It looks like that the number of Maldivians who are opposing the practice of circumcision is growing day by day. Previously,
and admitted that he was traumatized by the experience. Now another person has asked me to publish her argument on this blog. It is a bit long but very informative and it looks like she has given a lot of time in writing this.
The foreskin has apparently been branded as a protective sheath for sensitive glans of the penis. It has been blamed for the urge to masturbate, various forms of cancer in men and women, as a spiritual impediment to male fertility and status, as a facilitator of various infections from gonorrhoea to HIV and also surprisingly for being unclean and undesirable appendage. Gods have been known as given the command to get rid of it, doctors have by turns vilified and defended it, courts have been asked to punish those who cut it off, and passionate defenders of ‘genital integrity’ have railed against equally sincere proponents of the ‘holy cut’.
My first experience to circumcision came about on my first week in a hospital environment as a student nurse. The first time i witnessed this procedure , i thought, why a perfectly healthy child is going to be given general anaesthetics (GA) and part of his genitalia amputated , for no reason other than because his parents wanted it done?
It was strange to me then, for it is against what i have been thought at uni. If one is to subject a patient to the risks of anaesthesia , haemorrhage, pain, infection and scarring, you better have a good reason as well as the informed consent of the patient. Furthermore, at the back of my mind, the medico-legal ramifications of all our actions started bombarding. Should anything go wrong with the circumcision, i wondered how the surgeon could possibly have justified his conduct to the jury: there was no medical justification to the procedure, the baby was not unwell in any kind of way and the baby had perfectly normal genitalia. ‘Do you mean to say, doctor,’ i imagined a judge asking, ‘that you anaesthetised this baby and removed part of his penis simply because his parents asked you to? Do you think, doctor, that your action was in the best interests of your patient, the child?’
Fortunately, circumcision rarely goes badly wrong. It is a minor surgical procedure, often by adopting very brutal methods, without anaesthetic by people all over the world for thousands of years. The circumcision that i witnessed at the hospital was a ‘freehand’ circumcision under GA, where the foreskin is cut off with scissors and the incision sutured to control the bleeding. Complication rates run at up to about 3 % of circumcisions and usually relate to post-operative bleeding and infection, both of which can usually be remedied with simple measures. Occasionally, too little too much foreskin is removed and as with any surgical procedure, unwanted scarring would occur. Uncommonly, bleeding may be severe and difficult to control or a serious infection may set in. There have been deaths from both haemorrhage and infection following circumcision.
There are some genuine medical indications for circumcision that can arise at any stage in life. The most common problem that leads to circumcision is phimosis, where the tip of the foreskin becomes too tight to allow full retraction of the foreskin over the head of the penis. This occurs in about 1% of the males and generally becomes apparent before puberty. It has traditionally been treated by circumcision, how ever the use of steroid creams and gentle retraction is often that is all required. It should not be confused with the adhesions between the foreskin and the glans that cause a delay in retraction- this is normal for many uncircumcised boys and results in great variability of the age at which the skin can be fully retracted. Usually , these adhesions will resolve spontaneously with time ; if problematic or associated with recurrent infections (balanitis), the adhesions can be divided in a simple procedure. More serious and chronic infections, such as balanoposthitis or balanitis xerotica obliterans, may require circumcision, as can penile cancer (an uncommon cancer that generally develops later in life).
So the vast majority of boys and men will never have a genuine medical reason for circumcision.
This is the joint opinion of the colleges of physicians, pediatricians, surgeons and urologists from Australia and NewZealand.
Their statement that “ there is no medical indication for routine neonatal circumcision” reflects the opinion of most doctors across the developed world. Their policy statement is perhaps the most useful document that any parent contemplating circumcision of their child could read, as it contains a clear summary not only of the medical perspective but also what we know about foreskins and how we should look after them, just like a woman should look after their breasts.
Despite this, some radical voices, from a very small minority of the medical profession continue to advocate the routine circumcision of baby boys. Their reasons for doing so now include research suggesting that circumcision may reduce the incidence of urinary tract infection (UTI) in baby boys, of HIV infection in men and of cervical cancer in women. It is important to address these public health matters, as they certainly may constitute a better reason for circumcision than previous notions have done.
The strongest such evidence relates to UTI; it is apparent that circumcised boys have lower rates of these infections, however most of these infections can be easily detected and treated with out complications. It is estimated that it would take more than 100 circumcisions to prevent one UTI in the first year of life. For otherwise healthy babies , the statistics would not suggest a net benefit from circumcision as far as UTIs are concerned.
The question of HIV transmission is inconclusive now with fresh research done in 2007 suggesting that they have found no sufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men . As i said ,the research on this matter done previous to the 2007 one, is unlikely to do anything more than distract from the primary public health message of safe sexual practice.
Of more relevance is of the question of a link to cervical cancer, which is associated with Human Pappiloma Virus (HPV). Again, research about different rates of HPV infection depending on circumcision, is in its infancy. One large study has suggested that circumcised men may harbour less HPV and thus, presumably, infect fewer women with the virus. This may or may not lead to a lower risk of cervical cancer in women. Furthermore, it would be an extraordinary and unprecedented idea that one person should have a surgical procedure in infancy in order to prevent another person from potentially contracting a carcinogenic infection at some time in the future.
It would seem a bit unfair, for example, to subject a boy to the risks of circumcision on these grounds if he subsequently if he becomes a celibate monk or priest. It seems far more reasonable that us women should choose whether or not to have unprotected sex with uncircumcised males, or take other measures , such as vaccination against HPV or pap smears, to reduce the risk of cervical cancer. HPV has also been linked to cancer of the penis , how ever since this is such a rare disease (affecting one in 100,000 men ), and one that occurs in both circumcised and uncircumcised men, no convincing argument can be mounted to justify circumcision as a worth while prevention strategy.
Many cultures practice circumcision at various ages and for various reasons. In Maldives is is done on the premises of an Islamic practice. The Jewish culture of circumcision at eight days of age (the brit milah) is perhaps the best known ritual, but it was also practised by ancient Egyptians and various indigenous cultures, as well as some parts of Africa and the South Pacific. Christians of the Copic persuation and Christians in some parts of Africa are also known to advocate circumcision , as do many Muslims, just like in Maldives.
In the last few days, i have asked the parents of circumcised boys who i have come across about their reasons for circumcision. Circumcision was a strong part of of their culture. What is also interesting is that is how uncomfortable many Maldivians are with talking about circumcision.
For the majority of males, the presence or absence of foreskin will make little appreciable difference to health, self image or sexual function. In the absence of good medical reasons to circumcise boys, perhaps decisions based on culture and religion present the strongest case for the operation.
Personally, i would be asking ‘ will my son take me for doing this?’ On this test, i suspect that many Jewish men or Muslim men (or those form other cultures in which circumcision is an integral part of the male journey) probably would be happy that the decision was taken. When things go wrong, however, faith and tradition can be of little comfort. It seems particularly dubious to me that a man injured by circumcision would thank his parents for at least trying to make him look ‘ just like dad’.
So think carefully about circumcision, and be aware that if your doctor is advocating it as a routine procedure, he or she is swimming very much against the strong tide of current medical opinion.
More on the policy statement on circumcision from the Australasian College of Physicians can be found from this link.
