Owsei Temkin, renowned medical historian, has written: ". . . we are all apt to accept a historical myth where we cannot rely on historical knowledge. Where history is lacking, mythology takes its place, and those who disdain history are among the foremost victims of mythology."1 This is most certainly true when we consider male circumcision.

Although much progress has been made since 1949 in dispelling 19th-century myths about the male foreskin (for example, that infantile phimosis was a pathological abnormality; that circumcised men were immune to syphilis; that the foreskin was a "cesspool"; and that circumcised boys did not masturbate), others have proved more persistent. Among these are the idea that ritual circumcision, as practised by certain tribal peoples, arose as a hygiene measure; and the assertion that the removal of the foreskin makes no difference to sexual function.

There is no evidence that customary circumcision originated as a hygiene measure. Many primitive cultures carried out a variety of mutilating procedures on different parts of the body, including the genitals of both boys and girls, but the reasons for these practices are obscure and contested. These cultures also practised cannibalism, human sacrifice, infanticide, widow-burial, foot-binding and other traditions not endorsed today. Conflicting theories have been advanced to account for the rise of ritual operations on the male and female genitals, among which are the following: 2

• a propitiatory sacrifice or sign of submission to a deity (probably a milder form of a ritual which began as human sacrifice);

• an offering to the god or goddess of fertility to ensure children;

• a mark of tribal identification;

• a rite of passage from childhood to adult responsibility;

• an attempt to emphasise feminine or masculine characteristics in girls and boys by removing the parts of the genitals (clitoris and foreskin) believed to resemble the genitals of the opposite sex; and

• a means of humiliating and marking defeated enemies and slaves.

The only point of agreement among proponents of the various theories is that promoting good health had nothing to do with it. In the days before aseptic surgery, any cutting of flesh was the least hygienic thing anybody could do, carrying a high risk of bleeding, infection and death. None of the ancient cultures which traditionally practised circumcision have claimed that the ritual was introduced as a hygiene measure: African tribes, Arabs, Jews, Muslims and Aboriginals explain it differently, but divine command, tribal identification, social role, respect for ancestors and promotion of chastity figure prominently.3 It was only in the late 19th century, when mass circumcision was being introduced for "health" reasons, that doctors sought legitimacy for the new procedure by claiming continuity with the distant past and reinterpreting its origins in terms of their own hygiene agenda.4,5

Although the policy statement recently issued by the Royal Australian College of Physicians reaffirms earlier statements that there is no medical indication for routine circumcision, it does suggest that tribal circumcision arose as a hygiene measure in desert environments, and it is disappointingly silent on the significance and role of the foreskin itself as a normal and prominent part of the male genitals.6 Despite the assertion of most contemporary advocates of circumcision that circumcision makes no difference to sexual response, there is a vast medical literature on the significance of the foreskin. In the Graeco-Roman world doctors considered the foreskin so important that they devised treatments to lengthen those which did not provide generous coverage of the glans.7 During the Renaissance and 18th century the centrality of the foreskin to male sexual function and the pleasure of both partners was recognised by anatomists Berengario da Carpi, Gabriello Fallopio and William Harvey, in popular sex manuals like Aristotle's master-piece,2,8 and by physicians like John Hunter, who also appreciated the importance of the foreskin in providing the slack tissue needed to accommodate an erection.9

In the 19th century the role of the foreskin in erotic sensation was well understood by physicians who wanted to cut it off precisely because they considered it the major factor leading boys to masturbation. The Victorian physician and venereologist William Acton (1814–1875) damned it as "a source of serious mischief",10 and most of his contemporaries concurred.11 Both opponents and supporters of circumcision agreed that the significant role the foreskin played in sexual response was the main reason why it should be either left in place or removed. William Hammond, a Professor of Mind in New York in the late 19th century, commented that "circumcision, when performed in early life, generally lessens the voluptuous sensations of sexual intercourse",12 and both he and Acton considered the foreskin necessary for optimal sexual function, especially in old age. Jonathan Hutchinson, English surgeon and pathologist (1828–1913), and many others, thought this was the main reason why it should be excised.13,14

In the 1970s, a United States physician who had himself circumcised was so pleased with the result that he wrote an article urging everybody else to have it done, but even he acknowledged the loss of sexual sensation:

It is difficult to put numbers on so subjective an experience as sexual satisfaction, but contemporary Canadian researchers who have identified the complex innervation of the penis, the ridged bands and the frenular delta16,17 have provided physiological confirmation of the 18th-century folklore that a man's foreskin was "the best of your property".18