Traumatic impact of operations on children

American cases from the 1930s

Just how sensitive even very young boys can be to interference with their penis was revealed in a paper by David Levy published in 1945. He was a psychiatrist who treated children with psychological and behavioural problems. In many cases he found that their difficulties could be traced to an operation in early childhood or infancy, and that operations on the penis were especially likely to leave psychological and emotional, as well as physical, scars.

Many of David Levy’s cases offer striking evidence of the traumatic effect of operations such as circumcision and meatotomy on young boys. Both of these procedures were in vogue in the USA in the 1920s and 1930s, especially among the richer classes, who seem to have been always fretting fussing over the condition of their children’s genitals. Particularly disturbing is the revelation that it was not uncommon for young boys to be subjected to an operation known as meatotomy, that is, surgical enlargement of the opening of the urethra at the end of the penis (more commonly known as the piss-slit). Much like circumcision itself, this operation was recommended as a routine by some doctors, on the erroneous assumption that they knew better than nature - that because the opening looked small, it was not adequate to its purpose. In 1950 a contributor to the British Medical Journal commended the opinion of an American urologist that all male babies should be circumcised, and that “in addition to complete removal of the prepuce, the urethral meatus should be examined and if any obstruction is found, meatotomy should be performed” – all within “a few days after birth” (C.A. Royde, British Medical Journal, 21 January 1950, 182).

What is remarkable about the cases below is how vividly and bitterly the boys remembered what was done to them even at very young ages, and how their experience made them fearful and distrustful of doctors, and indeed their parents. It is also clear that the operations mentioned below were completely unnecessary: “long foreskin” is not an indication for circumcision (the foreskins of young boys are meant to be long); and there is nothing wrong with the foreskin of 3-year-old not being easily retractable (in fact, it’s not meant to be pulled back that early).

Overall, Levy’s cases present a sorry tale of medical ignorance, and of cruelty to children that, in any context but the privileged space of “medical procedure” or “health” would be regarded as child abuse.

“They cut my penis. I wish I was dead.”

Case 117: Fear of closed rooms and suicidal impulses, with intensification of destructive behaviour, following a circumcision at 6 years 7 months.

A boy aged 7 years 0 months, the eldest of 3 children, was referred because of soiling, negativistic behaviour, temper tantrums and suicidal impulses. His soiling was started at the age of 6 years 3 months, when he was displaying intense jealousy of the younger sibling. At the same time he started baby talk and returned to the habit of taking his toy bunny to bed with him, a habit he had given up three years previously.

At 6 years 7 months he was circumcised because of a long foreskin. He was not told what was going to happen to him. He was brought into the hospital by his father and operated on immediately. While still under the influence of ether he was put into an automobile and taken home. While riding home in a state of anaesthesia he repeated many times, “They cut my penis”, and “I wish I was dead.” He kept close to his mother the rest of the day and repeated the same statements.

In his play of the operation during treatment the patient became very active and dramatic. He had a boy escape from an automobile and shoot his father. Then, “the next day”, the father, now resuscitated got the boy as far as the elevator, whereupon the boy escaped, tore up the hospital sign, blew up the hospital and knocked the father down. A chase between father and son ensued. In the next play he placed the father on the operating table, had the son in the role of surgeon and stuck a dart in the patient’s neck. Killing the father, the physician, “more doctors and then “more people” ended the play.

Asked about his actual memory of the operation, he stated that he didn’t want to go to the hospital. His father forced him and the doorman fooled him. The doorman said, “There’s a pigeon inside. You get into the car, and I’ll catch the pigeon.” That’s how they got him into the car. When he knew he was fooled he began to fight. The door was locked. He knew he was on the way to the hospital by the way his father acted. Since “that” he never goes near that hospital. When his father got him in, they took him up in the elevator. After he was upstairs he tried to get down. After they put him in “the white thing”, he got half dressed again. Then his father pushed him. “When they had the ether on, it looked as though you were seeing a lot of colours. It was red and yellow, and it got louder and louder.” He illustrated with loud noises. “I could see more and more colours, and the taste of it got more and more worse. When the voices got as terrible as it could go, and the taste got worse as it could go, then it stopped, and it wasn’t long.” After the operation he was dizzy, and he rode home in the car. The examiner asked him what the operation was. he didn’t know. I asked if he remembered saying “They cut my penis.” He didn’t.

