Thursday, June 14, 2007

 
A CUT BELOW

Clearly, for some parents, circumcision of their male children is a religious requirement. For others it is a matter of choice, hopefully after some informed decision-making with a medical professional.

What is not clear is why, after maybe four millennia of men getting along fine with or without a foreskin, a debate rages over the health consequences of what is basically a simple cosmetic procedure. Is this debate just another form of earlier conflicts over circumcision as an identification with antagonistic religious groups, or is it driven by a misinformed and mistaken view of anatomy, physiology, and psychology?

In order to judge the value of arguments for and against, we must understand what circumcision is. Most males are born with an extension of skin from the shaft of the penis, known as the prepuce, which covers all or most of the tip of the penis (glans), which includes the opening of the urinary tube (urethra). This skin is generally loose, and generally slides back on its own somewhat when the penis becomes erect, though in young boys (6 years and under) it may be too inflexible to pull back comfortably. Almost all uncircumcised men can urinate comfortably without having to pull back on the prepuce.

The underside of the skin (against the skin of the glans) has mucus cells and tends to secrete a small amount of lubricating mucus, combined with some sweat and skin cells which forms a whitish goo, called smegma, that keeps the skin surfaces from chafing. There are no large blood vessels in the prepuce, which has instead a network of tiny arteries, capillaries, and veins. During erection, the prepuce fills with blood and swells, though generally not as much as the other penile tissues.

The nerve supply in the prepuce (and glans) is similar to most other skin areas of the body. In other words, the area is sensitive but not as much as, say, fingertips, soles of the feet, or lips.

Surgically removing the prepuce basically uncovers the glans permanently and removes the mucus secretion. Because there are no large blood vessels, doing the procedure to an infant generally requires no special technique to stop the bleeding other than crimping the cut edges (before cutting) or applying a bandage with slight pressure. For older boys and adult men, most often dissolving sutures are used to bring together the cut edges of the wound. When healed there is often some residual loose skin, which may stretch out to a thin layer during erection.

As surgeries go, infant circumcision is relatively simple (even a pediatrician can do it!) and highly successful. The risks of bleeding, infection, and botched surgery are present but extremely small when the procedure is performed by an experienced and skilled practitioner using good aseptic technique. Of course, no one should routinely circumcise a sick baby or one with a congenital malformation of the penis

Reversing a circumcision is highly complicated and never completely possible. Practically speaking, it is a one-way street.

That brings up one of the most fundamental questions in the debate over infant circumcision: Do parents have a right to impose a non-essential cosmetic surgery on their baby boys?

Since American law accepts that parents have a right to abort their unborn fetuses, as well as to decide where, what, when, and how their born children eat, sleep, get an education, it seems logical that the decision to circumcise or not rests with the parents – as long as circumcision is not intrinsically harmful.

If harm means pain, then circumcision (along with immunizations, ear piercing, and delay in feeding) is problematic since it hurts. Ample evidence exists to show that babies react to circumcision the same way as they do to other potentially painful stimuli: heart rate and blood pressure increase, they fidget and frown, and – in case you’ve never noticed – they cry. Measures to relieve pain – local anesthetic injected below the skin at the base of the penis, analgesic cream applied directly to the foreskin, sucking on a pacifier (or the Jewish favorite, a wine-soaked piece of gauze) – are all somewhat effective in reducing the stress reactions, though it is sometimes uncertain if they primarily relieve the adult observers rather than the babies themselves.

Of course, adults don’t like to see babies in any distress. One can see sympathetic grimaces and an undertone of “Ooh!”s in a room of adults witnessing a circumcision, often louder and more intense than the baby’s squeals. Normal, caring adults tend to project their own anxiety about pain and suffering onto the behavior of the little ones, for whom they feel a need to protect.

At any rate, as best as we can tell in a pre-verbal infant, there is pain with circumcision. As mentioned above, the foreskin does not have an over-abundance of sensory nerves, so most grown men who have circumcisions are sore for only 3-7 days afterwards. Arguments have been made that babies are excessively fussy or clingy for weeks after circumcision, but there is no reliable evidence to support this; most babies feed, sleep, pee and poop normally within a few hours of the procedure.

And NO ONE REMEMBERS THE PAIN OF BEING CIRCUMCISED AS A BABY!

Anyone who claims as an adult that he remembers his circumcision as a baby is delusional, demented, or deceiving.

Therefore, in the big picture of pain management, a baby that has temporary pain which produces no memory trace ends up the same as one who never had the pain at all.

So what other harm can come from circumcision?

Disfigurement? Probably a matter of esthetic values (notice I avoided the word “taste” there). Should be weighed against the desire to look the same as other men in the family or tribe. At any rate, since in most civilized societies penises are not publicly displayed, one can easily hide any embarrassment from a circumcision (or lack thereof).

Sexual dysfunction? Much has been written about “decreased sensitivity” of the head of the penis, leading to decreased sexual response in circumcised men, but it is not logical to use a before- and after- comparison in men who have no memory of having a foreskin. To date, there is no reliable evidence of decreased sensitivity nor of sexual dysfunction overall in circumcised men compared to non-circumcised, nor has there been any reliable statistical analysis of the difference in sexual response of their partners. Most of the mythology regarding this issue emanates from medieval religious writings, spiced with the wildly conjectural focus on sex in contemporary Western society since the 1960’s. But no real data.

Balance the highly speculative “loss of sensation” with the very real and not uncommon development of phimosis in adult men, a condition in which the foreskin becomes constricted and inflexible and cannot be pulled back. Many conditions such as infection and connective-tissue disease can cause phimosis, which occurs in about 1 in 1000 uncircumcised men. It frequently causes significant discomfort with erection, sexual dysfunction, and, in severe cases, obstruction of the flow of urine. It can be improved with application of steroid creams, treatment of an underlying condition, or partial surgery, but circumcision is the most reliable treatment and essentially cures the problem.

