As an outgrowth of the middle class, the medical establishment reflected and validated these social changes and offered treatment for the anxieties they inevitably produced, thereby laying the foundations of the modern therapeutic state — defined by Thomas Szasz as the political order in which social controls are legitimized by the ideology of health [1]. For instance, in traditional agrarian society adulthood was considered to begin at puberty. Industrialized, middle class society extended the boundaries of childhood by ore than a decade so that middle class males could receive the specialized professional and academic training required by a modern industrialized society. The formidable anxieties engendered by this transformation found expression in an intensified focus on childhood sexuality. In conformity with middle class social mores, physicians theorized that childhood should be a period of complete asexuality and, consequently, that children should be kept ignorant of sexual and reproductive information until their delayed marriage. The functional significance of this change was that young people, who in previous generations had been expected to marry and commence sexual activity in early adolescence, were now required to restrain themselves from sexual activity and remain continent until they were in their twenties. Young people who were unable to suppress their sexual drives were subjected not only to social censure, but to medical interventions as well.
2. Supporting medical theories
2.1 Degenerative theory of disease and the notion of reflex neurosis
For reasons unrelated to the rise of the American middle class, two French physicians in the 1820s, Xavier Bichat (1771-1802) [2] and Francois Broussais (1771-1838) [3], developed a new model of disease — the theory degenerative disease. This model postulated that the human body was allotted a finite amount of vital energy which could either be conserved through correct living or permanently lost through wrong living. Energy depletion led to degeneration, which in turn led to the production of disease. Middle class American physicians readily adopted this theory, but they expanded it to imply that manifestations of sexuality necessarily represented life-threatening losses of vital energy. Non-procreative use of the sexual organs, even within marriage, was viewed as dangerous. The result was the formulation of the Reflex Neurosis Theory of Disease, which postulated that the sexual organs and the erotic sensations they produced were the cause of all human disease. To validate this theory, American physicians redefined normal human sexual behaviour, reproductive anatomy and sexual function in terms of pathology.
Pathologization of sexual behaviour
The pathologisation of normal sexual behaviour resulted in the masturbation hysteria. The term masturbation was frequently used in a generalised way to describe any sexual activity outside the context of heterosexual marital coitus for the purpose of procreation, but in practice a diagnosis of masturbation generally followed the discovery of a child’s either having sexually stimulated him/herself or having engaged in sexual activity with another person. Physicians relied on spurious logic to support the pathologisation of sexual behaviour. Clinical interviews with patients suffering from what would today be ascribed to the effects of malnutrition, overwork, venereal disease, bacterial or viral infections, mental disorders, and tobacco or alcohol poisoning invariably revealed a past history of masturbatory activity. On this basis it was easy to conclude that masturbation had brought on these conditions. The inhabitants of the United States were at first reluctant to accept the theory that masturbation was harmful, and many resisted doctors’ interference in the lives of their children; but the rising flood of articles in medical journals that allegedly proved the harm of masturbation gave physicians the power to overcome this resistance and enforce their own convictions.
Pathologization of sexual anatomy
In order to validate the Reflex Neurosis Theory of Disease, physicians were compelled to pathologize the three distinguishing features of the normal juvenile foreskin, namely, generous length, adherence to glans and narrowness of the preputial orifice. These perfectly natural qualities were demonized under the general diagnosis of phimosis. Physicians coined the term congenital phimosis to specify that the adhesion of the immature foreskin to the glans in infants was really a congenital birth defect. They adopted the term acquired phimosis to indicate a fictitious condition in which a previously detached foreskin became adherent as a result of masturbation. The term hypertrophic phimosis or redundancy indicated a type of phimosis whose sole symptom was a foreskin that doctors arbitrarily deemed to be too long.
