February 7, 2019
"Circumcision’s Psychological Damage" is the 7th article in a series published in Psychology Today which claims that circumcision is harmful. Psychology professor Patrick O’Connor argued that circumcision during infancy or childhood causes mental trauma that affects males throughout their lives.  My analysis follows.
O’Connor began by disparaging the proposed CDC guidelines that were released in late 2014 , saying they were based on a 2012 AAP policy statement  that was “sharply criticized” by a group of international physicians.  He failed to mention that the AAP issued a response, which appears in the same publication, in which the AAP task force refuted the claims put forth by its critics.  O'Connor wrote that the CDC failed to consider the evidence that circumcision causes psychological harm.
PSYCHOLOGICAL EFFECTS ON INFANTS
1. Circumcision Causes Immediate Harm
O’Connor cited a 1997 University of Alberta study to show that circumcision is often performed on infants with either no pain relief or ineffective pain relief.  But since that study was published, both the 1999 AAP Task Force  and the 2012 Task Force  recommended that circumcision patients should receive adequate pain relief. And a University of Rochester study showed that by 2003 some 97% of residency programs recommended the use of anesthesia.  So it's likely that most circumcision patients today receive effective pain relief.
O'Connor cited Howard's 1994 study to show that post-operative pain is “severe” and “persistent.”  O'Connor said that other negative outcomes include infection and death, citing Van Howe's studies published in 1997 and 2004. The first question one might ask is: What is the relevance of physical complications, physical pain, and mortality in an article that is supposed to be about psychological harm?
At any rate, these citations do not demonstrate that circumcision is harmful. Howard measured only the effectiveness of acetaminophen and only for the Gomco method. Howard used a small sample size (23 neonatal infants given acetaminophen and a placebo control group of 21.) Howard reported “significant improvement, however, in the group of neonates who received acetaminophen 6 hours postoperatively. It thus seems that acetaminophen may provide some analgesia in circumcised neonates after the immediate postoperative period.”
Van Howe's 1997 study  was based on his personal examination of boys for “sports physical and well-child examinations, and sick visits where a genital assessment was part of a physical examination for a specific problem.” Exams were conducted in Minocqua, a rural town in northern Wisconsin with a population 95% white and a median age of 52.  His patients are hardly representative of the general population of American boys
In his 2004 study Van Howe discussed the difficulty in determining actual death statistics and uses for his circumcision cost-analysis a figure of 9-12 deaths in 80,000 patients derived from a British report.  But Speert reported just one death in 566,000 circumcisions in New York during 1939-1951.  And Wiswell reported zero deaths in 100,000 circumcisions performed in U.S. Army hospitals during 1980-1985. (Wiswell reported two deaths caused by UTIs among the nearly 36,000 uncircumcised boys. In other words, while circumcision didn't pose a risk of death, not being circumcised posed a risk.) 
2. Pain from Circumcision in Infancy Alters the Brain
O’Connor wrote that circumcision affects brain functioning, citing Talbert's 1996 study  and Gunner's 1981 study  to show that the cortisol hormone spikes during circumcision. Both studies have small sample sizes. Talbert tested for circumcision of five newborns, while Gunner tested eight infants 3-5 days old. There is no indication that pain relief was provided. While Gunner indicated that the circumcisions took 16-36 minutes, many physicians report that the procedure takes just 5-10 minutes. Four of Gunner's infants received a pacifier, and “use of the pacifier significantly reduced crying.” Gunner reported “a rapid return to pre-circumcision state,” with most infants exhibiting drowsiness or light sleep within 30 minutes. Gunner added that the study "data are open to several alternative interpretations."
O’Connor cited Taddio's 1997 study to show that “circumcised infants are more sensitive to pain later in life.”  The CDC observed that Taddio "compared use of topical lidocaine-prilocaine cream (EMLA) with placebo", but "did not include a study arm for more effective methods of analgesia such as dorsal penile nerve block (DPNB) or subcutaneous ring block. It is unclear whether the study results would have been the same had another arm with a more effective analgesic modality been included." 
