If You Prick Us - Masculinity and Circumcision Pain in the United States and Canada, 1960–2000
At a Glance
Section titled “At a Glance”| Metadata | Details |
|---|---|
| Publication Date | 2020-03-01 |
| Journal | Gender & History |
| Authors | Laura M. Carpenter |
| Citations | 2 |
Abstract
Section titled “Abstract”Male circumcision - the surgical removal of the foreskin of the penis - has long been a contested practice in Anglo-American countries. Competing beliefs about pain as potentially redemptive and as essentially malign have fueled the controversy, with medical professionals and lay people alike debating whether circumcision causes or ameliorates physical or emotional pain, as well as how to respond to that pain. Because circumcision is a surgical intervention performed on bodies that are physiologically male, arguments about circumcision and pain have been indelibly shaped by changing cultural beliefs about boys, men and masculinity - beliefs which have informed approaches to circumcision and pain in turn. This study, which focuses on the period from 1960 to 2000 in the United States and Canada, examines how shifting understandings and enactments of masculinity, in concert with evolving practices in biomedicine, have transformed approaches to circumcision pain. My analysis centres on routine circumcision - the excision of the foreskin as a matter of course, for social, cultural or preventive health reasons, rather than as a religious observance or remedy for specific medical complaints. I examine the multiple ways in which pain is conceptualised and articulated, recognising that physical and emotional pain are inextricably intertwined (despite frequent efforts to differentiate them), and that separating them reinforces mind-body dualism.1 To be sure, pain is just one of many factors that propel debate over male circumcision. Also contested are the questions of whether the practice protects or imperils health, whether it belongs under medical jurisdiction, whether it can be ethically consented to by parental proxy, and whether it exceeds the degree of religious and ethnic difference societies can tolerate (to name but a few possible issues). A thoroughgoing analysis of these and other broad battles waged around and through controversy over foreskin removal is, however, beyond the scope of this single article.2 Like other feminist scholars, I conceptualise gender not as universal or static, but rather as constructed through social processes and taking distinctive forms in different contexts.3 What ideals and norms are associated with masculinity and femininity and how they are enacted and regulated in particular places and periods influences myriad other aspects of social life, including medicalised cultural practices like male circumcision. Conversely, social and cultural practices influence gendered norms and behaviours in ways which hold possibilities for social change. Since the late 1800s, masculinity in Anglo-America has, mostly - but not always - been associated with imperviousness to pain. Delineating the circumstances under which male pain is recognised, as well as what responses the recognition of boys’ and men’s pain inspires, can open new ways to think about gender and sex and about the relief of human suffering.4 This analysis springs from a larger study examining controversy over male circumcision in the United States, Canada and Great Britain from 1870 to 2015. It takes a case-comparative approach, using similarities and differences across national contexts to illuminate and theorise broader patterns and processes while recognising historical specificity. As settler-colonial offspring of Great Britain, Canada and the United States share a great deal, both with one another and with Britain, including democratic political systems, cultural practices and institutions and affluent capitalist economies, as well as highly sophisticated medical and scientific establishments which have enjoyed close ties for over 200 years.5 The countries also show some similarities in terms of their experience of tensions and transformations around gender and family life.6 Of particular relevance here, two competing approaches to pain, deriving from British political theory, have been highly influential in both nations (and throughout the West).7 According to one perspective, initially articulated by eighteenth-century conservative thinkers like Edmund Burke, pain is educational and annealing. According to the other view, propagated by nineteenth-century liberal theorists like John Stuart Mill, pain is something wholly negative and worthless that ought to be avoided altogether. My comparison is additionally inspired by the countries’ similar yet divergent histories around male circumcision. In the 1870s, British, US and Canadian medicine transformed circumcision from a Jewish and Muslim religious rite, to a routine medical procedure, which grew increasingly popular through the 1930s.8 Although routine foreskin removal subsequently fell out of favour in Britain, rates continued to climb in Anglophone North America, peaking in the early 1970s at roughly 70 per cent in Canada and 90 per cent in the United States.9 At that point, Canadian and US approaches to circumcision began to diverge. This