Circumcision of Infants and Children : Short-Term Trauma and Long-Term Psychosexual Harm

Non-therapeutic infant male circumcision is a permanent surgical alteration to the penis that may cause significant physical, sexual and psychological harm. Physical harms include unintended adverse effects of the surgery itself (e.g., complications such as bleeding, infection, excessive removal of foreskin leaving insufficient shaft skin to accommodate erections, etc.), as well as the inherent loss of healthy, functional tissue. Sexual harms that necessarily follow from circumcision include the loss of all sensation in the foreskin itself, and the loss of all sexual functions that involve the physical manipulation of the foreskin. Additional sexual harms that may follow circumcision include reduced sexual sensation in the remaining penile structures, difficulty with masturbation, increased chafing in both the circumcised man and his sexual partner, as well as reduced overall psychosexual/psychological tension relief and subjective satisfaction. Psychological harms include short-term trauma as well as the potential for long-term emotional disturbances, including sadness, frustration, distress, and anger—akin to post-traumatic stress disorder (PTSD). In this paper, the extent and severity of these various harms are considered and it is argued that they are more serious and more widespread than is commonly believed.


Introduction
Non-therapeutic infant male circumcision is "the most commonly performed surgery in the United States" [1].It is most often performed for cultural or religious reasons, although it is also frequently performed in hospital settings as a routine procedure, at least in the United States (in contrast to other developed nations) [2], where it was adopted by the medical establishment in the late 1800s as a "cure" for masturbation, along with other perceived physical and/or spiritual ailments [3] [4].In recent decades, the circumcision of infants and other young boys in the absence of disease or deformity has increasingly been recognized as being in conflict with well-established principles of medical ethics [5]- [7] and even human rights [8]- [10].As Dekkers et al. (p. 180) [11] noted, both male and female circumcision constitute "an invasive intervention in the external genital organs" without valid medical indication.
According to Peterson (2001, p. 285), "no person has the right to surgically inflict their religious, sexual, or cosmetic preferences on another person… Parents have a duty to protect their children from harmful practices, and no tradition should be enforced by the permanent alteration or disfigurement of the body of an individual who is legally incapable of providing informed consent."[12] Indeed, as several authors have argued, such an extreme interference with a child's genitals would ordinarily be viewed as a form of child sexual abuse- Bigelow (1995, p. 97) [13]- [15].The irreversible cutting and removal of part of a child's sexual organ is a very serious interference [16].

Physical Complications and Harms
Remarkably, there has been little serious research into the anatomy, physiology, and functions of the penile foreskin-however, see [17]- [19].As a consequence, the harmful effects of its removal, especially in comparison with female forms of circumcision (or "genital mutilation"), are incompletely known [20] [21].Instead, researchers in circumcising cultures have focused almost entirely on the claimed "health benefits" of circumcision, and on new kinds of circumcision methods.Yet as Alice Dreger, a professor of Clinical Medical Humanities and Bioethics at the Feinberg School of Medicine has noted, "No one seriously thinks [that 'health benefits' are] the reason to circumcise infants.This is… latched on to by [those] who are looking for a reason to justify a pre-existing desire to circumcise… baby boys.[The American jurist] Oliver Wendell Holmes pointed out that judges tend to know how they want to rule, and then they go on to figure out how to justify the ruling.Routine neonatal male circumcision seems to be a lot like that.People want to do it, and they fish around for a good reason."[22] Nevertheless, several risks and harms of circumcision have been identified, notwithstanding the (relative) lack of research into the question [23].For example, a recent study in the Canadian Urological Association Journal found (p.260) that, "Most physicians performing neonatal circumcisions in our community have received informal and unstructured training, [leading to] unsatisfactory results [being] witnessed in our pediatric urology practice.Many practitioners are not aware of the contraindications to neonatal circumcision and most nonsurgeons perform the procedure without being able to handle common post-surgical complications."[24] Grimes (p.126) made a similar observation as far back as 1978: "Surgical mishaps continue to occur… A partial inventory of operative accidents and their sequalae includes denuding of the penis shaft; incomplete circumcision with residual deformity; lacerated scrotum; subglanular fistula; bivalved, grooved or amputated glans; concealed penis; and cautery burns."