The father reported that the anaesthetic used for the operation was ethyl chloride. He felt he had to trick the child into going. The child fought against undressing, fought off the physicians and had to be forcibly anaesthetised before they could get him undressed and into the operating room. The father and the anaesthetist applied the force. The father “felt sick about it for a week”, the whole experience was “so brutal”.

The patient had repressed the memory of the operation itself. When told about it, he interrupted and drew on a paper a picture showing how they cut the foreskin off. When this was repeated in play he said suddenly, “I’m trying to remember. I said, ‘Buy me a gun and shoot me; if you don’t I’ll shoot myself’.” But he never recovered the memory of his saying “They cut my penis.”

After the operation there was an intensification of all previous symptoms, especially the tantrums with destructive behaviour. Until that time the tantrums were relatively mild. Suicidal impulses were first observed immediately after the operation. Fears of being in a room alone also developed thereafter, though the patient was not afraid of the dark. It developed into a true phobia. When he took a bath the door had to remain open. If his mother closed it he would jump out of the tub.

“He won’t hurt the wee-wee?”

Case 61: Anxiety-provoking experiences of operative procedures, starting at 16 months [sc. meatotomy: cutting of penis to enlarge urethral opening]

A boy aged 10 years 4 months, the elder of two boys, was referred because he was “afraid of everything, including terrors and nightmares.” In infancy he had a strong startle reaction to noise. The mother noticed that he often shuddered in response to noise when sleeping, and that he was “terror-stricken” when a door banged. At the age of 2 years, in a subway station, he shrieked whenever a train approached. Later, for several years, in the same situation he would put his hands to his ears. He reacted strongly to anything unfamiliar, and yet presented no difficulty at 3 years when his family moved to another apartment. He was afraid of the dark from infancy to the age of 8 years. Then he asked to have lights turned out at night, in order to “fight off” his fear. He also had a fear of moving pictures, but in the two years previous to his referral had “forced himself to go”.

Except for vaccination and injections of toxin anti-toxin at 6 months, to which he had no untoward reaction, his first operative procedure was a meatotomy because of a narrow urethral opening at 16 months of age. It was done by a quick incision without an anaesthetic. At that time his only words were “da-da” and “No”. Before the operation was done he clamped his hand down over his penis. There was some struggling and crying. The mother held him in position for the operation.

A year later, when taken to the same physician for a general physical examination, he had “a look of terror” and asked, “He won’t hurt the wee-wee?” (By 22 months he was “using good sentences.”)

He had night terrors and a “terrified shriek” in his sleep preceding the age of 2 years and following the operation an 16 months. Almost nightly since the age of 4 or 5 years he shrieked, cried or just sat up in bed trembling. …

At four and a half years a number of moles on his hand were removed by excision. The mother held him again for this operation. It was during this period that a governess told him that if he masturbated his penis would be cut off.

Four or five weeks before he was referred the maid found him with a rope around his neck, the other end tied to the doorknob. The maid asked what he was doing. He said he wanted to choke himself, but having changed his mind, turned it into a play.

His night terrors were of chopped-up hands, people chopped up and his trying to put them together unsuccessfully, and especially a witch trying to kill him. In all his dreams it was a woman who attacked him. He actually thought that his mother was plotting against him. “I always think she’s going to plot on me, something I inherited, something I got.” Frequently his dreams dealt with sensations of anaesthesia, and with is ideas of birth. … His fears all resolved into a fear of castration by his mother. He insisted that he remembered the first operation clearly.

He said, “My mother never told me. I remember it clearly. It was the same doctor and the same table I had my tonsils out. I was a baby. Maybe 1 or 2 years old. The way I picture it, I was 2 years old. I remember it hurt a lot. I was always scared about my penis being hurt, but only on the tip. A lot of things happened to my penis. Once it hurt and swelled up where the blackhead is. My aunt told me to put a cold rag on it. I was scared I’d always have the pain and someone would have to rip it apart to get the pain out. They’d rip it apart and sew it up again. It hurt because they used a thin knife. There’s a line running in back of the penis, and if you cut at the tip, then the knife will go down the line, and the penis will be cut all open. I get scared while I talk about it.”