Since the foreskin is the most highly innervated part of the penis, and since masturbation among normal (not circumcised) boys generally involves manually stimulating and manipulating the foreskin, and sliding the mobile sheath of the penile skin up and own the shaft (the structure of the foreskin facilitated a wide range of motion), masturbation was seen as a cause of reflex disease through the medium of the foreskin. In the absence of the germ theory of disease, American physicians who did not regard masturbation alone as the primary cause of disease, attributed bacterial, viral and fungal diseases, as well as the pathological symptoms of malnutrition, overwork etc, to phimosis. Even in the absence of a diagnosis of phimosis, the foreskin itself was indicted as a cause of disease. Phimosis in females, defined as adherence of the clitoral prepuce to the clitoris, was viewed in much the same light.
Pathologization of sexual function
In accordance with the Reflex Theory of Disease, erotic sensation was redefined as irritation, orgasm was redefined as convulsion and erection was redefined as priapism. Physicians argued that these manifestations of sexual function were both symptoms and cause of disease and, likewise, that stimulation of the genitals could cause problems in distant parts of the body, such as the heart, brain, back, digestive organs and eye.
The pathologization of normal male sexual function soon led to the invention of spermatorrhoea. Physicians defined spermatorrhoea as a serious venereal disease whose sole symptom was the ejaculation of sperm under any condition other than marital intercourse. The release of sperm in nocturnal emissions or masturbation was now classified as a venereal disease as dangerous as any other — if not more dangerous because more people suffered from it more often. Hundreds of case reports published in medical journals all over the western world proved, to the satisfaction of most physicians, that spermatorrhoea was a real and dangerous disease. French physicians such as Claude-Francois Lallemande (1790-1853) and Leopold Deslandes (1797-1852) [4] were the acknowledged world authorities n the treatment of spermatorrhoea. Their preferred treatment was to insert long steel rods, also known as bougies, up the urethra and cauterize the passage, as well as the prostate and seminal vesicle, with silver nitrate. This was supposed to slow the production and halt the loss of sperm. Lallemande also advised amputation of the foreskin in difficult cases of spermatorrhoea and in order to stop masturbation among boys.
In the United States Lallemande’s enthusiasm for circumcision caught the attention of Edward H. Dixon (1808-1880). In his Treatise on the Diseases of the Sexual Organs (1845) he became one of the first north American advocates of both therapeutic foreskin amputation (to correct an existing problem) and of the universal imposition of the ancient Hebrew rite of infant circumcision (as a prophylactic against possible future problems). [6] Dixon claimed that phimosis, which he defined as an elongation of the foreskin, was the primary cause of most serious diseases. At first Dixon and Lallemande were largely ignored, and for the next two decades circumcision was overlooked while other surgical treatments for masturbation, phimosis and spermatorrhoea were developed and trialled.
2.2 Castration
Since surgical amputation of body parts in general was considered thoroughly modern and advanced, physicians experimented with specific amputations of the sexual organs to treat masturbation. In 1842 the Boston Medical and Surgical Journal (now the New England Journal of Medicine) reported that Dr Winslow Lewis of Boston had severed and tied the left spermatic artery of a young man being treated for excessive masturbation [7]. In 1843 one of the first reports of castration for masturbation was published by Dr Josiah Crosby of Meredith Bridge, New Hampshire. After cathartics and emetics had failed to cure a 22-year old man, whose health had reportedly been ruined by masturbation, Crosby castrated him and pronounced him cured. [8] The American medical profession responded with interest. Two years later Dr Samuel McMinn published, in the Boston and Medical Surgical journal, a revolutionary report about an insane woman living near Tuscaloosa, who had taken a razor and amputated the whole of her external organs of generation. McMinn arrived at the scene and fully expected the woman to die from her massive wounds, but she survived. As her wounds healed, her reason miraculously returned. Fascinated by this outcome, McMinn speculated:
And the results of this case may suggest a remedy. Whether it was the great loss of blood, the removal of the organs and the counter-irritation consequent that cured the patient is a question for the consideration of the profession. [9]
The title he gave to his report, however, betrayed his own, and presumably the journal editor’s opinion as to the source of the cure. The report was dramatically entitled Insanity cured by excision of the external organs of generation.
