Procedures to prevent the eversion of the foreskin have been in use since antiquity for various reasons. Beginning in ancient Rome as a supposed means of preserving the voice, preputial infibulation largely disappeared in Europe until it experienced a revival during the Victorian era as a clinical weapon in the medical ‘war on masturbation’. Although circumcision was the most common method of preventing masturbation in the USA and Britain, infibulation was frequently used as an alternative, being used in mental institutions and orphan asylums, and receiving endorsement from leading medical authorities.

INTRODUCTION Medical procedures designed to prevent the eversion and retraction of the foreskin, such as binding it shut or perforating it and holding it closed with a metal clasp, have been in use since antiquity, and have been carried out until the modern era for various reasons. However, the term ‘male infibulation’ is commonly used with an imprecision that has obscured its precise historical meaning. Infibulation refers specifically to the process of piercing the lips of the foreskin to fit it with a metal clasp or ring. The devices used for this varied from a silver, gold or bronze ring (later referred to as circellus or annulus), to a metal clasp (referred to as a fibula), and even to safety‐pins. The simple binding of the foreskin to keep it securely closed was accomplished with a simple leather lace, called in Greek a kynodesme[1]. Whether secured by a simple lace or by a metal clasp, the object of these procedures was the same; the temporary narrowing or closing of the foreskin to keep it securely over the glans penis. Closure of the introitus vaginae as part of ‘female circumcision’ procedures is also called infibulation. This procedure is still practised in some African and Muslim cultures today, but is not the focus of this article.

THE ROMAN METHOD: INFIBULATION The first written report on this method of infibulation was provided by the Roman writer Aulus Cornelius Celsus (25 BCE to 50 AD). Celsus gives the following detailed description of the surgical procedure: The foreskin covering the glans is stretched forwards and the point for perforation marked on each side with ink. Then the foreskin is let go. If the marks are drawn back over the glans too much has been included, and the marks should be placed further forward. If the glans is clear of them, their position is suitable for the pinning. Then the foreskin is transfixed at the marks by a threaded needle, and the ends of this thread are knotted together. Each day the tread is moved until the edges of the perforations have cicatrized. When this is assured the thread is withdrawn and a fibula inserted, and the lighter this is the better. But this operation is more often superfluous than necessary. [ 2 ]. Celsus provides no information on the objective behind infibulation, except to state obliquely and disapprovingly that it was mainly performed on youths, sometimes on account of the voice and sometimes for the sake of health. This possibly refers to an earlier idea, reported by Aristotle (384–322 BCE): This development [of the voice at age 14]is greater in those who attempt sexual intercourse; for in those who indulge vigorously the voice even changes to that of a man, while in those who abstain the opposite is the case; and if they help to check it through exercises, as some do who are engaged in the choruses, the voice remains the same for a long time and the change that it undergoes is altogether slight.[3]. A more detailed understanding of male infibulation can be found in the works of other ancient writers. For example, the Roman poet Martial (38–100 AD) often referred to infibulation in his epigrams. In one epigram, he implies that comedy actors and singers who played the cithara wore a fibula, apparently to enhance their sexual attractiveness and thereby to increase their income [4]. This is corroborated in the satires of the poet Juvenal (58–140 AD). In a satire devoted to the subject of Roman wives, he charges that: ‘Some pay a lot to undo the pin of a comic actor.’[5] In another epigram, Martial describes a young athlete whose ‘swollen penis has been unpinned by the smith’[6] and is now ready for sexual intercourse. As some fibulae were apparently more easily removed than others, it is likely that, at least among hired singers, preputial fibulae were worn more as an eye‐catching genital adornment and as part of the standard costume of the cithara player, rather than a medical device. As such, the fibula would have raised the stakes in subsequent bargaining for supplementary sexual services. (Fig. 1). Figure 1 Open in figure viewer PowerPoint Antique bronze plastic of an infibulated Roman eunuch playing a cithara‐like instrument. The Greek medical writer Oribasius (325–403 AD) also gave a detailed description of male infibulation, which he calls krikôsis. Oribasius implied that this procedure was still common in his day. One variation between his technique and that of Celsus is that the perforations made in the foreskin are widened with palm fibres before a tin stud is inserted to aid in cicatrix formation [7]. Unfortunately, the manuscript is incomplete and no description of the fibula or the rationale for the operation have survived.