[25] Aside from accidental amputation of the glans during neonatal circumcision [26] [27], included among the wide range of additional complications and harms that have been described in the literature, are bleeding and hemorrhage [28], skin bridges and adhesions [29] [30], meatal stenosis (in up to 20% of cases) [31] [32], keloid formation [33], painful neuromas [17], toxicity to anesthetic [34] [35], botched circumcisions [36], urethral fistulas [37], bacterial infections [38], methicillin-resistant Staphylococcal aureus [39], STIs [40], HIV infection [41], reduced penis size and/or buried penis [42], post-circumcision penile cancer [43], ischemia of the glans penis [44], denudation of the penile shaft [45], erectile dysfunction and impotence [46], gastric rupture due to lack of anesthesia [47], ruptured bladder [48], tachycardia and heart failure [49], acute venous stasis and swelling of the abdomen [50], loss of the whole penis [51] (e.g., tragic David Reimer case), 1,2 and even death [54]- [57].Moreover, as Svoboda and Van Howe (p. 2) recently stated, "circumcision adversely affects the developing infant brain by causing trauma-grade increases in heart rate, blood pressure and stress hormone levels.Some 1 David Reimer committed suicide in Winnipeg on May 4, 2004, by gunshot to the head.Evidently, the destruction of his penis by an unnecessary electrocautery circumcision, his subsequent orchidectomy on the advice of John Money, and resultant unrelenting psychosexual trauma, led to the taking of his own life-see Colapinto [52]. 2 Following the attempted suicide of her own teenage son as a result of his circumcision, Massie [53] reported that severe psychological distress following circumcision may be responsible for causing a number of male adolescent suicides: For example, Dontsa Lwane, 19 years, committed suicide after a botched circumcision-died January 8, 2005, Queenstown, South Africa.His brother, Wandile Lwane, 21 years, also committed suicide (after learning of Dontsa's death)-died January 9, 2005, Queenstown, South Africa.Similarly, Beasley Allen Terrebonne committed suicide as an adult after a botched circumcision and resultant depression-died Dec 23, 2008, Thibodaux, Louisiana, USA.
infants do not cry because they go into shock.Mother-infant bonding and feeding is disrupted, as are infant sleep patterns.Circumcised infants become more irritable and less consolable than their intact peers."[23] While the risk of the most severe harms is often described as "low", some scholars and ethicists have argued that our tolerance for risk should be close to zero, since the surgery under consideration would be performed on a healthy child without his consent [58] [59].Needless to say, all such risk is entirely avoidable if the child is not subjected to medically unnecessary surgery in the first place.
In the case of circumcisions performed on post-pubescent males, as is common in South Africa and elsewhere [60], tethered erections with insufficient shaft skin remaining to accommodate the full tumescence of the penis (sometimes resulting in painful intercourse with chafing) may also contribute to sexual function difficulties [61] -also see [62] [63].
As Williams and Kapila (1993, p. 1231) stated, "The literature abounds with reports of morbidity and even death as a result of circumcision."[57] Tragically, as noted above, avoidable deaths do occur following neonatal circumcision.For example, a recent death was reported in 2012 by Robbins [64]. 3 According to Bollinger (2010, pp. 87-88), "thousands of boys have died since this practice was first medicalized 160 years ago.These boys died because physicians have been either complicit or duplicitous, and because parents ignorantly said 'Yes', or lacked the courage to say 'No'.Every one of these boys would have had a chance at life had he not been circumcised."[54]

Psychological Considerations
What about psychological considerations?In some circumcised men, lifelong psychological maladjustment may be apparent [65].Indeed, the trauma resulting from painful circumcision may itself contribute to long-lasting psychological vulnerability in some susceptible individuals [66]- [70].Perry's work also demonstrates the vulnerability of the infant brain to trauma and the potentially long-term adverse effects that may follow [65] [71].Hammack et al. (p. 565) [72] reported that, "Exposure to traumatic events can increase the risk for major depressive disorder (MDD) as well as post-traumatic stress disorder (PTSD)…" Menage [73] as well as Behrendt and Moritz [74] reported PTSD among women who had undergone genital cutting (female circumcision).Likewise, the trauma associated with the male circumcision experience, particularly when carried out without anesthesia [75] is likely to imprint itself onto the child's still-developing central nervous system (CNS) [76].PTSD is a possible complication resulting from unanesthetized circumcision-Rhinehart [77], as is heightened pain sensitivity at least during the several months following circumcision, which Taddio et al. (p.602) [78] described as "an infant analogue" of PTSD.In addition, Hermann et al. (p.278) reported that, "neonatal pain experiences induce long-term alterations in pain sensitivity [79]"-also see [80] [81].Gaensbauer (1995, p. 122) reported that trauma experienced by preverbal infants resulted in "symptomatology consistent with typical post-traumatic diagnostic criteria… The [adverse] developmental implications of early trauma, particularly if it is severe, appear to be significant."[82] Neonates exposed to preverbal trauma (e.g., unanesthetized circumcision) may subsequently benefit from psychotherapeutic counseling [83] [84].
