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• The history of Jewish circumcision - a response to Lang
  Guy Cox
  Published on: 11 September 2013
• Sloppy scholarship and the anti-circumcision crusade.
  Stephen Moreton
  Published on: 17 July 2013

• Published on: 11 September 2013

  The history of Jewish circumcision - a response to Lang

  • Guy Cox, Honorary Associate Professor
  • Other Contributors:
    • Brian Morris, John N. Krieger

  A recent Commentary piece by Lang¹ contains a substantial historical error. He writes "Milah is merely a token clip of the very tip (the overhang flap or akroposthion) of the prepuce, which leaves most of the organ system (including all its essential functions) intact." No reference is cited, but the source appears to be Wallerstein². Medical considerations make this unlikely,...

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  A recent Commentary piece by Lang¹ contains a substantial historical error. He writes "Milah is merely a token clip of the very tip (the overhang flap or akroposthion) of the prepuce, which leaves most of the organ system (including all its essential functions) intact." No reference is cited, but the source appears to be Wallerstein². Medical considerations make this unlikely, and the available historical evidence contradicts it. From the medical perspective, if the circumcision scar can migrate in front of the corona glandis it tends to shrink and create a secondary phimosis or a trapped penis. If treated early this can be remedied without further operation³ but re-circumcision may be necessary⁴. Leaving it untreated can have serious consequences⁵. Successful outcomes, with or without further surgery, result in a fully exposed glans. Deliberate removal of only the excess foreskin, without subsequent retraction and exposure of the glans, therefore poses a serious risk of creating an intractable secondary phimosis.

  All available evidence suggests that Jewish circumcision did expose the glans. There is no pre-Hellenic representation of Jewish circumcision - there is almost no surviving early Jewish iconography, and the Jewish prohibition of exposing the genitals⁶ means that in any case penises would not be depicted. However, Egyptian circumcision long predates Jewish circumcision, and there is good reason to believe that the Jewish practice was derived from the Egyptian⁷. Iconography of circumcised Egyptians is abundant, and detailed⁷. One can see from these that the glans was completely exposed, though there could be a 'cuff' of residual inner foreskin behind the glans. This is exactly what would be expected from descriptions of the chituch operation (described by Lang¹ as milah). The foreskin is forcefully stretched forward and severed in front of the glans. The outer layer springs back behind the glans and the residual inner foreskin is pushed back to meet it⁷. There is a 5,000 year old Egyptian illustration of the technique⁷, and the same technique is still used today in both medical and ritual circumcisions. There is also much textual evidence that Jewish circumcision exposed the glans. It is recorded that Jewish athletes competing in Graeco-Roman games wore a cap to cover the glans⁸.

  The chituch type of circumcision does leave sufficient loose skin for foreskin reconstruction by stretching to be possible, and there is Biblical evidence that this did occur⁹. Roman surgeons wrote about techniques for foreskin restoration to re-cover the glans after circumcision⁸. Many Jews became Hellenised and wished to compete in athletic events⁹, for which a reconstructed foreskin was a more seemly solution than a cap (especially since the cap could be lost in the heat of competition⁸). It has long been accepted that periah - ablation of the inner foreskin - was a later introduction into Jewish ritual circumcision10. This technique is also still currently used in both ritual and medical circumcision⁷. Foreskin restoration would have been virtually impossible after the introduction of periah so periah could not have been part of the operation before the Hellenistic period, and it was a prescribed part of the rite in the Talmudic period three of four centuries later. It is therefore hard to escape the idea that periah was introduced to hinder circumcision reversal^1,2,7. Following the destruction of Palestinian Jewish culture in AD 70 Jewish populations were dispersed. Since new ideas would not be adopted everywhere at the same time, it would be unlikely that periah was adopted by all Jewish communities at the same time. Circumcision reversal was still a topic of discussion late in the first century AD¹¹. The important point is that periah did not affect the exposure of the glans penis, it just made circumcision reversal more difficult.

  We would also add, as a postscript, that Lang's use of the sale of Viagra as a metric of erectile dysfuntion1 seems curious when many studies in the developed and developing countries have actually investigated the topic directly. Large-scale studies in the US¹², Australia¹³ and Africa¹⁴ have shown that circumcised men are significantly less likely to suffer from erectile dysfunction. Sales of Viagra in the richest country of the world reflect nothing more than the ability to pay for it.

  REFERENCES

  1. Lang DP. Circumcision, sexual dysfunction and the child's best interests: why the anatomical details matter. J Med Ethics 2013. (Epub ahead of print May 28. doi 10.1136/medethics-2013-101520).

  2. Wallerstein E. Circumcision - An American Health Fallacy. New York: Springer, 1980:281pp.

  3. Blalock HJ, Vemulakonda V, Ritchey ML et al. Outpatient management of phimosis following newborn circumcision. J Urol 2003;169:2332-4.

  4. Patel H. The problem of routine infant circumcision. CAMJ 1966;95:576-581.

  5. Sancaktutar AA, Kilincaslan H, Atar M et al. Severe phimosis leading to obstructive uropathy in a boy with lichen sclerosus. Scand J Urol Nephrol 2012;46:371-4.

  6. Genesis 9, verses 20-24

  7. Cox G, Morris BJ. Why circumcision, from prehistory to the 21st century. In: Bolnick DA, Koyle M, Yosha A (eds), Surgical Guide to Circumcision London: Springer. 2012:243-59.

  8. Rogers BO. History of external genital surgery. In: Horton CE (ed). Plastic and Reconstructive Surgery of the Genital Area. Boston: Little Brown & Co. 1993:3-15.

  9. 1 Maccabees 1, verses 15-16

  10. Bryk F. Circumcision in Man and Woman. (tr. Felix Berger). New York: American Ethnological Press, 1934:342 pp. (Facsimile reprint New York: AMS Press, 1974)

  11. 1 Corinthians 7, verse 18

  12. Laumann EO, Maal CM, Zuckerman EW. 1997. Circumcision in the United States. Prevalence, prophylactic effects, and sexual practice. JAMA 1997; 277:1052-7.

  13. Richters J, Smith AMA, de Visser RO, Grulich AE, Rissel CE. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006;17:547-554

  14. Krieger, JN. Circumcision, sexual function and sexual satisfaction. In: Bolnick DA, Koyle M, Yosha A (eds), Surgical Guide to Circumcision London: Springer 2012:233-239

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 17 July 2013

  Sloppy scholarship and the anti-circumcision crusade.

  • Stephen Moreton, Scientist

  By Stephen Moreton Ph.D.

  Whilst it is right and proper that the circumcision issue be debated, it is disturbing that many of those who oppose circumcision rely heavily upon selective literature citations, untested speculations about foreskin function, fear-mongering aimed at making circumcised males feel they have been sexually damaged, and denialism about the proven benefits of the procedure, while ignoring pub...

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  By Stephen Moreton Ph.D.

  Whilst it is right and proper that the circumcision issue be debated, it is disturbing that many of those who oppose circumcision rely heavily upon selective literature citations, untested speculations about foreskin function, fear-mongering aimed at making circumcised males feel they have been sexually damaged, and denialism about the proven benefits of the procedure, while ignoring published criticisms of their arguments. Predictably all these academic sins are committed by circumcision opponents in the current issue of the Journal of Medical Ethics. Rather than rebut each author in turn, which would be tedious, I will concentrate on just one, the article by David Lang, "Circumcision, sexual dysfunction and the child's best interests: why the anatomical details matter"1. Most of the usual academic sins are repeated in his opinion piece, making it a good example of anti-circumcision polemic.

  Part of the reason Lang's piece is so bad is his use of popular, non- peer-reviewed, or biased sources. Lang is heavily reliant on an opinion- piece by Fleiss in a popular magazine called "Mothering: the Magazine of Natural Family Living"2. To anyone familiar with popular but unscientific views, the word "natural" always sets alarm bells ringing, as it is so often associated with the appeal to nature fallacy. Lang's reference list also reads like a "Who's Who" of the anti-circumcision movement: Fleiss, Cold, Taylor, Bollinger, Van Howe, Darby, Svoboda ... all well known to be passionately anti-circumcision and therefore, it may be argued, not impartial, and some of whom have clocked up impressive tallies of rebuttals and critiques in the medical literature.

  Proceeding now to the technical points, citing Fleiss2 Lang tells us that the foreskin contains "more than 20000 nerve endings". Fleiss gives no experimental data in support of this, but instead refers to an old paper3 which does not give the 20000 figure, directly. It has to be inferred by extrapolation, and exaggeration, from a single square centimetre of a single foreskin which contained 212 nerve endings. It is not clear where on the foreskin the sample came, which is important as the distribution of nerve endings may vary. Nor is it stated how old the donor was, which matters as nerve ending density may decline with age. It includes nerve endings of any kind, including temperature receptors, but there were only two of the touch receptors (Meissner's corpuscles) that circumcision opponents harp on about. There is no indication of how typical this particular sample was, nor any comparison with other body parts to provide a control. And to arrive at 20000 one has to multiply by 94.3 square centimetres, which is a very generous foreskin, even assuming both inner and outer surfaces are being counted. None of this mattered for the purposes of the original study, but Fleiss' extrapolation is absurd and, without a control, worthless.

  Copying another of Fleiss's errors, Lang complains about, "desensitisation of the glans ... due to successive layers of keratinisation from constant exposure and abrasion". As before this is not backed up by peer-reviewed science. Like the oft-repeated 20000 figure, it is an urban myth. What scant evidence there is indicates no difference between circumcised and uncircumcised members4.

  Continuing with his theme of copying uncritically from Fleiss, Lang lectures about drying of the glans and interruption of "the normal circulation of blood". Without wishing to sound facetious one may retort, "So what?" In the absence of evidence that these things matter, they are irrelevant, although it could be argued that drying creates an environment less conducive to pathogens.

  The doctrine of the gliding motion is next. Circumcision immobilises the remaining skin and thereby "destroys the mechanism by which the glans is normally stimulated", Lang parrots Fleiss. It may be countered that circumcision enhances the actual mechanism by which the glans is stimulated - direct contact with the vaginal wall. Many men do find their foreskins gliding back and forth during coitus, but others have short foreskins that retract behind the glans upon erection. Where is the research indicating how many men experience gliding, what they (and their partners) think about it, and whether the greater contact with the vaginal wall experienced by a bare glans compensates for its loss? What would a condom do to it?

  Finally breaking from echoing Fleiss, Lang begins copying unquestioningly from Cold & Taylor5. Meatal stenosis, we are told, occurs in "in 5-10% of circumcised males" citing these two circumcision opponents, but theirs' is a secondary source, which in turn cites five others. The first is an author (Van Howe) whose later more detailed study on this topic was discredited6. Three others were studies of children circumcised because of foreskin pathology, which may be associated with meatal stenosis. The remaining study found an 8 % incidence but had no control.

  Some recent studies find dramatically lower figures. 0.55 % and 0.9 % in Iran7,8 and 0.01 % for English boys9. Another Iranian study found 6.6 %, but none at all when petroleum jelly was applied for 6 months post- op10. Meatal stenosis has long been regarded as subjective and tricky to define and diagnose consistently, with differences of opinion even as to its significance11.

  "The prepuce is primary, erogenous tissue necessary for normal sexual function. The complex interaction between the protopathic sensitivity of the corpuscular receptor-deficient glans penis and the corpuscular receptor rich ridged band of the male prepuce is required for normal copulatory behavior" Lang cuts and pastes from Cold & Taylor. But others dismiss this as unproven speculation12. Although the sample size was small, when men were asked to rank the different parts of their penis with respect to sexual sensation, the glans was first, the prepuce last13. Sexual sensation is mediated by genital corpuscles, which are absent from the prepuce14.

  In the recent African HIV prevention trials, thousands of men were circumcised and compared to controls. These studies included sexual function. In the Ugandan trial, 98 - 99 % of both the intervention and the control groups reported satisfaction with their sexual function after two years15. In the Kenyan trial, 64 % of men found that sensitivity improved after circumcision, and 54.5 % reported greater ease of achieving orgasm16. The most recent meta-analysis on the subject found that circumcision has no adverse effect on male sexual function17. Circumcision opponents greatly overstate the alleged erogenous merits of the foreskin.

  Lang switches to a study by two other prominent, anti-circumcision figures, Bollinger & Van Howe18 to claim that "circumcised men are 4.5 times more likely to use an erectile dysfunction drug than intact men." Unfortunately, Lang ignores the subsequent criticism of this study19. Its self-selected sample was recruited through advertisements on two websites with strongly anti-circumcision content. It is hard to imagine a more effective way of ensuring a biased sample, short of advertising specifically for circumcision opponents. Indeed the loaded title of the advertisement, "Male circumcision trauma survey" comes close to doing exactly that. In their reply, Bollinger & Van Howe concede the potential for bias, and that their results are "unconfirmed"20.

  When Lang gets to his next point, "18% of adult American men (of whom approximately three-fourths are circumcised) have erectile dysfunction" he finally cites a credible source21. But it is a source that linked erectile dysfunction to cardiovascular problems, diabetes, lack of exercise and age, not to circumcision. The aforementioned meta-analysis found no association between circumcision and erectile dysfunction17.

  Lang concludes his section on the alleged harm of circumcision with an extraordinary combination of speculation and barrel-scraping. The USA, he tells us, "accounts for 46% of Viagra sales" and, whilst conceding that this "could be explained by any number of factors unrelated to circumcision", speculates that this is due to truncation of the perineal nerve.

  In the absence of any credible evidence that circumcision causes erectile dysfunction, speculations about the perineal nerve are moot. And the popularity of Viagra, which can be a recreational drug, in the wealthiest country on earth, with a high consumption of all manner of pharmaceuticals, can indeed be explained without recourse to baseless fear -mongering about circumcision.

  Done properly, circumcision does not damage sexual function. But misleading claims put about by its opponents do damage the self-esteem of circumcised males by needlessly making them feel they are damaged, and are missing an important part of their anatomy. And they distress parents by deceiving them into believing they have harmed their sons. This is certainly an effective way to draw angry and motivated new recruits into the anti-circumcision movement, and into "surveys" on "circumcision trauma", but it is misleading and unethical.