Ten years later, in 1855, Dr William Taylor published a similar report involving a cigar-maker from Philadelphia who had gone insane and hacked off his penis and testicles with a broken bottle. [10] Although he bled profusely, his wounds healed, and his reason returned. No further proof was needed. A revolutionary new surgical approach to masturbatory insanity had been established just as the innovation of aseptic surgery was opening new vistas for surgical ambition. Orthodox American medicine now embarked upon the wholesale amputation of sexual organs as a the preferred cure for a wide range seemingly unrelated conditions. In mental hospitals inmates were castrated on a massive scale in order to stop them from masturbating and thereby restore their sanity. Right up until the beginning of the twentieth century boys caught masturbating were frequently committed to insane asylums where they could be circumcised, castrated and shackled in their cells [11, 12]. Females were subjected to female castration, a surgery involving the removal of the ovaries, aimed at curing them of hysteria, epilepsy or nymphomania.
2.3 Spermectomy, neurectomy and other treatments
Various other surgeries aimed at eliminating sexual desire and thereby stopping masturbation also were developed. Spermectomy was invented as a less drastic alternative to castration, and consisted in the surgical removal of the spermatic ducts rather than the testicles. [13] Neurectomy had a certain vogue in the 1890s. Commonly performed on boys who had been caught masturbating, this involved the physician severing the dorsal nerves of the penis in order to destroy sensation and function completely and permanently. [14, 15] American physicians also resorted to relatively less drastic measures, such as slitting open the urethra , corporal punishment [18], blistering the penis with caustics, acids or heat [19], flaying the skin of the penis with razor blades [20], sewing the penis shut with metal wire (infibulation) [21], encasing the genitals in plaster or lockable metal cages [22, 23], or fitting the penis with rings studded with sharp teeth to discourage erections [24].
In the case of females, the preferred treatment for epilepsy and masturbation was clitoridectomy. One of the first reports of therapeutic clitoridectomy was published in the San Francisco Medical Press in 1862, the abstract of which explained:
Dr E.S. Cooper, editor of the San Francisco Medical Press, relates two cases of removal by the scalpel of the clitoris in young girls who were inveterately addicted to the habit of masturbation, and for whom there was apparently no alternative but hopeless insanity or an early grave. The result was a perfect cure in one case, and in the other the practice was broken up, and all the mental faculties improved, except the memory, which is not restored. [24]
In the late 1860s the British obstetrician Isaac Baker Brown developed and promoted clitoridectomy as a cure for epilepsy and other mental problems in women. His claims of miracle cures aroused widespread interest at first, but his methods eventually alarmed professionals in the new specialty of obstetrics, and in 1867 his conduct was called into question and expelled from the Obstetrical Society. Although many continued to believe in the value of clitoridectomy, Brown’s main offences were an unprofessional degree of self-promotion and failure to obtain informed consent from his patients. (He was in the habit of chloroforming any patients who came to his surgery and performing the operation on them, no matter what the problem they complained of, without telling them what he was going to do.) The British medical press was overwhelmingly in favour of banning Baker Brown, but he was vigorously defended in the United States. The editor of the influential Medical Record strongly criticised the anti-clitoridectomy crusade in England and demanded, What now will be the chance of recovery for the poor epileptic female with a clitoris? [26]
3. Circumcision as therapy
On 1 December 1855 the English surgeon Jonathan Hutchinson (1828-1913) published a paper that was to become one of the most influential texts in the history of circumcision advocacy, On the influence of circumcision in preventing syphilis [27]. During the 1850s London experienced a massive immigration of Jewish settlers from the ghettos of eastern Europe, attracted by the liberal and tolerant attitude prevailing in England. Hutchinson reported that at the Metropolitan Free Hospital in east London, where many of the immigrants settled, fewer Jews than Englishmen sought treatment for syphilis. Being innocent of any awareness of the principles of statistical analysis, epidemiology, the germ theory of disease or the quarantine effect of ghetto living, Hutchinson asserted that only circumcision