the operation; the father then applied to the Family Court for an order that the circumcision go ahead, while the mother sought an injunction restraining the father from having the boy circumcised. In its judgement the court came down firmly on the mother’s side, and ruled that the child’s best interests required that he not be circumcised, and it issued orders accordingly. An important aspect of the judgement is that it referred to the well-known High Court decision in “Marion’s case”, in which parents sought permission to have their handicapped daughter sterilised. The court held that if parents wanted to perform what it termed a “special medical procedure” on a child, they required permission from the Family Court. The judge in the Adelaide case did not go into the question of whether non-therapeutic circumcision of a minor was also a special medical procedure (some legal authorities <a href="http://www.cirp.org/library/legal/boyle1/">have argued that it is</a>), but he did observe in passing to make another point that “circumcision is a procedure which parents are able to consent to as an aspect of their responsibility.” Note that the reference is to parents (plural). Whether non-therapeutic circumcision of a minor is in fact a procedure to which parents may validly give surrogate consent was not the point being decided here, and the judge’s remark on this is more in the nature of a passing comment than a substantive legal ruling – or in legal terminology, an obiter dictum (thing said by the way) rather than <a href="http://www.alpn.edu.au/node/60">a ratio decidendi </a>(the reason for deciding). What is of permanent legal significance, however, and relevant to Peter’s situation, is that the court went on to make this statement: “The child, of course, is too young to consent to the procedure and it involves an exercise of parental responsibility about which the parents cannot agree. The court must then make the decision.” These words establish a clear legal precedent that the (informed) consent of both parents is required for circumcision of a child for which they are responsible, and that if they disagree the matter must come before the Family Court for a decision. That being the case, any parent who acts unilaterally is potentially in contempt of court, and any doctor who fails to obtain the consent of both parents may be acting unlawfully. Source: Family Court of Australia, Adelaide, 19 December 2003; in the matter of K (father) and H (mother), under Justice Strickland; 2003 FamCa 1364 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Family Court case of K & H: Legality of circumcision may require consent of both parents darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Father’s anguish at circumcision of son</h1> <h3>"Consent procedures for circumcision must be tightened"</h3> A New South Wales father was so distressed at the unauthorised circumcision of his baby boy, and by the bland indifference of the authorities to whom he appealed for justice, that he has set up a <a href="http://www.mycircumcisiondisgrace.org/index.html">website to explain his case</a>. The man, Peter – who wishes to remain anonymous to protect the identity of his son – told Circinfo.org that his 6-week old son was circumcised at his partner’s request while he was overseas on a business trip. But he does not blame his partner nearly as much as the doctor who performed the surgery. “She was a victim of the blatant untruths that are spread to justify circumcision – well-meaning but ignorant. She thought that because I was circumcised I would want the boy to be done, or that all boys were circumcised as a matter of routine. I blame the doctor for three unforgivable omissions: failing to tell my partner that circumcision is very much a minority practice these days; failing to give her a copy of the Royal Australasian College of Physicians policy, which states clearly that circumcision is not widely practiced here, and is certainly not recommended; and, most importantly, for failing to obtain my explicit, written, informed consent as the other parent.” The doctor should also have been aware that the Australasian Association of Paediatric Surgeons recommends that if parents insist of circumcision, it should not be done until the boy is at least 6 months old. The doctor’s failure to seek the consent of the other parent is the nub of Peter’s anger. The <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">British Medical Association</a> insists as a matter of policy that doctors who perform circumcision operations on minors must obtain written authorisation from both parents. In Australia there is no such obligation, but an open slather situation that can easily give rise to tragic situations like Peter’s case, or the <a href="https://www.circinfo.org/bundaberg.html">scandalous affair in Bundaberg</a> in 2004. In that incident, an estranged father who did not even have legal custody of the children, then under the care of the mother, took advantage of a permitted access visit to race the boys (aged 5 and 9) off to a compliant surgeon, who circumcised them on the spot, no questions asked. There was a half-hearted attempt to prosecute the man for assault, but the case was dismissed when his barrister (generously provided by Legal Aid) assured the magistrate that he had acted out of sincere religious conviction. (He was of Turkish origin, and claimed to be a practising Muslim.) There was no attempt to prosecute or even discipline the surgeon for performing an unnecessary operation without valid consent. The case attracted some publicity at the time, but apparently not enough to persuade the medical regulatory authorities that this rule-free situation was placing boys at risk of harm. Disappointingly, there was nothing about the need for a defined consent procedure in the RACP policies issued in 2004 and 2010. If there had been, both Peter and his son might have been spared their respective agonies. “You can imagine my shock and despair when I got home and found what had happened: my beautiful boy with a mangled penis. I had been circumcised – as was the fashion back then – but I had always resented that it was done without MY consent. I hated it, and was determined that my son would not be deprived in the same way. I was looking forward to watching him grow up whole and unblemished. To put it mildly, I was pretty upset when these dreams were shattered.” Peter’s mood was not improved by the indifference and hostility of the authorities to whom he appealed for help. Politicians thought it was none of their business; the Human Rights Commission did not feel that there had been any infringement of the boy’s human rights, nor of Peter’s rights as a parent; bureaucrats advised him that there was nothing they could do; legal authorities informed him – as though they were imparting great wisdom, known only to the select few – that while any form of female circumcision was illegal in most Australian states, circumcision of male minors was perfectly legal, commonly performed and, really, what was all the fuss about? Peter sent three letters to Senator Bob Brown, that doughty champion of the rights of rivers, whales, trees, refugees etc etc, who of all people might have been expected to have some sort of conscience on this issue. He eventually received a reply from a staffer, informing him that the Greens did not have policies on specific medical procedures. Moral vacuity and intellectual inanity “I was dismayed by the intellectually infantile level of the responses, and their moral vacuity. There was not a hint of sympathy, except perhaps from the NSW Commissioner for Children, who said that she did not agree with medically unnecessary circumcision of male minors. Elsewhere there was no suggestion that there were difficult ethical, moral and legal issues here, that required careful thought, not mere catchphrases.” Considering that fewer than 15% of Australian boys are circumcised these days, Peter thought there might have been a constituency that regarded uncircumcised as normal and circumcision as a misfortune, or at least an aberration. “It seems I was wrong”, he admitted. “All I got was apathy, indifference and a sort of mocking incredulity that I should be so concerned with such a trivial issue. The whole experience left me deeply shaken, with a complete loss of faith in the moral fibre of our guardians (politicians, bureaucrats and medical regulators), and even doubts as to their basic competence.” Peter hopes that <a href="http://www.mycircumcisiondisgrace.org/index.html">his website</a> will alert other parents to the appalling loophole in the child protection safety net that would allow any stranger to kidnap a boy in the street, take him to one of the medical practitioners who perform circumcision operations without medical need, and have him done on the spot. “I think that boys ought to have the same level of legal protection against circumcision as girls currently enjoy against mutilation of their genitals. I don’t expect this to happen any time soon, but while we are waiting for the law to catch up with medical ethics I don’t see why boys should have no protection at all. Even dogs have greater protection these days. At the very least, the rules and procedures for circumcision should be tightened up so that outrages like the one that I and my boy experienced cannot happen again.” <a href="http://www.mycircumcisiondisgrace.org/index.html" rel="noopener" target="_blank">Peter's website, My circumcision disgrace, can be reached here</a> <h2>Comment: Open slather on circumcision of boys must end</h2> At a bare minimum, the rules covering non-therapeutic circumcision of male minors ought to include written consent of both parents; proof of identity and of responsibility for the child; where parents disagree, circumcision not to be performed unless ordered by Family Court; signed declaration by parents that they have read and understood the RACP policy statement and a full statement of all the risks and possible adverse consequences (both physical and psychological) of the operation; requirement to watch a video of (a) the circumcision procedure (b) instructions on after-care and handling of complications and (c) appearance and care of the normal (uncircumcised) penis; a cooling-off period of at least 48 hours; operation performed by a fully trained and competent surgeon, with full anaesthesia and post-operative pain control; no rebate from Medicare unless the operation is clinically necessary <h3>Family Court case of K and H: Circumcision may require consent from both parents</h3> Although the authorities to whom Peter appealed for help seemed confident that a single parent’s consent was sufficient to procure the legal circumcision of a child, there is actually some doubt on this question; their certainty may arise from ignorance of the law rather than knowledge of it. A relevant court decision is a judgement of the Family Court in Adelaide in 2003, in the matter of K and H. The case involved the child of a Tanzanian (Muslim) father and an Australian (Anglican) mother; the father wanted the boy circumcised, the mother did not. Their dispute came before the court because the paediatric surgeon consulted by the parents declined to proceed unless both parents agreed to the operation; the father then applied to the Family Court for an order that the circumcision go ahead, while the mother sought an injunction restraining the father from having the boy circumcised. In its judgement the court came down firmly on the mother’s side, and ruled that the child’s best interests required that he not be circumcised, and it issued orders accordingly. An important aspect of the judgement is that it referred to the well-known High Court decision in “Marion’s case”, in which parents sought permission to have their handicapped daughter sterilised. The court held that if parents wanted to perform what it termed a “special medical procedure” on a child, they required permission from the Family Court. The judge in the Adelaide case did not go into the question of whether non-therapeutic circumcision of a minor was also a special medical procedure (some legal authorities <a href="http://www.cirp.org/library/legal/boyle1/">have argued that it is</a>), but he did observe in passing to make another point that “circumcision is a procedure which parents are able to consent to as an aspect of their responsibility.” Note that the reference is to parents (plural). Whether non-therapeutic circumcision of a minor is in fact a procedure to which parents may validly give surrogate consent was not the point being decided here, and the judge’s remark on this is more in the nature of a passing comment than a substantive legal ruling – or in legal terminology, an obiter dictum (thing said by the way) rather than <a href="http://www.alpn.edu.au/node/60">a ratio decidendi </a>(the reason for deciding). What is of permanent legal significance, however, and relevant to Peter’s situation, is that the court went on to make this statement: “The child, of course, is too young to consent to the procedure and it involves an exercise of parental responsibility about which the parents cannot agree. The court must then make the decision.” These words establish a clear legal precedent that the (informed) consent of both parents is required for circumcision of a child for which they are responsible, and that if they disagree the matter must come before the Family Court for a decision. That being the case, any parent who acts unilaterally is potentially in contempt of court, and any doctor who fails to obtain the consent of both parents may be acting unlawfully. Source: Family Court of Australia, Adelaide, 19 December 2003; in the matter of K (father) and H (mother), under Justice Strickland; 2003 FamCa 1364 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Family Court case of K & H: Legality of circumcision may require consent of both parents darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Foreskin - habits, care and management:</h1> <h3>Father of three boys offers good advice from family experience</h3> The following letter was sent to Circumcision Information Australia by a man in his late 60s, born in country Victoria and now living in a major coastal city. As an uncircumcised man himself and the father of three uncircumcised sons, he knows what he is talking about when it comes to foreskin care and management. His basic message is: leave it alone, don’t worry about, and handle minor problems as they arise in a conservative spirit. Warning: some of the comments below are of an explicitly sexual nature. Dear Circumcision Information Australia I read your brochure for parents on care of the penis, which I thought was very sensible. I’m glad you mentioned possible problems, as the penis, like any other bodily organ, can have problems from time to time. Episodes of balanitis (inflammation of the glans) are more common than many people think, but they do not require circumcision. I first got balanitis when I was 14, but it responded quickly to a medicated cream and was gone in a few days. I had another episode when I was in my early twenties, when open weave nylon underpants were the vogue. My doctor just looked at them and said, “Are they nylon.” I said “Yes”, and he replied: “Don’t wear artificial fibres in underclothing; they don’t let the body breathe properly and can be irritants.” Cream again solved the problem. I had another episode more recently, after many problem-free years, whilst in Central Europe, where it was very hot and humid. I asked my local travelling companion if he could get some cream, which he did, and he remarked that he also had the problem occasionally. Again, it quickly did the trick. I think that tight underclothing is a frequent cause of the sweating which gives rise to balanitis. I don’t think boys should wear any underclothing in hot weather, and only very loose cotton underwear at other times. When I was a boy we only wore them on Sunday, like most other people in our community. As a man gets older his foreskin, even if very loose, can start to tighten up. I noticed that my acroposthion [the tapering part of the foreskin, extending beyond the glans] was becoming less easy to draw back over the corona last year and mentioned this to my urologist, fearing the worst. He examined it and prescribed a cream, which he said to apply lightly to the area a couple of times a day, and the foreskin would loosen up again If the problem recurred, repeat the process. This worked instantly and I’ve only had to apply the cream once since. Washing foreskins is a great shibboleth: they don’t need washing nearly so much as people say, and certainly not until puberty. It is, in my view, mainly the natural secretions arising from sexual activity (how’s that for a euphemism!) which create any real need to wash frequently. The interior of the foreskin should never be washed with soap or body lotions etc; that’s like cleaning one’s mouth out with soap. Yours sincerely David Priestly In reply to our inquiry about what sort of creams were applied to resolve the balanitis and tightness problem, and what style of underpants he preferred, the author of the letter replied: I can’t remember what I used the earlier times in adolescence or my twenties, but I was subsequently told by a doctor that a Canesten, a cream commonly prescribed for women, was useful, and I still have the tube of ointment from Europe. It is Fenistil, made by the Swiss company Novartis, and contains, <a href="http://english.consumerhealth.eg.novartis.com/cms.php?id=products_fenistil">so it’s English website says</a>, Dimethindene. When I saw him about my acroposthion getting a bit tight, my doctor told me that he almost never circumcises older men whose prepuces start to get tight, but instead prescribes the cortisone cream he recommended to me. He commented that circumcision is a more difficult operation than usually thought, and that in older uncircumcised men the sudden permanent exposure of the glans, which (especially in cases of long foreskins) has been covered for nearly a lifetime, can be very painful for a long time. I wore boxer shorts for many years, but currently wear very soft cotton underpants, I suppose half-way between briefs and boxers. If doing heavy physical work I wear no underclothing at all, as I find it more comfortable. I was surprised by your comment that circumcised men often preferred tight underwear, because the rubbing of the fabric on the exposed glans can be uncomfortable, and tight underpants reduce the movement. I had no idea that the bare heads of circumcised penises would still feel uncomfortable after so many years. <h3>Note on medications</h3> <a href="https://en.wikipedia.org/wiki/Clotrimazole" rel="noopener" target="_blank">Clotrimazole</a> (brand name Canesten or Lotrimin) is an antifungal medication commonly used in the treatment of fungal infections (of both humans and other animals) such as vaginal yeast infections, oral thrush, and ringworm. It is also used to treat athlete’s foot and jock itch. <a href="http://english.consumerhealth.eg.novartis.com/cms.php?id=products_fenistil" rel="noopener" target="_blank">Dimethindene</a> (brand name Fenistil) is an anti-histamine used to treat inflammation of allergic origin. Various forms of steroid cream (cortisone, betamethasone valerate, and others) are very effective in resolving tight foreskin problems. See <a href="https://www.circinfo.org/Treatment_of_phimosis.html">pages on treatment of phimosis</a> for details. <h3>Further comments on foreskin care and management</h3> In a further letter, David elaborates on foreskin care, from his own experience and that of his father and his three sons … and dispels many old prejudices and myths. The acroposthion, even more than the rest of the foreskin, is what sets people off. My brothers were allowed to play with their circumcised penises, but I was not allowed to fiddle with mine, because it had a moving part and the glans, being protected, was supersensitive. The first time I became aware, as it were, of what I now know to be the acroposthion as a separate entity, was during a medical examination just before I began secondary school. I was 10 years old and was then boarding with a family, as I’ve mentioned, and was taken by the mother to their doctor, so that he “Could just have a look at you”. I was asked to strip off to my undies and he proceeded to look at my eyes, test reflexes etc. After a while he asked me to take my underpants off and come and stand right in front of him. He first fiddled with my balls, made me cough etc, and then ran his thumb and forefinger down my penis, grasped the foreskin extending beyond the tip and rolled it firmly between his thumb and forefinger. It was not comfortable, and I could feel for the first time that the foreskin had two layers, a soft loose outer one and a firmer tubular inner one. He then let it go, but grasped the very tip and pulled it out as far as it would go, without actually hurting and repeated the performance. It no longer felt so tubular inside. He then let it go and from the shaft of the penis, pulled the foreskin back as far as it would go, again without actually hurting, closely inspected the head of the penis, which luckily was clean as I’d not cleaned it specially, not expecting anything like this. Evidently satisfied he pulled it right forward, but pulled it back and forth again a few times. I had never had a medical examination before, and I was so frightened that I didn’t get an erection, which was what I expect was intended. He then said I could go over to the chair on which my clothes were lying and get dressed whilst he spoke quietly to the mother, who had watched the whole examination in silence. He did not like the overhang as I’ve found since with others. It’s too long, they say. When I was married I had a medical examination, mainly testing for blood groups etc, using my wife’s doctor, an old English man who, whilst very pleasant personally, was a keen circumciser, as I discovered. When he saw my penis for the first time, he told me I had a redundant foreskin. I didn’t know what he meant, as it worked properly and seemed OK to me. He said it was too long and would cause troubles and that I had to get circumcised. I said I’d think about it – which I did, but I thought that I wouldn’t do it. He and my mother-in-law tried to get my wife to have the boys circumcised, but I insisted that they were not to be. After the first one my wife was happy with things as they were and told her mother not to raise the matter again if, as happened, she gave birth to further sons. My father very much wanted to get me circumcised, but once he found out that I did not want to be, he said that it was my choice, but that I would have to look after my foreskin properly. This was in early adolescence, i.e. 13 years in my case, by which time my foreskin had become easily retractable. He told me to pull the skin back to urinate, grasping the foreskin from behind the glans, not at the tip or opening, which he said would risk infection from dirty hands. Afterwards I should shake off excess urine and just release the foreskin and let it slide forward naturally. He also told me to pull the foreskin back in the same way when in the shower or bath and just let fresh water (not soap) bathe the glans, and that if there was any smegma, to rub it off gently with my forefinger and thumb. I should not use cloth on the glans and never use soaps etc, as they irritated the delicate tissues. He said not to pull the foreskin forward (as is often taught these days), as this can cause it to fold back on itself and become uncomfortable or swell up and get stuck. He also said that if it had rolled forward by the time bathing was ended, merely to pull it back to let any water out, but not to dry it with a towel. It would roll forward when it was ready. After a time as I grew through adolescence, I found that my foreskin never rolled forward after being pulled back in the shower until I was about to dress, keeping the glans really fresh and naturally damp, whilst in no way diminishing its sensitivity, which formal washing and drying with cloths would have done, let alone the harm from harsh soaps. This practice certainly did not make it any shorter either. I found that this worked very well for me, and I taught my sons the same ways when it was due time. My father was evidently speaking from his experience from the time before he was circumcised. I have no idea why he got circumcised, or why he was so keen on doing it to others (maybe Aesop’s fable about the fox who lost his tail …), but at least he let me be and gave very good advice on how to look after an uncircumcised penis. He told me, after I asked him how he knew such things, that his father, who was not circumcised, had taught him. When I had sons he told me that I should get them circumcised, but when I said that I would not (which he must have known) reminded me to tell them how to look after their foreskins as he had for me at adolescence. Having a foreskin which extends beyond the glans, even when erect can sometimes present a minor problem during intercourse (though it makes no difference, or improves sensation, with masturbation and similar handling). Although the foreskin opening is very stretchable, if it is very loose it won’t slide back during penetration of itself, nor during intercourse, but tends to just move over the glans, rather than letting it become exposed. This is not very satisfactory for either partner. We discovered by trial and error that the best approach was to pull the foreskin right back after penetration and keep it held back. This allows the foreskin to slide on the shaft, leaving the glans fully exposed and giving maximum pleasure to both participants. I have written this, not to be salacious, but because I have seen claims by pro-circumcisionists suggesting that a foreskin of this type (i.e. like mine), needs to be removed because it limits sexual pleasure. This is rubbish. I was totally mystified as a young man when I heard assertions that the penis of a circumcised man and an uncircumcised man looked the same when erect. They might occasionally, but certainly not always. I have never seen another uncircumcised male with an erection since I was about 12, and had no idea that in some cases the foreskin would pull back naturally during an erection to expose the glans. I hope that this information is of use to parents and uncircumcised boys, even though it’s only from the experience of one man and all others may be different. P.S. Incidentally, re dirty hands and urination. When I was at university, the chairman of our College council was a well known old medico. Once, giving a talk to the students after dinner, he began jocularly, by saying to us that he supposed we all washed our hands after touching our penises when urinating. Yes yes, we all went. He then said that if we thought about where our hands had been, what they’d been touching and how much we, as young men, valued our penises, we should wash our hands before, not after touching them. It brought the house down. With best regards David Priestly <h2>Secret men’s business: What dads once told boys about their body</h2> <h3>Comments by Circumcision Information Australia</h3> David was born in western Victoria in 1944, at the height of the vogue for circumcision, and it was only by an odd chance that he himself was not circumcised. In an account of his childhood and adolescence <a href="http://www.historyofcircumcision.net/index.php?option=content&task=view&id=83">available at History of Circumcision</a>, he recounts the prejudices and hostility that his unusual penis aroused at that time, but also his firm attachment to his foreskin, and his adamant resistance to the idea that he should get circumcised. What is particularly interesting about David’s letters here is the how he shows that in the days before circumcision became accepted, and knowledge of foreskin physiology and habits was lost, correct advice on foreskin care was handed down from father to son. This is still the case in cultures where circumcision never got a foothold. Neither David’s grandfather nor his father were circumcised (though his father had it done as an adult for unstated reasons), and having the experience of growing up intact they passed the knowledge down. No doubt David’s grandfather had similarly been advised by his own father, and so back in time through all the male line. The story they told about the ease and simplicity of foreskin care, and the many pleasures of having one, was very different from the narrative that appeared in the manuals of baby and child care being published at the same time. From the late nineteenth century these were full of Victorian myths and prejudices about the foreskin, painting it as difficult to look after, prone to problems, and likely to encourage both disease and bad habits. Such myths linger even today in many popular publications. The old medico’s advice is very sound. Unless a person has some sort of urinary tract infection (such as gonorrhoea), urine is sterile, and can safely be used to wash hands and even the interior of the foreskin itself. People forget that our hands are generally much dirtier than our genitals. The first-hand knowledge from somebody with the good sense and wide experience as our correspondent here is a most valuable corrective to all this antiquated nonsense. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Father of three boys offers sound advice on foreskin care and management darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> By the 1950s advocacy of female circumcison (meaning excision of the clitoral hood) had become a rather fringe preoccupation, but the the idea was not entirely dead. The big difference was that the procedure was now recommended as a simple hygiene measure, and even as a means of enhancing sexual pleasure, not for cooling the libido or curing nervous problems. <h3>If the male needs circumcision for hygiene, why not the female?