Circumcision: American health fallacy

Book Reviews The Health of the Children, by MILDRED BLAXTER. Heinemann. London. 198 1. 272 pp. f 14.95 This book is an outstanding critical review of the literature concerning the impact of social class on the health of children. As an aspect of this effort. the author has reviewed several other areas that are helpful in distinguishing the relative contributions of a number of other influences on children’s growth. development and illnesses. Infant mortality is analyzed from many perspectives including type of death. nutrition, parental alcohol and ciagarette use, access to medical care and social class. The next chapter details the consequences of perinatal disadvantages such as anoxia. cerebral palsy, and sensory impairments. Other chapters offer careful reviews of physical development, especially height, childhood accidents, and the interactional impact of medical and psychiatric illness on children and their families. The first three sections emphasize with a harsh clarity the profound effect of social class on “health behavior” and mortality. The chapters are tightly written and the amount of data is overwhelming. The book has 219 pages that include over 700 references. My only criticism is that in some chapters there is so much data and analysis, that the reader would benefit from greater emphasis on the conclusion section. The Health of the Children is an invaluable resource and reference work for those interested in virtually any aspect of childhood health. I would encourage pediatricians, health planners. sociologists, epidemiologists, and politicians (especially those urging cutbacks) to read this book. Child Psychiatry Serricr Massachusetts General Hospital Boston. MA. L’.S.A.

MICHAEL S. JELLINEK

Circumcision: American Health Fallacy, by EDWARD WALLERSTEIN. Springer. New York, 1980. 204 pp. 821.95 In contemporary America there are a number of “rights movements”. They include the movements for civil rights, equal rights for women, and rights for homosexuals as well as the inore familiar and time-honored labor movement which still struggles for decent treatment of migrant and other non-unionized workers. More recently, organizations have arisen to defend the right of women to abort unwanted pregnancies; and some day non-fecund couples who hope to have a child through adoption may claim this as a right. Adoptees claim the right to know their original parents, while the biological parents claim the right to privacy. Children are also supposed to have rights: physical health. emotional wellbeing, and optimal stimulation of their cognitive capacities. Cleari\ not all of these “rights” can be valid: some are contradictory to others. But, as pointed out by Mary Kathleen Benet (The Politics of Adoption, Free Press, 1976). even seemingly antithetical positions may represent similar values: “Adoption and abortion have the same friends.. Both seem to their proponents to involve the same issues.. the right of individuals to choose their fate, and to create their families when and how they wish”. The recent course of political thought in the West suggests that what ultimately determines whether or not a “right” exists in our society is how closely the postulated right comes, or how essential it is. to the individual’s ability to determine the destmy of his or her own mind or body. It IS In the context of these questlons that Wallerstem’s book on circumcision should be read and considered. Does a child have a right to grow into maturity with the entirety of the body he was born wrth’? Mr Wallerstein tries to persuade us that. in the absence of convincing arguments to the contrary. the answer 1s yes. Few sublects in medical literature are as tamted by emotlonal controversy as circumcision. Believers justify the