MALE INFIBULATION IN THE EARLY MODERN PERIOD During the Renaissance and its aftermath, the rediscovery and distribution of classic medical texts, such as those of Celsus and Galen, provided European medical writers with a model of health, disease and treatment that restructured medical thinking along classical lines. There is no evidence that preputial infibulation remained a part of medical practice after the Classical era or that the rationale for it had survived as part of European consciousness. Instead, Renaissance writers and their intellectual descendants felt obliged to repeat the medical information found in classical medical texts and to interpret it after their fashion. The first ‘modern’ edition of Celsus was published in Florence in 1478, and it is only after this date that medical writers included infibulation in their medical surveys. Thus, early modern writers addressed infibulation, not because it existed in their world, but because Celsus had mentioned it. The weight of classical precedent could perhaps have influenced some doctors to execute an infibulation, but there is no evidence to confirm this. Instead, Renaissance and early modern medical writers drew upon the rediscovered and redistributed classical medical texts to demonstrate their erudition. For instance, the Italian anatomist and surgeon Gabriel Fallopius (1523–1562) was inspired by his reading of Celsus and Martial to speculate that in antiquity the fibula was applied primarily to musicians because ‘sex corrupts the voice.’[8]. In later centuries, the combined weight of re‐circulated classical medical texts and the seminal works of Renaissance writers put added pressure on medical writers to address infibulation as a matter of course. The famous French surgeon Pierre Dionis (1650–1718), personal physician to Louis XIV, added his highly critical opinion of the Roman rationale for preputial infibulation, calling it one of the three most pointless and unnecessary surgical operations, all of which should be rejected (the other two being circumcision and surgical de‐circumcision). Dionis intoned: I do not know who invented the infibulation of boys, but this operation shocks the conscience. One pulls the foreskin forward and, piercing it transversely with a threaded needle, one leaves a large thread until the holes have cicatrized. Then, removing the thread, one replaces it with a large iron ring, which remains in place until the patient reaches the age of majority. They used to claim that this ring prevented association with women (until the age of 25, at which time it was removed), forced them not to dissipate themselves, and that they conserved themselves to produce strong children in a condition to serve the Republic [ 9 ]. This is a prime example of how the simple statement found in Celsus was increasingly elaborated upon over the centuries since its rediscovery. Celsus makes no mention of infibulation being done to serve the Roman Republic (509–27 BC), which is not surprising, because the Republic had ended about the time of his birth. Martin Schurig (1656–1733), in his Spermatologia of 1720 [10] continued the tradition of scanning classical medical lore and presenting a wide range of curious topics. Not only did he follow the emerging pattern of addressing such arcane and, to his world, irrelevant topics as foreskin restoration and circumcision, he provided one of the most erudite discussions of infibulation that had yet appeared. Schurig paid homage to Celsus, but he also presented the appropriate poems of Martial as corroborative evidence for the precise intent behind Roman infibulation. In addition to citing the classical texts, Schurig completed his historiographic account with references and quotations from contemporary medical writers, such as Dionis, Peter Uffenbach (1566–1635), Johannes Rhodius (1587–1659), and Joannes Benedictus Sinibaldus (fl. 1650), all of whom had mentioned infibulation in their medical writings. Schurig also cited Johann Vesling (1598–1649) and Jean Riolan (1577–1657), who reported the ‘well‐known facts’ that among the Arabians, Persians and Egyptians are religious zealots who wear enormous preputial rings as a means of guaranteeing their chastity [10]. Equally inspired by reading Celsus, early explorers and writers reported finding infibulation practices in various parts of the world. Cornelius de Pauw (1739–1799), for instance, provided his own interpretation of the rationale behind the infibulation technique found in Celsus, and added his own highly dubious retelling of travellers tales about alleged infibulation practices among contemporary Greeks and Turks: Also the Caloyers or Greek monks, who perform acts of penitence almost as bizarre as the Fakirs and the Bonses, have themselves infibulated with the largest ring a man can tolerate. Among these frenzied creatures, one meets those who wear in their foreskin a ring of iron, six inches in circumference, weighing more than a quarter of a pound. It is impossible to imagine a form of fanaticism more cruel than this. Perfect