</h3> The infant clitoris is hidden, covered by the prepuce. The midline raphe may not open sufficiently in later life. A variety of symptoms can develop, attributable to accumulation and contamination of smegma. In these instances, the simple expedient of probing and cleansing can be rewarding. <div>* * * * * *</div> When we were interns, 33 years ago, the staffroom conversation one day came around to the clitoris of the female infant. As I remember, the sum total of knowledge of the subject among those present was zero. I became curious. In the nursery I learned something I had not learned from school or from books, namely that the infant clitoris is hidden. The prepuce covers it at birth. The midline raphe invariably is intact. If the male needs circumcision for cleanliness and hygiene, why not the female? When does the raphe open? Throughout the years, in practice, I found that it may remain intact even into multiparous life. Also I have found that when the raphe does not open, smegma accumulation can cause trouble. Moreover, if the raphe opens only a pinpoint, bacteria can enter to cause contamination of the debris. This, then, can cause symptoms. If, at about two years of age, a little girl has not opened the raphe by exercises like riding kiddy-bikes, or by self-examination, or if the raphe has not opened spontaneously, there usually is found an area of irritation. This is especially so if a very small opening is present. Then come the symptoms of irritation, scratching, irritability, masturbation, frequency and urgency. In adults, the same conditions exist, with associated smegmaliths that may cause dyspareunia and frigidity. If the male needs circumcision for cleanliness and hygiene, why not the female? I have operated on perhaps 40 patients who needed this attention. Illustrative Cases A youngster was suspected of having epilepsy. At about two years of age, she was brought to my office with the mother and was left alone while I examined the mother. I noticed the child masturbating by rubbing back and forth in a sitting position. She finally toppled over in hyperventilation. The disorder disappeared with the simple expedient of female circumcision and the cleansing away of irritants. Adult women with three or four children have been seen whose chief complaint was dyspareunia. Examination revealed a rosary-like group of nodules under the prepuce of a hidden clitoris. Female circumcision was done. Smegmaliths were cleansed away. Very thankful patients were the reward. For the first time in their lives, sex ambition became normally satisfied. Most of the patients have been children 2 to 10 years old who complained of signs and symptoms that suggested cystitis. Urine analyses were usually negative. The mothers complained about the irritability of the children, their unusual habits and sometimes their bedwetting. When examination revealed the presence of a hidden or partially hidden clitoris, it was a simple procedure for the doctor to effect return to normality. The same reasons that apply for the circumcision of males are generally valid when considered for the female. The Technique The procedure is easy. However, it is so distressing to the patient that general anesthesia should be used to avoid making an enemy for life. A blunt probe is inserted into the raphe and swung around the head of the clitoris. There is usually no bleeding, or at least very little. The area is then cleansed of contaminant debris or of smegma that occasionally is formed into stones of various sizes. The raphe normally should be open in early childhood. It is seldom that the prepuce will overgrow again once it has been opened. The mother should be carefully instructed about teaching the child hygienic habits. The signs and symptoms caused by contaminated smegma, retained smegma or smegmaliths usually clear up when the cause is removed. The same reasons that apply for the circumcision of males are generally valid when considered for the female. C.F. McDonald, MD, "Circumcision of the female", GP, Vol. 18 No. 3, September 1958, pp. 98-99 <a href="http://www.noharmm.org/circumfemale.htm" rel="noopener" target="_blank">A version with illustrations available here</a> <h3>New reasons for circumcision, 1959:</h3> <h4>And a new technique, with a specially invented clamp</h4> Redundancy or phimosis of the female prepuce can prevent proper enjoyment of sexual relations; yet some modern physicians overlook indications for circumcision. Indications for, and relative contraindications against, use of this procedure are presented, and a new technique is described. Properly carried out, circumcision should bring improvement to 85 to 90 per cent of cases - with resulting cure of psychosomatic illness and prevention of divorces. <div>* * * * * *</div> Circumcision of the female is not a new subject. Early writings testify that this problem was known and discussed by physicians of the Roman Empire. Bryk in 1935 compiled a comprehensive book on the history and practice of male and female circumcision. The 265 references abstracted in his text cover the circumcision of the female from the ancient Egyptian era (approximately 1500 B.C.) to the present day. The value of this procedure in improving function has been accepted by various cultures for the past 3,500 years. Although this subject is not new, there are indications for its use that are being overlooked by some modern physicians. Indications for Circumcision In general terms, the main indications for circumcision are: (1) functional need - lack of ability to have a climax or ability to have one only with considerable difficulty, (2) an anatomic or mechanical factor that needs correction. When does this problem present itself and become our concern and responsibility as physicians? It is advisable to investigate sexual compatibility if unexplained symptoms of a psychosomatic type are elicited or if the problem of divorce is present. If there is no shyness or embarrassment on the doctor's part and his attitude is correct, the patient is seldom embarrassed. Often a patient appreciates being questioned on this subject because she had thought this might be her problem. If a patient is not sure that she has ever experienced a climax, it is probable that she has not. Patients with psychosomatic illness and marital problems make up a good portion of all types of medical practice. If these problems are based on abnormal anatomy, and it is corrected, these patients are often permanently cured. This cure is explained by the common origin of the primitive urges and of the subconscious, from which psychosomatic illnesses develop. Failure to elicit proper history and to examine patients carefully is illustrated by the following case. Mrs. B. G., age 34, had five divorces before coming to my office as a patient. She was found to have a rather severe redundancy and phimosis, and had never experienced a climax. After being circumcised, she remarried the last man she had divorced and has had no further sexual problem. She stated that she "wasted four perfectly good husbands." While having the five marriages and divorces, she had a great number of psychosomatic symptoms and illnesses. During this time she had been examined and treated by a number of physicians. None of them had told her of the severe phimosis and redundancy or suggested its correction. She has had no recurrence of psychosomatic illness since the circumcision five years ago. No tranquilizers, injections or other treatments were used. A difficult phase of the problem is presented when the wife of a recurrent ulcer patient states, "What difference does it make that I do not enjoy sex life if I do not refuse my husband"? In the earlier years of married life this form of prostitution is possibly not too harmful. A number of problems will probably develop in time however, because this practice is contrary to our instincts. If a man is legally married to a woman but not "mated" with her, one of four complications will probably develop: (1) a divorce, (2) another woman, (3) excessive use of alcohol or (4) suppression of normal urges with psychosomatic illness. Two Common Abnormalities The two common problems that make the highly sensitive area of the clitoris unable to be stimulated are phimosis and redundancy. Sebaceous glands about the clitoris attempt to prevent adhesions of the prepuce to it. This sometimes fails and the clitoris is tightly adherent to the prepuce. This defect is recorded as 1 plus or 25 per cent of the normal surface adherent, to 4 plus or complete coverage. A prepuce for the protection of the clitoris is normal and useful, but if it is excessive and extends past the eminence of clitoris it can prevent contact and is harmful. This excess is also classified from 1 to 4 plus. The greatest amount of redundant prepuce I have observed extended approximately one inch past the clitoris so that it is classified 4 plus. Thus, a 1 plus would represent approximately one-fourth inch of redundant tissue. Figure 5 represents a 3 plus redundancy. In general, the greater the degree of phimosis or redundancy, the greater the probability of satisfactory result by its correction. A 3 or 4 plus phimosis or 3 or 4 plus redundancy could be the anatomic indication. A combination of a 2 plus redundancy and 2 plus phimosis, could be an indication as well. Two rather unusual conditions which could be indications are the hard fibrotic prepuce and the type in which the prepuce is stretched tightly across the glans. Routine circumcision because of a functional problem alone, without the proper anatomic indications, will probably be of no benefit and might be harmful. Additional Indications The following situations would indicate the need for circumcision although less phimosis or redundancy is present. 1. If the patient is quite adipose, a circumcision could be indicated although she has less anatomic defect. Obstruction by the adjacent tissues adds to her problem. This operation may help cure her adiposity by relieving psychosomatic factors. 2. If the husband is unusually awkward or difficult to educate, one should at times make the clitoris easier to find. 3. If the clitoris is quite small and is difficult to contact, a circumcision might help by making it more accessible. Relative Contraindications On the other hand, there are relative contraindications that make one more cautious and more selective in deciding to operate, for example: 1. Frigidity from psychologic causes, such as fear of pregnancy, early adverse training and experiences. 2. Incorrect attitude of patient or husband concerning desire to be helped, factors of abnormal jealousy, excessive psychoneurosis. Percentage of Favorable Results What percentage of favorable results can be expected when the previous indications are followed? To determine this percentage, a questionnaire (Figure 1) was sent to women whom I had circumcised within the past 15 years. One hundred twelve questionnaires were completed and returned. (Figure 2) gives the results obtained. A greater proportion of poor results occurred in early cases, giving evidence that my indications have improved. If cases are carefully selected, one should expect 85 to 90 per cent to show satisfactory improvement. This percentage could not be expected without adequate instructions to both the patient and her husband. When the anatomic problem is borderline, this instruction should be given before performing a circumcision in order to avoid unnecessary surgery. FIGURE 1, Questionnaire Sent To Patients Patient's Number ___________ This questionnaire will be used as the statistical basis for a medical report. Your name will not be used. Kindly check in blanks and mail in enclosed envelope. Surgery: Circumcision done on _____________ 1. Could you have an orgasm prior to surgery: If your answer is yes: (a) Were you improved? If your answer is no: (b) Are you able to have an orgasm now? The woman should be taught to develop voluntary control of the vaginal constrictor muscles. The judicious use of testosterone or stenedial to increase the sensitivity and size of the clitoris might be indicated. Advice concerning the male and female "libido curve" (Kinsey report) often helps to relieve a common worry of young wives. The interest and cooperation of the patient might be stimulated by a few words expressing the fact that it is a privilege (not a duty) to enjoy one of the greatest physical pleasures. FIGURE 2, Questionnaires Received: 112 (a) 73 had never experienced an orgasm: 9 Not Successful (12.4%) 64 Successful (87.6%) (b) 39 had experienced an orgasm with difficulty: 5 Not Improved (12.5%) 34 Improved (87.5%) The husband must be instructed in female anatomy, proper body position, trituration, to develop desire, and such psychologic considerations as patience, atmosphere, kindness, affection, foreplay and other pointers suggested by his personality. Instrument for Female Circumcision <a href="http://www.noharmm.org/femcirctech.htm" rel="noopener" target="_blank">For illustrations, click here.</a> <a href="http://www.noharmm.org/instruments.htm" rel="noopener" target="_blank">To compare instruments used on boys, click here.</a> Note adjustment screw on tip of handle to adjust the pressure applied by the jaws. After the surgeon clamps the instrument, it remains in place without effort. The instrument is seven inches long. Technique of Circumcision It seems that such a relatively minor procedure should not require much detailed description. However, the fear of scar tissue formation, bleeding and the lack of a descriptive technique in the usual surgery texts, might prevent some physicians from attempting it. A few lines will be devoted to my previous technique, then a more simplified technique will be described. Allow two weeks before the next menstrual period. Give 3/4 gr. seconal one-half hour prior to surgery. Trilene inhalation makes the injection of 2 per cent Xylocaine or Nesacaine less painful. Most of the injection for adequate anesthesia can be made from one point, starting at the mid-line, about one inch anterior to the edge of the prepuce. The first injection is made three-eighths inch deep, to each side of the clitoris (Figure 5). Without removing the needle from the skin, the anesthetic is then injected subcutaneously to the base of the lateral attachment of the prepuce. The needle is then removed and injections are directed cephalad, as close as possible to the sides of the clitoris (Figure 6). This latter injection reduces the discomfort of separating the phimosis. The clitoris itself is not injected. The prepuce is then freed with a blunt probe. More Trilene is occasionally needed at this time, but the rest of the surgery should be painless. The operative area is resterilized. In the past, two long mosquito forceps were used to help perform the circumcision. They maintained the proper relationship of the internal and external skin layers and controlled the bleeding prior to suturing. Because the procedure was technically difficult and time consuming, I developed a clamp to be used for the procedure (Figures 3 and 4). Clamp for Procedure This instrument is seen with jaws open Figure 4 and closed in Figure 3. It is simply a "vice-grip" pliers with strong, specially designed jaws for this procedure. After opening, the lower triangular plate or jaw (which is not perforated), is placed under the prepuce and the jaws are partially closed. A tooth thumb forceps is then used to reach through the hole in the upper jaw and pull the desired amount of prepuce into the clamp (Figure 7). The adjusting screw on the handle of the pliers can be turned to adjust for the various thicknesses of prepuce before the pliers are clamped. The cam action not only exerts adequate pressure to compress the tissues at the narrow lower edge of the upper jaw, but also sets itself so that no more force is needed by the operator. After a lapse of five minutes, the surgeon uses a scalpel to excise the prepuce within the upper jaw, being careful to stay close to the inner wall of the clamp (Figure 8). After the triangular piece of excised prepuce is removed, only the lower blade can be seen (Figure 9). The jaws are then opened and the clamp removed. On a thin prepuce, sutures are not necessary (Figure 10). When there is a doubt whether they are needed, however, the edge is reinforced with a few 5-0 plain catgut sutures on an atraumatic needle. This technique is extremely simple, accurate and bloodless. It has given excellent results because of the reduced healing time and absence of sear tissue. Postoperative Treatment To prevent recurrence of the phimosis until the raw surfaces are healed, a special preparation is applied to these surfaces after surgery. This is a wax containing Benzocaine 5 per cent and Terramycin 3 per cent. This preparation is heated to the melting point in its containing tube before being used. The patient is seen every two or three days for the purpose of keeping the adhesions free. Empirin and codeine, or Percodan, is given for postoperative discomfort. If the surgery is done on Friday morning, the patient can return to work on Monday. Complete recovery requires approximately ten to 14 days. W.G. Rathmann MD, "Female Circumcision: Indications and a New Technique", GP, Vol. 20, No. 3, September 1959, pp. 115-120 Biographical note W. G. Rathmann MD has a varied medical background. After completing internships and residency training at U.S. Marine hospitals in Chicago, Seattle and Fort Stanton, N.M., he owned and operated a hospital in Carazozo, N.M., for three years. Since 1938 be has been in general practice in Inglewood, Calif. A member of the senior surgical staff of Centinella Hospital, Inglewood, Dr. Rathmann is also on the staff of five other hospitals in the southern Los Angeles area. A graduate of the University of Nebraska, Academy Member Rathmann has a special interest in psychosomatic diseases. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Female circumcision in the 1950s darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Female genital mutilation happening in Australia</h2> by Emily Bourke for AM Health authorities in Australia say they are concerned about the growing number of women who have undergone some form of genital mutilation. Female circumcision is illegal in Australia, but experts say there is evidence that it is being practised here. More and more migrant women are also seeking help after having the procedure in their home countries. Across Africa, the Middle East and parts of Asia, female genital mutilation is practised on about three million girls and women each year. The centuries-old custom has been outlawed in Australia since the 1990s. But that has not stopped it happening here, according to Dr Ted Weaver from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. "There is some evidence to suggest that it does happen in certain parts of Australia," he said. "It's hard to gauge the actual numbers because it's prohibited by legislation and it's something that is performed in an underground way. "But certainly there have been reports of children being taken to hospital after having the procedure done with complications from that procedure." Melbourne's Royal Women's Hospital says it is seeing between 600 and 700 women each year who have experienced it in some form. Somali-born Zeinab Mohamud, from the hospital's Family and Reproductive Rights Education Program, says much of her work involves untangling some outdated cultural traditions and religious misconceptions. "Some questions that we ask the women is 'why were you doing it?' and they will tell you, 'because of my religion'," she said. "We bring imams or priests to convince them that there is nothing from both books that says you have to do circumcision to girls. So why are you doing it?" Ms Mohamud is optimistic the practice will end, but she fears migrant communities or individual women will be demonised. "Some people when they hear they say, 'how can that happen?' It's when something is cultural and the people have been doing it for so long, it's not easy to either eliminate it or to say, 'you have got a bad culture'," she said. "You have to work with them, listen to them. You have to know where they are coming from in order to help them." Dr Ted Weaver agrees and he says ordering people against the practice would be inappropriate. "If we try and dictate and pontificate about this and not provide culturally appropriate care, we'll further disenfranchise those women," he said. "Any progress will be incremental. I don't think that it's something that will stop overnight. "But I think all we can do is advocate against it, speak out, try to educate women, try to empower women, certainly in this country, and we should do our best for international organisations that are also espousing the same message." <a href="http://www.abc.net.au/news/stories/2010/02/06/2812147.htm?section=justin" rel="noopener" target="_blank">Posted Sat Feb 6, 2010 11:15am AEDT</a> <h3>Comment</h3> The ABC's report was in recognition of the United Nations' declaration of 6 February as International Day Against Female Genital Mutilation, but the UN's position has been condemned as sexist, misandrist (men-hating) and hypocritical by the <a href="http://www.icgi.org/">International Coalition for Genital Integrity</a>, which asks why the UN is concerned only with women and ignores the much larger number of boys and young men who are forced to submit to various forms of genital cutting. ICGI writes: The United Nations says that female circumcision is now widely recognized as a violation of human rights. And so, the UN has declared February 6th as the “<a href="http://www.unifemuk.org/news-international-day-against-female-genital-mutilation.php">International Day Against FEMALE Genital Mutilation.</a>” Instead, it should be declaring an “International Day Against HUMAN Genital Mutilation.” We say the UN is sexist and misandrist. The UN is also hypocritical. In 1989 the UN issued its <a href="http://www2.ohchr.org/english/law/crc.htm">Convention on the Rights of the Child</a>, which “proclaimed and agreed that everyone is entitled to all the rights and freedoms set forth therein, without distinction of any kind, such as … sex.” Ironically, by declaring an International Day Against Female Genital Mutilation, the UN has also circumcised their Convention on the Rights of the Child. The World Health Organization says female circumcision can cause severe bleeding, urinary and reproductive tract infections, and even death. All of these are also true for male circumcision. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Female genital mutilation in Australia darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Female genital mutilation happening in Australia</h2> by Emily Bourke for AM Health authorities in Australia say they are concerned about the growing number of women who have undergone some form of genital mutilation. Female circumcision is illegal in Australia, but experts say there is evidence that it is being practised here. More and more migrant women are also seeking help after having the procedure in their home countries. Across Africa, the Middle East and parts of Asia, female genital mutilation is practised on about three million girls and women each year. The centuries-old custom has been outlawed in Australia since the 1990s. But that has not stopped it happening here, according to Dr Ted Weaver from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. "There is some evidence to suggest that it does happen in certain parts of Australia," he said. "It's hard to gauge the actual numbers because it's prohibited by legislation and it's something that is performed in an underground way. "But certainly there have been reports of children being taken to hospital after having the procedure done with complications from that procedure." Melbourne's Royal Women's Hospital says it is seeing between 600 and 700 women each year who have experienced it in some form. Somali-born Zeinab Mohamud, from the hospital's Family and Reproductive Rights Education Program, says much of her work involves untangling some outdated cultural traditions and religious misconceptions. "Some questions that we ask the women is 'why were you doing it?' and they will tell you, 'because of my religion'," she said. "We bring imams or priests to convince them that there is nothing from both books that says you have to do circumcision to girls. So why are you doing it?" Ms Mohamud is optimistic the practice will end, but she fears migrant communities or individual women will be demonised. "Some people when they hear they say, 'how can that happen?' It's when something is cultural and the people have been doing it for so long, it's not easy to either eliminate it or to say, 'you have got a bad culture'," she said. "You have to work with them, listen to them. You have to know where they are coming from in order to help them." Dr Ted Weaver agrees and he says ordering people against the practice would be inappropriate. "If we try and dictate and pontificate about this and not provide culturally appropriate care, we'll further disenfranchise those women," he said. "Any progress will be incremental. I don't think that it's something that will stop overnight. "But I think all we can do is advocate against it, speak out, try to educate women, try to empower women, certainly in this country, and we should do our best for international organisations that are also espousing the same message." <a href="http://www.abc.net.au/news/stories/2010/02/06/2812147.htm?section=justin" rel="noopener" target="_blank">Posted Sat Feb 6, 2010 11:15am AEDT</a> <h3>Comment</h3> The ABC's report was in recognition of the United Nations' declaration of 6 February as International Day Against Female Genital Mutilation, but the UN's position has been condemned as sexist, misandrist (men-hating) and hypocritical by the <a href="http://www.icgi.org/">International Coalition for Genital Integrity</a>, which asks why the UN is concerned only with women and ignores the much larger number of boys and young men who are forced to submit to various forms of genital cutting. ICGI writes: The United Nations says that female circumcision is now widely recognized as a violation of human rights. And so, the UN has declared February 6th as the “<a href="http://www.unifemuk.org/news-international-day-against-female-genital-mutilation.php">International Day Against FEMALE Genital Mutilation.</a>” Instead, it should be declaring an “International Day Against HUMAN Genital Mutilation.” We say the UN is sexist and misandrist. The UN is also hypocritical. In 1989 the UN issued its <a href="http://www2.ohchr.org/english/law/crc.htm">Convention on the Rights of the Child</a>, which “proclaimed and agreed that everyone is entitled to all the rights and freedoms set forth therein, without distinction of any kind, such as … sex.” Ironically, by declaring an International Day Against Female Genital Mutilation, the UN has also circumcised their Convention on the Rights of the Child. The World Health Organization says female circumcision can cause severe bleeding, urinary and reproductive tract infections, and even death. All of these are also true for male circumcision. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Female genital mutilation in Australia darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h4>The UN Approach to Harmful Traditional Practices: Conceptual Problems</h4> The following article by R. Charli Carpenter was published in the International Feminist Journal of Politics in 2004. Abstract This essay responds to Winter, Thompson and Jeffreys' critique of the UN approach to harmful traditional practices. By questioning why these authors address only a limited set of harmful practices in the West, in particular missing the problem of infant male circumcision, I argue their critique is less radical than it appears. Indeed, the article reproduces what I see as the most problematic and gendered assumptions in the UN's approach: namely, the conceptualization of harmful practices solely in terms of women's victimization and men's benefit. Keywords: boys, children, circumcision, culture, feminism, gender, harmful practices, infants, women This essay responds to Winter, Thompson and Jeffreys' article 'The UN Approach to Harmful Traditional Practices: Some Conceptual Problems' (2002). They argue that in emphasizing only those practices affecting women and children in non-western countries, the UN obfuscates harmful traditional practices (HTPs) to which western women and children are exposed. This is an important argument. However, the authors do not go far enough in critiquing the UN approach to HTPs. Indeed, three of the thorniest conceptual issues are not analyzed at all, but are instead reproduced within the text of the article. First, the authors accept the assumption that only practices performed 'for male benefit' are harmful. Second, they seem to treat only women as victims of 'culture'. Third, although the UN claims to address abuses against 'women and children', only certain abuses against children (those that fit the two above assumptions) seem to be included. Together, these blinders explain why the authors' list of harmful western practices affecting children excludes what is perhaps the most obvious one of all: the genital mutilation of infant boys, euphemistically known as 'infant male circumcision'. Infant Male Circumcision in the United States [1] In the USA, 3,000 male infants are circumcised each day (AAP 1999: 686), generally without anesthetic, having given no consent, risking surgical complication or death and as the medical community has now admitted, receiving no verifiable medical benefits (AMA 2000). [2] The practice involves strapping down an infant boy, tearing the foreskin from his glans, and then either slicing or burning the foreskin off, leaving the glans (normally an internal organ) exposed (Fleiss 1997: 6). The UN Fact Sheet describes cultural practices as 'reflecting values and beliefs held by members of a community for periods often spanning generations' (UN Fact Sheet: 2). Ellsworth (1999) demonstrates that culture alone accounts for the practice in the USA. Contrary to popular belief, there are no convincing hygienic or medical indications for mutilating infants' penises (AAP 1999: 686). The practice in the USA originated in the Victorian era as a means of punishing boys who masturbated (Fleiss 1997: 1). The routinization of circumcision took place alongside the pathologization and medicalization of childbirth within the US medical establishment (Rooks 1998). Today, with circumcision rates declining in western countries, parental decisions regarding circumcision remain based on tradition, the key consideration being whether the father was circumcised (Brown and Brown 1987). Is circumcision a harmful practice? First, even when successful, it is acutely traumatic for babies (Anand 1987: 1325). Circumcision cuts off 'more than 3 feet of veins, arteries and capillaries, 240 feet of nerves, and . . . 