article focuses on the period from the 1960s - when North American medical elites (chiefly physicians) began to seriously question routine circumcision on multiple grounds, including its relationship to pain - through to the late 1990s, when US and Canadian medical associations revised their policies on foreskin removal to reflect new views about pain (as well as concerns about consent, efficacy and more). My account centres on the elite physicians (primarily pediatricians), biomedical scientists and grassroots opponents who have driven the public debate about circumcision pain.10 These actors mainly address practices in their own nations, but communicate regularly across borders. My data comes primarily from major medical journals (chiefly Pediatrics and the Canadian Medical Association Journal).11 Additional data come from materials produced by the American Academy of Pediatrics (AAP), Canadian Paediatric Society (CPS) and key anti-circumcision groups (such as the US-based National Organization of Circumcision Information Centers [NOCIRC] and the National Organization to Halt the Abuse and Routine Mutilation of Males [NOHARMM], along with the Canada-based Association for Genital Integrity [AGI]). After a brief review of Anglo-American approaches to foreskin removal and pediatric pain from the 1870s to the 1950s, I narrow my focus to the United States and Canada from the 1960s to 2000, delving into the ways in which changing understandings of masculinity, in combination with new perspectives in medicine, affected beliefs about, and responses to, circumcision pain, as well as vice versa. This discussion reveals how social and scientific trends in late twentieth-century Anglophone North America helped to perpetuate and to challenge the equation of masculinity with imperviousness to pain. It also highlights the conditions under which Canadians and US Americans have perceived boys and men as vulnerable to emotional suffering: namely, when they experience their genitals as differing from those of other males. Moreover, because women played unusually prominent roles in interpreting male circumcision pain, my analysis offers insight into the ways gender influences who constructs knowledge about whose pain - a central theme of this forum. My study additionally explores another important dynamic Bourke and Wood identify in their introduction: how gender intertwines with other identity categories - here, age - to shape interpretations and experiences of pain. For centuries, Britons and their North American cousins viewed male circumcision as a Jewish or Muslim religious ritual at best and a disfiguring, heathen practice at worst.12 In the 1870s, however, Anglo-American physicians - the great majority of whom were White, Christian men - began to medicalise circumcision, advocating it as a cure for ailments from epilepsy to masturbation, then seen as a disease. By the late 1880s, physicians on both sides of the Atlantic were promoting routine foreskin removal as a means of preventing ‘congenital’ phimosis (foreskin not retractable at birth) and ‘venereal’ disease, among other ills. During the same period, western European scientists (who, like physicians, were predominantly White men) were challenging the commonsense belief that humans of all ages experienced physical pain. Previously, doctors and lay people generally had agreed that the younger the person, the more intense their experience of pain - though whether pain was beneficial or harmful was contested.13 In the 1870s, however, a new, scientifically-derived view emerged. Scholars like German neuroanatomist Paul Emil Flechsig proposed that infants could not feel pain because their nerves were not completely myelinated (covered with insulating matter).14 Others, like German surgeon Alfred Genzmer, used experimental methods, like ‘prick[ing] premature infants with fine pins’, to conclude that pain is ‘exceptionally poorly developed in the neonate’.15 Many Victorian physicians embraced the perspective that infants did not feel pain.16 For one thing, it was convenient. Even though effective and relatively safe anesthesia and analgesics became available in the 1840s, they remained risky, particularly for the very young. Moreover, this belief meshed with popular Darwinian views that infants, like women and members of ‘savage’ races, were ‘primitive’ beings who experienced reflex responses, rather than pain as adults knew it.17 The medicalisation of male circumcision and new ideas about age differences in pain dovetailed perfectly. If logic dictated that preventive procedures should be performed before there was anything to prevent, and human beings developed the capacity to feel pain only gradually, as their nerves myelinated, it made sense to circumcise boys in infancy, when it could be done without the risk and bother of anesthesia. It may seem counterintuitive that circumcising baby boys without pain relief became popular during this period, given that urban middle-class Anglo-Americans - the people who could afford elective surgery - tended to sentimentalise childhood, at least with respect to their own offspring. However, children were still widely viewed as economic assets, rather than as priceless and non-productive.18 New cultural