could account for the difference in the incidence of the disease. Despite its obvious flaws, Hutchinson’s paper was widely reported in foreign medical journals and continued to be cited as authoritative right up until the 1940s. In 1857 it was used as evidence at medical tribunal in Vienna, where a certain Dr Levit (under the influence of a modern western education and possibly impressed by the anti-circumcision movement in reform Judaism in Germany at that time) refused to allow his newborn son to be circumcised. The local rabbinate, under the influence of Dr Joseph Hirschfeld, held up Hutchinson’s paper as proof that circumcision was not an outmoded rite, but a modern and scientifically valid means of avoiding disease. It was sufficient justification for the rabbinate to seize Levit’s son and forcibly circumcise him against his father’s wishes. Levit was left without legal recourse to protect his own child. [28]
On the strength of Hutchinson’s figures, circumcision as a prophylactic intervention now made a cautious reappearance in orthodox American medicine. At a meeting of the Boston Society for Medical Improvement on 12 August 1861, a Dr White presented a paper in which he mentioned that circumcision could prevent masturbation. [29] Seven years later Dr Charles Bliss, of Syracuse, New York, published an account of his success in curing masturbation by partial amputation of the prepuce. [30] In 1869 a learned article by the Baltimore physician A.B. Arnold described the history of circumcision in the religious context of Jews, Muslims and certain African peoples. [30] The new surgery was being legitimised by being placed in a long history, even though it was a non-western and largely Asiatic history.
3.1 The American Medical Association
Hailed in his lifetime as the father of orthopaedics and indeed as one of the most distinguished benefactors whom the American medical profession has produced for the glory of medicine and the good of mankind [32], Dr Lewis A. Sayre (1820-1900) was certainly among the most distinguished believers in the therapeutic powers of circumcision. He served as vice-president of the American Medical Association in 1870 and as president in 1880. At the annual meeting of the AMA in 1870 he delivered a remarkable paper entitled partial paralysis from reflex irritation, caused by congenital phimosis and adherent prepuce [33]. Supporting his claims with numerous case studies and clinical evidence, and deploying the most scientific methodologies available at that time, Sayre proved to the satisfaction of his audience that a long, adherent foreskin could not only cause paralysis in various limbs, but also hip-joint disease (probably tuberculosis of the hip-joint), hernia, bad digestion, inflammation of the bladder and clumsiness. In each case Sayre reported that amputation of the foreskin had cured the problem. For the rest of his career Sayre urged physicians always to examine a boy’s prepuce in all cases of disease. Whenever phimosis, as defined by reflex theory, was found, Sayre advised immediate amputation of the foreskin. Because of his professional reputation and impeccable credentials, major American medical schools steadily incorporated Sayre’s theories and therapies into their curricula.
During the late 1860s and throughout the next decade epilepsy was increasingly the focus of medical interest, as indicated by the growing number of articles on the subject published in medico-scientific journals. Capitalising on the new anxiety, Sayre reported to the New York Pathological Society in 1870 that phimosis was also the cause of epilepsy [34]. A few English physicians had been experimenting with circumcision as a treatment for epilepsy since 1865 [35], but they attributed the problem to the tendency of the foreskin to encourage masturbation, and thus cited prevention of masturbation as the key to curing the condition. Sayre maintained that a long foreskin alone had the power to induce violent epileptic convulsions, and that circumcision had cured every case of epilepsy that he had encountered. As with paralysis, hundreds of case reports were published over the next 75 years, all validating Sayre’s advocacy of circumcision as a cure for epilepsy.
At the annual meeting of the AMA in 1875 Sayre delivered another important lecture on phimosis. Here he informed his audience that he had discovered that a long and adherent foreskin could cut off the circulation of blood to the spinal column, thereby causing lameness, curvature of the spine, paralysis of the bladder and club foot. [36] Miraculously, he reported, circumcision brought an immediate cure to all these patients, including the patient with the club foot. In the same lecture he also described several cases in which clitoridectomy brought instant relief to paralytic girls.