He thought that if they didn’t put a hole in his penis he would be unable to urinate, and his kidneys would burst. …

Beside night terrors and his fears about his penis, he had fears of the dark, of staying home alone, of an illustrated Bible (because it had “scary” pictures in it), and of the room in which it was, of long hallways and closets, of physicians and nurses, and going places.

Of his play in early childhood, a report from his nursery school teacher states that when he was 4 years old his play “centred around the destruction of things” and threats towards his teacher, of cutting her up, burning her up, etc. During a rest period he yelled from his bed, “I’ll cut my face off, I’ll cut my head off, I’ll cut my hands off, I’ll cut my wee-wee off.”

Fear of doctors after circumcision

Case 47: Fear of physicians and taxis following an operation [circumcision] at 3 years

A boy aged 8 years 10 months was referred for psychic vomiting and fears. At the age of 2 years he had been frightened by a foghorn on a boat. He stuttered at intervals for two to three weeks thereafter. At the age of 2 years 3 months he screamed at an examination of his throat. His tonsils an adenoids were removed at that age because of frequent colds. …

Because of a tight foreskin his penis had since his birth been occasionally retracted. Circumcision was necessary, and at the age of 3 years 8 months this operation was performed with general anaesthesia. After leaving the hospital he was afraid to enter a taxicab. Previously, taxicabs had evoked no fear; in fact, he had an unusual interest in taxicabs and other automobiles and travelled frequently to nursery school in taxicabs. Also, fear of physicians was noted at this time.

“Is my penis all right?”

Case 23: Fear of haircuts and of the dark and increased frequency of bed-wetting following an operation [meatotomy] at 2 years 11 months

A boy aged 5 years 9 months was referred for disobedience and incorrigibility at school. He had always been sensitive to noise, though there was no history of “startling” to noise in infancy. At 2 years 11 months a meatotomy had been performed with gas anaesthetic at a physician’s office. He was taken there by his parents. The father was with him in the office, while the mother was in the waiting room. The whole operation, from the time he entered the room until the time he left, lasted ten minutes. When he saw his mother after the operation, he said, ‘That’s a bad doctor. I don’t like him”, and then, “Is my penis all right?” He was brought back twice for dressings, and cried but did not struggle. The mother picked him up and comforted him. At the first post-operative examination the physician stretched the glans penis to note the opening of the urethra. No sutures were taken. The mother applied lotion for ten days.

Previously the child had wet the bed occasionally; after the operation he did so nightly. Also, he refused for two months to have his hair cut. For a period, too, he wanted a light in his room.

Source:  David M. Levy, Psychic trauma of operations in children; and a note on combat neurosis, American Journal of Diseases of Children, Vol. 69, 1945, 7-25

NOTE: It is not clear from Levy’s account whether the boys subjected to meatatomy had already been circumcised when younger. If they had already been circumcised it may be that the meatotomy operation was in fact necessary, since meatal stenosis (ulceration and narrowing of the urethral opening) is a common complication of circumcision.

Persad R, Sharma S, McTavish J, et al. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Br J Urol 1995;75(1):91-3

Robert Van Howe, Incidence of meatal stenosis following neonatal circumcision in a primary care setting, Clinical Pediatrics, Vol. 45, Jan-Feb 2006

ABSTRACT

The objective of this study was to prospectively document the incidence of meatal stenosis in boys. The study included a consecutive sample of boys whose visit with the physician included a genital examination in a private primary care pediatric practice in rural northern Wisconsin. Meatal stenosis was diagnosed in boys from 1.94 to 12.34 years of age. The diagnosis was made in 24 of 329 circumcised boys who were Tanner I development and older than 3 years of age (7.29%, 95%CI=4.48-10.10%). Nearly all required meatotomy to resolve their symptoms. All of the boys with meatal stenosis were circumcised neonatally (exact OR=3.54, 95%CI=0.62-infinity). The ratio of circumcised boys to noncircumcised boys in this study provided 80% power to demonstrate a 21.4% difference in the incidence of meatal stenosis between circumcised and noncircumcised Tanner I boys 3 years and older. Meatal stenosis may be the most common complication following neonatal circumcision. The frequency of this complication and the need for surgical correction need to be disclosed as part of the informed consent for neonatal circumcision. A careful meatal examination is indicted in any circumcised boy with abdominal or urinary complaints.



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