Susan Blank, M.D. is the Chair of the American Academy of Pediatrics Task Force on Circumcision
March 16, 2010
Susan Blank, M.D.
New York City Department of Health and Mental Hygiene
125 Worth St. Box 73
New York, NY 10013
Dear Dr. Blank:
As the author of Circumcision: The Hidden Trauma, I have studied the psychological effects of circumcision. These effects are generally unrecognized by medical doctors, but they are a necessary part of evaluating the advisability of the practice. As you work on developing circumcision policy, I hope you consider the known and unknown psychological effects of circumcision.
Infant neurological development, clinical experience, trauma theory, and research on circumcised infants all support the conclusion that circumcision is traumatic. Circumcision results in extreme pain and significant increases in heart rate and level of blood stress hormone. Some infants do not cry because they go into shock from the overwhelming experience. Anesthetics, if they are used, do not eliminate the pain or the trauma. Long-term infant behavioral changes and disruptions in mother-child bonding due to circumcision have been observed. An MRI showed permanent changes to a circumcised infant’s brain.
Circumcision trauma has long-term effects. In a medical journal survey of 546 circumcised men who reported circumcision harm, the following effects and feelings were noted.
- anger, rage, sense of loss, shame, sense of having been victimized and mutilated
- low self-esteem, fear, distrust, and grief
- relationship difficulties, sexual anxieties, and depression
- reduced emotional expression, lack of empathy, and avoidance of intimacy
Some of these men wish they had been given a choice at a later time rather than having circumcision forced on them when they were too young to resist. The survey does not suggest that all circumcised men have such feelings or how common the feelings are, only that they persist in some circumcised men, and more research is needed. Lack of awareness and understanding of circumcision, avoidance of the discomfort of questioning circumcision, and fear of disclosure help to explain why many circumcised men do not express dissatisfaction. Medical societies in Australia, New Zealand, and the United Kingdom recognize the long-term psychological risks of circumcision.
Some harmful effects may not be connected to circumcision because they appear many years later. Because circumcision is common in the U.S., its effects are common and interpreted as normal. Symptoms of circumcision trauma fit the symptom pattern of post-traumatic stress disorder (PTSD). American discomfort with and avoidance of the topic is a PTSD symptom. Some people cannot even say the word “circumcision.”
As a trauma, circumcision changes the brain. Does circumcision affect the prevalence of autism and ADHD which both occur about four times more often in boys than in girls? We do not know. Sudden infant death syndrome occurs more often in boys than in girls. The rise and fall of male infant mortality correlates with the rise and fall of the circumcision rate. Is circumcision a contributing factor? We do not know. Perinatal experience can affect later behavior. Other unexplored areas include testing male children and adults for changes in feelings, attitudes, and behaviors (especially antisocial behavior); physiological, neurological, and neurochemical differences; and sexual and emotional functioning. Of course, it would be unwise and irresponsible to recommend circumcision until we know the answers to these questions.
As discussed in my journal article “Circumcision Policy: A Psychosocial Perspective,” those who participate in circumcision policy committees are subject to psychosocial factors connected with circumcision. Dealing with these psychosocial factors can start with recognizing the potential bias of committee members. For example, an effect of (circumcision) trauma is the compulsion to repeat it on others. Conflict of interest is not just financial. Members of circumcision policy committees should disclose their circumcision status, number of circumcisions performed, circumcision status of any male children, and religious or ethnic background. Disclosure of this information would help in the assessment of the credibility of the committee and its work. Members of such committees should be held to at least the same standard as peer reviewers. As stated by the International Committee of Medical Journal Editors, “any conflicts of interest that could bias their opinions” should be disclosed, and reviewers “should disqualify themselves from reviewing specific manuscripts if they believe it to be appropriate.”
Medical organizations should also be aware of the potential legal implications associated with a flawed policy. A law journal article claimed that the failure to act in a scientifically responsible manner could make a medical organization liable for trade association misconduct connected with publishing negligent recommendations on circumcision.
Thank you for your work. Please let me know if I can be of assistance. I would be pleased to send a copy of my book upon request.
Very truly yours,
Ronald Goldman, Ph.D.
Circumcision Resource Center
P.O. Box 232
Boston, MA 02133
Note: In 2013 Susan Blank, M.D. was invited by a national newspaper to participate in a written debate on circumcision with Ronald Goldman, Ph.D. She refused.
For additional information please see
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders IV-TR (Washington, DC: Author, 2000).
Anand K. & Scalzo F. Can adverse neonatal experiences alter brain development and subsequent behavior? Biol Neonate 2000;77(2):69-82.http://www.cirp.org/library/pain/anand4/
Boyle G. et al. Male circumcision: Pain, trauma and psychosexual sequelae. Journal of Health Psychology2002;7:329-343.http://www.cirp.org/library/psych/boyle6/
Chamberlain, D. Birth and the origins of violence. Pre- and Perinatal Psychology Journal (Winter) 1995; 10: 57-74. https://birthpsychology.com/journals/volume-10-issue-2/what-babies-are-teaching-us-about-violence
Drevenstedt G. et al. The rise and fall of male infant mortality. Proc Natl Acad Sci USA 2008;105:5016-5021. See Fig. 3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2278210/ http://circumcision.org/circumcision-and-male-infant-mortality/
Giannetti M. Circumcision and the American Academy of Pediatrics: Should Scientific Misconduct Result in Trade Association Liability. 85 Iowa L. Rev 1507 (2000). http://www.cirp.org/library/legal/giannetti/
Goldman R. Circumcision policy: A psychosocial perspective. Paediatrics & Child Health 2004;9:630-633.http://www.circumcision.org/wp-content/docs/CircumcisionPolicy_A_Psychosocial_Perspective.pdf
Goldman R. The psychological impact of circumcision. BJU Int 1999;83(Suppl 1):93-102.http://www.cirp.org/library/psych/goldman1/
Goldman R. Circumcision: The Hidden Trauma. Boston: Vanguard Publications, 1997. http://circumcision.org/circumcision-the-hidden-trauma/
Hammond T. A preliminary poll of men circumcised in infancy and childhood. BJU Int 1999;83(Suppl 1):85-92. http://www3.interscience.wiley.com/cgi-bin/fulltext/119091408/PDFSTART
Jacobson B. et al. Perinatal origin of adult self-destructive behavior. Acta Psychiatr Scand 1987;76:364-71.http://www.cirp.org/library/psych/jacobsen1/
Laumann E. et al. Circumcision in the United States. JAMA 1997;277:1052-7. See Table 1.http://www.cirp.org/library/general/laumann/
Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis J 1999;29:215-21.http://www.cirp.org/library/psych/rhinehart1/
Taddio A, Katz J, Ilersich AL, Koren G: Effect of neonatal circumcision in pain response during subsequent routine vaccination. Lancet 1997;49:599-603. http://www.cirp.org/library/pain/taddio2/
van der Kolk B. The compulsion to repeat the trauma: Re-enactment, revictimization, and masochism. Psychiatr Clin North Am 1989;12:389-411. http://www.cirp.org/library/psych/vanderkolk/
No response was received.
Similar messages were sent to other members of the AAP Task Force including (all MDs) Ellen Buerk, Douglas Diekema, Steven Wagner, Waldemar Carlo, Michael Brady, Lynne Maxwell, Andrew Freedman, Sabrina Crago, Peter Kilmarx, and Lesley Atwood. Others at the AAP who received copies were Errol Alden, Jay Berkelhamer, Dan Walter, Renee Jenkins, Roger Suchyta, and David Tayloe. Those at the Centers for Disease Control working on circumcision policy also were included.