3.2 Masturbation hysteria and circumcision
Alarm amounting to hysteria about masturbation reached a climax in the last decades of the nineteenth century. From 1800 to the early 1870s there was an astounding 750 per cent increase in the number of articles in medical journals on masturbation. From the 1870s to the 1880s the number of papers on masturbation increased by 25 per cent, and from the 1880s until 1900 by a further 30 per cent. Among the more influential American physicians who noticed this obsession, and who contributed to it, were Abraham Jacobi (1830-1919) and M.J. Moses. Jacobi was the founder and first president of the American Pediatric Society, the first chairman of the Section on Diseases of Children of the AMA, and president of the New York State Medical Society, the New York Academy of Medicine and the Association of American Physicians. Both Jacobi and Moses asserted that Jewish boys were immune to masturbation because they were circumcised, and that non-Jews were especially prone to masturbation, and all the terrible diseases that resulted form it, simply because they retained their foreskin. Moses and Jacobi’s studies acquired canonical authority, and their claims that the foreskin was the prime risk factor for epilepsy, paralysis, malnutrition, hysteria and other nervous diseases, were regularly cited by medical writers for the next few decades. [37]
In 1871 Moses published a very influential and widely-cited article, The value of circumcision as a hygienic and therapeutic measure, in the New York Medical Journal. In a key passage he cited his experience as an Israelite as giving him the authority to speak on the value of circumcision as a health, and specifically as an anti-masturbation, measure:
As an Israelite I desire to ventilate the subject, and as a physician have chosen the medium of a medical journal, that I may not be trammelled in my expressions I refer to masturbation as one of the effects of a long prepuce; not that this vice is entirely absent in those who have undergone circumcision, though I never saw an instance in a Jewish child of very tender years, except as the result of association with children whose covered glans have naturally impelled them to the habit. [38]
It is quite clear from the context that the title word hygienic has a different meaning from today. At that time circumcision advocates used words such as hygiene to denote moral hygiene, not personal cleanliness. Moses’ paper had a big impact on American physicians, who now argued that castration should be abandoned in favour of circumcision, since circumcision cured all the same diseases, but did so without affecting the power to procreate. An article in the Medical Record in 1895 explained the power of circumcision to stop masturbation thus:
In all cases [of masturbation] circumcision is undoubtedly the physician’s closest friend and ally. To obtain the best results one must cut away enough skin and mucous membrane to rather put it on a stretch when erections come later. There must be no play in the skin after the wound has thoroughly healed, but it must fit tightly over the penis, for should there be any play the patient will be found readily to resume his practice, not begrudging the time and extra energy needed to produce the orgasm. It is true, however, that the longer it takes to have an orgasm, the less frequently it will be attempted, and consequently the greater the benefit gained. [39]
3.3 More miracle cures
The list of previously incurable diseases that orthodox physicians now claimed to be able to cure or prevent by means of circumcision continued to grow. A textbook from 1895 declared:
Only within recent years, since the physiology of nervous reflexes has become better understood, has [circumcision] become a generally accepted operation with thinking surgeons. Not alone for local conditions is the operation demanded. In all cases in which male children are suffering nervous tension, confirmed derangement of the digestive organs, restlessness, irritability and other disturbances of the nervous system, even to chorea, convulsions and paralysis, or where through nerve waste the nutritive facilities of the general system are below par and structural diseases are occurring, it should be considered as among the lines of treatment. [40]
Thousands of such reports and opinions were published in reputable American medical journals. In 1890 Dr William D. Gentry (1836-1922) produced a typical example, Nervous derangements produced by sexual irregularities in boys, which detailed the frightening and varied consequences of phimosis, as well as the miracle cure offered by circumcision:
Whilst I was physician to the children’s home at Kansas City in 1884-85, there was brought to the home from some similar institution in Chicago a child of two and half years, who was blind, deaf and dumb. It was nervous, fretful, and caused the matron a great deal of trouble. It was dwarfed and presented the peculiar general appearance which nearly every boy will present who is afflicted with sexual derangement. As soon as I saw the child the thought came into my mind that his trouble had some connection with such derangement, and on making an examination I found that he had phimosis. With the consent of the father of the boy I operated and removed the derangement. In two months the child could see and make sounds as if trying to speak. In six months he could hear, see and speak. [41]
Where today do we hear this gushing tone?