beliefs about boys and men being, or needing to become, tough, strong and impervious to pain also helped facilitate the spread of routine circumcision. In the early 1800s, Anglo-Americans generally associated ideal manliness with selflessness, earnestness and integrity.19 By the late 1800s, concerns about urbanisation and modernisation led to a new emphasis on physical courage, stoicism, endurance, and the rejection of the feminine - including girlish sensitivity to pain.20 These beliefs about masculinity remained influential in the early twentieth century, even as the rise of Freudian theory prompted some Anglo-American medical professionals to worry that circumcision could cause emotional suffering among boys old enough to remember the surgery, particularly if they were ‘sensitive’ (read: feminine).21 These concerns became largely moot in Britain when routine circumcision fell out of favour in the 1950s, for reasons mostly unrelated to pain.22 In North America, however, whether foreskin removal caused or prevented male suffering came to be a topic of considerable controversy. Routine infant circumcision enjoyed strong support from the Anglophone North American medical community. Buoyed by the expansion of private, fee-for-service health insurance and hospital birth following the Second World War, circumcision rates rose from approximately 50 per cent of Canadian and 60 per cent of US males in the 1930s to roughly 70 per cent and 90per cent, respectively, by 1970.23 The popularity of routine foreskin removal depended in part on the belief, supported by Freudian theory, that boys would suffer emotionally if their penises did not resemble those of their (increasingly) circumcised fathers and brothers. As Dr Benjamin Spock opined in his bestselling childcare guide, ‘circumcision is a good idea, especially if most of the boys in the neighborhood are circumcised - then a boy feels “regular”’.24 Although postwar ideals favoured ‘strong and silent’ men who could endure pain, and fears of ‘feminised’ boys and dependent men abounded, efforts to forestall emotional pain by ensuring boys’ genital conformity apparently were not interpreted as coddling or emasculating.25 Due to the persistent, widespread belief that babies did not feel physical pain, anesthesia and analgesics were rarely used in routine circumcision. As Chicago surgeon Max Thorek advised in his popular 1938 textbook, Modern Surgical Technique: ‘Often no anesthesia is required. A sucker consisting of a sponge dipped in some sugar water will often suffice to calm a baby’.26 Yet, some mid-century scientists began to question prevailing perspectives on pediatric pain. For example, in 1952, animal experiments by French neurologist André-Thomas demonstrated that a creature’s nerves did not need to be myelinated for it to feel pain. Not coincidentally, the liberal view that pain should be avoided and ameliorated whenever possible was ascendant during this period.27 When as an intern I was compelled to circumcise the babies delivered by members of the staff, I protested against the cruelty of doing this procedure without an anesthetic. I was assured by everyone that the babies felt no pain, they only screamed that way because they didn’t like to be held still while the operation was in progress. For some reason I remained unconvinced.29 MacKay moreover noted that some adult men experienced so much emotional distress from having been circumcised as youths that they sought to restore their foreskins. In a major review of the literature on circumcision’s risks and benefits published in 1970, US Air Force pediatrician Noel Preston drew on research from child psychology to posit that post-operative discomfort (‘the fretful, circumcised newborn, his glans swollen and cyanotic for three to five days’) represented the kind of ‘tension’ that could result in (unspecified) delayed ‘psychologic’ complications. Preston also dismissed as outmoded the fear that intact boys would suffer emotionally if their penises differed from those of circumcised fathers, brothers and male peers. ‘This is the latter half of the 20th century, a time supposedly to celebrate individuality and freedom of choice’, he wrote. ‘If being uncircumcised is embarrassing to a boy he can always be circumcised later’.30 Other physicians emphatically rejected the idea that circumcision could provoke emotional suffering. University of Toronto surgeon Philip Klotz spoke for many when he declared that men seeking foreskin restoration ‘require the services of a psychiatrist rather than a surgeon’.31 Dismissing those men who could not resign themselves to the results of an operation performed in their youth as mentally disturbed befitted and reinforced the postwar equation of masculinity with strength and stoicism. Yet, ideas about gender were beginning to change. Following the lead of second-wave feminists, who had been critiquing traditional gender norms for a decade, some men in the 1970s began advocating for new, less impassive versions of masculinity.32 Participants in the early men’s movement, most of whom were White and middle-class, believed that boys and men could and should admit to feeling physical and emotional pain. To the extent that they convinced the broader public of