resignation and superhuman patience is necessary to tolerate these fetters, which proves how difficult it would be for these celibate Asiatics to maintain their vow of chastity if they did not take care to tie themselves up. One also reads of similar things among Turkish monks, such as the Calenders, Dervishes, and the Santons, who also wear these muzzles, and whose holiness the people judge according to the largeness of their rosary and ring. This is all the more astonishing because these miserable creatures are circumcised. They apparently unfasten these rings when they commit the enormous crime of which they are accused. To mortify their flesh and their minds, they occasionally couple with mules and she‐asses, while the mule driver, devotedly kneeling, thanks these saints for the honour they do to his animals [ 11 ]. Although de Pauw has absolute faith in the veracity of these tales (even though he admits that they come fifth‐hand), the modern reader would be wise to maintain a healthy scepticism. Other examples of equally questionable accounts of infibulation may be found in Dingwall's book on the subject [12]. European traveller's tales of infibulated Turkish monks describe them as typically walking about nude from the waist down and often holding musical instruments. However, it is possible that such tales of circumcised Turkish monks who had a ring driven through some sort of piercing in the glans penis became confused and mixed with Celsus’ account of the preputial infibulation of Roman singers. Curiously, a late renaissance statue on the facade of the Kaiserhaus building in Hildesheim, Germany depicts a singer whose foreskin is infibulated with a large ring (Fig. 2). Unfortunately, the building and its facade was completely destroyed during a bomb attack in World War II. The costume of the Hildesheim singer is identical to that depicted in a 16th century French woodcut of a Turkish Muslim Calander, reproduced in an account of a voyage to Turkey by Nicolas de Nicolay (1517–1583) (Fig. 3). However, here the Muslim wears a ring that runs through a transverse piercing just behind the surgically externalized coronal glans. The foreskin has been ablated, according to Muslim custom. De Nicolay writes: Figure 2 Open in figure viewer PowerPoint Infibulated singer at the Kaiserhaus, from 1587 [Stadtarchiv Hildesheim, Germany]. Figure 3 Open in figure viewer PowerPoint Turkish Calandar with typical ear rings and infibulation. [I]n their ears [they] wear great rings of iron, and likewise about their neck and arms, and under their privy members they do pierce the skin, thrusting through the same a ring of iron or silver of an indifferent size and weight, to the intent that being thus buckled, they can by no manner of means use luxury, although they would and had thereunto commodity [ 13 ]. It is unclear whether the piercing merely runs through the remnant penile skin of the circumcised penis, or whether it runs through deeper penile structures.

POPULATION CONTROL IN THE 18TH CENTURY The Enlightenment and Industrialization evoked new concepts of national economy and its relation to population control. The English economist Thomas Robert Malthus (1766–1834) was one of those theoretical pioneers who vehemently advocated population control in western countries. His influential work, An Essay on the Principle of Population, first published in 1798, marked the beginning of the Malthusian movement. In Germany, the controversial surgeon Carl August Weinhold (1782–1829) tried to combine these theories in 1827 and advocated a policy of mandatory state‐sponsored infibulation. His book On the Overpopulation of Middle‐Europe and its Consequences for the Nations and their Civilization suggested compulsory infibulation at the age of 14 for all those male citizens who were deemed unfit to propagate. This included criminals, beggars, chronically diseased people, unmarried servants, and apprentices and soldiers of the lower ranks. The infibulating wire was to be stamped with an official metal seal to avoid illegal removal. Weinhold also provided a detailed regimen of punishments for those who refused to obey the state's medicolegal authorities [14]. Although his ideas seem to have been rejected unanimously by most authors, Weinhold enjoyed eminence and authority in Germany because of his position as Head Surgeon of the University of Halle‐Wittenberg [15, 16]. A public campaign arose against the Infibulisten which was nicely demonstrated in a satirical illustration (Fig. 4). Note the blacksmith in the centre of the illustration, who was to apply the fibula to the condemned persons, and Weinhold himself defending his position against his opponents from a cloud at the top. Obviously, Weinhold was neither an effective university teacher nor an acceptable surgeon. Several attempts to dismiss him from his position were finally overcome by his early, possibly self‐induced, death in 1829 [17]. Figure 4 Open in figure viewer PowerPoint Satirical 1827 illustration attacking Weinhold's infibulation campaign.