3.4 Anti-sexual nature of circumcision
The early promoters of circumcision fully acknowledged the sexual functions of the foreskin and advocated circumcision as the intentional destruction of those functions. One of many such acknowledgements was published in an issue of the Medical News in November 1900:
Finally, circumcision probably tends to increase the power of sexual control. The only physiological advantage which the prepuce can be supposed to confer is that of maintaining the penis in a condition susceptible of more acute sensation than would otherwise exist. It may be supposed to increase the pleasure of the act and the impulse to it. These are advantages, however, which in the present state of society can well be spared, and if in their loss some degree of increased sexual control should result, one should be thankful. [42]
In 1902 an editorial in the American Practitioner and News made clear the anti-sexual motivation behind the doctrine of circumcision as a hygienic measure:
Another advantage of circumcision is the lessened liability to masturbation. A long foreskin is irritating per se, as it necessitates more manipulation of the parts in bathing. This leads the child to handle the parts, and as a rule pleasurable sensations are elicited from the extremely sensitive mucous membrane, with resultant manipulation and masturbation. The exposure of the glans penis following circumcision lessens the sensitiveness of the organ. It therefore lies with the physicians, the family adviser in affairs hygienic and medical, to urge its acceptance. [43]
4. Early twentieth century
After the germ theory of disease had become widely accepted and vitamins had been identified, most bacterial diseases, such as tuberculosis, were silently removed from the list of diseases caused by phimosis. Even so, most American physicians tenaciously clung to the belief that phimosis was pathogenic and the cause of diseases, such as epilepsy, in ways not yet understood. Year by year the list of diseases blamed on phimosis continued to grow. Doctors even attributed suspicions deaths to phimosis. [44]
4.1 Abraham Wolbarst and the cancer scare
Abraham Wolbarst (1872-1952) was a urologist practising, among other places, at the Beth Israel Hospital and the Jewish Memorial Hospital in New York. In January 1914 he published, in the Journal of the American Medical Association, the first of series of papers indicting the foreskin as the culprit in the diseases that were to haunt the imagination of the twentieth century. Wolbarst was a prominent and influential member of both the AMA and the notorious American Society of Sanitary and Moral Prophylaxis, a reform organisation dedicated to the abolition of childhood and extra-marital sexuality. His views on sexuality were characteristically extreme. In the 1930s he argued that adult masturbators should be sterilized and forbidden to marry, and in 1914, in his influential paper, Universal circumcision as a sanitary measure, he added his own statistics to those of Hutchinson in order to prove that circumcision conferred immunity to syphilis, and to argue that it should be made compulsory as a means of reducing the incidence of masturbation and many other problems as well. He stated that it was generally understood that irritation derived form a tight prepuce may be followed by nervous phenomena, among these being convulsions and outbreaks resembling epilepsy. It is therefore not at all improbable that in many infants who die in convulsions, the real cause of death is a long or tight prepuce. He added that it was the moral duty of every physician to encourage circumcision in the young [46, 47].
In this paper it is clear that the title word sanitary denotes moral restraint rather than the absence of germs or dirt.
It is important to note that until this time circumcision was primarily imposed as a therapy for children and adults, but not as prophylaxis for infants. As a result of Wolbarsts’s ceaseless lobbying and agitation, however, the radical notion of universal, non-therapeutic, involuntary circumcision of young babies slowly gained acceptance among American physicians. (The procedure was non-therapeutic because it was performed on normal, healthy children showing no signs of deformation or disease.) Medical textbooks were rewritten to instruct obstetricians and pediatricians to examine the penis of every newborn boy to determine whether the foreskin was retractable. If not )as was usually the case), the advice was that it be removed immediately.