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procedure on the grounds of hygiene, cancer prevention, and various aspects of mental health, including better sexual functioning, lack of self-consciousness, and a better identification with one’s circumcised .father, brothers and playmates; non-believers call it a mutilation, dispute all the claims of the other camp, and venture to suggest that routine circumcision of male infants should be legally actionable. In his introduction to Wallerstein’s book, Nicholas Cunningham, a pediatrician, asks: “Can you imagine what one good lawsuit on behalf of a lost foreskin would do today?” Of course all this makes good copy and good fun, and the majority of readers, medical and otherwise, who have no particular axe to grind (no pun intended) can enjoy watching the opponents go at each other tooth and nail. In the midst of the controversy, however, Edward Wallerstein, a layman, has managed to write a well-researched book which avoids polemics. Though clearly aligned against the circumcisers. he tries to be fair. In addition to 18 chapters of text, the book contains three appendices which provide anatomical information for those who need it as well as a summary of the position on circumcision taken by the American College of Obstetrics and Gynecology. There IS an impressive section of notes and bibliography. over forty pages in length. Wallerstein’s qualifications to write a book on circumcision may seem unusual, but after reading the book, one comes away wondering whether anyone at all can claim expertise about this procedure. He is a retired businessman and industrial engineer who for 5 years worked as a communications coordinator at Mount Sinai School of Medicine. The fate of the male genitalia, or any part thereof, is bound to be of interest in an era dedicated, like ours, to better definition of the respective roles, abilities, and sensibilities of the sexes. What is more, it is not only the male genitalia which are at issue: Wallerstein dedicates a chapter to female circumcision, which is common in Egypt and certain other parts of the world, and involves partial or total clitoridectomy, and at times more extensive extirpation of the vulva. The author makes a point which is doubly impressive by virtue of his understatement: if one is outraged at learning for the first time about these patently cruel procedures on female children and adolescents, is it not mere familiarity that keeps us from outrage about comparable procedures on the male? In his first chapter. Wallerstein declares, “Circumcision is the only surgery performed (routinely) for prophylactic purposes”. He indicates the reasons most commonly given for the procedure, then calls attention to repprts which question their validity. In subsequent chapters he explores the history of circumcision, including some anthropological material placing this type of surgery in the larger context of body-altering and mutilating procedures which occur as tribal rituals. He then brings in historical documentation indicating that the popularity of circumcision began in Europe and American in the nineteenth century, as a result of Victorian interpretations of reports concerning the sexual life and health of Jews and of certain primitive tribes which practice the procedure. The use to which these reports was put, according to Wallerstein, was to justify circumcision as a hoped-for panacea for a variety of sexual ills, including venereal disease and masturbation. The author takes us back to the days of Sylvester Graham and John Harvey Kellogg, whose surnames are heard in American kitchens to this day. but whose strange theories about sexual excesses are little remembered. These two men were evidently typical of a common trend in American thinking which eventually resulted in sexual discharge being seen as an important evil to be combated-frequently by physlcal means, such as healthful flour. crackers, or cereals. or by surgical procedures. Circumcision never caught on m Europe to the degree it’

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Book Reviews

did in the Umted States, though figures from the British Navy are cited to indicate that it was quite popular in England in the early part of this century. The British began moving away from it by the 1940% whereas in the United States it was still on the rise, to the point where, in 1980. almost 90% of American newborn males were circumcised. Wallerstein examines the various rationales: hygiene. increased sexual staying power or responsiveness, risk of malignancy in the mile or his female partner, appearance. osvcholoeical benefits. He finds substantial holes in all of them, He raises the question of pain, and examines the assertion that newborns feel little or no pain when circumcision is performed. And before closing with an “appeal to reason!‘, he gently raises the issue of money. Who benefits from the l$million circumcisions performed for non-religious reasons in the United States this year? Is it possibly he case (if no clear benefit to the child can be shown) that the primary beneficiaries are those physicians who perform the procedure? Whatever one’s views on the topic, a reading of this book will be salutary for pediatricians, obstetricians, urologists. and anyone who is interested in children’s health, children’s rights, the rights of the adults who grow out of the children, and the interesting area of overlap between myth, custom, and medical practice. It is well written and well researched, and avoids hysterical rhetoric. It raises serious questions about the way medical fashions become established; and although Wallerstein steers clear of religious argument, the book left a clear implication in this reviewer’s mind that thoughtful physicians who belong to circumcising religious groups would do well to examine the Dotential hazards and doubtful benefits of this surgery and represent them to their co-religionists. The book’s only serious deficit is the relative lack of material concerning psychological effects of circumcision. There is an extensive body of psychoanalytic thought about this surgery, beginning with Freud, who viewed it as a symbolic castration, and numerous case reports which have appeared over the years support this idea. There are also the theories of Bruno Bettelheim. published in his book Symbolic Wounds, which draw on anthropologists’ observations and attempt to revise Freud’s thinking. According to Bettelheim. male circumcision is partly conditioned by women’s wish to limit male powers, as well as by the wish of males to be more similar to females and to submit to a bloody mutilation of their genitals in the hope of gaining for themselves some of the generative power which they see as the exclusive property of women. While objective data on such matters are obviously harder to obtain than those on incidence of circumcision, venereal disease, and so forth, the book would have been richer had it contained more extensive review of the psychiatric literature. It is undoubtedly true that some boys have felt self-conscious about being in a non-circumcised minority; but many psychiatrists believe that there is a universal fear of castration in young boys, and it seems important to consider what the effect might be of superimposing an actual operation on the penis (even one not remembered, since it leaves a physical difference) on this fear. Such a combination may lead, in the aggregate, to substantially more pathology than the self-consciousness of the unoperated male in the locker room. And finally, can we use the logic of self-consciousness to justify the procedure’? What if the custom were to remove an ear or a finger, and people argued against leaving children intact because they would feel stigmatized? As valuable as custom is, it should be subject to rational review, Particularly when the integrity of the body is at stake. 1

