 Circumcision
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.
- At present, around 80% of US males have been
circumcised, mostly for non-religious reasons. The frequency of
newborn circumcision has fallen in the USA from 90% in the 1950s
to around 60% today.
- In Korea, more than 90% of men have been circumcised,
usually in their teens and twenties.
- In the UK in 1948, around 20% of boys were
circumcised shortly after birth, more commonly among middle class
families and those living in the south of England. Then, 50% of
grammar school boys, 84% of public school boys and 60% of graduates
were circumcised. By 1975, only 6% of boys born in the UK were
circumcised.
Why Circumcise?
Reasons for circumcision fall into three broad groups:
- For an immediate medical indication
- To prevent future disease
- As an act of religious dedication
Circumcision for an Immediate
Medical Reason
Non-Retractable foreskin in Children
Contrary to common belief, the foreskin cannot be
pulled back (retracted) in almost all newborn babies. Well-meaning
parents do not need to try cleaning under the foreskin until it
has become fully retractable of its own accord because attempts
to pull back a non-retractable foreskin can result in pain and possibly
injury.
About 50% of one-year-old boys will have a non-retractable foreskin,
30% of two-year-olds, about 10% of four-year-olds and about 5% of
10-year-olds.
The small percentage of adults who have a persistently non-retractable
foreskin have a slightly increased chance of developing phimosis
(see below), but this persistence is not a reason for circumcision.
Phimosis
(foreskin contraction)
In phimosis (foreskin contraction), 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.
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% of boys will develop this condition by the time they
are 17 years old. Symptoms can include
- irritation or bleeding from the edge of the
foreskin
- stinging or pain on passing urine (dysuria)
- inability to pass urine (acute or, rarely,
chronic urinary retention)
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
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.
Paraphimosis
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.
Circumcision to Prevent Future Disease
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.
Penile
Cancer
Cancer of the penis is an extremely rare disease
and, in the early part of the last century, was almost unheard of
in circumcised men. However, there is some evidence that circumcision
may only offer protection from penile cancer if done in childhood,
and adult surgery may not offer any protection.
Poor personal hygiene, smoking and exposure to wart
virus (human papilloma virus) increase the risk of developing penile
cancer at least as much as being uncircumcised.
Circumcised men are more at risk from penile warts
than uncircumcised men, and the risk of developing penile cancer
is now almost equal in the two groups.Therefore, routine circumcision
cannot be recommended to prevent penile cancer.
Sexually
Transmitted Disease
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 symptom with this infection so they
are more likely to unknowingly pass on thrush to their sexual partners.
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
Views conflict on whether circumcision can prevent
HIV infection. A recent review in the British Journal of Urology
concluded that there is no link between having an intact foreskin
and HIV infection, whereas another paper in the British Medical
Journal takes exactly the opposite view.
Circumcision may be appropriate as a routine preventive
measure only in regions that have a high rate of HIV infection,
such as sub-Saharan Africa. The existing evidence is inadequate
to recommend circumcision as an HIV-preventive measure in the UK.
Cervical Cancer
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.
Urinary Tract Infection (UTI)
Since 1987, several studies have suggested that
uncircumcised male infants are up to 10 times more likely to contract
a urinary tract infection (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.
Circumcision as an Act of Religious
Dedication
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.
Judaism
In the book of Genesis (17: 10-14), circumcision
represents the covenant made by God with Abraham and his descendants.
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.
Islamic rules
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.
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.
How is Circumcision Performed?
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.
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 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 minimizes the
amount of skin removed). Preputioplasty may preserve sexual sensation,
although its advantage over circumcision is not yet established
The surgery
The surgery is performed under a general anaesthesia
and can be carried out as a day surgery case. However as general
anaesthesia is involved it is wise to stay overnight as the candidate
can be severely disorientated for some time from the effects of
the anaesthesia.
Following surgery
The penis will be stitched, bandaged and wrapped.
Walking will be difficult and uncomfortable for some days. It is
important for the candidate to rest during this period, no major
activity should be planned. Sexual activity should be prevented
for 2 - 3 weeks.
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