20,000 nerve endings' (Fleiss 1997: 5). Negative side effects of successful circumcisions include disfiguration and desensitization (Klauber and Boyle 1974); effects on the neonate's brain development (Goldman 1997: 110); and a higher risk for STDs (Donovan et al. 1994). Moreover, 1 in 476 routine circumcisions in the USA is likely to result in complications (Christakis et al. 2000: 246), including uncontrollable bleeding, infections and in extreme cases, removal of the entire penis (Fleiss 1997: 7). It is estimated that between 1 in 24,000 and 1 in 500,000 baby boys will die from complications related to the procedure (Thompson 1990: 9). Even if there were no side effects and anesthesia were always used, allowing parents to consent to the permanent mutilation of their children promotes the property status of children, which is in itself harmful both to children and to society (Somerville 2000). It also violates the universal right to bodily integrity. As Bhimji (2000) argues, legitimizing the violation of a human right is harmful, not only to the person whose rights are violated, but also to the promotion of a culture of human rights generally. How could an analysis of 'harmful traditional practices against women and children' in the West miss such an obvious case as infant male circumcision? The authors adopted the UN's conceptual definition of HTPs (p. 78), therefore only certain practices with certain victims were consistent with their analysis. First, Winter et al. uncritically accept the UN claim that the relevant practices are those that have 'been performed for male benefit' (UN Fact Sheet: 2). This emphasis on beneficiaries rather than perpetrators is a useful way of glossing over the fact that many of the practices in the UN Fact Sheet are perpetrated directly by women on other women or small children of both sexes (see pp. 81 and 88). It is, however, not a meaningful criterion analytically because some women also benefit from such practices. [3] Moreover, this formulation excludes altogether those harmful practices justified solely as benefiting women. This may partly explain why infant male circumcision is not addressed either at the UN, or by the authors. Two of the most common reasons given for circumcising boys are that circumcision protects women against STDs, and that female partners prefer circumcised men sexually (Lightfoot-Klein 1996). Second, the assumption appears to be that only women can be victims of HTPs: 'the concept has been developed as a way of naming and combating some of the most blatant forms of male domination of women' (p. 72). In short, practices that otherwise fit the description, but affect males, do not count. I suspect the exclusion of harm to males from the definition of 'cultural practices' is linked to the association of 'women' with 'culture', which has often been used to justify lack of attention to human rights abuses of women (Peterson 1990). By designating cultural practices as 'harmful' the UN rightly denies the validity of this stance, but it simultaneously reproduces the assumption that it is women, not men, who are victims of culture. Indeed, patriarchy-legitimating abuses to which men and boys are typically subjected, including sex-selective massacre, conscription, sexual violence in prisons, gay-bashing and socialization into hegemonic masculinities do not appear to be considered 'cultural' practices (and some may not even be considered 'harmful'). While it may be countered that the UN's objective with HTPs (and the authors') is precisely not to (again) focus on adult men, the exclusion of male infants from attention is more surprising given the UN's apparently sex-inclusive focus on 'children' as well as 'women'. Here, it is analytically important to distinguish cases where children as such are harmed from cases where girls and boys experience harm differently. Winter et al. cite some examples of the former, such as infanticide (p. 82) and the medicalization of childbirth with its increase in child mortality rates (p. 85). However, other forms of abuse are sex-related: for example, although both boys and girls are raped and beaten, girls are more vulnerable to sexual abuse, and boys to physical abuse (including mutilation) in the West. According to the UN's approach, harmful practices 'against women and children' seem to include cases where children of both sexes are injured, but only girl children seem to be emphasized as victims of sex-related abuse. For example, Winter et al. describe 'male sexual abuse of female children' in much detail (pp. 83â€“4) but ignore the issue of child-beating, much of which is perpetrated by mothers on sons. Given this conceptualization of HTPs it becomes less surprising that infant male circumcision is on neither the UN's radar screen nor the authors', but it is hardly less problematic. That the UN criteria explicitly exclude practices such as infant male circumcision speaks not only to the UN's cultural bias, but also to the utter inadequacy of its focus to counter some of the most prevalent human rights abuses in western culture. If the only harmful traditional practices on the UN agenda are those done to women for the benefit of men then any practices affecting males (including children) or ostensibly done for women's benefit will be neglected. The authors are silent on this matter: despite their claims of addressing 'conceptual problems', their analysis is primarily substantive. At the conceptual level, they reproduce instead of question the most fundamental problems of all. R. Charli Carpenter Department of Politics and IR Drake University <h3>NOTES</h3> 1. This argument should not be construed as a comparison of infant male circumcision to the more extreme forms of FGM. I agree with many other feminists that these practices are not comparable in scope or severity. Infant male circumcision can and should be condemned on its own lack of merit. 2. The Circumcision Information and Resource Pages on the Web include a compilation of statements on circumcision by the medical establishment in industrialized countries around the world. <a href="http://www.cirp.org/library/statements" rel="noopener" target="_blank">See http://www.cirp.org/library/statements</a> 3 For example, FGM has persisted in places over the objection of some men partly because it benefits the older women and the female cutters (Gruenbaum 2001). <h4>REFERENCES</h4> American Academy of Pediatrics (AAP). 1999. 'Circumcision Policy Statement', Pediatrics 103 (3): 686â€“93. American Medical Association (AMA). 2000. 'Report 10 of the Council on Scientific Affairs: Neonatal Circumcision.' <a href="http://www.ama-assn.org/ama/pub/article/2036%C3%83%C2%A2%C3%A2%E2%80%9A%C2%AC" rel="noopener" target="_blank">Online at http://www.ama-assn.org/ama/pub/article/2036â€“2511.html</a> Anand, K. 1987. 'Pain and Its Effects on the Human Neonate and Fetus', New England Journal of Medicine 317: 1321â€“9. Bhimji, M. D. 2000. 'Infant Male Circumcision: A Violation of the Canadian Charter of Rights and Freedoms.' <a href="http://www.longwoods.com/hl/pdf/circum.pdf" rel="noopener" target="_blank">Online at http://www.longwoods.com/hl/pdf/circum.pdf</a> Brown, M. S. and Brown, C. A. 1987. 'Circumcision Decision: Prominence of Social Concerns', Pediatrics 80 (2): 215â€“19. Christakis, D., Harvey, E., Zerr, D. M., Feudtner, C., Wright, J. and Connell, F. 2000. 'A Trade-off Analysis of Routine Newborn Circumcision', Pediatrics 105 (1) Supplement: 246â€“9. Donovan, B., Bassett, I. and Bodsworth, N. J. 1994. 'Male Circumcision and Common Sexually Transmissible Diseases in a Developed Nation Setting', Genitourinary Medicine 70: 317â€“20. Ellsworth, K. 1999. 'Universal Human Rights in Discourse and Practice: The Culture of Circumcision in U.S. Foreign Policy.' Paper presented at the Western Political Science Association Annual Conference, Seattle, WA (March). Fleiss, P. 1997. 'The Case against Circumcision', Mothering 85 (Winter). <a href="http://www.mothering.com/10-0-0/html/10%C3%83%C2%A2%C3%A2%E2%80%9A%C2%AC" rel="noopener" target="_blank">Online at http://www.mothering.com/10-0-0/html/10â€“1-0/10â€“1-circumcision85.shtml</a> Goldman, R. 1997. Circumcision: The Hidden Trauma. Boston, MA: Vanguard Publications. Gruenbaum, E. 2001. The Female Circumcision Controversy: An Anthropological Perspective. Philadelphia, PA: University of Pennsylvania Press. Klauber, G. and Boyle, J. 1974. 'Prenuptial Skin-Bringing Complications of Circumcision', Urology 3: 722â€“3. Lightfoot-Klein, H. 1996. 'Similarities in Attitudes and Misconceptions toward Infant Male Circumcision in North American and Ritual Female Genital Mutilation in Africa.' The Fourth International Symposium on Sexual Mutilations: Global Perspectives on Male and Female Genital Mutilation: Circumcision, Ethics, and Human Rights, Lausanne, Switzerland. <a href="http://www.fgmnetwork.org/intro/mgmfgm.html" rel="noopener" target="_blank">See also http://www.fgmnetwork.org/intro/mgmfgm.html</a> Peterson, V. S. 1990. 'Whose Rights? A Critique of the ''Givens'' in Human Rights Discourse', Alternatives 15 (3): 303â€“44. Rooks, J. 1998. Midwifery and Childbirth in America. Philadelphia, PA: Temple University Press. Somerville, M. 2000. '<a href="http://www.intact.ca/canary.htm" rel="noopener" target="_blank">Altering Baby Boys' Bodies: The Ethics of Infant Male Circumcision</a>', in Margaret Somerville The Ethical Canary: Science, Society and the Human Spirit, pp. 202â€“19. Toronto: Viking. Thompson, R. S. 1990. 'Routine Circumcision in the Newborn: An Opposing View', Journal of Family Practice 31 (2): 189â€“96. <a href="http://www.cirp.org/library/disease/UTI/thompson/" rel="noopener" target="_blank">Available at http://www.cirp.org/library/disease/UTI/thompson/.</a> United Nations. Fact Sheet No. 23, Harmful Traditions Practices Affecting the Health of Women and Children. <a href="http://www.unhchr.ch/html/menu6/2/fs23.htm" rel="noopener" target="_blank">Available at http://www.unhchr.ch/html/menu6/2/fs23.htm</a> Winter, B., Thompson, D. and Jeffreys, S. 2002. 'The UN Approach to Harmful Practices: Some Conceptual Problems', International Feminist Journal of Politics 4 (1): 72â€“95. Source: R. Charli Carpenter, "A Response to Bronwyn Winter, Denise Thompson and Sheila Jeffreys, 'The UN Approach to Harmful Traditional Practices: Some Conceptual Problems': Some Other Conceptual Problems", in International Feminist Journal of Politics, Vol. 6, No. 2, June 2004, 308â€“313 (ISSN 1461â€“6742 print/ISSN 1468â€“4470 online Â© 2004 Taylor & Francis Ltd; website: <a href="http://www.tandf.co.uk/journals" rel="noopener" target="_blank">http://www.tandf.co.uk/journals</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource FGM and the United Nations darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>The old dilation vs circumcision debate gets interesting</h2> <h3>Introduction</h3> As the incidence of routine circumcision in Britain reached its peak in the early 1930s, a controversy in the correspondence columns of the British Medical Journal revealed that just about as many doctors were opposed to the procedure as in favour of it. The correspondence is notable for the dismal quality of much of the argument, depressing lack of knowledge about male anatomy and sexuality, and blythe disregard for medical ethics. Anecdotes and "wise saws" were tossed around as though they were hard facts; nobody was aware of existing research which showed infantile phimosis to be normal or that assumptions about the "greater erotic sensitivity" of the glans were erroneous; and there was no suggestion that boys might miss their foreskin or were entitled to a say in whether they were allowed to keep it. [1] The dominant obsession â€“ with the squeaky cleanliness of the glans â€“ harks right back to William Acton's nervousness about the role of "secretions" in "premature sexual arousal" and masturbation. Much of the discussion centred on such Victorian medical principles as the physical dangers of masturbation, and the necessity for instant action against "congenital phimosis". If these points in favour of circumcision did not impress, advocates trotted out their clinching argument: that it provided protection from, if not immunity, to syphilis. But the debate is also remarkable for an entirely new note in British medical discourse: the suggestion that doctors should not be concerned with moral issues like masturbation, and the revolutionary suggestion that phimosis in infants was not a disease or abnormality at all. Although most of the opponents of circumcision laboured under the delusion that "congenital phimosis" in infants had to be treated urgently, the provocative Dr Ainsworth dared to state that phimosis was an "imaginary disease" and even recommended that the infant foreskin be left entirely alone, thus pointing the way toward <a href="http://www.cirp.org/library/general/gairdner/" rel="noopener" target="_blank">Douglas Gairdner's demolition</a> of "congenital phimosis" the following decade. The controversy was kicked off by a letter from D.I. Connolly, who deplored the high rate of injury and death arising from infant and childhood circumcision, and proposed his own patent method for separating and stretching the foreskin. Much of the resulting debate was the old circumcision vs. dilation argument which still gripped <a href="http://www.historyofcircumcision.net./templates/pages/should_he_be_circumcised_1941.html">Alan Guttmacher in 1941</a>. The zeal with which Connolly and his commentators recommended their patent methods for either cutting or stretching was not matched by the clarity of their exposition; most gave such a confused description of their technique that one wonders whether they could have given clear instructions for making a cup of tea, let alone for operating on one of the most complex sites of the male body. <h3>The letters</h3> <h4>The controversy is sparked off</h4> Although circumcision is performed frequently in all parts of the world, yet I think that this minor operation is capable of causing much trepidation even to the most experienced of surgeons. Complications occur now and again, but the most dreaded sequel of all is haemorrhage. This latter has been known to be the cause of death. It is not necessary to stress this fact; it is known only too well to many amongst us. Shock also may be an immediate cause of death. Other complications such a sepsis and ulceration do arise, and the latter may have serious later consequences. Hence the question arises: Is there any reliable, efficient method of treating severe phimosis other than by a cutting operation? In my opinion there is such a method, and one worthy of extensive trial. This method â€“ or operation rather â€“ should be performed as early as possible, say within the first week of the infant's life. No anaesthetic is needed. After thoroughly cleansing all the parts, using any reliable antiseptic â€“ for example, bichloride of mercury â€“ and wiping with antiseptic spirit, the child's legs are held firmly by an assistant standing at the head of the infant and the latter lying on his back. Strict asepsis must be practised as in any major operation. The instruments necessary are: Spencer Wells forceps, dressing or sinus forceps, and a blunt probe. The operator should draw the prepuce downwards with the index finger and thumb of his left hand. Gently insert the closed blades of the Spencer Wells forceps into the prepuce, of course avoiding the urinary meatus. Using care, push the blades gently upwards and at the same time opening the blades and thoroughly stretching the outer layer of the prepuce. Keep the blades in this position and manoeuvre the prepuce back beyond the glans penis. Then separate the inner layer of the prepuce from the glans by means of the blunt probe. Apply the blades of the sinus or dressing forceps to the inner layer of the prepuce and repeat to it what has already been done to the outer layer â€“ that is, manoeuvre it back to beyond the neck of the glans. Clean away all smegma and secretion that may have accumulated on the surface of the glans penis. The next and important step is the dressing. It is absolutely necessary to keep the entire prepuce in the position as described for the next few days. To do this, I have devised a circumcision dressing shield made of fine rubber, perforated with holes to allow the passage of fine tapes. These latter can be carried round the groins and tied off securely there. The shields are made up in sealed antiseptic cartons ready for use. They are impregnated with a zinc oxide cum boric powder. If necessary, some ribbon aseptic gauze may be first applied firmly around the retracted prepuce, and then the shield may be applied. Usually the mother is intelligent enough to be able to reapply the shield (if necessary). The child may be brought to the hospital or the surgery for redressing. The whole procedure should not take more than five minutes. The points in favour of it are: (1) absolute efficiency; (2) no haemorrhage; (3) fouling of the wound is reduced to a minimum â€“ the child is not able to kick off the shield dressing when efficiently applied and tied, hence sepsis is not so likely to occur; (4) if care and gentleness are used in the operation, shock is negligible; (5) anxiety and worry as to haemorrhage is removed from the surgeon's mind. The circumcision shields are made to my design by F. Whitehead and Co, Pickets Street, London S.W. 12. D.I. Connolly BMJ, 24 August 1935, p. 359 <h4>Responses</h4> I was interested in the technique described by Dr D.I. Connolly, as I endorse his view that circumcision can be followed by many unfortunate consequences. Apart from the immediate physical effects, there is considerable evidence that an operation which is a perfect result from a surgical point of view may yet cause psychological trauma, which may either show itself at once, or become obvious only in adult life. As the likelihood of such psychological trauma appears with the age of the child, it seems wise to deal with the condition at the earliest age possible, whether the prepuce is already adherent or the opening so small that adhesions are likely to occur. I first learned from Mr Geoffrey Keynes about five years ago that stretching the foreskin was a useful alternative to circumcision, and since that time I have not found it necessary to operate on any male child in my practice except in the case of orthodox Jews. My method is to stretch and free the foreskin daily, using a probe and sinus forceps, and doing it so gently that the child does not protest. This method will entail daily visits for one or two weeks, but after that the foreskin is quite free and can be pushed back by the mother when the child is washed as often as seems necessary to keep the glans clean. The stretching may be started soon after birth, and as a rough guide that a baby can stand this amount of interference, I usually wait until it has regained its birth weight. With adequate patience the whole thing can be done entirely without pain or risks, and to my mind the operation of circumcision in childhood is now seldom justifiable. Cecile Booysen Dr Connolly is to be congratulated on having taken a first step towards the treatment of phimosis. May I hope that he will soon take a second? The cool assumption of some surgeons that they know better than providence how little boys should be made is laughable and irritating. it is quite time that this horrible mutilation should no longer be regarded as having any sanitary or therapeutic value, and phimosis should be relegated to the list of imaginary diseases. Circumcision is, and always was, a tribal rite, and has no place in surgery. R. Ainsworth Referring to Dr D.I Connolly's letter, I am glad to hear of someone at last who is opposed to unnecessary circumcision: the majority of doctors and most nurses are obsessed with the idea that 90 per cent of male infants should be circumcised. The prepuce has its definite uses, which need not be gone into here. I myself have practised a similar method to the one described by Dr Connolly for over thirty years â€“ with success, but with this difference: I always use a local anaesthetic and no dressings or appliances. After separation of the prepuce from the glans penis, the prepuce is completely retracted, a mild antiseptic ointment is applied, and the foreskin is replaced in its normal position. All that is necessary thereafter is that the prepuce should be completely retracted once daily and the ointment applied by the nurse or mother until it goes back easily and the mucous membrane, when abraded, is seen to be healed. This usually requires about seven to ten days. Subsequently the prepuce should, for purposes of cleanliness, be retracted in the daily bath and cleaned with a little wet cotton-wool. D. Gordon Carmichael Although severe phimosis in infants may occasionally require circumcision, I was once told by a surgeon with twenty years in general practice that he had almost entirely avoided the operation by completely stripping back the foreskin, aided by dilatation if necessary, in the newborn and others, and by instructing the mother to see that it would peel back and to clean behind it each time the child was bathed. My own small experience is confirmatory. Every urologist would welcome the instilling of this particular habit of cleanliness into possible future patients. Malcolm Baillie Dr D.I. Connolly's very excellent procedure in the treatment of phimosis has one serious drawback â€“ the prepuce still remains. The teaching that the male should be circumcised on the eighth day has stood the test of time, and still remains sound. That the prepuce should be removed, whether phimosis is present or not, is an opinion which deserves the careful consideration of every doctor practising midwifery. Circumcision becomes a gentle art if practised in accordance with this theory. Joseph McAuley BMJ, 7 September 1935, p. 472 <h4>More responses</h4> Your correspondent Dr R. Ainsworth has apparently overlooked one important and well known fact when he writes that "circumcision is and always was a tribal rite and has no place in surgery", namely, the occurrence of carcinoma of the penis in the uncircumcised, and the extreme rarity of its occurrence â€“ if ever at all â€“ in those who have been circumcised. M.M. Posel In India, where I practised for over twenty years, no Hindu is ever circumcised; it is the mark of the Mohammedan. (In the Moplah rising, the Mohammedans forcibly circumcised Hindus who fell into their hands.) Imagine the reception a European doctor would meet with who practised it on all and sundry! This being so, what was to be done with Hindu infants who, having phimosis, had well developed rupture due to straining? I asked a ell-known Brahmin doctor with a large practice in the Punjab â€“ R.B. Balkishau Kaul of Lahore. He said that, whatever the difficulty, circumcision could never be done on a Hindu infant. All that was needed was to roll the prepuce sideways between finger and thumb, which broke down any adhesions, and then to push it back over the glans. This method was the same as that practised by Indian dais (midwives) when drawing milk from a woman's breasts. The nipple is gently trolled between finger and thumb. It is then easy to milk out any coagulum. Kathleen Vaughan Divergent views having been expressed on this subject, may I attempt to sum up and clarify the position? Dr McAuley's letter raises the point which is the crux of the matter: Should the prepuce be removed whether phimosis is present or not? I suggest that phimosis, especially if extreme, demands circumcision for these reasons. (1) Many infants so affected cry excessively until the operation is done: thereby (2) they may develop hernia. (3) Various troubles â€“ for example, nocturnal enuresis, "fits", and, in later life, epithelioma of the glans and paraphimosis â€“ are associated with phimosis. (4) In patients with phimosis suffering from gonorrhoea, complications arise, and treatment is more difficult than in the circumcised. (5) The disadvantages in the event of marriage are obvious. Although difficult of proof, there is little doubt that the prepuce, especially a long one, renders boys more likely to acquire the habit of masturbation. For this very good reason alone I think circumcision desirable, phimosis apart, If the reasons given for circumcision are sound, then stretching operations find no place. I venture to describe the method I use, as it is not the orthodox one. It is well to wait until the infant is 2 to 3 weeks old, and feeding is well established. Local anaesthesia is always used, novutox or locosthetic (P.D. & Co), being injected with a fine needle at the root of the penis on the dorsum and below at the peno-scrotal junction. This makes the operation entirely painless, as I have repeatedly proved. After thorough sterilising of all the parts with spirit and biniodide solution, the end of the prepuce is seized on the dorsum on each side of the middle line with small, narrow-bladed Spencer Wells forceps. Traction on these parts puts the prepuce on the stretch. A similar forceps is then passed down under the prepuce (dorsally), and opened widely, stretching the prepuce and freeing it from the glans, right down to the neck of the latter. The blade of a pair of straight, blunt-pointed scissors is then passed under the prepuce and the latter slit down dorsally to the neck of the glans. The prepuce is then separated, if necessary, from the glans on each side, and cut away, beginning at the fraenum and ending on the dorsum. The cutting is carried round close to the neck of the glans, leaving just enough skin and mucous membrane to be stitched together. During these various manoeuvres traction is made on the forceps originally applied, so as to steady and stretch the prepuce. Often no vessels need tying â€“ at the most, one on the dorsum and one on the fraenum. The free edges of the skin and mucous membrane are united by a few sutures of fine iodised catgut, using a small, half-circle Hagedorn needle. A narrow strip of sterile gauze is wrapped round and tied on. The operation takes very little longer than the usual one, and the skin edge left is almost a perfect "circle"; any after-trimming of the edges is rarely necessary. The advantages of this method are two: (1) there is no possible risk of injury to the glans; and (2) seeing exactly what one is doing, it is possible to remove the whole of the prepuce, which is the main point. results are entirely satisfactory, and in my experience shock, sepsis, haemorrhage etc are unknown. Stitches absorb or work out, and healing is complete in five to ten days. I hope I have shown, in reply to the flagrant statements of one of your correspondents, that "circumcision" is not a "horrible mutilation", that it "has a sanitary and therapeutic value", and, being ordained by Providence from very early times (doubtless for good reasons), it is not a "cool assumption" on the part of surgeons doing this operation that they "know better how little boys should be made". And if phimosis is to be relegated to the list of imaginary diseases, why not make a clean sweep, and say that cancer, tuberculosis, and the rest do not exist? G.W. Thomas This subject, like the big gooseberry, seem to crop up every few years, but nothing very fresh has been said on either side, and too often arguments are built up on irrelevant facts or theories. An example of this is given by Dr R. Ainsworth: "Circumcision was and is a tribal rite"; ergo, there is nothing more to be said in its favour. But was not fire itself at first an object of savage worship â€“ yet we do not discard our kitchen stoves? Again, the argument is brought up that the prepuce "being a work of providence" (with a small p, however), must be perfect. This strange argument would seem to abolish all evolution from the present-day perfection of everything, and one wonders was the five-toed horse perfect in its day and, if so, why was our one-toed animal evolved? But these are side issues. The crux of the whole matter is: Does removal of the prepuce lessen the incidence of syphilis? If this can be answered on the affirmative â€“ and surely the Jewish practice can provide statistics to settle it â€“ then circumcision is surely a duty in all cases. F.G. BMJ, 21 September 1935, p. 560 <h4>Another contribution</h4> It is 42 years since I qualified. For many of these years I circumcised most of the boys. Latterly it is never done. Dr D.I. Connolly describes "unfortunate consequences", which I fully confirm â€“ severe haemorrhage (one death from this cause), obstruction caused by sticky lymph at the urethral orifice, eczema round the scar, irritation of the glans penis. With firm determination the prepuce can always be pressed back. A few years ago Messrs C.H. Fagge and F. Steward of Guy's [Hospital] discontinued the operation, and there now exists a widespread objection to it, as shown by the correspondence in your columns. It may be worthy of record that I have been compelled to perform he little operation for a man of 80 years and, last year, for a man of 52 years, both with excellent results. Vaughan Pendred BMJ, 28 September 1935, p. 603 <h4>Yet further correspondence</h4> To the other not negligible points in favour of circumcision already recorded by many of your correspondents, I hope you will permit me to add that all those whom Providence (with a capital P) has cast for the lot or doom, of working in a venereal disease clinic (and especially one for seafarers) can have only preference for the circumcised patient. He is cleaner, easier to handle and treat, and his condition is easier to diagnose. While there is no convincing evidence yet presented of less incidence of syphilis in the circumcised, our observation here is that in patients with primary syphilis presenting themselves for diagnosis and treatment, there is a higher proportion of sero-negative cases among the circumcised. Obviously the lesion has been the sooner noted by its circumcised bearer; and this is true of all the other lesions occurring on the glans or frenum or on under-surface of prepuce. The sooner noted the sooner is treatment sought. Venereal warts and buboes are rarer in the circumcised. Many adult males who have experienced sexual intercourse before and after circumcision have, on questioning, reported either "no difference" or "better"; none has said worse. Mr Havelock Ellis records the preference of the copulating woman for the circumcised male. And look you, Sir, providence (surely now with a small p) has contrived that gorilla and chimpanzee be born without prepuce. [2] H.M. Hanschell If your correspondent F.G. would refer to the Journal of January 27th, 1934, (p. 144) he would find reported some facts relevant to the question "Does the removal of the prepuce lessen the incidence of syphilis?" [3] An inquiry into the relation between presence or absence of the prepuce and acquired venereal disease in 400 consecutive patients attending the department for venereal diseases at Guy's Hospital failed to show any appreciable differences, and we were led to believe that as far as our own facts went, there was no lessened risk of acquired syphilis in the circumcised. V.E. and N.L. Lloyd No doubt more than enough has already been written in your columns on circumcision, and views have been expressed with almost religious fervour. I feel, however, that the letter of Dr Cecile Booysen should not go unchallenged. She writes: Apart from the immediate physical effects, there is considerable evidence that an operation which is a perfect result from a surgical point of view may yet cause psychological trauma, which may either show itself at once, or become obvious only in adult life. I do not know, nor does she tell us, on what evidence this assertion is based; but I am confident that the treatment she practises in place of circumcision will most certainly tend to bring about a most serious psychological trauma â€“ namely, the habit of masturbation at a not very much later date. As I understand it, the treatment consists of stretching and freeing the foreskin daily for "one or two weeks", and when it is free the mother is instructed to carry on "when the child is washed as often as seems necessary to keep the glans clean". She adds, "with adequate patience the whole thing can be done entirely