According to Geisheker (2013, p. 24), "Only 14% of US neonates enduring circumcision received any anesthesia… [often] a topical ointment, ineffective… and contraindicated for neonates or when applied to mucosal tissue."[85] According to Taddio et al. (p.599), "Circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants…" [78] Unfortunately, as Cold and Taylor (1999, p. 37) reported, "local anesthetic cream (EMLA) does not relieve the pain associated with circumcision because of the complexity of penile innervation and the multiple layers that would have to be penetrated by the topical cream in the newborn penis" [17]-also see [75] [86].
Research into the effects of circumcision on subsequent pain sensitivity is urgently needed given the potential adverse consequences both for the child's psychological wellbeing (e.g., the development of a sense of basic trust versus basic mistrust, the key psychosocial task during infancy-see Erik Erikson [87]) and the psychosexual wellbeing of the man he will later become [85].

pointed out, "Circumcision is a [wounding] that happens before a baby is capable of understanding the profound pain and [one] that is forced upon him without his consent in the [most] vulnerable first days of life. Circumcision interferes with the maternal/infant bond, disrupts breastfeeding and normal sleep patterns, and undermines a male's first developmental task of establishing trust… Every sexual experience a male has after circumcision is [based] on a neuronal background of pain, even if the male does not [consciously] remember or recognize it... Hyper-reactivity, defensiveness, or the inability to cope when faced with threatening or frightening situations are evidence of early trauma caused by neonatal circumcision." [88]
Grimes ([25], p. 127) has offered a similar perspective: "The application of crushing clamps and excision of penile tissue... probably do little to engender a trusting, congenial, relationship with the infant's new surroundings."(cf.Leboyer, [89], Birth Without Violence).
Both Talbert et al. [90], and Gunnar et al. [91] reported that serum cortisol levels (indicative of stressful physiological arousal) increased sharply immediately following infant circumcision and remained elevated for several days-see also [25].Williamson and Evans [92] compared the adrenal cortical response in infants circumcised with local dorsal penile block and those circumcised without anesthesia, and reported (p.412) that, "The adrenal cortisol response to surgery was not significantly reduced by the administration of lidocaine." There is also evidence that infant or childhood traumatic events (which would include traumatic circumcision) may be associated with subsequent psychotic breakdown [93]- [97].Since the worldwide incidence of circumcision is considerably higher among males than females, and if circumcision is a causal factor in susceptible individuals, a greater proportion of males would be expected to suffer a subsequent schizophrenic episode.Indeed, based on a systematic review of the worldwide incidence of schizophrenia, McGrath [98] reported (p.4) that, "Males have a significantly higher incidence of schizophrenia compared with females (median male to female risk ratio = 1.4)", supporting the possibility that traumatic circumcision may be a causal factor in subsequent psychotic breakdown. 4ecause of the lack of myelination of nerve fibers and the lack of descending inhibitory tracts in the spinal cord [99]- [101], the infant nervous system is particularly vulnerable to painful trauma such as unanesthetized infant circumcision [102]- [104].Although the prefrontal cortex is immature in infants, functional differences associated with positive and negative environmental conditions are observed from the very outset [105].Thus, infant circumcision may cause adverse changes to brain structure and function in the prefrontal cortex that impact adversely on a child's subsequent personality development.Likewise, the neurons in the brain's sexual pleasure center, denied sensory input from the free nerve endings and sensory receptors in the amputated foreskin during the critical developmental period, may atrophy and die or be reassigned to other functions.Based on Hubel and Wiesel's experiments at Harvard University into the deprivation of sensory input to the visual cortex of kittens during the critical developmental phase, similarly, neonatal circumcision might lead to an irreversible loss of perception of sexual sensation from the foreskin that would normally be received in the brain's sensoryreceptive area [106]- [107].Thus, even if sensory input from the amputated foreskin could somehow be restored later on (which it can't), the brain's sensory-receptive area could not perceive such sensation due to likely neuronal degeneration and death (and/or reassignment to other tasks).