INFIBULATION DURING THE MEDICAL PANIC OVER MASTURBATION From the late 18th until the 20th century, a major hysteria over masturbation erupted in European and American medical circles. This antisexual campaign can be seen in a wider context as one aspect of a growing fatalistic tendency of the medical profession to target sexual behaviour, function and anatomy as the causes of almost all diseases and social problems. As part of the professional masturbation hysteria, doctors argued and ‘scientifically’ proved to their satisfaction that masturbation was itself a dangerous, debilitating and deadly disease, as well as a potent cause of a myriad other diseases. The first milestone in this medical campaign was the publication of A Treatise on the Diseases Produced by Onanism (1758) by the respected Swiss physician Samuel Auguste Tissot (1728–1797). Tissot had a major impact on the development of the professional anti‐masturbation movement from the second half of the 18th century onwards [18]. Physicians adopted his theories and invented a wide array of severe surgical, medical, dietary and behavioural therapies for preventing masturbation. Especially in the USA, where a chaotic and unregulated organization of the medical profession pushed doctors towards radicalism and extremism in theory and practice, surgical amputation of the foreskin, i.e. circumcision (deliberately executed without anaesthesia to combine ‘treatment’ with punishment) became the most common surgical intervention against masturbation in boys during the 19th and 20th centuries [19-22]. Extremist religion, and extreme antisexualism and antiphallicism, provided a fertile ground for the acceptance of an obviously antiphallic, intentionally destructive surgery. Infibulation of the foreskin was also used as a means of controlling male sexuality. Among the first medical recommendations for preputial infibulation as a surgical method of preventing masturbation in boys was the German translation and commentary on Celsus by Johann Christoph Jaeger (1740–1816) [23]. In an extended footnote, Jaeger argued for the use of infibulation to halt masturbation, claiming that caused little pain and was easily performed. Jaeger supported his argument by citing the writings of the German physician Samuel Gottlieb von Vogel (1750–1837), who advocated the use of infibulation in a home medical guide aimed at parents and teachers [24]. Vogel admitted that he had not yet performed infibulation, but related that he got the idea for it from Celsus. However, Vogel disingenuously implied that Celsus used infibulation as a method of preventing masturbation, insinuating that Celsus stated that the operation prevented erection, was relatively painless, was quick to perform and was an unfailing method of preventing onanism. In the USA, preputial infibulation as a preventive of masturbation was in institutional use as early as the 1860s. In his account of a tour of American insane asylums, Glasgow physician Alexander Robertson reported that Dr Wilson Lockhart (1825–1910), the superintendent of the Indiana Hospital for the Insane, had formerly used a system of running a ‘silver ring through the prepuce’ of patients ‘to prevent its retraction, but in their efforts to continue the vile practice it had been torn out.’[25] Thereafter, Lockhart medicated his patients with bromide of potassium to repress all sexual impulses. Another important American medical endorsement for the antimasturbatory infibulation of boys was made by the German‐born Abraham Jacobi (1830–1919). A giant of 19th‐century medicine, Jacobi is considered to be the founder of paediatric medicine in the USA. Among his many honours, he served as the president of the American Medical Association in 1912. His views on masturbation were characteristically hostile. While he normally advocated circumcision for masturbation [26], enuresis [27] and epilepsy [28], in a paper on masturbation in young children that he delivered at a meeting of the Medical Journal Association of New York in November 1875, Jacobi mentioned ‘infibulation, as advised by Celsus’, as a means of control, along with inflicting an artificial sore on the surface of the penis to discourse manipulation [29]. Another important endorsement of preputial infibulation as a preventive of masturbation was made in 1876 by the Glasgow physician David Yellowlees (1837–1921) who, from 1863 to 1874, served as the medical superintendent for the Glamorgan County Lunatic Asylum in Wales. In 1874, he was appointed to the post of physician superintendent of the Royal Glasgow Asylum, Gartnavel, which he transformed into a keen centre of psychiatric thought. Yellowlees firmly believed, along with most of the profession, that the foreskin was anatomically necessary for the erection of the penis, reasoning that its physiological use was to give a cover for the increased size of the organ during erection. Preventing the foreskin from providing coverage of the elongated erect