Citing Anand's 2000 paper, O’Connor speculated about the effect of pain on an infant’s behavior patterns. Anand discussed the effects of "exposure to repetitive pain"; however circumcision is normally a singular event. Anand noted that "treatment of circumcision pain with a topical anesthetic decreased their responses to vaccination pain at 4-6 months of age."  O'Connor wrote that Victoria's 2013 study "found that painful procedures in the neonatal period were associated with site-specific changes in the brain that have been found to be associated with mood disorders." O'Connor failed to inform readers that Victoria studied newborn rats, not humans.  The CDC said that the Victoria study "may not be representative of the experience in humans." 
3. Infant Circumcision has Psychological Consequences for Men
O’Connor claimed that men don’t publicly express negative feelings about their own circumcision because of shame and denial, citing Goldman's 1999 paper.  Goldman’s assertions, in fact the entire paper, was highly speculative and contained little foundation. Goldman accused men of denying or repressing their feelings, yet offered no evidence. As a closed circle argument that is impossible to refute, the accusation of denial has no value. 
A 2015 survey of 1,000 American men found that 86% of circumcised men were satisfied with their status, and just 10% wish that they had not been circumcised. By comparison 67% of uncircumcised men were happy with their status, and 29% wish that they had been circumcised. In other words, an uncircumcised man is three times more likely than a circumcised man to disagree with his parents' decision. 
O’Connor wrote that some men circumcised in infancy experience symptoms of PTSD, depression, anger, and intimacy issues that were associated with negative feelings about their circumcision, citing Goldman,  Hammond,  and Boyle. 
Goldman conceded that “there is no empirical research on circumcision trauma and memory.” He admitted that "the effects of circumcision trauma can be chronic and so deeply embedded that it is very difficult to distinguish them from personality traits or effects resulting from other causes.” In other words, a researcher with an anti-circumcision agenda who is looking for psychological harm might mistakenly attribute as circumcision trauma what are actually personality traits or mental problems from other causes. Goldman speculated that newborns might be able to retain memory of trauma. But Strange reported that “early memories are extremely rare” and adults “appeared to have a reduced threshold for accepting” details regarding [false] memories from age 2. Strange concluded that “childhood amnesia increases [the] susceptibility to false suggestion.” 
Hammond conducted a survey of 313 men for the anti-circumcision group NO-HARMM. The respondents were self-selected, and data was collected from self-reporting, which is considered a less reliable method for data collection than researcher examination. In analyzing Hammond's paper, the CDC found that the study "lacks a detailed description of its methodology or whether an attempt was made to obtain responses from a representative sample of circumcised men, or simply to men who are against circumcision."  Hammond's results conflict with a 2015 Queen's University study that utilized standardized measures and was less susceptible to selection bias. 
Boyle cited Rhinehart, a psychologist who reported that several of his middle-age patients suffered PTSD and claimed that many of them remembered their own circumcision. Rhinehart failed to consider the possibility that the psychologist himself guided his patients to associate their problems with circumcision. Rhinehart compared a parent's circumcision decision to the decisions of concentration camp officers on which prisoners would live or die.  The CDC noted that Boyle "focused on psychological effects of circumcision based on performing circumcision without anesthesia, which is not the standard of care recommended by the American Academy of Pediatrics." 
Current research into memory does not show that adults have the ability to recall traumatic events that occurred during the first six months of life. A 2013 Brain Connection article reported that "college students could recall events even if they were only 2 years old when the experiences occurred. Moving and a family member’s death seemed to emerge from the haze of amnesia around the more traditionally accepted age of 3.” However “there were no verifiable reports for recollection of events occurring before age 2.” 
Further research indicates that most early childhood memories are false memories.
"Current research suggests that memories cannot be formed before the age of 3... Researchers explained that most first memories that we formed are fictional patchworks... “While 2- and 3-year-olds can remember something for a short time, the hippocampus is required for long-term storage of those memories. The hippocampus matures slowly and does not reach maturity until we are 3 or 4." 