Psychological research [108] demonstrates that there are wide individual differences in personality structure, constitution and the ability to cope with stress.Thus, a significant proportion of adult males who have a more susceptible personality make-up (i.e., those who are constitutionally predisposed towards higher negative mood states such as anxiety, stress, and depression) may suffer various degrees of debilitating PTSD due to ongoing unresolvable sexual frustration related to their circumcisions.This could lead to chronic elevations in negative moods and circumcision-induced learned helplessness-see Seligman's work [109].

"The removal of the foreskin causes deficiency of sexual sensation, incomplete sensual gratification during acts and emotional and sexual frustration. No matter what the circumcised do they are unable to achieve direct, complete and adequate natural satisfaction because they lack the receptors for it. The completion of gratification that they perceive is brain-generated. The sensorial deficit induces a psychological transformation or the circumcision complex that simulates the accomplishment of sexual gratification…
The nervous tension that inadequate fulfilment accumulates in the psyche is inflammable… The circumcision complex makes up for an erotic insufficiency.Its compensations substitute and mask the lost pleasure."[110] Circumcision causes irreversible physical, sexual, and neurological damage [19] [111] [112], heightened pain sensitivity at six months post-circumcision [78], and possible future psychosexual dysfunction [77] [113] [114].
Indeed, not only is the sexual satisfaction of the circumcised man likely to be adversely affected by the removal of his erotogenic foreskin, the sexual satisfaction of his female partner may be constrained also [115]- [117].
As Bensley and Boyle (2003, p. 595) pointed out, "While vaginal dryness is considered an indicator for female sexual arousal disorder, male circumcision may exacerbate female vaginal dryness during intercourse.O'Hara and O'Hara reported that women who had experienced coitus with both intact and circumcised men preferred intact partners by a ratio of 8.6 to one.Most women (85.5%) in that survey reported that they were more likely to experience orgasm with a genitally intact partner… Presence of the movable foreskin makes a difference in foreplay, being more arousing to the female.Women reported they were about twice as likely to experience orgasm if the male partner had a foreskin."[115] Why might women with genitally intact partners prefer their sexual experiences?As Johmann (2003) has sug gested, using colloquial language to make the point: "The basic problem for the average [circumcised] American man is that his penis has been so desensitized… that normal sexual intercourse with a female does not provide enough stimulation-hence the…man must work at it, banging away, trying to feel something."[118]

Lifelong Harm and Sexual Disability
The foreskin is highly innervated erogenous tissue [17] [19] [111] [112], which following its removal, can no longer provide sensory input to the brain and/or to the autonomic nervous system [116].The foreskin also provides cumulative erotogenic sensations via its gliding mechanism to stimulate the glans, and vice versa [120].Any sexual activity involving the physical manipulation of the foreskin is necessarily lost to circumcision [60] [121].To claim then, as Morris and Krieger (2013, p. 2644) have, that "male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction" [122] defies logic and lacks common sense.Indeed, such a claim rests upon artificially narrow definitions of each of those terms [123] and contradicts the biological synergy of structure and function. 