without pain or risks". I have no doubt that the child exhibits no sign of pain, but rather of pleasure, for as every child's nurse knows, nothing quiets a child so much as gentle manipulation of his genitals. At the same time, nothing is more apt to start the habit of masturbation than regular and long-continued manipulation of the penis. We are many of us familiar of us with the melancholy sight of a child of 3 or 4, or even younger, masturbating, and most investigators in this field are satisfied that this practice in the very young is the result of unwise handling by parent or nurse, which has taught the child he possibility of pleasurable sensations from friction on those parts. In a letter in he next column Dr Carmichael advocates much the same procedure. His treatment requires seven to ten days intensive manipulation, followed by occasional handling at bath time. In my view, if the glans can only be kept clean by regular manipulation of the foreskin, then it had better be left dirty or its covering removed surgically. Whether it is any more necessary to cleanse the male glans than it is to wash out the virgin vagina I will leave to your readers, but in my view the increased liability to syphilis and cancer in the uncircumcised is sufficient justification for removing the foreskin. C.E. Gautier-Smith BMJ, 5 October 1935, p. 642 <h4>The debate continues</h4> I am afraid that I must have earned, in my short time, the disapprobation of a number of your readers, for in my blundering ignorance I have assumed the mantle of a divinity and "shaped the ends" of some thousands of small boys. Yet I am unrepentant, for never have I had a complaint as regards ill after-effects. In view of my own slight experience I should unhesitatingly have any male children of my own circumcised within the first four weeks. The benefit conferred in respect of cleanliness alone is well worth any so-called risk of psychological trauma. I cannot convince myself of the reality of this phenomenon occurring in any child under, say, 5 years of age. I have a distinct recollection of my own circumcision at the age of 2, yet I altogether fail to perceive any gross mental lesion resultant therefrom. No person with any great experience of more or less routine circumcision in all cases of even "tightness" of the prepuce, as distinct from real phimosis, can have failed to appreciate the resultant benefit in the general health and well-being of the children. This was not the case in children whose prepuce was merely "well stretched". In almost all cases when such was done it was later found necessary to circumcise the child, whereupon all trouble ceased. "Bad technique!" exclaim all the "stretching" experts. No doubt but the technique was exactly that employed by Dr D.I. Connolly. Complications are, in my experience, due in almost all cases to poor nursing and careless mothers, and, even with the poorer classes in Glasgow as out-patients, were notable by their slight incidence. Haemorrhage need never occur with skill and careful ligation, and in cases where there is any tendency to general oozing I always found that a touch of adrenaline upon the dressing was always quite sufficient. I am interested in the theory that the operation may lessen the liability to syphilitic infection. Your letter from the Drs Lloyd seems to negative this, but I do think it is worthy of full investigation. At present I have twelve continuous treatment cases under my care. Of these only four have been circumcised. one can form no valid conclusion from such small figures, but it would be interesting to hear from some hospital authorities or VD clinics whether circumcision does, apparently, lessen the risk. D.W. Walker For many years I have been interested in circumcision as practised both in males and females in various parts of the world, and in my book to be published soon this essentially "tribal rite", as rightly described, will be fully investigated. When we come to inquire into the origin of this strange custom we meet many difficulties, but certain facts give support to the view that it originated from entirely different motives, such as (1) hygienic and prophylactic (useless, of course); (2) a possible association with phallic worship (and that, as we know it today, the remains of prehistoric human sacrifice connected with the cult); (3) a sacrifice of a portion to the gods to preserve the rest from harm, a practice well illustrated in other parts of the body; (4) to promote chastity â€“ history supplies examples of its total failure in this respect. Where did the practice originate? It was not compulsory, except among the priesthood, in ancient Egypt, and there is strong evidence that it was introduced into that country by the Negroes. It has been practised in West Africa for over five thousand years, without variation, and today the circumcision societies are still in a flourishing condition. It is general among the Jews, who took the custom from either the Babylonians or the Negroes, probably the latter. It is untrue to say the spread of the custom in Africa is due to Islam; it existed, of course, thousands of years, before Islam. It is interesting to note that during the Roman occupation of Egypt any doctor performing the barbaric operation was executed â€“ a harsh measure, but I believe some punishment should be reserved for those who waste valuable space in medical journals advocating the mutilation. T. Gerald Garry BMJ, 12 October 1935, p. 702-3 <h4>More arguments</h4> While avoiding the pros and cons of circumcision of male infants and children, I should like to express my entire agreement with Dr C.E. Gautier-Smith â€“ that manipulative surgery should find no place in the treatment of phimosis and allied conditions. The operation of circumcision, anaesthetic apart, is attended with very few risks. Haemorrhage should be very rare if the fraenal vessels are first tied before any incision is made and a simple tourniquet applied at the root of the organ (inch jaconet folded in three and held firmly in Spencer Wells forceps); a clean cut with a scalpel is made, taking care not to remove too much foreskin â€“ that is, flaying the glans penis. Redundant mucous membrane having been cut away, two lateral and one dorsal catgut sutures (Halstead) are inserted; a dressing applied, such as gauze impregnated with tinct. benz. co. does quite well. It is understood that the tourniquet is first released to make sure that there is no oozing before applying the gauze. Primary healing should be the rule, as soiling of the wound is prevented. Some of my colleagues have informed me that where necessary they sometimes do a circumcision on a newborn infant while awaiting the arrival of the placenta, with gratifying results. Of this line of treatment I myself have no experience. It has the great merit, however, that there is no anaesthetic risk, and it is done at a time when an infant can best tolerate trauma; but personally I would consider it a somewhat hurried proceeding. S.A. Montgomery With regard to your correspondence on circumcision the following case may be of interest. My son, now aged 6, was born with a long, tight foreskin. As I was against circumcision at the time, he was left uncircumcised. When he was 6 months old I noticed that he continually handled his penis. A colleague found adhesions, which he freed, and since then the foreskin has been pushed back every night at bath time and the parts thoroughly washed. There has been no recurrence of the handling on his part, except on one or two occasions when nightly washing has been omitted and there has been some slight inflammation. The boy now does the washing himself as a matter of routine, which falls into place with the cleaning of ears, teeth etc. The points I wish to stress are: (a) it is really difficult to keep the parts clean in the uncircumcised, and (b) regular pushing back of the foreskin and washing does not always conduce to masturbation, whereas dirty, itching parts do. I hesitate to have the boy circumcised now because I think it quite likely that a psychological trauma may result from the operation at this age. I know of at least one case where a boy of 4 years, one of twins, was circumcised, in which the operation was undoubtedly a great shock, and this may have farreaching results. With regard to what Dr H.M. Hanschell says of the preference of copulating women for the circumcised male: this may be due to the fact that the glans is less sensitive after circumcision in infancy and that therefore coitus can be prolonged. If this is the explanation it is an argument in favour of circumcision which should not be overlooked. Ejaculatio praecox with its concomitant unhappiness to both partners is common enough to call for investigation. W.M.C. My own personal experience leads me to echo Dr D.W. Walker's advice, although my experience is admittedly trivial in comparison. My elder brother and myself both required this attention at school age; two of my friends required it when medical students; recently an official in my town hall, with two grown-up children, had to absent himself for circumcision â€“ a very uncomfortable kind of operation for an adult, apart from the inevitable ribaldry as to change of faith and so on which ensues among the easily amused. I was foolish enough myself to listen to the advice of one of our maternity and child welfare staff, who stretched he prepuce of my elder son, with the result that he required at school age the operation he should have had as an infant. It is too bad that boys should suffer discomfort or be subjected to an operation at school age or later which should be carried out in infancy. M.D., D.P.H. I suggest that all male children should be circumcised. This is "against nature", but that is exactly the reason why it should be done. Nature intends that the adolescent male shall copulate as often and as promiscuously as possible, and to that end covers the sensitive glans so that it shall be ever ready to receive stimuli. Civilization, on the contrary, requires chastity, and the glans of the circumcised rapidly assumes a leathery texture less sensitive than skin. Thus the adolescent has his attention drawn to his penis much less often. I am convinced that masturbation is much less common in the circumcised. With these considerations in mind it does not seem apt to argue that "God knows best how to make little boys". R.W. Cockshutt BMJ, 19 October 1935, p. 763-4 <h4>Will the letters never cease?</h4> The question of circumcision seem to lead to a partisanship as violent as politics. I fancy that this enthusiasm for universality, apart from what has been called "tribal rites", is of fairly recent origin. I do not recall any clamour for it in the 1880s. At that time it was regarded as a tiresome minor operation, sometimes required on account of an objectionable and adherent prepuce. It was. I think, in the naughty nineties that the idea of promiscuous circumcision began to gain ground. For a time I fell in with the fashion. But it annoyed me to see the healthy progress of the infant sometimes even temporarily interrupted; and in still more to see occasionally the lactation of the mother interfered with by her worrying over the child. Still more was I upset by two unusual cases which occurred in the practice of a friend (who was, by the way, a very capable surgeon, priding himself particularly on his thoroughness in this minor operation). In each of these the cicatrix contracted and drew the loose skin of the penis up over the glans to form a fresh false prepuce. In one case the operation had to be done three times. In the other the difficulty was obviated by slitting the false prepuce longitudinally, so that any subsequent contraction would tend to pull the skin off the glans instead of over it. On discussing these cases with a well-known gynaecologist, I was surprised when he gave his opinion that it was very seldom necessary to resort to circumcision. From that time I reverted to "detachment and dilatation", with careful instruction as to subsequent daily cleansing of the parts beneath the prepuce. I never had any reason to be dissatisfied with the result of this method as a substitute for circumcision. Of course, neglect of such regular cleansing may lead to minor troubles later on. But the ill results of uncleanliness are not confined to the penile region. I do not know of any statistics which suggest that the circumcised are less liable to venereal disease. Nor have I any reason to believe that the uncircumcised are more prone to masturbation; on the contrary, I can recall the cases of two mothers, who each had one sone circumcised and the other not. The complaint of each of these mothers was that the circumcised boy was always "playing with his penis"; but the uncircumcised boy did not do so. I have no use for the argument that was once used to me â€“ that I was throwing away fees for operation. A.H. Williams Brevity is the soul of wit: I will be brief. If the technique I have described is followed closely and the dressing shield applied to the retracted prepuce, there will be no need for any other operation. But â€“ and this is most important â€“ the prepuce must be kept back for at least four to five days after the stretching etc. I have a long experience of the older radical method of circumcision. I would not think of doing it any more. My object in writing to the Journal was to advocate an extensive trial of the method of stretching plus dressing shield pressure; also, I started on the assumption that something must be done to overcome the severe phimosis. I am grateful to all those who have stated their experiences. it was not my intention to enter into the question of the functions of the prepuce, nor into any abstruse problems concerning the origins of circumcision. These are, however, of great interest. Has it ever occurred to anyone that a vaccine prepared from the smegma bacillus may possibly be of practical use â€“ for example, in connexion with tuberculosis therapy? D.I. Connolly I have been waiting in vain to see someone mention what I consider to be by far the best treatment for phimosis, and which I have used for thirty years. When a male child is born the penis is at once examined, and if the glans cannot be properly exposed I ask the mother and father whether they will have the child circumcised. I make arrangements with the nurse (usually the district nurse) for the next day. having seen the mother we go into the next room, and the nurse holds the child between her knees. A probe and a blunt pair of scissors are probably all that is necessary. Having separated all the foreskin from the glans a straight cut is made down the dorsum to the base of the glans. The foreskin is rolled back to form a scar around the penis on a level with the base of the glans. Occasionally one or two stitches are put in. A small piece of gauze is wrapped round it, to be renewed if it gets washed off. I explain that the penis may appear rather swollen on the second or third day, but that [this] need not be worried about. On the tenth day it has healed, and the foreskin has entirely disappeared. I have never had the slightest trouble over bleeding, as the fraenal artery is not approached, and the dressing has never given any trouble. I have done this on a few occasions to adults, under local anaesthesia, with the result that after a few months the foreskin has entirely disappeared. Of course, a few stitches have to be used. Norman H. Joy I have been watching the correspondence regarding this operation to see if any improvements on the technique of the late