this, these men paved the way for physicians and lay people to reconceive of foreskin removal as a potential cause of pain for males in multiple ways. The lack of consensus about circumcision and pain was apparent in the first US and Canadian medical association policies on the surgery, both issued in 1975. The American Academy of Pediatrics (AAP) and Canadian Paediatric Society (CPS) agreed that circumcision was not ‘medically necessary’ but took different stances on pain. The all-male AAP Task Force’s statement did not mention physical pain or discuss pain relief, but it suggested that delaying circumcision beyond the preschool years could ‘induce psychologic problems’.33 In contrast, the (apparently) all-male CPS Foetus and Newborn Committee described foreskin removal as physically painful and denounced the practice of offering newborns ‘only a sugar ball to suck on as a soother’ during circumcision, noting that ‘no one would perform a circumcision on a two-month old infant without first administering anaesthesia’.34 Given the absence of ‘any known neurophysiological difference between these two age groups’, the CPS declared that infants should either receive anesthesia during circumcision or retain their foreskins. The Canadian statement also addressed concerns about boys suffering from a lack of ‘genital resemblance’ by invoking the changing social context: ‘conformity must now be considered in relation with the peer group in a society with a rapidly diminishing demand for circumcision’.35 Rates of routine circumcision began to decline in the 1970s, more rapidly in Canada than in the United States. The advent of national health insurance in Canada in the late 1960s contributed to the divergence, insofar as it discouraged procedures deemed unnecessary (though the United States also saw growing concern with high medical costs). Subtly different national norms of masculinity may have exerted some influence as well. Insofar as popular media portrayals of Canadian men as ‘victims’ and ‘losers’ disposed to ‘melancholy and masochism’ reflected real-life dispositions, male pain may have garnered more sympathy in Canada than in the ‘will to win’-oriented United States, where conflict over the Vietnam War may have fueled ongoing tension about whether ‘real’ men were supposed to be violent or peaceful, impervious or susceptible to pain.36 For the baby to be plucked from his bed, strapped in a spread and with is with other of The of and excision of however, to a relationship with the new In other proposed that the physical pain caused by circumcision was not only because it was (as he saw but also because it could cause emotional In was one of a of North American physicians in this period who circumcision to child To represented an of over different of pain to infants, because these their University of Toronto that physical pain from circumcision could have a negative the with his and noted that unnecessary to very children is perceived by the of society as a of child arguments with the of child and growing concern with child of all then as well as with the broader also reflected a in the and of prompted in part by the experiences of US in Vietnam and associated with beliefs about men and the however, North American doctors were not to male circumcision as to child Many prominent physicians continued to that routine foreskin removal was beneficial to health, or to In their review of the Toronto physicians and that circumcision is not an but that the to that it is and that nerves are during the first to of that an is this perspective routine infant circumcision was both to the need for anesthesia at which risk to the procedure, and as one circumcision not to have psychologic circumcision would in at an experience at a is in these mostly for its which comes as a that the 1970s were the of second-wave and the early men’s movement, and that women the were medical in was a analysis of published by and from University and from Medical which whether were to or and that have gender differences in or - boys being more - but and of the did proposed that circumcision practices be The study however, even in Of the that the study between and three in medical three used and research to support the that circumcision affected and but of them gender differences and only one on circumcision and A by then at the University of and to gender differences in infant in the first At the time these were foreskin removal so often in research on pediatric pain that one research felt it that ‘circumcision of male infants has been used as a to study the of newborns to Yet, and their in terms of human and did not what many could it be to study infant pain in only one sex or is with medical research practice into the Wood and Bourke discuss in their on males and to growing medical routine circumcision remained popular in Anglophone North America, the birth of grassroots groups in the in the United States and in As one of the broader health that in the 1960s and 1970s, the anti-circumcision much - including some members - 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For example, Paul and both at the University of that pain from a less than pain from circumcision and that was safe and to In of this and similar US began