5In an online survey (N = 1369), Bronselaer et al. (2013, p. 820) reported that, "For the glans penis, circumcised men reported decreased sexual pleasure and lower orgasm intensity [compared to intact men].They also stated more effort was required to achieve orgasm, and a higher percentage of them experienced unusual sensations (burning, prickling, itching, or tingling and numbness of the glans penis).For the penile shaft a higher percentage of circumcised men described discomfort and pain, numbness and unusual sensations."[125] Bronselaer et al. (p.820) concluded that, "This study confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning.Furthermore, this study shows that a higher percentage of circumcised men experience discomfort or pain and unusual sensations as compared with the uncircumcised population.Before circumcision without medical indication, adult men, and parents considering circumcision of their sons, should be informed of the importance of the foreskin in male sexuality." 6n an empirical study (N = 163) of fine-touch penile pressure thresholds in circumcised versus genitally intact men, Sorrells et al. (2007, p. 865) reported that, "The fine-touch sensitivity of 19 locations on the penis was measured using Semmes-Weinstein monofilament touch-test sensory evaluators•••to create a penile sensitivity map." [126] Sorrells et al. (p.869) found that, "circumcision removes the most sensitive parts of the penis and decreases the fine-touch pressure sensitivity of the glans penis.The most sensitive regions in the uncircumcised penis are those parts ablated by circumcision.When compared to the most sensitive area of the circumcised penis, several locations on the uncircumcised penis (the rim of the preputial orifice, dorsal and ventral, the frenulum near the ridged band, and the frenulum at the muco-cutaneous junction) that are missing from the circumcised penis were significantly more sensitive." 7 [126] Other empirical evidence reveals severe sensory neurological damage from male circumcision.For example, Podnar [131] compared elicitation of the penilo-cavernosus reflex among circumcised and genitally intact men.He reported (2011, p. 582) that, "It is known that foreskin, but not glans penis, contains a high density of fine-touch mechanoreceptors.Clinically the penilo-cavernosus reflex provides information on function of the sacral nerves.The study demonstrated that in the majority of circumicised men this reflex cannot be elicited clinically…" [131] Podnar [131] found that while the penilo-cavernosus reflex was elicited clinically in 92% of genitally intact men, it could only be elicited clinically in 27% of circumcised men, providing strong evidence of a statistically significant (p < 0.001) diminution in sexual response in circumcised versus genitally intact men.Podnar (p.584) further commented that, "the penilo-cavernosus reflex is assumed to have the physiological function of... being part of the ejaculation process… [and may account for the] difference in sexual function between these two populations of men".[131] Psychosexual difficulties including premature ejaculation (PE) among young men [132], and lack of sexual sensitivity, delayed ejaculation, and erectile dysfunction among older men [113] [134] [135], as well as longlasting PTSD in some cases appear to be pervasive in circumcising cultures [135]- [138].Dias et al. (2014, p. 122) reported that following adult circumcision, "there was an increase in frequency of erectile dysfunction (9.7% versus 25.8%, p = 0.002) and delayed orgasm (11.3% versus 48.4%, p < 0.001)."Also, Kim and Pang (2006, p. 619) have reported (N = 373) that, "There was a decrease in sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings."[140] While acknowledging many factors are involved in the etiology of erectile dysfunction (ED) which impacts adversely on the psychosocial health and quality of life (QoL) of sufferers and their sexual partners, it is unlikely to be a coincidence that in circumcising cultures such as the USA, 52% of middle-aged men suffer from varying degrees of erectile dysfunction, whereas in non-circumcising cultures such as Germany, the prevalence is only 19% (see Wespes et al., 2012, p. 4) [141].