  Whether or not to circumcise should be decided on quality peer- reviewed evidence that withstands scrutiny. Not urban myths, untested speculations, and discredited "surveys" on biased samples by biased authors. But that is all Lang offers us. It is ironic that the title of Lang's opinion piece should state that "the anatomical details matter" and he then proceeds to get them wrong, or to exaggerate their importance. His details do not matter. The facts do, and they do not support the anti- circumcision crusaders' claims about impairment of sexual function.

  References.

  1. Lang, D.P. "Circumcision, sexual dysfunction and the child's best interests: why the anatomical details matter". J Med Ethics, 2013;39:429- 31.

  2. Fleiss, P. The case against circumcision. Mothering: the Magazine of Natural Family Living. 1997;Winter:36-45.

  3. Bazett, H.C., McGlone, B., Williams, R.G., Lufkin, H.M., Depth, Distribution and Probable Identification in the Prepuce of Sensory End- Organs Concerned in Sensations of Temperature and Touch; Thermometric Conductivity. Archives of Neurology and Psychiatry, 1932;27:489-517.

  4. Szabo, R., Short,R.V., How does male circumcision protect against HIV infection? BMJ, 2000;320:1592-4.

  5. Cold, C.J., Taylor, C.R. The prepuce. Br J Urol., 1999;83:34-44.

  6. Schoen, E.J. Letter to the editor. Clin Ped., 2007;46(1):86.

  7. Simforoosh, N., Tabibi, A., Khalili, S.A.R., Soltani, M.H., Afjehi, A., Aalami, F., Bodoohi, H. Neonatal circumcision reduces the incidence of asymptomatic urinary tract infection: a large prospective study with long-term follow up using Plastibell. J Ped Urol., 2012;8:320- 3.

  8. Yegane, R-A., Salehi, N-A., Koshdel, J-A. Late complications of circumcision in Iran. Pediatr Surg Int., 2006;22:442-5.

  9. Cathcart, P., Nuttall, M., Meulen, J., Emberton, M., Kenny, S.E. Trends in paediatric circumcision and its complications in England between 1997 and 2003. Brit J Surg. 2006;93:885-90.

  10. Bazmamoun, H., Ghorbanpour, M., Mousavi-Bahar, S.H., Lubrication of circumcision site for prevention of meatal stenosis in children younger than 2 years old. Urol J., 2008;5(4):233-6.

  11. Belman, A.B., Filmer, B.B., Immergut, M.A., Schoenberg, H.W. Pediatrics, 1978;61:778-80

  12. Alanis, M.C., Lucidi, R.S., Neonatal circumcision: A review of the world's oldest and most controversial operation. Obstet Gynecol Surv., 2004;59(5):379-95.

  13. Schober, J.M., Meyer-Bahlburg, H.F., Dolezal,C. Self-ratings of genital anatomy, sexual sensitivity and function in men using the 'Self- assessment of genital anatomy and sexual function, Male' questionnaire. BJU Int., 2009;103:1096-1103.

  14. Rhodin, J.A.G. Histology. 1974. Oxford University Press, London.

  15. Kigozi, G., Watya, S., Polis, C.B., Buwembo, D., Kiggundu, V., Wawer, M.J., Serwadda, D., Nalugoda, F., N., Bacon, M.C., Ssempijja, V., Makumbi, F., Gray, R.H., The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakia, Uganda. BJU Int., 2008;101:65-70.

  16. Krieger, J.N., Mehta S.D., Bailey R.C., Agot, K., Ndinya-Achola, J.O., Parker, C., Moses, S. Adult male circumcision: Effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med., 2008;5:2610 -22.

  17. Tian, Y., Liu, W., Wang, J.Z., Wazir, R., Yue, X. & Wang,K.J. Effects of circumcision on male sexual functions: a systematic review and meta-analysis. Asian J Androl., 2013; in press.

  18. Bollinger, D., Van Howe, R.S. Alexythmia and circumcision trauma: a preliminary investigation. Int J Men's Health, 2011;10:184-95.

  19. Morris, B.J., Waskett, J.H., Claims that circumcision increases alexithymia and erectile dysfunction are unfounded: a critique of Bollinger and Van Howe's "Alexithymia and circumcision trauma: a preliminary investigation". Int J Men's Health. 2012;11:177-81.

  20. Bollinger, D., Van Howe, R.S. Preliminary results are preliminary, not "unfounded": reply to Morris and Waskett. Int J Men's Health. 2012;11:181-4.

  21. Selvin, E., Burnett, A.L., Platz, E.A. Prevalence and risk factors for erectile dysfunction in the US. Amer J Med., 2007;120:151-7.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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