DRAFT RESEARCH PROPOSAL
CONSEQUENCES OF PERINATAL TRAUMA--GENITAL MUTILATION / CIRCUMCISION--AND SOMATOSENSORY AFFECTIONAL NURTURANCE
UPON THE ADULT BRAIN:
NUCLEAR MAGNETIC RESONANCE (NMR) AND POSITON EMISSION TOMOGRAPHY (PET) SCAN EVALUATIONS OF BRAIN STRUCTURE AND FUNCTION
James W. Prescott, Ph.D.
Institute of Humanistic Science
5175 Luigi Terrace #35
San Diego, CA 92122
February 14, 1992
March 17, 1992 (REV)
CONSEQUENCES OF PERINATAL TRAUMA--GENITAL MUTILATION /
CIRCUMCISION--UPON THE ADULT BRAIN:
NUCLEAR MAGNETIC RESONANCE (NMR) AND POSITON EMISSION TOMOGRAPHY (PET) SCAN EVALUATIONS OF BRAIN STRUCTURE AND FUNCTION
James W. Prescott, Ph.D.
Institute of Humanistic Science
A. SPECIFIC AIMS
It is proposed that the extraordinary sensory bombardment of excruciating painful stimuli associated with genital mutilation in infancy has deleterious effects upon the normal structural and functional development of those brain structures associated with genital sensory stimulation/function and the normative experiences of pain and pleasure. Such early trauma upon the pleasure systems of the brain is proposed to have a deleterious impact upon the development of affectional bonds that depends upon those intact brain structures that are essential for the formation of affectional bonds in human relationships, particularly, the development of intimacy in sexual affectional bonding.
It is further proposed that these early traumatic experiences of genital mutilation, particularly, if they are uncorrected by subsequent positive pleasure experiences , are very likely to be expressed later in life in personal and intrapersonal dysfunction involving depression, alienation, anger, self-destructive and socially destructive behaviors. These hypotheses are based upon the well established effects of early somatosensory stimulation and deprivation upon the developing brain and behavior (Cannon, 1939; Cannon & Rosenbleuth, 1949; Berman, Berman and Prescott, 1974; Coleman, 1971; Essman, 1971; Floeter & Greenough, 1979; Heath, 1968,1972ab, 1975, 1977; Higley, Suomi, Linnoila, 1991; Higley, Hasert, Suomi, Linnoila,1991; Laudenslager, M.L., Reite, M., & Harbeck, 1982; Laudenslager and Reite, 1984; Laudenslager, Capitanio and Reite, 1985; Melzack and Scott, 1957; Melzack and Burns, 1965; Prescott, 1967, 1968, 1971, 1975ab, 1976, 1977, 1979, 1980, 1990; Reite, et. al., 1982; Riesen, Dickerson & Struble, 1977; Rosenzweig, Krech, Bennett & Diamond 1968; Saltzberg, Lustick and Heath, 1971; Struble and Riesen,1978; Sharpless, 1969, 1975; Snider & Maiti, 1976; and Tassinari, 1968; and from the known effects of prenatal, perinatal and early infant trauma upon later adult functioning (Anand & Hickey, 1987; Diamond, 1990; Faro & Windle, 1969; Jacobson, Eklund, Hamberger, Linnarsson, Sedvall & Valverius, 1987; Jacobson, Nyberg, Eklund, Bygdeman & Rydberg, 1988; Jacobson, Nyberg, Gronbladh, Edlund, Bygdeman & Rydberg;, 1990; Levy, 1945; Porter, Miller & Marshall, 1986; and Salk, Lipsitt, Sturner, Reilly & Levat, 1985) and others.
1. Consequences of Failure to Provide Effective Pain Relief During Surgical Procedures Upon Physiology, Behavior and Health Status.
There is now incontrovertible evidence that the failure to provide effective pain relief during surgical procedures in neonates results in such stress to the neonate that the psychophysiological integrity of the neonate is so severely compromised that it results in enhanced morbidity and mortality in such neonates. It is now informed medical opinion that "the response of newborns to the stress of cardiac (Anand, Hansen and Hickey, 1990) and noncardiac (Anand, Sippell & Aynsley-Green, 1987; Anand, Sippell, Schonfield & Aynsley-Green, 1988) operations is substantially greater than that of adults " (Anand and Hickey, 1992). Specifically, Anand and Hickey (1987) have previously proposed a physiologic basis "for the use of deep levels of anesthesia and postoperative analgesia to attenuate the extreme responses of newborns to perioperative pain and stress" (Anand & Hickey, 1992).
The findings of Anand & Hickey (1992) upon variations in the effectiveness of anesthesia and postoperative analgesia in neonatal cardiac surgery are so dramatic and relevant to the study proposed herein that direct quotations from their Results and Conclusions are particularly warranted:
Results. The neonates who received deep anesthesia (with sufentanil) had significantly reduced responses of beta-endorphin, norepinephrine, epinephrine, glucagon, aldosterone, cortisol, and other steroid hormones; their insulin responses and rations of insulin to glucagon were greater during the operation. The neonates who received lighter anesthesia (with halothane plus morphine) had more severe hyperglycemia and lactic acidemia during more severe hyperglycemia and lactic acidemia during surgery and higher lactate and acetoacetate concentrations postoperatively (P<0.025). The group that received deep anesthesia had a decreased incidence of sepsis (P=0.03), metabolic acidosis (P<0.01), and disseminated intravascular coagulation (P=0 .03) and fewer postoperative deaths (none of 30 given sufentanil vs. 4 of 15 given halothane plus morphine, P<0.01).
Conclusions. In neonates undergoing cardiac surgery, the physiologic responses to stress are attenuated by deep anesthesia and postoperative analgesia with high doses of opioids. Deep anesthesia continued postoperatively may reduce the vulnerability of these neonates to ;complications and may reduce mortality. (N Engl J Med 1992; 326: 1-9).
In the above study, the authors were particular to note and describe the mechanisms of increased stress and its relationship to sepsis:
The increased incidence of sepsis in the halothane group may have been related to postoperative changes in immune function; such changes have been correlated with hormonal stress responses in adult patients. Beta-endorphins, glucocorticoids, catecholamines, and prolactin are important regulators of immune responses; such interactions may be integrated by the hypothalamus (p.7).
The consequences of significantly increased release of stress hormones upon the developing brain and later behaviors have yet to be fully appreciated. The finding of extended periods of non-rapid-eye-movement sleep in neonates undergoing circumcision without anesthesia by Emde, et al (1971) is a case in point. The findings of Porter, Miller and Marshall (1966) demonstrated that spectrographic analyses of neonatal pain cries could distinguish between cries to circumcision and other stressors and that these neonatal cries could also be distinguished by listening adults.
It takes no leap of faith or evidence to recognize that such pain states will interfere with the maternal-infant bonding process which is known to have its own adverse consequences upon brain structure, function and behavior (supra; and Marshal, et. al, 1982).
Although, it is beyond the scope of this introductory review to systematically cite numerous animal studies on the effects of maternal stress upon fetal and neonatal brain development, function and behavior, the study of Peters (1990) is illustrative of these kind of studies. Peters (1990) reviewed earlier findings that maternal stress modifies 5-hydroxytryptamine (5-HT) receptor binding in several brain regions of the adult offspring and alters the intensity of behavioral responses to 5-HT receptor agonists. In a further study of the same maternal stressor (crowding combined with daily saline injections during the final week of pregnancy), an elevated maternal plasma free tryptophan level without significantly affecting total tryptophan was reported. The increased maternal plasma tryptophan was associated with significantly increased fetal brain levels of tryptophan, 5-HT and 5-hydroxyindoleacetic acid (5-HIAA, a metabolite of 5-HT). These increases were found to be maintained at 10 days postnatal life.
Since 5-HT is recognized to have a role in the control of neuron development during the perinatal period, it was suggested that the stress-induced increase in fetal brain 5-HT synthesis may play a part in the mechanisms by which prenatal stress influences adult behavior.
Similar arguments can be made for the flooding of the neonatal brain with adrenal corticosteroids and other stress hormones from the hypothalamic-pituitary-adrenal system consequent to circumcision stress which have unknown long-term consequences for "encoding" and influencing the developing brain with a possible permanent induction of a psychobiological substrate or pattern of psychophysiological stress that interacts with, influences and confounds all subsequent experiences of pain and pleasure.
This is to say that such profound neonatal pain involving the unique sensory-brain systems that are designed to mediate pleasure may be contributory to the establishment of "sado-masochistic" processes at a most fundamental neurobiolgical level that is beyond the normative range of conscious awareness. Additionally, the possible enhancement of "androgenization" of the developing brain due to excessive output of adrenal androgens consequent to perinatal and postnatal stress, e.g. circumcision, is a possible contributory mechanism to such later behaviors.
Another consideration. What extent, if any, are the mechanisms that convert androgens to estrogens within the brain affected or impaired by perinatal and postnatal trauma? And what are the long term behavioral implications of such a possibility? (Baum, 1979; Phoenix, Goy and Resko, 1968; Diamond, Liacuna & Wong, 1973). What are the long-term consequences of a "hyperandrogenization" of the developing brain for enhanced aggression; quality of male-female relationships; and the capacity for intimacy in sexual relationships? Although, these questions are not directly related to the immediate objectives of this proposal they do reflect issues that are related to the overall consequences of perinatal and neonatal trauma, as it is reflected in acts of circumcision, particularly, as these procedures have been conducted without analgesics or anesthetics.
2. Relationship of Perinatal Trauma To Later Violent Behaviors.
It is perhaps helpful and informative to describe in more detail some of the recent experimental findings that link early perinatal trauma to adult violent behaviors. One of these most dramatic studies was reported by Jacobson, et. al (1987). The summary of this study is provided by the abstract which reads as follows:
The study was undertaken to test whether obstetric procedures are of importance for eventual adult behavior of the newborn, as ecological data from the United States seem to indicate. Birth record data were gathered for 412 forensic victims comprising suicides, alcoholics and drug addicts born in Stockholm after l940, and who died there in 1978-1984. The births of the victims were unevenly distributed among six hospitals. Comparison with 2,901 controls, and mutual comparison of categories, showed that suicides involving asphyxiation were closely associated with asphyxia at birth, suicides by violent mechanical means were associated with mechanical birth trauma and drug addiction was associated with opiate and/or barbiturate administration to mothers during labor. Irrespective of the mechanism transferring the birth trauma to adulthood--which might be analogous to imprinting--the results show that obstetric procedures should be carefully evaluated and possibly modified to prevent eventual self-destructive behavior.
Specifically, the authors reported that perinatal Asphyxia ( a lack of oxygen) carried a risk factor for suicides from hanging, strangulation, drowning and gas poisoning that was five times greater than for controls; for perinatal mechanical trauma, e.g. breech presentations, forceps delivery and multiple nuchal loops, the risk factor for suicides from hanging and other mechanical injuries was twice as great as controls; for perinatal opiate/barbituate use the risk factor for drug addiction was approximately three times greater than the controls.
In a subsequent study, Jacobson, et al (1988) evaluated the role of obstetric pain medication in adult amphetamine addiction in the offspring. In this study of 200 amphetamine addicts and 195 non-addicted sibling controls he reported that there was a 5.6 times greater incidence of amphetamine addiction when nitrous oxide was given for 4.5 hours or longer vs. 0.25 hours or less. Based upon their statistical data, the authors also concluded:
To the extent that the cases in this study are representative for the addict population in Stockholm, the number of amphetamine addicts in Stockholm can be estimated to have been less than 60% of the present level if nitrous oxide had not been administered in the past (apparent from data for various exposure levels, Fig. 3.).
In this writer's analyses of the data in Fig. 3, according to the percentage of amphetamine addicts and non-addicted siblings for the five conditions of duration of nitrous oxide analgesia, the risk factor for amphetamine addiction was 7.2 times greater when nitrous oxide was given for 4.5 hours or longer vs. 0.25 hours or less.
In this analyses, it should be noted that of the 141 amphetamine addicts there was a lower percentage (17.0%) in the category of nitrous oxide duration of less than 0.25 hours than of the 154 non-addicted siblings where 27.9% fell into this category. In short, for this short duration of nitrous oxide inhalation there were 64% fewer amphetamine addicts when compared to the controls. Thus, this short term duration of nitrous oxide inhalation appears to confer some prophylactic benefit for the prevention of amphetamine addiction when compared to the non-addicted siblings.
For the most extreme group of nitrous oxide inhalation which was 4.5 hours or greater, there was an 18.4 percent of amphetamine addicts in this group compared to 7.1 percent for the non-addicted siblings. In short, there was a 159% greater incidence of amphetamine addicts in this group compared to the incidence of non-addicted siblings.
When these two groups are compared, viz the 64% reduction of amphetamine addicts in the short duration of nitrous oxide inhalation of less than 0.25 hours to the 159% increase of amphetamine addicts in the longest duration of nitrous oxide inhalation of 4.5 hours or greater (when compared to the controls), the increased risk for amphetamine addiction is 7.2 times greater for the longest nitrous oxide inhalation group when compared to the shortest duration of nitrous oxide inhalation of 0.25 hours or less.
The interesting unanswered question is why a mild exposure to nitrous oxide inhalation would confer a "protective" function of reduced risk (64%) to amphetamine addiction when compared to controls?.
In a third study by Jacobson, et al (1990) the risk for opiate addiction in adult offspring was evaluated as a consequence of the administration of opiates, barbiturates and nitrous oxide for greater than one hour in all subjects during labor within 10 hours before birth. There were 139 opiate addicts compared to 230 non-addicted siblings in this study.
It was found that in subjects who had subsequently become addicts there was a significantly increased percentage of mothers (25%) who had received opiates or barbiturates, or both, when compared to unmatched non-addicted siblings (16%); and these mothers also received nitrous oxide for longer periods and more frequently. In short, there was a 56% increase in opiate addiction, as a consequence of opiate, barbituate and nitrous oxide administration during labor. After controlling for a number of other variables it was found that the risk for adult opiate addiction increased to 4.7 times for the three drug administrations when compared to matched sibling controls.
In an earlier study of 52 adolescent suicides, Salk, et. al., (1985) reported three prenatal/perinatal risk factors that significantly discriminated the suicide group from the two matched non-suicide control groups. These were: l) respiratory distress for more than one hour at birth; 2) no antenatal care before 20 weeks of pregnancy; and 3) chronic disease of the mother during pregnancy which were found in 81% of the suicide cases. These authors could not speculate as to the mechanisms by which prenatal/perinatal birth trauma were linked to suicidal behaviors.
David Levy in a 1945 study on the "Psychic Trauma of Operations In Children" reported on three cases of male circumcision at ages 12 months (2) and 6-1/2 years. Psychological trauma included the development of night terrors, temper tantrums and rage. In the 6-1/2 year old suicidal impulses developed. Levy reports:
"...a circumcision at the age of 6 years 7 months, was preceded by a struggle of the patient with his father and the anesthetist before they overpowered him. Immediately after the anesthesia wore off, he said over and over, "They cut my penis. I wish I were dead." The rest of the day the patient never left his mother's side. Thereafter his previous temper tantrums developed into destructive rages. During the treatment he played numerous killing games, in which his father was the principal victim. The operation represented a castration by his father."(p.10).
Questions must be raised as to the extent to which rage and suicidal behaviors are engendered by the assaults of circumcision whether conducted during the newborn or child/pre-pubertal periods. (There are approximately a third more suicides than homicides in the U.S.). Is there a link between circumcision and the willingness to kill oneself or others for one's religious or national beliefs? The willingness of many fundamentalist monotheistic men to die or kill for their religious beliefs is well known and the possible link of genital mutilation to these homicidal/suicidal behaviors is more than worthy of study.
Jacobson, et al (l987) noted in their study that hypoxia during birth might cause minimal brain damage that could result in destructive behaviors. However, these authors questioned whether neurological injuries due to hypoxia could be the main factor, "since altogether rather few victims suffered from asphyxia during birth. None of the 86 suicides from poisoning by solid or liquid substance and none of the 53 alcoholics was reported to have been asphyxial."
There are several points to be made concerning these two studies. First, Faro and Windle (1969) in their experimental asphyxial studies in monkeys documented both immediate and delayed brain damage by as much as 10 years in these monkeys. In short, there is a delayed "time bomb" of brain damage that occurs long after the initial injury or insult. It would appear that later stages of brain development are dependent upon earlier stages of brain development which must be normal if later stages of development are to be normal. Secondly, there are a variety of traumas/injuries that can similate or mimic asphyxial effects. Thirdly, the criteria customarily employed for the identification of "asphyxia" may be too insensitive to reflect the actual damage sustained to the brain. Fourthly, there are interaction effects, e.g. maternal-infant separation or isolation of prematures in incubators confers a degree of somatosensory deprivation that can interact with mild degrees of hypoxia that can result in greater brain impairments than either injury alone.
For example, sensory deprivation (like asphyxia) can damage the sensory receptors and sensory pathways of the brain. This neuronal damage from sensory deprivation prevents normal sensory stimulation of the brain, like asphyxia, which is essential for normal brain development and function. The combination of these two events can and most likely are of greater damage than either event taken separately (Prescott, 1975b).
The behavioral data from cross-cultural studies are summarized below that provides further support for the role of early sensory experiences upon later behavior and thus, necessarily, the brain processes that mediate such behaviors.
3. CROSS-CULTURAL PERSPECTIVES: EARLY SENSORY INFLUENCES UPON BRAIN DEVELOPMENT AND BEHAVIOR:
There is a well established body of scientific data that documents the role of sensory stimulation and deprivation upon brain development and emotional-social, psychological and mental development (supra, p.l). From the perspective of the developmental neuropsychological sciences there can be little question that the extraordinary pain experienced by newborns, children and adolescents who are subjected to ritual genital mutilations has a profound influence upon the brain and later behaviors. It is this writers conviction that the extraordinary pain and trauma experienced through genital mutilations--an organ and brain system that is designed for the experience of sexual pleasure and the expression of sexual love--has permanently altered normative brain development for the normal expression of sexual pleasure and love. It is proposed that this genital pain, particularly in combination with the failure of affectional bonding in human relationships has long-term developmental consequences for the ability of such individuals to differentiate pain from pleasure in love relationships; to develop intimate sexual relationships; and to be characterized as peaceful, egalitarian and compassionate individuals.
The above described relationships seem more plausible when it is considered that the brain system which is designed for the experience of pleasure and the expression of sexual love is first encoded with extraordinary and excruciating pain through genital mutilations. In such individuals, all subsequent acts or experiences of genital pleasure are experienced upon a neuronal background of genital pain that is now deeply buried in the subconscious/unconscious brain.
As previously stated, it is this developmental neuropsychologist's conviction that these early experiences of genital pain contributes to the encoding of the brain that begins the neurobiolgical foundation for sado-masochistic behaviors. The brain system that has been designed for pleasure has first and foremost become saturated or encoded with pain that now limits and qualifies all subsequent experiences of pleasure. When these early experiences of genital pain are followed by a developmental deprivation of physical affectional pleasure in the maternal-infant relationship and in the adolescent sexual relationship then violent destructive behaviors are an extremely likely outcome (Prescott, 1975, 1979ab, 1989,1990).
A summary of the cross-cultural studies conducted by this writer that have related measures of infant/child/adolescent pain (genital mutilation, harsh child rearing practices and painful initiation rites); pleasure; and pleasure deprivation (failure of affectional binding in the maternal-infant relationship and adolescent sexual repression) to later adult anti-social and violent behaviors are provided in Tables 1-VII to provide further behavioral support for the basic hypothesis of this study.
It should be noted that in primitive cultures, genital mutilations during infancy are rare and commonly occurs at later childhood or at adolescence as initiation rites or "rites of passage". Thus, genital mutilation rituals in these cultures are not expected to have the same consequences upon the developing brain and behavior, as expected in those cultures that perform genital mutilations during the neonatal period or early years of childhood.
Tables 1 and II summarize the social-behavioral characteristics of primitive cultures that engage in male and female genital mutilations. Tables III & IV provides a similar summary for those cultures that punish pre-marital and extramarital sex. Table VI provides a similar summary for those cultures that inflict pain on the infant by the nurturant agent. In general these cultures are patrilineal, subordinate women to men, have low nurturance of children, are sexually repressive, violent and have a high god that is perceived as violent and involved in human morality (Tables 1-VI).
Table VII summarizes the 49 primitive culture study which was able to predict with 100% accuracy the torture, mutilation and killing of enemy captured in warfare in 49 primitive cultures distributed throughout the world from two measures of deprivation of physical affection, viz. in the maternal-infant relationship and in the adolescent sexual relationship (Prescott, l975;1979;1990). The deprivation of infant physical affection alone predicted the adult violence and non-violence in 80% (39/49) of the cultures, thus, attesting to the powerful role of early sensory experiences upon later adult behaviors. It is emphasized that there is other theory or data base that has yielded such high predictive validity for violent and non-violent behaviors and which is based upon the known sensory systems and brain processes that mediate these behaviors.
Further, there is persuasive scientific evidence that brain dysfunction/damage very likely underlies those violent behaviors induced by Somatosensory Affectional Deprivation--SAD--(Prescott,1968,1975,1976; Saltzberg, Lustick and Heath,1971; Heath, 1972ab, l975; Berman, Berman and Prescott,1974; Struble and Riesen,1978; Floeter and Greenough,1979).
Equally significant is the prediction that the cumulative consequences of these developmental experiences of genital pain and affectional deprivation precludes the possibility of realizing the spiritual dimensions of human sexuality. These relationships have been discussed elsewhere and are mentioned herein to indicate some of the far-reaching implications of this SAD theory and the proposed study (Prescott, 1990).
In summary, the above cross-cultural data provide support for the thesis that the confounding of pain and pleasure during the formative periods of brain development has far reaching implications for the development of patterns of adult behaviors and value systems that involve peaceful and violent behaviors. It is again emphasized that this theory and data support the hypothesis that the early encoding of those developing brain structures that are designed to experience pleasure with excruciating pain provides the neuropsychological foundation for individuals who are predisposed to experience pain to experience pleasure; or who derive pleasure from the experience of pain, i.e. sado-masochistic behaviors which are reflected in the measure of "torture, mutilation and killing of enemy captured in warfare", as reported in the cross-cultural studies cited above.
The above cited studies and many others provide support for the unequivocal conclusion that variations in the sensory/physical environment during the formative periods of brain development influence the structural and functional development of the brain and behavior, particularly, the effects of maternal stress upon fetal and neonatal brain development and behavior,as well as the effects of post-natal stress of various kinds upon brain development and behavior.
It has yet to be established, however, whether a specific form of extreme sensory trauma to the developing brain, viz, genital mutilation, has demonstrable effects upon the structural and functional development of the adult human brain. It is the objective of this research proposal to attempt to document such effects and that this search is more than warranted by the available scientific findings on the role of early sensory experiences and trauma upon brain development and behavior.
4. Specific Hypothesis To Be Tested
Specifically, it is proposed to evaluate the genital sensory projection fields in the cerebral neocortex and cerebellar cortex; the frontal cortical fields defined by projections from medialis dorsalis; somatosensory projection fields in cerebral neocortex and cerebellar cortex; and selected limbic system structures in genital mutilated and intact adults utilizing NMR imaging of the above described brain structures. Surface coil technology will be utilized to obtain optimal imaging enhancement of specially selected brain structures. Visual and auditory sensory projection fields will also be examined, as part of the "controls" in this study. Abnormalities are not expected to be found in the visual and auditory sensory projection fields of the cerebral neocortex and cerebellar cortex.
It is expected that MR Imaging will detect structural differences in the genital sensory projection fields in the cerebral neocortex and cerebellar cortex and in those brain sites involved in mediating pain and pleasure between genital mutilated, intact and super-nurtured subjects.
Additionally PET Scans will be conducted to evaluate how the brain processes positive (non-exploitive, non-violent) images of a sensual-sexual-erotic nature and negative (exploitive, violent) images of a sexual nature. It is anticipated that there will be less activation of neocortical and cerebellar cortical structures associated with the above imagery in genital mutilated subjects than in intact or super-nurtured subjects. This PET scan test will also be able to document the variability of higher brain integrations of sexually pleasant and unpleasant imagery in the subjects to be evaluated.
Although, the challenges are great to demonstrate the injuries of a single massive sensory assault against the developing brain, it is anticipated that for the reasons cited above and with appropriate subject selection and controls that the hypotheses will be confirmed. It is emphasized that the continuing sequalae of pain and discomfort over many months, if not years, during "recovery" has a continuing influence upon the brain and its development which enhances the possibility of finding brain effects consequent to genital mutilation. As previously stated, it is well know that not all consequences of early "insults" or "injuries" to the developing brain are immediately manifested but are often delayed in their manifestation many years later (Levy, 1945; Faro and Windle, 1969; Jacobson, et al,1987, 1989, 1990 and Salk, et al., 1985).
Further, it is emphasized that it is not only the effects of acute sensory trauma upon brain development and behavior that will be evaluated but also the necessary co-factors of diminished or failed "affectional bonding" due to the impairments inflicted upon the pleasure sensing systems of the brain (by this neonatal pain) that now becomes cumulative throughout development; and which are also manifested in major differences of "affectional bonding" due to significant differences in child rearing practices in the subjects tested. The expected impaired ability to experience and integrate sexual pleasure with the higher neocortical systems of the brain, as a consequence of limited early affectional bonding, will also be contributory to finding differences between the experimental and control groups.
5. Specific Brain Structures For Enhanced MR Imaging Evaluation
a) Cerebrum and Cerebral Neocortex
The rationale for selecting specific sites of the cerebral neocortex for enhanced imaging rests upon the thalamocortical radiations to the neocortex (all information from the sensory systems are routed to the cerebral neocortex through the dorsal thalamus); and from specialized studies that document specific neocortical foci associated with stimulation of the genital system. The sensory system of primary importance for this study is the somatosensory system with its projections to somatosensory cortex (Sm l and Sm 11). The prefrontal neocortex which has strong connections with the limbic system receives and integrates information about sexuality and emotionality and is also a cortical area for intensive evaluation.
The specific genital sensory projection field within Somatosensory Cortex can be seen from Figure l(Geschwind, 1980) which portrays the "homonculus"--a body image projection upon the cerebral neocortex. Guerit and Opsomer (1991), not surprisingly, demonstrated that the largest somatosensory cortical evoked potential (SCEP) from stimulation of the dorsal nerve of the penis/clitoris is recorded over EEG position Cz (See Figure 2). The smaller SCEP from genital stimulation compared to posterior tibial nerve stimulation was attributed, in part, to the anatomical deeper location of the genital sensory projection field within the interhemispheric fissure (Penfield and Rasmussen, 1950) and poses special challenges for MR Imaging Analysis.
Specific areas within the frontal lobe is another primary area for enhanced MR Imaging Analyses. In numerous studies involving methods of stimulation, lesions and ablations, MacLean and his associates have provided extensive documentation of the cerebral representation of penile erection in squirrel monkeys (MacLean and Ploog, 1962; MacLean, l962; MacLean, Denniston & Dua, 1963; MacLean, Dua & Denniston, 1963; Dua & MacLean, 1964; MacLean, 1978; MacLean, 1990).
These investigators found positive loci for erection from electrical stimulation in three corticosubcortical subdivisions of the limbic system. The first subdivision corresponds to the known anatomical distribution of hippocampal projections to parts of the septum, anterior and midline thalamic nuclei, and hypothalamus. The second subdivision involves parts of the anatomical system comprising the mammillary bodies, mammillothalamic tract, anterior thalamus, and cingulate gyrus. The third subdivision involves loci found in the gyrus rectus, the medial part of the medial dorsal nucleus of the thalamus, and regions of their known connections. Other anatomical systems were found to be associated with penile tumescence, e.g. rhythmic hippocampal after-discharges where the animal assumed a quiescent state upon termination of the hippocampal after-discharges; and the ponto-cerebellar system.
The finding most relevant to this study is the central role that the medial dorsal nucleus of the thalamus has in penile tumescence because of the projections of medialis dorsalis to prefrontal cortex, particularly, orbitofrontal cortex. As MacLean (1962) noted: "Indeed, it (medialis dorsalis) is such a potent point that stimulation here may elicit close to full erection even under deep anesthesia" (p.299). MacLean (1962) continues:
The prefrontal cortex, which is connected to the medial dorsal nucleus, is a relatively recent addition to the new mammalian brain. From our limited knowledge of its functions, it might be inferred that it is largely concerned with anticipation and planning as it pertains to both self-preservation and preservation of the species (p.299); and
In regard to this last finding it is pertinent to recall that frontal lobotomy, which severs the connections between the medial dorsal nucleus and the orbitofrontal and prefrontal cortex, sometimes results in bizarre, uninhibited sexual behavior (p.294).
It does not take a great deal of interpretive skills to suggest that genital trauma may induce damage/dysfunction in medialis dorsalis and its resulting connectivity with orbitofrontalandprefrontal cortex. Such damage/dysfunction could well provide the beginning neural substrate for the latter manifestation of sexual-social dysfunctions of various kinds dependent upon subsequent developmental experiences involving the affectional systems of the brain.
More specifically, Prescott (1971) outlined the special importance of medialis dorsalis and its projections to orbitofrontal and prefrontal cortex with respect to his SAD(Somatosensory Affectional Deprivation) theory of depression, sociopathy and violent behaviors:
The inhibitory forebrain areas, particularly the frontal orbital cortex, are implicated in this theoretical neuronal model not only because of the study of Anand, et al. (1959) but also because of those studies by Kennard and Ectors (1938); Kennard, Spencer and Fountain (1941); and Ruch and Shenkin (1943) in which lesions in frontal orbital cortex (Area 13 of Walker) produced hyperactivity in the form of 'pacing' or 'forced circling' movement stereotypes which would perseverate for as long as the test period of three hours. Equally important was the observation of a 'definite reduction in emotional expression' with reduction or elimination of 'fear' and 'aggressive' behaviors which were apparently replaced by 'gazing into the distance with a blank expression' when the animal was not engaged in stereotypical pacing or running. This was interpreted as an'over-reactive' response to the presence of an observer. The dramatic similarities of these behaviors in animals with frontal orbital cortex lesions with the behaviors of isolation reared animals hardly need further emphasis.
Additional evidence implicating the frontal orbital gyri (Areas 13 & 14) in the behavioral disorders of the somatosensory deprived animal are the marked autonomic changes produced by stimulation of these areas, particularly, the development of sham rage by stimulation of Area 14 (Livingstone and Davis, 1947). More recent evidence has been obtained in implicating the orbital gyri in emotional behaviors in the study of Butter,et al. (1970), in which orbital frontal lesions in rhesus produced hyper-reactivity, heightened oral tendencies, and a reduction in aggressive behaviors. As noted above, it is of more than passing interest that sham rage was also produced by cerebellar stimulation (Dow and Moruzzi, 1958), which may be suggestive of further support for a possible functional link between the cerebellum and frontal orbital gyri.
It should be noted that any cerebellar-orbital gyri linkage that would be mediated by thalamic relay nuclei would necessarily involve the dorsomedial nucleus since Rose and Woolsey (1948) have proposed that the frontal granular cortex be defined as that part of the frontal lobe which serves as a projection areas for the dorsomedial nucleus. More specifically, it is known that medialis dorsalis (MD) consists of three distinct substructures: Pars paralamellaris, Pars parvocellularis, and Pars magnocellularis which projects to Areas 8, 9, and orbitalis (Areas 1, & 14), respectively, within frontal granular cortex (Akert, 1964).
Thus, Pars magnocellularis of medialis dorsalis (MD) assumes a critical role in any thalamic mediated cerebellar-orbital gyri linkage. Evidence to support this actual anatomical linkage is sparse; however, the study of Nimi, et al. (1962) demonstrated terminal degeneration in medialis dorsalis subsequent to unilateral lesions of the cerebellar nuclei which is supportive of these speculations. The finding of Fox (1949) that pars magnocellularis of DM receives pathways from the amygdala and of Guillery (1959), who traced fibers to it from the midbrain tegmentum and septal region, give greater interpretative significance to Heath's (1969/1975) findings of septal and cerebellar spiking activity in the somatosensory deprived rhesus.
It is appropriate to mention the observations of Dow (1970) that the extraordinary development of the neocerebellum in the higher primate corresponds specifically to the development of the frontal and temporal association areas and not to the cerebral cortex as a whole, and that projections from association areas of the frontal and temporal lobes to the pons in man constitute 1/5 of the whole of the internal capsule (as the fronto and tempero-pontine fibers). Thus, sufficient neuroanatomical, neurophysiological and behavioral evidence appears to exist to encourage speculation of a cerebellar--orbital frontal--limbic--reticular circuit in the mediation of abnormal emotional behaviors (pp10-11).
It is for the above reasons that special attention must be given to Areas 8,9,13 and 14 within the frontal granular cortex in the enhanced MR Imaging analyses of these brain structures.
There is substantial evidence that the cerebellum plays a major role in the regulation of autonomic nervous system activity and emotional-social behaviors (Prescott, 1976). It is beyond the scope of this proposal to review this evidence as background for the study of cerebellar structures in this proposed research. A few studies should suffice.
Anand, et. al (1959), utilizing evoked potential techniques, demonstrated strong functional relationships between the paleocerebellum and limbic system structures. They report:
(i) Projections from posterior paleocerebellum. Stimulation of the posterior paleocerebellar structures, including the flocculonodular lobe, evoked potentials in all the limbic regions from which recordings were obtained. The results indicated quite heavy projections from the flocculonodular and adjoining posterior regions.
(ii) Projections from anterior paleocerebellum. Stimulation of anterior paleocerebellum evoked potentials mainly to orbital cortex and hippocampus. There was evidence also of connections with the hypothalamus (p.452).
Specifically, stimulation of the lingula, centralis, and culmen of cerebellar cortex resulted in evoked potentials in the limbic region; and stimulation of the pyramis, uvula, nodulus, paraflocculus and flocculus resulted in evoked potentials in the orbital surface of the cerebral cortex. These authors conclude:
The present observations point to the existence of extensive projections from the posterior part of the paleocerebellum (including the flocculonodular lobe) to most of the limbic structures of frontal and temporal lobes as well as to the hypothalamic regions. These projections appear to be especially strong to orbitomesial cortex, and amygdaloid-hippocampal complex"(p.456).
Additionally, MacLean, Denniston and Dua (1963) reported positive loci for penile erection in the substantia nigra, pons and the brachium pontis, thus, suggesting the involvement of a "nigro-ponto-cerebellar" pathway in penile erection.
Heath (1972ab, 1975) has provided substantial electrophysiological evidence for extensive connections between the cerebellum and limbic system structures through stimulating and recording from the deep cerebellar nuclei.
In addition to the above specific areas of the cerebellum that have been identified for enhanced MR Imaging there is merit to also examining the corticopontine projection areas on the cerebellar cortex which involves primarily Lobules H1-H IX of the intermediate-lateral cerebellar hemispheres.
The effects of sensory deprivation or altered and abnormal sensory environments upon brain development and behavior are well documented. It is this mechanism of somatosensory trauma and deprivation which is proposed to be the mediating process of a variety of early traumatic events of obstetric drugs, genital pain, sensory deprivation and other stressors, including asphyxia that damages the affectional neuronal systems of the brain. It is this damage that compromises or prevents the development of affectional bonds of pleasure since the brain systems that mediate pleasure have been damaged by these early insults and injuries that began in utero. Thus, the presence of postnatal TLC or somatosensory affectional stimulation may not be assimilated by the infant because of prenatal/perinatal neuronal damage to the pleasure systems of the brain. This thesis constitutes the neuropsychological foundation of my SAD (Somatosensory Affectional Deprivation) theory of alienation, depression, addiction and violent behaviors.
It is for these reasons that SAD is proposed to be the process or mechanism which can account for the linkage between prenatal/perinatal trauma, obstetric drugs and suicides that have been reported by Salk, et al.(1985), and by Jacobson, et, al. (1987, 1988, 1990). It is emphasized that the first consequences of SAD are hyper-reactivity and depression which are the precursors to other forms of violence, particularly that of suicide. Unfortunately, neither the Salk, et al. nor Jacobson, et al studies have reported on the degree of infant isolation in incubators or the degree of post-natal somatosensory affectional deprivation of the infant/child who later became addicted or committed suicide. It is emphasized that these phenomena must be quantified in any future developmental studies of this kind, if the most valid and reliable assessment of early insults/injuries are to be assessed.
The SAD (Somatosensory Affectional Deprivation) theory is offered as an alternate explanatory mechanism to that of "imprinting" that has been offered by Jacobson, et al (1987, 1988, 1990) for the explanation of the consequences of adult drug addiction and suicide to perinatal trauma.
In further elaboration, Somatosenory Affectional Deprivation (SAD) theory is based on the nature of brain processes where it has been well established that activation of the pleasure circuits of the brain inhibit the activity of the violence circuits of the brain. This normative reciprocal relationship ceases to function when the neuronal circuits of the brain that mediate pleasure are insufficiently developed--a form of brain dysfunction/damage--due to sensory deprivation of physical affectional pleasure, specifically, somesthetic (touch) and vestibular (movement) sensory stimulation. Gentle touch and rocking of the infant are powerful sensory stimuli for pleasure, comfort and a sense of "basic trust" for the infant/child. When these sensory stimuli are absent and, in addition, are replaced by painful sensory stimulation, then the neurobiological foundation for depressive, addictive and violent behaviors is established.
In brief, the emotional pain of affectional deprivation--the failure of love--in the maternal-infant and parent-child relationships; and in our sexual relationships seeks relief through drugs, alcohol and violence--in the rage of our physical assaults against others; beatings, rape, homicide or assaults against our own bodies in self-mutilation and drug addiction where the final solution is suicide--one of the leading causes of death in our children and youth. Why should our children and youth be committing suicide in such great numbers--a 112% increase from l980 to l985 for children aged 10 to 14 years? Does genital mutilation in combination with SAD facilitate suicidal and assaultive behaviors?
A further correlate to the above relationships and why certain postnatal traumas are tolerated (genital mutilations) is to be found in our cultural mores that places a high moral value on pain, suffering, deprivation; and, conversely, immorality upon the physical pleasures of the body, particularly the sexual pleasures of the body. It is for these reasons that the pain of genital mutilations are tolerated and supported and why the pleasures of genital stimulation are commonly forbidden, e.g. masturbation--with all the developmental neuropsychological and moral consequences that such events have upon the individual and culture. These issues have been reviewed elsewhere and are mentioned herein, to indicate the developmental and cultural complexity of the phenomena to be studied, namely, the consequences of genital mutilation upon brain development and behavior (Prescott, 1989)
For all of the above reasons it is reasonable to pursue an exploratory study of the possible consequences to the developing brain from the sensory trauma inherent in genital mutilations. Positive findings would, necessarily, have a dramatic effect upon raising the level of human consciousness of the world that is permitting such damage through genital mutilations upon helpless newborns and children throughout the world.
In addition to providing scientific information to help end the torture and mutilation of children inherent in genital mutilations, these research findings would also provide a foundation for later studies that would examine the possible linkages of these early traumas upon the development of later violent and sado-masochistic behaviors, particularly its contribution to the various forms of sexual violence that are all too prevalent in those cultures that inflict genital mutilation upon infants and children. In this respect, the commentary of MacLean (1962) on the relationship between sexuality, fear and aggression is relevant:
Sexuality, fear and aggression: The foregoing considerations are germane to the close connection between sexuality and fear and aggression. As is well recognized, fighting is frequently a preliminary to both feeding and mating. One sees combative behavior even in the nursing babe which will angrily fight the breast if no milk if forthcoming, and at the same time develop penile erection. Proceeding caudally from the level the level of the anterior commissure, one can follow neural structures involved in fearful or angry, combative behavior lying proximal to those concerned with feeding and sexual responses. Within the space of a millimeter, one may pass from a point at which stimulation results in erection and an apparent state of placidity to one at which the electrical current elicits erection in conjunction with an angry or fearful ;type of vocalization and showing of fangs ((MacLean and Ploog, 1962). As one lowers the electrode a little deeper, one may obtain only fearful or angry-appearing manifestations during stimulation, yet see erection appear as a rebound phenomenon after stimulation is terminated.
One is reminded of a statement in Freud's "Three Contributions to the Theory of Sex": "The sexually exciting influence of some painful affects such as fear, shuddering, and horror is felt by a great many people throughout life and readily explains why so many seek opportunities to experience such sensation..." (3, p.63). One thinks of pyromania, for example. (p.296).
I would add other examples besides pyromania that may be more relevant to our cultural condition: the significant rise and predominance of horror films; "slasher" films, sexual violence in films and in real life (rape). It is not an excess of speculation to suggest that dysfunction in the basic neural systems of the brain that regulate sexuality, emotionality, social-sexual relationships and "Consciousness" may well underlie the prevalence of sexual sociopathy and psychopathy in our culture. And that genital mutilation and other forms of assault to the development of the pleasure/ affectionale systems of the brain would constitute significant contributions to those brain dysfunctions that, undoubtedly, underly these social-cultural disorders.
On the positive side and from an evolutionary perspective there are also significant implications on the role of the above discussed brain structures for the development of social and sexual altruism and the realization of the spiritual dimensions of human sexuality which must include an integration of the sexual systems of the limbic brain with the frontal lobes and cerebellum (Prescott, 1976ab,1990). It is here that the commentary of MacLean (1962) on sexuality and altruism is also of particular relevance:
Sexuality and altruism: Thus far we have considered neural and behavioral findings that would appear to shed some light on psychiatric observations that the acts of mastering, devouring and procreating seem to be inextricably tied to one another.
In concluding, we have yet to consider a subject that goes to the roots of man's idealism and altruism--namely, the close connection of feeding, sustaining and sexuality. A concern for the welfare and preservation of the species is based on sexuality. The mother when feeding her baby at breast experiences well-being and may have sensations associated with tumescence in the genital region. Subjective analyses have shown that there may be a comparable reaction in the feelings of those who find joy in helping and sustaining others.
In giving the results of the stimulation studies we pointed out that penile erection was obtained by stimulating structures along the course of the mammillothalamic tract and in parts of the anterior and medial thalamic nuclei (MacLean and Ploog, 1962). Heretofore these structures have been looked upon as silent areas of the brain. The mammillothalamic pathway, the pathway numbered three in Figure 2, is, as LeGros Clark and Meyer emphasized, not found in the reptilian brain but appears for the first time in the mammal (Clark and Meyer, 1950). It is possibly pertinent to the increasingly complicated sociosexual behavior that one finds in ascending the phylogenetic scale of the mammal, that this pathway and its related nuclei attain their greatest size in man. Thus there seems to be support for the assumption that Nature did not stop at the primitive level of the hypothalamus, but endowed us with considerable brain stem and cortex with which to promote the preservation of the species.
It may be particularly significant that the medial dorsal nucleus which projects to the orbital and prefrontal cortex develops in association with the anterior group of nuclei and literally embraces them. As pointed out, the ancient midline portion of the medial dorsal nucleus is implicated in penile erection. Indeed, it is such a potent point that stimulation here may elicit close to full erection even under deep anesthesia (MacLean and Ploog, 1962).
The prefrontal cortex, which is connected to the medial dorsal nucleus, is a relatively recent addition to the new mammalian brain.
It is here that we must return to the cerebellum and the concept of the Quadrune Brain (Prescott, 1983) and its role in the regulation of social-sexual and emotional behaviors and its further role as an integrative system of higher brain systems --the frontal lobe--(the brain of Consciousness) with that of lower brain systems--limbic brain--(the brain of the Sub-Conscious and Unconscious). As Dow (1974) has noted there is an evolutionary significance of the cerebellum that is poorly understood:
This extreme phylogenic development (of the cerebellum) is not related to the cerebral cortex as a whole but specifically to the development of the frontal and temporal association areas whose projection to the pons in man as the fronto-and temporo-pontine fibers makes up one-fifth of the whole of the internal capsule (p.110).
....Something important seems to happen to convulsive phenomena, to a variety of vegetative function, to emotional behavior and perhaps even to the highest level of intellectual function when a cerebellar influence is introduced into the nervous system. Whatever it does to modify the activity of other parts of the brain, it probably does the same thing in all its possible varied roles. Its uniformity of structure throughout vertebrates and within its various division in higher mammals makes this most likely. (p.115)
The evolutionary and developmental significance of the cerebellum in understanding the higher functions of homo sapiens and the cultural evolution of homo sapiens has been uniquely addressed by Torgersen (1954) which merits restatement here:
The data indicate that girls have a larger cerebellum in early childhood, whereas boys probably have a slightly larger cerebral cortex. The rapid growth of the cerebellum in girls parallels the precocious ossification and maturation in the female sex. It is probable that endocrinology in later years has prevailed to such an extent that the role of the central nervous system in maturation has been overlooked. The observations recorded indicate that the cerebellum promotes maturation whereas the cerebral cortex has a retarding effect. This is also what is to be expected considering the importance of a slow maturation rate to the processes of learning involved in cerebral activity.
The sex differences in muscular performances have probably appeared too obvious to appeal to the scientific mind. As known, girls generally prefer to put the thread in the needle, boys vice versa. The cerebellar pattern of coordination in girls expresses itself in "grace" and in particular performances like dancing, writing, sewing and not least talking. Stuttering is rare in girls. May this be due to their relatively well developed cerebellum? (p.411).....and
Considering the small muscular mass compared with the apes, man is a cerebellar species. The decrease in brain volume which has taken place since the middle pleistocene probably mainly concerns the cerebral cortex. The remarkable variability of the brain weight with a range of 1000-2000 grams is characteristic of a new specific trait. Man is by far the youngest among the higher species and the human brain (is) in a stage of reorganization which tends to eliminate the cortical representation of ancient structures which are about to lose their functional significance. The net result will be an increase in relative cerebellar weight. Most probably the cerebellum is a "coming" organ in human evolution.
The frequent disturbances of coordination in higher cortical functions such as speech, indicate that man is in a stage of what may be called cerebro-cerebellar schizophrenia, the cortex being precociously evolved compared with the cerebellum. As regarding specific traits in man generally, the cerebro-cerebellar proportion evolves towards a feminization of the species and a better coordination.
No wonder that men of ideas like Goethe and Bolk did not find it a waste of time to meditate on the craniovertebral border and the folia of the cerebellum, nor that the following generations were stimulated by their ideas. Few fields in morphology show how much modern experimental, genetic and biometric research owes to the knowledge which has been accumulated by earlier generations, and to the inspiration which emanates from morphological tradition (p.416).
Although, there may be disagreement with some of these perspectives by Torgersen, there can be little doubt that the evolutionary and developmental significance of the cerebellum in the higher functions of homo sapiens has been seriously underestimated and neglected. This is particularly the case for the human functions of aggression/warfare;sexuality; superstition/religiosity; parapsychism and spirituality.
These latter issues have been addressed by many traditional scientists, as well as, non-traditional thinkers such as Gooch (1980) who has expressed an innovative and extraordinary vision of the role of the cerebellum in human mental life.
The significance of this research proposal goes well beyond the immediate objectives of documenting the effects of a particular onerous perinatal trauma upon the developing brain--genital mutilation. The ultimate significance of this research project addresses some of the most challenging concepts of the brain and behavior in the evolution of the human species, as they have been presented by MacLean (1962, 1990);
Heath (1964); Dow (1974, 1992); Torgersen (1954); and Prescott (1971, 1972, 1976ab,1990).
The issues of brain evolution and behavior addressed in this proposal must ultimately involve the spiritual dimensions of being human where sexuality is at the core of that spirituality and which has special implications for the role of the feminine in that sexuality and in the survival of the human species itself.
In summary, if the brain systems associated with sexuality, in the broadest meaning of that term, are damaged in the male through genital mutilation and/or other assaults and traumas, then it may never be possible for such males to participate in nor fully understand the higher psychological, (e.g. altruistic, nurturant and spiritual) processes associated with sexual functioning--a functioning that is already burdened and crippled with a psychology of shame and a religion of moral guilt. Positive findings from this research project would illuminate the deep schism of alienation that exists between male and female at the most fundamental neurobiological and neuropsychological levels which, in turn, can only further illuminate the disastrous consequences of such events for the future of the human species.
And the findings from this research project can only contribute to that "morphological tradition" that can yield "inspiration" for future generations.
C. EXPERIMENTAL DESIGN
It is recognized that there is difficulty in demonstrating the effects of a single injurious assault of limited duration upon the developing brain, although such insults to the developing brain have been previously demonstrated in other scientific studies, e.g., Faro and Windle (1969). An important part of this difficulty are the ameliorative influences of subsequent positive developmental life experiences upon the developing brain and behavior. For these reasons, it is imperative to control, as much as possible, for the presence or absence of such ameliorative developmental life experiences in the selection of the subject sample for study. The crucial variables of control involve the degree of somatosensory stimulation and deprivation (presence or absence of pain or pleasure, specifically, Somatosensory Affectional Deprivation--SAD) and of sexual activity/expression during the formative periods of development. It is these considerations that have influenced the selection of the subject sample and experimental design that are described below.
Subject Sample: The subject sample will consist of four groups of subjects consisting of six subjects per group for a total of twenty -four male subjects for study. Subjects will be 21 years of age or greater. The four groups are as follows:
A. Group A subjects will have experienced extensive genital mutilation that has required reconstructive surgery. Attempts will be made to obtain subjects with genital amputation and where reconstructive surgery has been performed to change the sex gender from male to female. This group represents the most extreme condition of genital mutilation.
B. Group B subjects will consist of those males who have been strongly emotionally and psychologically affected by circumcision to the extent that they have sought corrective procedures to restore the penile foreskin.
C. Group C subjects will consist of those males who have not been emotionally or psychologically impacted by being circumcised. These males will be characterized as being psychologically indifferent to the fact of their circumcised state.
D. Group D subjects will be a non-circumcised control group that will be drawn from La Leche League type families. This group will represent a "super-nurturant" control group that will reflect the optimal developmental conditions for optimal brain development. The selection criteria for this group are listed below.
DEVELOPMENTAL CRITERIA FOR OPTIMAL CONTROL GROUP
1. No use of alcohol, drugs or tobacco during pregnancy.
2. No complications of pregnancy, delivery and early post-natal life.
3.* No circumcision.
4. Apgar score eight or greater.
5.* No separation of infant from mother
at birth; nor during first two years of
postnatal life (not greater than 24 hours).
6.* Breastfeeding for at least two years desirable--not less than one year.
7.* Carrying of infant on body of mother is frequent.
8.* No placement of infant/child in day care before two years of life.
9.* Little or no use of physical punishment as
a common practice of
discipline in child rearing.
10. Low maternal stress: low spousal
conflicts; dual parents and/or significant
extended family support, i.e. a happy family.
11. Early onset of sexual activity. (Age of
onset and degree of sexual activity will
be obtained. Subjects with early rather than later age of onset of sexual activity
will be selected for this group).
12. Positive sex values.,e,g, masturbation is a normal healthy sex activity.
The following information will be obtained, wherever possible, for the other three study groups:
1. Use of alcohol, drugs or tobacco during pregnancy.
2. Complications of pregnancy, delivery and early post-natal life.
3.* Complications of circumcision; difficult recovery from circumcision
4. Apgar score .
5.* Extent of separation of infant from mother at birth or during first two years of postnatal life.
6.* Extent of Breastfeeding .
7.* Extent of carrying of infant on body of mother or caretaker.
8.* Time of onset and extent of placement of infant/child in day care .
9.* Time of onset and extent of physical punishment in the discipline of the child.
10. Extent of maternal and family stress:,e.g., spousal conflicts;
11. Whether and when being a single parent and nature of extended family support.
12. Time of onset and nature of sexual
activity (Age of onset and nature/degree of sexual
activity will be elicited) , as well as a history of sexual values.
The starred items are essential information variables. Given the design of this study where subjects are selected according to a developmental history of enriched vs impoverished Somatosensory Affectional Stimulation, it will be possible to address for the first time the consequences of such early sensory stimulation/deprivation upon brain development whether or not there are significant differences found on the circumcision variable. In short, the scientific outcome of this study is not limited to only the circumcision variable. Positive findings on the somatosensory affectional deprivation-stimulation continuum alone would fully justify the conduction of this pilot study.
D. SUBJECT IDENTIFICATION AND SELECTION PROCESS
To be developed in concert with:
Paul M. Fleiss, M.D. M.P. H.: La Leche League control subjects
James L. Snyder, M.D.: Genital reconstructive surgery group
James Bigelow, Ph.D. Foreskin reconstruction group
E. SPECIFIC BRAIN STRUCTURES FOR ENHANCED MR IMAGING ANALYSES
l. Somatosensory Cortex: Sm I & Sm II
2. Cz: deep interhemispheric fissure: genital sensory projection field
3. Frontal Granular Cortex:
a) Areas 8 and 9
b) Areas 13 and 14: Orbital
1. Posterior Lobe: Paleocerebellum
2. Anterior Lobe: Paleocerebellum
3. Neocerebellum: Intermediate-Lateral Cerebellar Hemispheres (Cortico-Pontine Projection Areas)--See Diagram
a) H I-- Intermediate
b) H II-- Intermediate
c) H III-- Intermediate
d) H IV-- Lateral
e) H V-- Lateral
f) H VI-- Intermediate/Lateral
g) H VIIA- Intermediate/Lateral
h) H VIIB- Intermediate/Lateral
I) H VIIIA- Intermediate/Lateral
j) H VIIIB- Intermediate
k) H IX-- Intermediate
F. BUDGET--To be developed.
G. Co-Sponsor: NOCIRC.
H. MEDICAL FACILITY: Department of Pediatrics, University of California, San Diego and/or other
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