PSYCHOLOGICAL EFFECTS ON CHILDREN AND ADOLESCENTS 
O’Connor argued that circumcision “clearly meets the clinical definition of trauma because it involves a violation of physical integrity.” But the current American Psychiatric Association clinical definition of trauma doesn’t include “a violation of physical integrity.”  And a child's bodily integrity is violated every time he receives a vaccine injection or blood test.
O'Connor cited three studies to demonstrate that children’s medical traumas share some of the same psychological elements of abuse. He described six studies that found that medical procedures involving genitals often produce symptoms similar to childhood sexual abuse. And he cited these and other studies to support his assertion that the circumcision procedure causes harmful psychological effects.
Most of the other studies weren’t accessible online or were behind a paywall, making it difficult to assess their validity. A review of the studies that are accessible – Hammond,  Cansever,  and Van der Kolk  – provides information that can lead to a different conclusion.
O’Connor characterized Hammond's work as “a study of adults circumcised in childhood.” But 94% of participants were circumcised in infancy and fewer than 5% between 1-17 years.
The CDC explained that the Cansever study
"is biased toward finding a psychological effect related to circumcision and ignoring perceptions by the parents that their children had not suffered untoward effects of circumcision, as it is noted by the authors 'from the interviews with the mother, it seemed, in general, that they had little understanding into the child's psychological state, regardless of circumcision. ... the child's needs and anxieties were rarely recognized and little or nothing was done to protect him from despair.' Many of the psychological tests used in the study were subject to biases of the psychologist's cultural interpretations of the children's responses." 
Van der Kolk focused primarily on chronic trauma including abuse or neglect, often by a family member or caregiver. O'Conner didn't explain how ongoing child abuse or neglect is comparable to a quick medical procedure. Nevertheless, Van der Kolk observed that “under most conditions parents are able to help their distressed children restore a sense of safety and control: the security of the attachment bond mitigates against trauma induced terror.”
4. The Majority of Boys Circumcised as Children and Adolescents Meet Diagnostic Criteria for Post Traumatic Stress Disorder (PTSD)
O’Connor described a study of 1,072 Filipino boys who were circumcised under medical conditions, and 505 who underwent ritual circumcision.The researchers reported that a majority of the boys fulfilled the diagnostic criteria for PTSD.  The CDC was "unable to determine whether the results show any statistically significant differences."  And given the lack of a control group of uncircumcised boys, the study is unusable.
Medical procedures are stressful for children. But parents and health care professionals can take steps to ease a child’s fears. The National Child Traumatic Stress Network recognizes that children can experience some traumatic stress following painful or invasive medical procedures.  The NCTS offers parents and medical professionals tips to minimize the potential for trauma. For instance, health care providers can reduce a child’s distress by taking the following steps.
• Actively assess and treat pain, using your hospital’s protocol.
• Provide child with information about what is happening and choices regarding treatment decisions when possible.
• Listen carefully for child’s understanding and clarify any misconceptions.
• Ask about fears and worries.
• Provide reassurance and realistic hope.
The NCTSN offers other tips for providing emotional support and encouraging parents to use support offered by the hospital or community.  One wonders how many of the pediatric subjects in the dozen studies that O’Connor cited received emotional support or appropriate information about the procedure. Further studies to determine the effectiveness of emotional support to help children cope with medical procedures would be helpful.
5. By Encouraging Circumcision, Medical Professionals are Shaming Boys’ Bodies
O’Connor falsely claimed that the CDC guidelines would give boys the message that their penises are “’bad’ or inferior”, and he offered no evidence that boys would be psychologically damaged. The CDC merely recommends that medical professionals educate adolescent boys that circumcision reduces the risk of acquiring STDs.  It's ironic that a critic of circumcision professes concern about the psychological effects of telling a boy that his penis is inferior - since that's precisely what intactivists tell circumcised males.
When checking the author's sources one finds that O'Connor repeatedly cited studies that aren't applicable to infant circumcision. He misrepresented the results of studies or took results out of context. And he failed to cite - much less address - studies that contradict his claims.
The author cited several papers by researchers who have a long history of anti-circumcision activism.         While researcher bias doesn't automatically discredit a study, readers should be particularly skeptical when considering a paper in which data, analysis, and conclusions support a researcher's partisan a