Mr A. Richardson of Leeds emerged, but so far have been disappointed. There is no question that the instruments used by the Jews, fashioned after the style of an Army button stick, which is slipped over the prepuce before section, is far and away the safest protection for the glans, and causes no trauma to the foreskin remaining. The key to the reconstruction is a stitch introduced on the left of the median raphe and passed obliquely to the right of the fraenum; it acts as a ligature to the fraenal artery; moreover, it puts the whole in position and avoids a knot of tissue beneath the penis. It is essential to ligature the two dorsal arteries, which can be done by passing a needle through the skin and mucosal cuff, and throwing the Spencer Wells forceps (already applied) over the ligature, thus serving two purposes. [4] Those who deny the existence of phimosis remind me of the old lady who, on visiting the zoo, was shown a giraffe. "There is no such animal", she exclaimed. A.P. Bertwhistle BMJ, 26 October 1935, p. 822-23 <h4>The discussion brought to a close</h4> I have been very much interested in the correspondence on circumcision. What it all comes to is this. Are doctors to be governed by purely medical reasons or not? Such arguments as those put forward that it lessens the likelihood of masturbation and the sensitivity of the penis, that it increases the pleasure of the partner in copulation etc, are scarcely in the realm of medicine, but of morality. Masturbation is a normal and harmless manifestation, except where it occurs in excess as a symptom of mental ill-health, and it savours if Jovian omniscience to interfere with the naturally provided erotic mechanism, although, of course, the untutored savage does not hesitate to do so, and could no doubt give many reasons for excising the clitoris or rupturing the perineum or ripping open the male urethra. To those who instance the occurrence of preputial lesions necessitating amputation in later life as a reason for preventive circumcision in infancy, one would say â€“ Why not eradicate the appendix, the tonsils? Why not expose the child to measles, mumps, whooping cough, and chicken pox? Or is the doctor supposed to be a prophet? Circumcision of the male prepuce, except when done in the presence of a definite physical lesion, as is the case with all the other bodily organs which are liable to disease, is a propitiatory gesture, incapable of justification on surgical grounds. J.L. Faull The description of a method of treating phimosis by the dorsal slit of the foreskin urges me to add yet another to the numerous letters on this matter. I too tried this as a substitute for the usual circumcision, but found the results far from satisfactory. With a lengthy foreskin, two flaps resulted, which hung down like miniature elephant's ears, and frequently became irritated from contact with urine. In more than one case a subsequent operation of circumcision was necessary to remedy this condition. I have now for many years used the following simple technique, which has given entire satisfaction. The foreskin is retracted, and after separation from the glans the preputial orifice is snipped at three points, one on the dorsum, the other two on each side of the fraenum, so that the three incisions are equidistant from each other. The foreskin is then fully retracted, and if the three snips have been accurately judged the foreskin should remain in this position. If too tight it is a simple matter to enlarge the incisions somewhat and secure an easy fit. The incisions made in the long axis of the penis become stretched to form three segments of a circle, and heal without producing any deformity such as that described above. The usual dressing is a strip of gauze soaked in sterile Vaseline, which effectually prevents soiling with urine. Should the opening be too wide the foreskin may slip forward, but it is not a difficult task for the nurse to push it back daily, and healing occurs perhaps more slowly, but equally satisfactorily. J.A. Pottinger The simplest method of relieving a phimosis in the newborn has not so far been mentioned in the discussion. This consists in simply splitting the foreskin with scissors, putting in three stitches, one at the corona and one at each anterior corner. Practically no interference with either the nerve or blood supply happens, and cosmetically the result is excellent. W.L. English I do not agree with Dr R.W. Cockshut that the less sensitive glans of the circumcised is conducive to chastity and forms a shield against sexual perversions. The Mohammedan is not any more chaste than the non-Mohammedan, nor is he free from sexual perversions. I should also have thought that the exposed glans would have attracted the adolescent's attention more than the covered one. As regards manipulative surgery in phimosis, I fail to see the objections raised by some of your correspondents. It has its place wherever practicable, and I have seen no ill effects follow its practice. Circumcision is the last resource, and it is possible that there is a certain amount of "psychic trauma" attending its performance on an introspective boy. Can it be that the circumcision of a highly sensitive and gifted boy made him inflict on the world his "castration complex"? M.P.K. Menon It seems that the opinion of the majority of your recent correspondents on the subject of circumcision in childhood for phimosis is that (1) it should be done when required; (2) the risk of operation and its consequences are small; (3) the manipulative stretching method has its drawbacks; (4) from a psychological point of view, it is undesirable and even embarrassing for the mother, nurse or, later on, the child himself, to pay so much and constant attention etc to his genital organs; (5) if venereal disease is contracted, the circumcised are in a cleaner and more hygienic state; and finally (6) some uncircumcised people fail to keep themselves clean, as is well illustrated in the following case. Some six or seven years ago a young Englishman, who acted as a representative for a British firm in Germany, came to me while on holiday in London on account of some white discharge from his penis. As he had been exposed to possible infection he was sure that he suffered from gonorrhoea. On examination, however, I found that his foreskin was adherent to the glans, and that between the two there was a thick layer of yellow-white cheesy smegma or concretion. It was very adherent, and owing to some inflammation it took me a few days to remove it gradually with warm alkaline lotion, and so separate the adhesions etc. The patient was, however, greatly surprised when I told him he did not suffer from gonorrhoea, but from the effects of local uncleanliness. L.B. Sheinkin A somewhat provocative letter which I wrote as a soporific in the hot hours of an early August morning has been followed by such a long correspondence that I wonder if you will allow me to thank those who have tried to point out my errors and to lead me into the right way. Many of the writers are so lost in admiration of their own techniques that reasons for their procedure are obviously of secondary consideration with them. But the one with whom I am most in sympathy is Dr H.M. Hanschell. He says that with universal circumcision his patients in a venereal disease clinic would be cleaner and easier to handle and treat. Not, be it noted, that the incidence of such disease would be lessened, or that treatment would be more efficient, but that Dr Hanschell would have an easier time. And if I were in his place I have no doubt that I should be of the same opinion. Now with regard to the condition known as phimosis, may I point out the elementary fact that the preputial orifice is surrounded by a fibro-elastic ring, and that fibro-elastic tissue stretches with varying degrees of ease and rapidity in different individuals. Anyone who as patiently watched the slow stretching of the perineal region in a primipara must realize this; and also that a very small opening can be gradually dilated to a great size without injury, provided that ample time is taken and the force exerted is not too great. Similarly, a small preputial orifice which cannot be stretched to the size of a threepenny bit in half a minute is not a pathological condition; and there is no justification whatever for losing one's patience and forcibly cutting or stretching it. If I innocently ask why it is so necessary that a baby's prepuce should be retracted at the earliest possible moment I know I shall be met with a sniff and a snort, and be shrivelled up by the magic word "cleanliness". So to those of the profession who have time to think, may I leave a few questions for consideration? What is the use of Tyson's glands, [5] and at what age do they begin to function; when does a natural secretion become dirt; and what dreadful thing will happen if a baby's prepuce is left entirely alone? R.W. Ainsworth This corespondence is now closed. - Ed. BMJ, 2 November 1935, p. 876-77 <h3>NOTES</h3> 1. In 1894 German researchers using the newly invented aesthesiometer discovered that the glans was quite insensitive, and their findings were confirmed by the English neurologist Henry Head in 1908. In his Studies in neurology (1920) he reported that the glans was about as sensitive as the heel of the foot. Other German researchers had established the rich and complex innervation of the prepuce in a study published in 1893, but there was no further work on the subject until the 1930s. The denser innervation of the foreskin was confirmed by R.K. Winkelmann in the 1950s, and again (quite decisively) by Chris Cold and John Taylor in the 1990s. A good summary and the full text of most of the key articles <a href="http://www.cirp.org/library/sex_function/" rel="noopener" target="_blank">is available at the CIRP</a>. On the normality of infantile phimosis, it is interesting to note that this had been written as early as 1916: <div>It is not widely enough realized, particularly by the lay public, that a condition of phimosis is normal at birth. It is inconceivable that children are born with actual deformities in this region as often as the statistics of circumcision would lead an observer to suppose. It is not until the penis undergoes its final development at puberty that the proper balance between the prepuce and the glans is struck.</div> Geoffrey Jefferson, "<a href="http://www.cirp.org/library/anatomy/jefferson/" rel="noopener" target="_blank">The peripenic muscle; some observations on the anatomy of phimosis</a>", Surgery, Gynecology, and Obstetrics (Chicago), Vol. 23, 1916, pp. 177-81 2. The truth about apes is quite the reverse: chimpanzees have a foreskin but no glans. This was observed as early as the 1690s in the first-ever anatomical description of a young chimp by Edward Tyson (1651-1708), who reported: "Whether there was any Balanus or Glans in the Penis of our Pygmie, or what it was, I am uncertain: I do not remember I observed any". (Orang-Outang, sive Homo Sylvestris, or the Anatomy of a Pygmie, London 1699, facsimile reprint, with introduction by Ashley Montague [London: Dawsons, 1966], p. 45). This has been confirmed by <a href="http://www.cirp.org/library/anatomy/cold-taylor/" rel="noopener" target="_blank">Cold and Taylor 1999</a>, and in Chris Cold and Ken McGrath, "<a href="http://www.cirp.org/library/anatomy/cold-mcgrath/" rel="noopener" target="_blank">Anatomy and histology of the penile and clitoral prepuce in primates</a>", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, New York, Kluwer Academic/Plenum Publishers, 1999. For further information on Tyson, see Ashley Montagu, Edward Tyson MD and the rise of human and comparative anatomy in England (Memoirs of the American Philosophical Society, Vol. 20, 1943), and Stephen Jay Gould "To show an ape", in The Flamingo's smile (Penguin 1986), pp. 263-80. Although both Montagu and Gould praise Tyson's skill as an anatomist, he did sow the seeds of much future confusion by claiming to discover glands under the foreskin which were supposed to secrete "smegma", thus giving rise to the mythical "Tyson's glands", which have proved such a stand-by for posthephobes and others who imagine the foreskin to be unclean. See also Note 5. Montagu later wrote a <a href="http://www.nocirc.org/symposia/second/montagu.html" rel="noopener" target="_blank">powerful essay against routine circumcision</a>, "Mutilated Humanity", given at the Second International Symposium on Circumcision, San Francisco, California, April 30-May 3, 1991. 3. The reference is to V.E. and N.L. Lloyd, "Circumcision and syphilis", British Medical Journal, 27 January 1934, pp. 144-6. For further discussion see Robert Van Howe, "<a href="http://www.cirp.org/library/disease/STD/vanhowe6/" rel="noopener" target="_blank">Does circumcision influence sexually transmitted diseases? A literature review</a>", BJU International, Vol. 83, Supplement 1 (January) 1999, pp. 52-62; and Robert Darby, "Where doctors differ: The debate on circumcision as a preventive of syphilis, 1855-1914", Social History of Medicine, Vol. 16, 2003, pp. 57-78 4. In his article, "Juvenile circumcision: A plea for a standardised technique", (Lancet, 12 January 1936, pp. 85-6), Bertwhistle expressed surprise that every modern textbook described a different method of circumcision, and also concern that the results were "by no means uniformly good". He commented that a repeat operation was often necessary "because of cicatrization of a foreskin left unduly long, and an objectionable lump [near] ... the frenum". Despite the pleas, <a href="http://www.cirp.org/library/complications/" rel="noopener" target="_blank">complications remained common</a>, and Gairdner reported <a href="http://www.cirp.org/library/death/" rel="noopener" target="_blank">16 deaths per year</a> in the 1940s. 5. Although one finds references to them everywhere (from new baby bulletin boards and circum-fetishist/posthe-phobic Yahoo groups to serious works of reference such as Wiley's International Dictionary of Medicine and Biology (1986, Vol. 3, p. 1207) and the new Oxford Dictionary of National Biography (entry for Edward Tyson, Vol. 55, p. 819), there is no such thing as Tyson's glands. The moisture beneath the prepuce consists simply of water, shed skin cells, secretions from the prostate, seminal vesicle and urethral glands, various sterols and fatty acids which normally protect skin surfaces, and a variety of benign bacteria. Very few men, and even fewer boys, generate any visible smegma. (See articles by Satya Parkash et al 1980 and 1982, and by Cold and Taylor 1999, <a href="http://www.cirp.org/library/sex_function/" rel="noopener" target="_blank">all available at CIRP</a>.) Cold and Taylor comment: <div>Even in modern textbooks, Tyson's glands are often described as the source of smegma; however, no evidence of Tyson's glands has ever been described outside of Cowper's macroscopic description of these glands in 1694. This may be one of the longest held myths in medicine. Cowper's description of Tyson's glands in the human is actually of hirsutoid papillomas of the glans penis, which are fibroepithelial structures and not glandular structures. Although other mammals have true clitoral and penile preputial glands which secrete sex pheromones, there is no current evidence of these glands in humans. (<a href="http://www.cirp.org/library/anatomy/cold-taylor/" rel="noopener" target="_blank">See CIRP web version for references</a>.)</div> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource For and against circumcision darby