penis, Yellowlees argued, would make erection so painful that it would be practically impossible and seminal emission extremely unlikely. Most American surgeons who adopted this line of reasoning campaigned for the permanent prevention of erection and manipulation through surgical amputation of the foreskin [30], but Yellowless considered such a drastic approach to be unwarranted in most cases. At the quarterly meeting of the Medico–Psychological Association, held in Glasgow on 3 March 1876, Yellowlees presented a paper in which he outlined his technique of piercing the foreskin at the very root of the glans with an ordinary silver needle and tying the ends together [31]. This intervention was used in at least a dozen boys, all with excellent results, or so it was reported. It is not known how long the infibulation was maintained. Yellowlees only admitted to having removed the wire from one boy because of irritation. He was impressed by the ‘conscience‐stricken way in which the patients submitted to the operation upon their penises’ and hoped to ‘try it on a large scale and go on wiring all masturbators.’[31] This report earned a favourable reception in the North America, where it was reprinted in the leading journals [32, 33]. Yellowlees’ reputation for identifying masturbation as a significant cause of mental disease and epilepsy attracted the attention of the leading authority on insanity, Daniel Hack Tuke (1827–1895), co‐editor of the Journal of Mental Science, who commissioned Yellowlees to write an article on the subject in his Dictionary of Psychological Medicine of 1892. Here, Yellowless expanded on his condemnation of masturbation and painted a very grim picture of the terrible mental and physical damage that resulted from this variety of sexual activity. He also detailed another version of punitive and supposedly therapeutic preputial infibulation: [S]ome direct operative interference, which shall prevent masturbation and show him [the patient] that he can live without it, may be of much service. The best form of such interference is so to fix the foreskin that erection becomes painful and erotic impulses very unwelcome. To accomplish this, the prepuce is drawn well forward, the left forefinger inserted within it down to the root of the glans, and a nickel‐plated safety‐pin, introduced from the outside through skin and mucous membrane, is passed horizontally for half an inch or so past the tip of the left finger, and then brought out through mucous membrane and skin so as to fasten outside. Another pin is similarly fixed on the opposite side of the prepuce. With the foreskin thus looped up any attempt at erection causes a painful dragging on the pins, and masturbation is effectually prevented. In about a week some ulcera[tion] of the mucous membrane will allow greater movement and with less pain, when the pins can, if needful, be introduced into a fresh place [ 34 ]. Yellowlees’ interest in masturbation seems to have deepened during his Gartnavel days, but it should be pointed out that his advocacy of infibulation was not limited to the treatment of inmates in lunatic asylums, and was, in fact, directed at parents, whose duty, he declared, was to prevent their children from adopting ‘the secret vice’. In the USA, the German‐born St. Louis surgeon Louis Bauer (1814–1898) also used infibulation as means of curing masturbation and epilepsy. Bauer founded the Brooklyn German Dispensary, which later expanded and became the Long Island College Hospital, of which he was a member of the surgical staff. He was also health officer of Brooklyn for 2 years, pathologist to the coroner of Brooklyn, and a brigade surgeon of the New York Militia. In 1869, he migrated to St. Louis, where he later founded and chartered the College of Physicians and Surgeons. In 1878, the erudite Bauer drew upon Celsus, Martial, Juvenal, and the work of Vogel and others, to justify the imposition of infibulation in the treatment of masturbation. In his first case, that of a 22‐year‐old youth, Bauer described his surgical technique as follows: I perforated the prepuce by a trocar on two opposite places, introduced through the wounds two pewter sounds, no. 2, and twisted them together like rings [ 35 ]. The result of this intervention was major swelling and tenderness, which, Bauer noted, effectively debarred the patient from indulging in his ‘bad habits.’ Indeed, Bauer proudly reported that he was able to keep up the irritation of the foreskin for nearly 8 weeks, thereby allegedly breaking the young man of the habit. In a second reported case, also involving a 22‐year‐old man, Bauer abandoned metal rings and described a different method of infibulating the foreskin: I transfixed the prepuce by two silk slings, and directed to fasten them in front of the glans penis on going to bed. The object of the infibulation being to wake the patient by pain when the penis should get in a state of erection [ 36 ]. Here, the therapeutic objective was the prevention of nocturnal seminal emissions, which Bauer believed, like most doctors of this era, were a potent cause of epilepsy. This patient believed that he had developed epilepsy as a result of a history of masturbation commenced at the age of 13 years. Bauer did not disagree with this assessment and avowed that the treatment cured the patient of all complaints. Evidence for the American medical endorsement of preputial infibulation as a preventive of masturbation is also found in the popular literature. The curious or anxious parent looking for information on controlling masturbation in their children would have found a wealth of medically sanctioned advice in various home medical guides. In 1888, the popular and influential surgeon and health reformer Dr John Harvey Kellogg (1852–1943), cofounder of the breakfast cereal empire, published a best‐selling book in which he reported his success at curing masturbation with infibulation, and revealed that infibulation had also been used institutionally in at least one American children's care facility: Through the courtesy of Dr Archibald, Superintendent of the Iowa Asylum for Feeble‐Minded Children we have become acquainted with a method of treatment of this disorder [masturbation] which is applicable in refractory cases, and we have employed it with entire satisfaction. It consists in the application of one or more silver sutures in such a way as to prevent erection. The prepuce, or foreskin, is drawn forward over the glans, and the needle to which the wire is attached is passed through from one side to the other. After drawing the wire through, the ends are twisted together, and cut off close. It is now impossible for an erection to occur, and the slight irritation thus produced acts as a most powerful means of overcoming the disposition to resort to the practice [ 37 ]. In the sphere of popularized medical knowledge, infibulation was also given a strong, 20th‐century endorsement in the home medical guides of ‘Professor’ Thomas Washington Shannon (1866–?). In his popular and successful book on eugenics, which ran to at least seven editions from 1914 to 1921, Shannon extolled the miraculous powers of circumcision to prevent masturbation, but also assured his lay readers that preputial infibulation would make masturbation impossible [38]. Infibulation remained current in medical practice well into the 20th century. It was recommended as an effective remedy against masturbation in a paper delivered in 1902 by John T. Winter (1842–1902) to the Washington Obstetrical and Gynecological Society. Winter served as a professor of theory and practice at the National University in Washington, DC. He was also one of the founders of USA Pharmacopeia, a professional association dedicated to the encouragement and promotion of the science and art of medicine and pharmacy. In his detailed report on the severe health problems caused by masturbation, Winter recommended that boys should be tied spread‐eagle to the bedposts at night. He strongly recommended that circumcision be used to prevent the habit, but as he ended his report, he underscored the value of infibulation, suggesting that one ‘pierce the prepuce with a silver needle, the ends of which should be tied together, and thus make erection impossible.’[39] In Germany, after World War I, infibulation as an antimasturbation intervention was largely abandoned, perhaps because of the dramatic societal changes that followed. Medicine necessarily shifted its focus away from sexual repression and more towards the more immediate health needs generated by the war and the postwar economic collapse. One of the last reported cases of infibulation dates from 1929, and details the case of a young man suffering from mental disorders but acting on out‐dated medical advice. The patient had infibulated and pierced his penis himself with 16 metal rings in several auto‐erotic acts [40]. In the USA, infibulation necessarily became increasingly rare as systematic programmes for routine neonatal circumcision were institutionalized throughout the country in major urban hospitals. Without foreskins to infibulate, infibulation necessarily disappeared from medical practice. Preputial infibulation has thus developed from an ancient Roman practice of indiscernible motivation, to a regrettable medical folly during the hysteria over masturbation. Increasingly, present urologists may be confronted with complications resulting from genital piercing and voluntary sexual mutilation of various degrees. The classical Roman infibulation will obviously remain rare among these cases.

ACKNOWLEDGEMENTS All translations are by F.M. Hodges unless otherwise indicated. Special thanks to Nancy L. Eckerman, Special Collections Librarian at the Ruth Lilly Medical Library at Indiana University School of Medicine, and to Rachael L. Drenovsky, Assistant Director of the Indiana Medical History Museum. They very generously provided very helpful biographical information on Dr Lockhart.