Moreover, in a study (N = 300) of alexithymia (a personality trait disorder associated with difficulty in emotional identification and expression)-measured via the 20-item Toronto Alexithymia Scale-in circumcised versus genitally intact males [142], Bollinger and Van Howe (2011, p. 184) reported that circumcised men were, "4.53 times more likely to use an erectile dysfunction drug" than genitally intact men [143].In addition, Wespes et al. [141] reported (p.32) that the highest prevalence of PE was found in the USA (31%) where circumcision is common, whereas in France (a non-circumcising culture), the lifetime prevalence was only 15%, suggesting that circumcision itself is a causal determinant of premature ejaculation.As Boyle (2012) commented, "Is it not more likely that it is precisely the lack of neurological control over the timing of ejaculation resulting from the severed neuronal circuitry after circumcision that is a major causal factor in PE?" [132] Indeed, Bollinger and Van Howe [143] found that young circumcised men were 2.56 times more likely than genitally intact men, to suffer from premature ejaculation-see also [144].At least 10 studies have been published comparing PE prevalence in genitally intact versus circumcised men [117] [139] [144]- [151].A metaanalysis based on all 10 studies (Van Howe [152]-Personal communication, 5 July, 2014) found a strong trend that circumcised men were more likely to suffer from premature ejaculation (OR = 1.15; 0.93 to 1.41).In addition, Michetti et al. [153] reported increased alexithymia among men with ED problems. 8

Post-Traumatic Stress Disorder (PTSD)
According to Boyle et al. (2002, p. 332), "A traumatic experience is defined in DSM-IV as the direct consequence of experiencing or witnessing of serious injury or threat to physical integrity that produces intense fear, helplessness or (in the case of children) agitation (American Psychiatric Association, 1994).The significant pain and distress described earlier is consistent with this definition.Moreover, the disturbance (e.g., physiological arousal, avoidant behavior) qualifies for a diagnosis of acute stress disorder if it lasts at least two days or even a diagnosis of post-traumatic stress disorder (PTSD) if it lasts more than a month.Circumcision without anesthesia constitutes a severely traumatic event in a child's life."[135] In the recently updated DSM-5, the very first criterion listed for a diagnosis of either Acute Stress Disorder (duration less than one month) or longer-lasting PTSD is "Exposure to actual or threatened death, serious injury, or sexual violence..." [155] There are two distinct periods of possible psychological trauma that in some cases may result in prolonged PTSD: the first is in response to the physical trauma of the actual genital cutting 7 Likewise, Morris and co-authors attempted to criticize the findings of Sorrells et al. [126].Again, they were rebutted in a response by Young [129].As Frisch (2012, p. 313) has noted in response to similar criticism of his own findings regarding adverse sexual effects of circumcision: "[As] in critical letters to the editor following other recent studies that failed to support their agenda, Morris et al. air a series of harsh criticisms against our study.As seen, however, the points raised are not well founded.It seems that the main purpose, as with prior letters, is to be able in future writings to refer to our study as an 'outlier study' or one that has been 'debunked', 'rejected by credible researchers' or 'shown wrong in subsequent proper statistical analysis'•••.As these critics repeatedly refer to Morris's pro-circumcision manifesto as their source of knowledge, their objectivity must be questioned."[130] itself; and the second during adolescence or adulthood, in response to the cognitive realization on the part of the individual that he has been exposed to a permanent, irreversible alteration in sexual sensation/performance as a result of his non-consented circumcision.
Newly circumcised boys may suffer sleep disturbances with periods of abnormally prolonged NREM sleep, increased wakefulness and inability to sleep, difficulties in feeding, and interference with the mother-infant bonding [20].Also, in a large scale study (N = 3253) in the Philippines, Ramos and Boyle [156] found that almost 70% of boys subjected to ritual circumcision ("Tuli") and 51% of boys subjected to medical circumcision satisfied the DSM-IV criteria for a diagnosis of PTSD, as measured via the Watson et al.PTSD-I scale [157].
According to Menage [158], circumcised men who have become aware that their sexual dysfunction may be at least partially a consequence of having been circumcised during infancy or childhood, have reported feelings of helplessness, abuse, frustration, and of being violated.Moreover, as Bensley and Boyle (2001, p. 215) reported, "Psychological consequences as a result of…surgery are well recognized in the medical literature (Mc-Guire & Parkes [159]).Potential effects of loss of body parts are: 1. Grief for altered body image or function, or both.2. Anxiety, depression, and sexual problems.3. Avoidance of or obsessive preoccupation with the loss."[113] While many circumcised men seem to "have no conscious issue" with being circumcised, it is possible that they have suffered a deep psychological trauma that is repressed within the unconscious psyche [20].Indeed, many women who have undergone even extreme forms of female genital cutting/FGM report being "satisfied" with their sex lives [160]; however, this may be due in part to the fact that they lack adequate knowledge of the relevant genital anatomy (such as the innervations and functions of the clitoris), and therefore may not know what it is that they are "missing" [121].A similar phenomenon may occur in the case of circumcised men, who typically know very little about the anatomy and functions of the penile foreskin-for further discussion, see Earp and Darby [123].Finally, within psychological theory, it is well known that individuals who have been subjected to irreversible harm have a tendency to "rationalize" (or even outright deny) the harm, in an attempt to reduce the discomfort associated with cognitive dissonance (see discussion below).