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Department o/’ Psychiatry Hamard Mrdicul School Boston. MA. V.S.A.

in Healing, Ritual and Drama, by T. J. SCHEFF. University of California Press. Berkeley, CA. 1979. 246 pp. No price given

Catharsis

This is a remarkable book that will be usefully read and appreciated by a broad range of audiences. Scheff is a scientist and scholar with considerable literary skill. This rare combination has produced a lucid account of a therapeutic process (catharsis) that takes the reader pleasurably through a critical review of published literature, relates the process to the professional interests of dramatists. psychologists, sociologists, and physicians. provides illustrations of modest experiments, and suggests an agenda for future research. In brief, Scheff argues that catharsis is a therapeutic process, signalled by various types of emotional discharges (e.g. laughing and crying) which release repressed emotions (e.g. fear and anger) in psychological and physiologically beneficial ways. Catharsis, whether achieved in the normal interaction of everyday life or in arranged encounters. occurs when “emotional distance” is optimal; that is. when there is a balance between the evocation of distressing repressed emotions and a sense of security. What constitutes proper balance of appropriate “distance” is easier to illustrate than to define. In the author’s view, systematic study of cathartic processes has suffered from neglect among both psychotherapists and social scientists who. even when they understand the contextual aspects of “emotion work”. do not apply what they know. The author illustrates broadly from relevant scholars as diverse as Freud and Durkheim and draws insightful illustrative materials on catharsis from literature. drama, and social rituals that develop in response to the recurring sources of stress in everyday life. .4 dominant characteristic of contemporary society, Scheff believes, is the “over-distancing” of encounters with repressed emotions. He does not comment on the probability that, for many if not most individuals, catharsis is experienced in ordinary interpersonal interaction or through existing drama and social ritual. He is convinced that cathartic encounters are not frequent enough currently. Consequently, social groups must contrive cathartic encounters that involve professional therapists. While he believes that more attention should be given to training health professionals to understand cathartic processes for their own as well as their patients’ benefit, SchelT also believes that therapeutic encounters need not be and should not be left to professionals alone because they can also be provided by lay therapists. Two incidental aspects of this book may be of interest. In his acknowledgement. Scheff pays his intellectual debts to a large number of colleagues who contributed to his thinking about catharsis. In so doing he illustrates a kind of active collegiality that is perhaps as rare these days among scholars as cathartic encounters are in society. Further, Scheff apparently believes in living as well as talking about his subject. In his pursuit of understanding catharsis he trained as a lay therapist and practiced in a community clinic in the evenings. SchefT’s experiential as well as intellectual involvement has produced an exciting book, Department of Sorioloyr

GEORGE L.

MADDOX

und Psvchiatrj Duke Vn;cersit) Durham, NC, U.S.A.

Child?, Edited by HELEN B. HOLMES, BETTYB. HOSKINS and MICHAEL GROSS. Humana Press, New York, 1981. 384 pp. $14.95 (paper) $7.95

The Custom-Made

STEVENL. NICKMAN

This volume is a summary of a stimulating workshop held in 1979 directed towards four goals: