From: www.tiscali.co.uk/lifestyle/
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What is circumcision?
Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce) of the penis. The first evidence of circumcision comes from early Egyptian wall paintings that are more than 5000 years old.
How common is circumcision?
About one-fifth of men worldwide have been circumcised, mostly
for religious and cultural reasons when the procedure is commonly performed
shortly after birth or around puberty. Although adults are occasionally
circumcised as an act of religious dedication, adult circumcision is most
commonly performed for medical reasons.
Why circumcise?
Reasons for circumcision fall into three broad
groups:
Circumcision for an immediate medical reason
Phimosis
Occasionally, the edge of the foreskin has a white, scarred,
inelastic appearance and will not pucker open as it is retracted. Between 1 and
1.5 per cent of boys will develop this condition by the time they are
17-years-old. Symptoms can include
The changes in the prepuce are known as balanitis xerotica
obliterans, which can become cancerous if left untreated. Circumcision is
advisable in most cases.
Acute balanoposthitis
Paraphimosis
Circumcision to prevent future disease
Sexually transmitted diseases
Far more effective and reliable methods than circumcision
exist to reduce the risk of contracting sexually transmitted diseases, such as
the use of condoms and adoption of safer sexual practices. Thus circumcision
cannot be recommended to prevent these infections.
Human immunodeficiency virus (HIV) infection
Cervical cancer
Urinary tract infection (UTI)
Circumcision as an act of religious dedication
Traditional religious circumcision is performed by a mohel
(pronounced mo-hell in Hebrew or moyle in Yiddish). It is usually carried out
on the eighth day after birth, unless there is a danger to the child's health,
in which case it should be delayed until that danger has passed. In the UK,
mohelim attend 40 to 50 circumcisions and have to pass practical and
theoretical examinations during their training before performing circumcision
alone.
Islam
Even those who consider circumcision an obligatory duty for
themselves do not see it as an essential requirement for others to become a
Muslim. However, the procedure is very commonly practised and is certainly seen
as an important external symbol of submission to God's will.
Should we avoid circumcision?
Adult males that were circumcised as infants do not usually
report sexual problems linked with their circumcision, perhaps because they
have never experienced sexual sensation with a foreskin. However, men
circumcised as sexually active adults quite frequently complain of sexual
problems arising from either reduced or altered penile sensation.
How is circumcision performed?
It is difficult to justify subjecting infants to this experience
when pain could be avoided with a brief general anaesthetic. Anaesthetic
injections that numb the penis or the whole genital region are not a reliable
substitute for general anaesthesia. If circumcision is important for religious
or cultural reasons, then the mohel, or other ritual circumciser, can still
perform the procedure and prayers with the assistance of an anaesthetist and
surgical team at hand. This practice may not be the traditional family
gathering associated with circumcision, but would fulfil religious obligation
without causing unnecessary suffering.
When circumcision is necessary for an immediate medical reason,
the surgeon would be prudent to try to preserve as much of the foreskin as
possible, through some form of preputioplasty (a plastic surgery procedure that
alters the shape of the foreskin but minimises the amount of skin removed).
Preputioplasty may preserve sexual sensation, although its advantage over
circumcision is not yet established.
Complications of circumcision
Can circumcision be reversed?
Female circumcision is not required by any religious group and
is a traditional practice prevalent in Africa, Southeast Asia and South
America. It is far more disfiguring, disabling and potentially dangerous than
male circumcision so cannot be viewed in the same light. The author fully
supports the World Health Organisation's policy that this procedure should
cease throughout the world.
Conclusions
Male circumcision is vitally important to some religious and
cultural groups. Hopefully, the use of general anaesthesia for infant
circumcision will increase. Medical and religious authorities should work
together to promote this change.
Very few absolute medical reasons exist for circumcision, and no
reasons exist to justify routine circumcision of infants outside areas with a
high rate of HIV infection. Far too many circumcisions are performed without
good reason in Europe and the USA. The best advice is 'if it isn't absolutely
necessary, don't circumcise'.
Author's note
In this condition, the opening of the foreskin is narrowed,
preventing retraction. Provided that the skin of the foreskin is normal and
inability to retract it does not cause problems with intercourse or recurrent
infections, no action is necessary.
This condition involves redness and swelling of the foreskin,
together with a discharge of pus from the space between the foreskin and the
glans. Sometimes the whole penis may be swollen and inflamed. Between 3 and 10
per cent of boys will develop this condition, depending on how the condition is
defined. Balanoposthitis is very occasionally the first sign of diabetes. If
there is no underlying cause, simple hygiene measures, mild painkillers and the
avoidance of tugging the foreskin are the only necessary treatments. Most cases
will recover without further intervention. Circumcision is only done for
recurrent and troublesome cases.
This condition is caused by forcibly pulling back the
foreskin behind the coronal ridge of the glans or head of the penis, without
its subsequent replacement. The foreskin then forms a tight tourniquet around
the glans, causing severe pain. The condition can sometimes be treated by
firmly but gently squeezing the trapped glans until the foreskin can slip over
it again. If this is not possible, the paraphimosis needs to be reduced under a
general anaesthetic. Circumcision is only very rarely necessary.
Prevention of disease is the second most commonly given reason
for circumcision after religious reasons, although the evidence that it has any
beneficial effect on future health is very poor. The practice is, more likely,
rooted in cultural traditions, although western societies may find this an
uncomfortable conclusion.
Sexually transmitted infections that cause ulcers on the
genitals (syphilis, chancroid, herpes simplex) are more common in uncircumcised
men. However, urethritis or inflammation of the tube that carries urine through
the penis (caused by gonorrhoea and non-gonococcal urethritis) is more common
in circumcised men, as are penile warts. Yeast infection (caused by candida or
thrush) is equally common in circumcised and uncircumcised men, although
circumcised men are less likely to have symptoms with this infection so they
are more likely to unknowingly pass on thrush to their sexual
partners.
Views conflict on whether circumcision can prevent HIV
infection. A recent review in the
A study in 1947 reported that Jewish women rarely developed
cervical cancer and the author attributed this finding to the fact that their
sexual partners were circumcised. Further studies over the past 50 years have
had contradictory conclusions, with experts enthusiastically championing the
case for and against circumcision. The evidence is inadequate to recommend it
as a preventive measure against cervical cancer.
Since 1987, several studies have suggested that uncircumcised
male infants are up to 10 times more likely to contract a UTI. One in 100
uncircumcised infants will develop a UTI, compared with 1 in 1000 circumcised
infants. A UTI is not usually a great risk to health, so it does not seem
reasonable to perform a surgical procedure on 100 infants to reduce the risk of
one developing UTI.
The circumcision of male children is a central feature of both
Judaism and Islam. It is also important in many African and New World cultures.
An increasing number of committed Jewish and Muslim people reject circumcision
on ethical grounds, although they are certainly the minority at present.
Attitudes to circumcision may provoke fierce hostility within families and
among communities. In the past, wars have been fought, and thousands have died,
to preserve the right to circumcise when rulers from other cultures forbade
it.
The divine law or sharia defines every aspect of Muslim life.
It is based upon the Holy Koran, the hadith (the sayings of the Prophet
Mohammed) and the sunnah (Prophet's tradition). All Muslims agree that these
are the three sources of Islamic law, but different groups interpret their
application in different ways. Circumcision is not mentioned in the Koran, but
has the status of sunnah. Only the Shafiite school of law regards circumcision
as obligatory (wajib), while the Hanafite, Jafarite, Malikite, Hanbalite and
Zaidite regard it as only recommended, because it is sunnah.
The foreskin is not simply a useless piece of skin, to be
disposed of without careful thought. It forms the covering of the head (glans)
of the penis in men and the clitoris in women. It is very rich in nerves
responsible for touch and the movement of the foreskin backwards and forwards
over the glans provides some of the pleasurable sensation experienced during
sex.
Although religious and cultural circumcision is frequently
performed without anaesthetic as part of an important ritual act, it is an
intensely painful procedure, even in newborn babies. Adults can testify to the
pain for themselves and can give informed consent to the procedure. Infants,
however, cannot. Physiological research has repeatedly shown bodily responses
that indicate infants experience severe pain during circumcision.
Happily, complications of circumcision are relatively rare,
although they may be under-reported following religious or cultural
circumcision. For this reason, figures on the rate of complications may not be
reliable. Complications include:
Attempts have been made to restore the foreskin following
circumcision since ancient times. Unfortunately, no procedure had satisfactory
results. Modern surgical procedures may have more success, but they are still
experimental and the long-term results are unknown. If foreskin restoration is
being considered, a urologist should be consulted.
Circumcision remains a controversial procedure, as it has been
for thousands of years.
The author wants to emphasise that he holds a deep respect for
all religions, including Judaism, Islam and the many other religious groups
that practise circumcision as an important feature of their faith. He regrets
any distress that this article might cause but hopes that it might be a useful
stimulus to thoughtful reflection on such a long-established traditional
practice.
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