Long-Term Psychosexual Harm: The Importance of Constitutional Predisposition
In their study into alexithymia, a personality construct characterized by the sub-clinical inability to identify and describe one's own emotions, Bollinger and Van Howe (2011, p. 184) reported that, "circumcised men had ageadjusted alexithymia scores 19.9 percent higher [than] intact men." [143] This suggests that circumcised men are more likely than genitally intact men to exhibit dysfunction in emotional awareness, impacting adversely on their social attachments and interpersonal relationships.Evidently, circumcision sometimes may result in longterm adverse psychosexual consequences among post-pubescent males [135] [161].However, the importance of individual differences in pre-existing psychological profiles must be recognized: circumcision-no matter how traumatic-will not affect all men in precisely the same way.Indeed, empirical psychological research suggests that there are wide individual differences in personality structure, constitution and the ability to cope with stress [108] [162].Accordingly, those who are constitutionally predisposed to respond to traumatic experiences with heightened negative mood states such as anxiety/neuroticism/depression [163] [164], may experience more negative psychosexual outcomes than those who are not so constitutionally predisposed.
For example, it is possible that psychologically vulnerable individuals who come to realize that their sexual sensation, function and/or satisfaction may have been permanently diminished as a consequence of their circumcisions (i.e., unwanted removal of erotogenic tissue) [17] may be more likely to experience elevations in negative moods such as sadness, depression, anxiety, stress, frustration, anger and hostility [108] [165].In some cases, this distress may result in unrelenting, psychological torment and PTSD throughout a man's life [166].
In a survey of the long-term consequences of neonatal circumcision among 313 "circumcised but unhappy" men, Hammond (1997, p. 126) reported that, "96.2% suspected or were confident that circumcision had resulted in a reduction of normal male capacity for sexual response and pleasure.The percentage breakdown of categories of circumcision-caused harm is as follows: Sexual Harm: 84%; Emotional Harm: 83.1%; Physical Harm: 81.5%; Psychological Harm: 75.1%;Low Self-Esteem: 74.4%; Problems with Intimate Relationships: 44.7%; Problems with Addictions/Dependencies: 25.6%.A remaining 13.1% of respondents variously attributed their non-intact state to their problems with masculine identity, self-confidence, and fear of doctors."[133] In an expanded survey (N = 546), Hammond (1999, p. 87) subsequently reported that, "Respondents reported profound shifts in how they perceived their genitals, themselves, and the society that imposed such a loss.Some revealed violent attitudes toward their circumciser and/or suicidal/homicidal feelings… Emotional distress, manifesting as intrusive thoughts about one's circumcision, included feelings of mutilation (60%), low self-esteem/ inferiority to intact men (50%), genital dysmorphia (55%), rage (52%), resentment/depression (59%), violation (46%), or parental betrayal (30%).Many respondents (41%) reported that their physical/emotional suffering impeded emotional intimacy with partner(s), resulting in sexual dysfunction.For some, lack of compassion from parents, siblings or friends fostered bitter interpersonal conflict or alienation.Almost a third of respondents (29%) reported dependence on substances or behaviors to relieve their suffering (tobacco, alcohol, drugs, food and/or sexual compulsivity).Generally, men have no acceptable outlet for serious feelings about circumcision.Predictably, 54% of respondents had not sought help for their suffering.The reasons given included: thinking no recourse was available (43%); embarrassment (19%); fear of ridicule (17%); and mistrust of doctors (11%)."[134] While these surveys suggest that a substantial cohort of circumcised men may be "suffering in silence" [121], the fact that a large number of circumcised men have reported no physical or psychosexual harm suggests that some men may have no conscious awareness of problems associated with circumcision (as discussed above).Other men may have insight into their circumcision-induced losses, but may exhibit little, if any, concern about their situation, raising the possibility of alexithymia [143], or perhaps even resilience [167].

Who Promotes Infant Circumcision? The Possibility of Harm Denial
Circumcised men may ask: "Who are you to tell me that I am damaged?I am just fine and sex couldn't be better."However, as highlighted in Freudian psychoanalytic theory, psychically wounded individuals may often use defence mechanisms such as denial and rationalization to justify their wounding [168] [169], as would be expected from cognitive dissonance theory [170].Such coping strategies may help to minimize any resultant hedonically unpleasant psychological impact.
Consistent with this view, it has been argued that infant circumcision may be largely promoted by circumcised men who are unconsciously seeking to perpetuate the procedure as a compensatory mechanism for their own unresolvable psychic wounding [171]- [173].Such men may resort to the psychological defences of denial, rationalization, and projection to justify its continuance [174].In this regard, Bigelow [13] has discussed the "adamant father syndrome" whereby a particular subset of circumcised fathers, against all rational discussion, vehemently insist that their own newborn sons also be subjected to the sexual-reduction surgery.Moreover, in the USA context, the sheer ubiquity of circumcision suggests that any altered personality and/or behavior of circumcised males may tend to be viewed as "normal" [20].Accordingly, circumcision practitioners may not have given much thought to the trauma and potential long-term adverse psychosexual consequences of the surgery they are paid to carry out.Instead, they may perform circumcisions as a matter of course, both because of parental/societal demand and the concomitant financial reward.
Careful research has demonstrated that circumcision status plays a major role in whether doctors are in support of circumcisions or not [171].In a survey of 572 primary care physicians, Muller (2010, p. 227) reported that, "Although most respondents stated that they based their decisions on medical evidence, the circumcision status of, especially, the male respondents played a huge role in whether they were in support of circumcisions or not.Another factor that had an influence was the circumcision status of the respondents' sons."[172] This is consistent with the view that those who have been subjected to circumcision themselves may need to "rationalize" what happened to them by appealing to supposed "health benefits" that may follow from the surgery.Also, parents who had subjected their sons to circumcision were clearly in favour of the procedure.Some circumcised men may also feel the compulsion to repeat the trauma by imposing genital cutting on others, including defenceless babies and children [175].Disturbingly, as pointed out by Forbes (2015, p. 263), a small proportion of fervent circumcision advocates may well have a psychopathological erotic circumfetishism disor-der [176].9

Conclusion
As Bollinger (2014) has pointed out, "No psychological study has ever concluded that circumcision is beneficial to a boy's psyche [whereas] more than one hundred scientific studies [have] found circumcision [to be] painful, traumatic, or psychologically harmful to men and boys."[177] Men who are constitutionally predisposed toward higher levels of emotionality [105] are more likely to suffer various degrees of sadness and unhappiness due to ongoing unresolvable sexual frustration and the realization of irreversible, circumcision-induced sexual deficits (in sensation, performance, and satisfaction), leading to chronic elevations in negative mood states.However, it should be noted that the emotional pain that some circumcised men experience must not be equated with psychological illness.Anger, grief, and resentment are normal emotions, not illnesses, although they are negative states of mind that are aversive and which individuals typically wish to avoid.Thus they can be counted among the psychological harms of circumcision in men who experience them.
With the advent of the internet, men who are "circumcised but unhappy" have the opportunity to communicate with thousands of other men who also feel aggrieved about having been subjected to involuntary genital surgery in infancy or childhood.As awareness of the physical and psychosexual harm that may result from circumcision continues to grow, it may become increasingly difficult for US doctors to deny that the non-therapeutic genital cutting of males is a form of harmful mutilation, as is already recognized in the case of female children [85] [178].With this changing zeitgeist, it is likely that there will be a growing cohort of circumcised men [133] [134] who may need psychological and psychosocial support to deal with their concerns and the ongoing psychosexual difficulties with which they struggle.