Book Review

Marked in Your Flesh: Circumcision from Ancient Judea to Modern America

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

N Engl J Med 2006; 354:310-312January 19, 2006

Article

Marked in Your Flesh: Circumcision from Ancient Judea to Modern America
By Leonard B. Glick. 370 pp. New York, Oxford University Press, 2005. $30. ISBN: 0-19-517674-X

A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain
By Robert Darby. 374 pp. Chicago, University of Chicago Press, 2005. $35. ISBN: 0-226-13645-0

Circumcision tends to provoke controversy, which is not surprising when one considers that circumcision invokes religion, medicine, and sex. The ritual cutting of the foreskin is a practice older than recorded history; a famous Egyptian bas-relief shows that circumcision was well established by 2400 b.c. Yet no one knows where or how the practice originated or even what its meaning was in ancient Egypt. Later, for reasons scarcely understood, circumcision became central to Judaism and Islam. Then, in a fascinating intellectual and cultural transformation, beginning in the late 19th century the ancient ritual was adopted by mainstream American and British physicians (though not their European counterparts) just as modern scientific medicine was dawning.

The Circumcision, by Giovanni Bellini, circa 1430–1516.

Although circumcision has a long and interesting past, its historiography has suffered from a lack of objectivity. Most books and articles on the subject have an agenda, either to advocate the practice as an effective, preventive health measure or, more commonly, to attack it as genital mutilation that violates the rights of children. The books by Leonard Glick and Robert Darby are firmly in the anticircumcision camp. These authors aim to use historical analysis to strip circumcision of its medical and cultural legitimacy by exposing the myths, erroneous beliefs, and bad science that have been used to promote it.

Glick, an anthropologist with a medical degree, describes himself as “a scholarly activist” who belongs to “several organizations dedicated to ending all forms of genital injury to male and female children throughout the world.” His tone is that of one who has seen the light, as he puts it, “that male infant circumcision is medically unnecessary, harmful to normal sexuality, and ethically unjustifiable.” Marked in Your Flesh is less a historical narrative than a polemic. It offers a collection of eclectic and loosely structured observations on dozens of sources spanning three millennia, from the Book of Genesis to the television sitcom Seinfeld.

Glick addresses two groups of questions. First, what are the characteristics and meanings of Jewish circumcision? “What did it mean originally, and does it still retain that meaning now? How has being circumcised influenced Jewish men's self-perception, and how have others perceived (or imagined) them and their mysterious rite?” Glick begins by describing the biblical account of God's covenant with Abraham: the promise to make Abraham “the father of a multitude of nations” in return for obedience to the divine will, symbolized by circumcision. The problem here is that Glick's attitude toward his sources is unclear. Although he states that modern scholarship has overturned received wisdom about the authorship and provenance of the Torah, he treats the account in Genesis of Abraham as a historical record. This treatment is not trivial. Many Jews, Christians, and Muslims believe that God appeared to Abraham and told him to cut his foreskin, and that the failure of Abraham's descendents to do so thousands of years hence violates a sacred covenant. Such a belief is a matter of religious faith, however, not of documented history.

The book's strongest sections chronicle the remarkably diverse views of circumcision within and surrounding the Jewish tradition. Glick surveys the rabbinic literature on circumcision through the ages, describes variations in the ritual operation, and discusses reactions to circumcision among Christians: Saint Paul, Peter Abelard, Martin Luther, and Laurence Sterne, among others.

Glick's second group of questions concerns “how and why . . . a Jewish ritual operation, rejected and vilified for nearly two millennia, [came] to be widely accepted as a routine postnatal procedure in American hospitals.” On this topic, Glick presents few new sources or fresh insights. During the past decade, several scholars have detailed how circumcision as a religious ritual was transformed into a secular medical procedure. On the basis of anatomical and physiological theories from the late Victorian era, physicians in America and England — above all, Lewis Sayre — used circumcision to treat diseases from paralysis to epilepsy, the underlying causes of which they imagined to be neural irritation caused by the foreskin. Predominantly in America and Britain, the same theory inspired a vogue of the surgery on women, in whom the clitoris and ovaries were suspected to cause all manner of ailments.

Perhaps one third of Marked in Your Flesh is devoted to reviewing the medical debate about neonatal circumcision. Professional journals have published thousands of papers about whether circumcision leads to a lower incidence of urinary tract infection, cancer, and sexually transmitted diseases. A balanced reading of the record suggests that circumcision carries both benefit and harm. It prevents rare penile cancer, but occasionally it seriously injures a baby. The American Academy of Pediatrics Task Force on Circumcision reviewed the medical literature and reported in 1999 that “existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.”

The task force saw the ambiguity in the data on the health benefits of circumcision. This ambiguity only increases when one learns, for example, that in July 2005 French and South African AIDS researchers halted a large, randomized, controlled trial of adult male circumcision to reduce the incidence of AIDS after early results showed that men who had undergone the procedure had a dramatically reduced risk of contracting HIV through intercourse with infected women. Much more research is necessary, which may not bear out this result. But while reading Glick's book, one senses that the idea of benefiting from circumcision is inconceivable to him. This unwillingness to suspend the belief that circumcision is an unalloyed evil weakens Marked in Your Flesh and limits its explanatory power.

Although Australian historian Darby also opposes neonatal circumcision, A Surgical Temptation benefits from his clear focus on circumcision in Britain and his clear prose. In the second chapter, titled “The Best of Your Property,” Darby argues that Englishmen at the turn of the 19th century considered the foreskin and penis a single organ. Circumcision, to their way of thinking, was a peculiar, disfiguring custom of Jews and Muslims. Yet a century later, British physicians embraced circumcision as an operation for preventing many ailments. What changed?

Darby traces a gradual process that began in the 18th century with “a great fear” of the moral and medical consequences of masturbation. This obsession resembled the anxiety of American parents nowadays about illegal drugs. Members of the medical profession, particularly the French surgeon Claude-François Lallemand, strove to explain the dangers of masturbation by linking it to a specific pathology. The result was the invention of “spermatorrhea . . . a chronic but life-threatening condition.” In effect, according to Darby, Lallemand was the intellectual leader of a movement that redefined normal male sexuality and the emission of semen as evidence of disease.

Victorian physicians, seeking to enlarge their sphere of influence, acted as “norm entrepreneurs,” Darby writes, and made the surgery the norm: “The demonization of the foreskin as a source of moral and physical decay was the critical factor in the emergence of circumcision and its acceptance as a valid medical intervention.” The principal value of Darby's research lies in the detailed description, based on original sources, of changing attitudes toward sexuality and how, in turn, these attitudes changed the way physicians and nonphysicians viewed the human body. He reminds us that during the late 19th century, not only was the foreskin suspect, but also any bodily structure that might produce “focal sepsis”: teeth, tonsils, and the colon, for example.

Circumcision was popular in Britain, mainly among the upper classes, but it never became a standard practice, as it did in the United States. After World War II, with the establishment of the National Health Service, neonatal circumcision lost the support of the medical establishment and, in consequence, its popular appeal. In Britain, it seems, physicians and parents never completely came to think of the circumcised penis as normal. In America, which is ostensibly a classless society, the power of normality is so great, as Ian Hacking observes in Rewriting the Soul (Princeton, N.J.: Princeton University Press, 1995), “that it displaced the Enlightenment idea of human nature as an organizing principle.” Since circumcision is unlikely to be as beneficial as its supporters claim or as detrimental as its opponents fear, so long as Americans consider the practice normal, parents will demand it and physicians will oblige them.

David L. Gollaher, Ph.D.
California Healthcare Institute, La Jolla, CA 92037