By the mid-1930s, when most of the medical profession had converted to the theory that epilepsy was a problem of the brain, Wolbarst clung to his conviction that the most likely cause was a tight foreskin. [48]. While he never abandoned this idea, he must have sensed the need to reformulate his arguments against the foreskin in order to tailor them to appeal to the changing interests and fears of the public. In the early decades of the twentieth century the number of articles on cancer in popular magazines rose dramatically, indicating a shift in the national focus. The Readers Guide to Periodical Literature listed thirteen articles on cancer between 1900 and 1904, but by 1909 the number had doubled, and by 1928 it had increased by 569 per cent. At the peak of this surge in popular anxiety about cancer in 1932, Wolbarst published what was long regarded as the definitive paper on circumcision as the most reliable preventive of cancer of the penis. Based on his observation (read contention) that Jewish men never got penile cancer, Wolbarst theorised that the disease was caused by the accumulation of pathogenic products in the preputial cavity. [49] Wolbarst offered no scientific validation in support of this notion, yet, based on this paper, the proposition that smegma was carcinogenic became widely accepted as a proven fact in the United States.
4.2 Advances in understanding the anatomy and development of the foreskin
In 1932 a research team at the University of Pennsylvania led by Dr H.C. Bazett published a detailed anatomical description of the innervation of the foreskin. They observed that the foreskin was richly networked with nerves and nerve endings and capable of detecting fine distinctions of touch and temperature. [50] The following year Dr Glenn A. Deibert, of the Daniel Baugh Institute of Anatomy at Jefferson Medical College, made a careful investigation of the development of the foreskin in utero and the process by which it separated from the glans after birth. [51] Deibert demonstrated that the adherence of the foreskin to the glans was neither phimosis nor a birth defect, but a normal stage of penile development. In 1935 the British anatomist Richard Hunter at Queen’s University, Belfast, published a similarly detailed description of the embryological development of the foreskin. No doubt because these findings did not support the prevailing orthodoxy that the foreskin was a useless, pathological defect, all three studies were completely ignored by the medical establishment. [52]
4.3 The Gomco clamp
The profit margin for circumcision procedures rose with the mass manufacture and wide distribution of the now ubiquitous Gomco clamp, invented in 1934 by Aaron Goldstein and Dr Hiram S. Yellen. Gomco is an acronym for the GOldstein Manufacturing COmpany, which later changed its name to the Gomco Surgical Manufacturing Corporation of Buffalo, New York. This cruel stainless steel device is still widely used today to crush the foreskin and isolate it so that it can be excised by scalpel. The standardization of its surgical technique facilitated the rapid institutionalisation of neonatal circumcision as a routine hospital procedure and led to the acceptance of the high and tight look (since the clamp usually produced a maximum loss of tissue) that came to be regarded as the normal appearance of the penis.
4.4 Popular perceptions
The September 1941 issue of Parents Magazine included the first published article on the advisability of routine circumcision that had ever appeared in a popular magazine with such a wide readership. The author was Dr Ian F. Guttmacher, an obstetrician at Johns Hopkins University Medical School, and he fed the public with many of the same myths and scare stories that had been in circulation since the nineteenth century. Like his predecessors, he admitted that circumcision causes blunting of male sexual sensitivity, but (like Hutchinson) argued that this was an advantage. As well as citing Wolbarst’s discoveries about penile cancer, Guttmacher reiterated the Edwardian myth about the necessity for daily scrubbing of the glans. Although this had been a clich of British Empire baby care guides from the 1890s until the 1930s, in Britain it had just been exposed as a myth by Douglas Gairdner. The idea was new to American medical literature, however, and just as a better understanding of normal infant anatomy triumphed in Britain, old myths became consolidated in the United States; with all the authority conferred by his professional title and institutional connections, Guttmacher told the public:
Present-day hygiene require that the prepuce, the hoodlike fold of skin which covers the end of the penis (glans) be drawn back daily and the uncovered glans thoroughly washed. Trouble occurs if this is neglected, for the secretion from the multiple glands lining the inside of the hood becomes caked, and within a few days the material may set up an inflammation. Such inflammation may lead to the growth of slender, strandlike bands of tissue between the inside of the prepuce and the glans, gluing the two together, thus forming an adherent foreskin.
Thus we see the Victorian myth of acquired phimosis taking on a new lease of life in the New World of space travel. To avert this frightening scenario, Guttmacher advised parents to have their boys circumcised at birth because doing so makes care of the infant’s genitals easier for the mother, and because it does not necessitate handling of the penis by the infant’s mother, or the child himself in later years, and therefore does not focus the male’s attention on his own genitals. Masturbation is considered less likely. Guttmacher succeeded in validating the perceived associations between the foreskin, difficult hygiene, inevitable masturbation, genital defects and the fear of touching the baby’s penis. It also served to legitimise the increasingly common practice on the part of large urban hospitals of instituting programs of automatic circumcision of the newborn, irrespective even of parental wishes [53-55].
4.5 Abraham Ravich and the myth of cancer of the prostate
Abraham Ravich was a urologist at Israel Zion Hospital, Brooklyn, from which position he became one of the most rabid crusaders for mass involuntary circumcision since Jonathan Hutchinson and Peter Charles Remondino. In 1942, expanding upon Wolbarst’s theory of smegma as a carcinogen, and repeating the myth of Jewish men’s immunity to such disease, he postulated a causal link between the foreskin and cancer of the prostate. He also restated the obscure theory (first suggested, without much evidence in 1926 [56]), that cervical cancer in the female was caused by smegma from the male [57]. The popular magazine Newsweek gave sympathetic coverage to Ravich’s claims and quoted his demand that there be an even more universal practice of circumcising male infants [58]. Among the many achievements that he listed for his entry in Who’s Who in America, Ravich credited himself with being the first to report on the value of neonatal circumcision as a preventive of genital cancers. [59].
5. World War II
Mass recruitment and conscription during World War II put a lot of men under the power of military doctors with the authority to institute a campaign of near-routine circumcision of servicemen in all branches of the armed forces. Even at the height of the war, Navy physician Lt Marvin L. Gerber confidently stated in he pages of the United States Naval Medical Bulletin that circumcision was one of the most commonly performed surgical operations in the navy, even more common than trauma surgery [60]. Military doctors alleged that epidemics of phimosis and paraphimosis among soldiers justified the mass circumcision campaign. Men were regularly humiliated by unannounced examinations of their penises (called short arm inspections), and many who had not been circumcised were declared to be suffering from phimosis and sent off to get cut; court martials were threatened if they showed reluctance.
5.1 Sexually transmitted diseases and the scapegoating of Blacks
Military records reveal that Black Americans were blamed for spreading venereal disease in the military and were thus made particular targets of circumcision campaigns. Military doctors such as Eugene A. Hand (1909-c.1972), a dermatologist (VD expert) at the naval hospital, St Albans, New York, were responsible for the military’s adoption of the view that Blacks were dangerous carriers of disease, and that the low rate of circumcision among them was the main reason for this. Capt Leonard Heimoff, US Army Medical Corps, declared that Negro troops were causing 70 per cent of all new cases of venereal disease, and he organised covert military police units to monitor the sexual life of civilian Black communities. [61] Heimoff’s report, like that of Hand and others, concluded that Blacks could not be taught to practise personal hygiene nor trusted to take precautions against contracting STDs — presumably a euphemism for claiming that they were too stupid and/or sex crazed to use condoms.
Where else today do we find this assumption guiding health policy?
The war coincided with an increased national obsession with the danger of VD. From 1930 to 1940 the number of articles on VD in popular magazines increased by 192 per cent, and at an annual rate of 17 per cent from 1940 to 1947, after which interest trailed of — presumably in response to the discovery of an effective cure for syphilis in the form of penicillin. At the height of this hysteria Hand delivered a paper called Circumcision and venereal disease at the annual meeting of the AMA in June 1947. Comparing the incidence of VD among Jews, gentiles and Blacks, and reporting that it was rare among Jewish men, Hand theorised that circumcision had a major protective effect:
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