Preventing foreskin problems is fairly simple, requiring only good skin hygiene, washing off excessive smegma from time to time, having adequate lubrication for sexual intercourse, and avoiding high-risk sex. Although many cases of foreskin infection (“ballanitis” ) can be prevented by these measures, care of the head of the penis is generally simpler after circumcision, which also decreases the rate of penetration into the body by HIV or cancer-causing human papilloma virus. Currently, circumcision is considered one of the most powerful ways to prevent the spread of HIV in Africa.

What’s left in the debate over circumcision, and this has always been the case, is a fairly even balance between the risk of doing the procedure in the first place and the benefits of a possibly healthier penis. It’s a tie, and not only do parents have a choice, but they must look to other reasons – religious, cultural, esthetic, but not medical -- to guide their decisions. Parents who think it is simply wrong to make such a decision for their baby need to realize that if, after growing up, their son wants to be circumcised, he faces a much more difficult and painful operation.

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Comments:
Reduced and lost sensation to circumcision is not "speculative." The foreskin is highly sensitive. Anybody who has one knows that. For those without the equipment to know this first-hand (so to speak), there's this study (abstract,pdf).

Remember... it's not just a question of whether removing the foreskin causes what remains to become less sensitive. The foreskin is erogenous tissue, sensitive both sexually and otherwise!!

Circumcision is sexual reduction surgery. That's a choice everyone deserves to make, for themselves.

Circumcision is the last holdout of the pre-scientific mindset lurking in the halls of medicine. Our grandfathers were circumcised, so we grandfather-in this procedure, even though there is no other body part we would ever cut off a child when almost everyone agrees it's completely unnecessary, take it or leave it, chosen (but not self-chosen) for culture or custom or aesthetics or religion or habit or fear or pressure!

If it's a "tie" on medical grounds (and that's generous), then circumcising an infant is unethical. In medicine, if a surgery is a "tie", that means it's not medicine, it's bunk!
 
Thanks for reading.
And the debate rages on . . .

Reduced and lost sensation to circumcision is not "speculative."

A reduction or loss is not relevant to one who has no memory of having a foreskin. To presume that he would be missing the erogenous potential of a foreskin is highly speculative.

Notwithstanding the article in BJU (I hope to read the whole report and maybe comment on it soon), in my practice, examining (by touching) penises elicits no different response from men with foreskins than men without. Again, the anatomical innervation of the foreskin is not overly abundant (as opposed to the urethral opening [meatus]).

The important point of whether one needs the sensitivity of a foreskin is whether it makes any difference in sexual function. There is no conclusive data to support that theory. Adult men who have painful phimosis seem to gladly make the trade, in which case circumcision is done to improve sexual function.

If it's a "tie" on medical grounds . . . then circumcising an infant is unethical.

In medical practice, it is not unethical to perform a procedure which causes no harm as long as the patient or patient's advocate desires it. Is all plastic surgery unethical?
 
Parents who think it is simply wrong to make such a decision for their baby need to realize that if, after growing up, their son wants to be circumcised, he faces a much more difficult and painful operation.

This gets to the heart of the error in your analysis, which anonymous seems to have also brought out. Ethics matter. You're saying medically it's a tie. Fine. Then you offer the statement above. It conforms closely with what Americans think, but it's woefully incomplete.

Parents who think it is simply right to make such a decision for their baby need to realize that if, after growing up, their son wants to be intact, he faces an impossible-to-change future.

A reduction or loss is not relevant to one who has no memory of having a foreskin. To presume that he would be missing the erogenous potential of a foreskin is highly speculative.

That is simply irrational. It's a selective abuse of logic designed to justify a desired outcome. A reduction or loss is not relevant to one who has no memory of having a left arm. To presume that he would be missing the functional potential of a left arm is highly speculative.

Of course, you'll challenge that by saying that we know a left arm is functional, so we can safely assume he'd miss it. But how many millions of men around the world live normal, healthy lives with a foreskin? How many choose to voluntarily undergo the procedure, absent any medical need? There are some, but that number is in no way convincing. Sort of like phimosis being "not uncommon", if you consider 1 in 1000 not uncommon.

I could also just as easily argue, in bold italics, that no one remembers the pain of [insert dubious medical procedure] as a baby, and pretend that it's a compelling argument. Ethically, an adult can choose to have circumcision. As you point out, not all medical problems with the foreskin need to be solved by cutting it off. So an adult gets to decide when something is wrong, but a baby doesn't get to decide when there isn't anything wrong, as long as his parents approve for their own reasons? No.

In medical practice, it is not unethical to perform a procedure which causes no harm as long as the patient or patient's advocate desires it. Is all plastic surgery unethical?

Plastic surgery is perfectly ethical if the person whose body will be altered is consenting. Do I have the right to consent (safe euphemism for force) to a rhinoplasty for my kid if I don't like the shape of his nose? Breast augmentation for my teenage daughter if I think her breasts aren't large enough to fit in with society? I hope you would say no.

Which leaves us with the notion of harm. Your argument simply assumes that American medicine wouldn't do this if it caused harm. No evidence exists, etc. Fine, but simple logic tells us that there are nerve endings in the foreskin. Removing them causes harm. The foreskin developed through evolution in all mammals, so we can also assume it has a functional purpose. Removing it causes harm. We can argue how much harm, because it's subjective.

Precisely because it's subjective is why we shouldn't be performing such medically unnecessary cosmetic surgery on infants. He might have a different opinion. If left intact, statistics tell us that he probably will choose to stay intact. Your opinion of parental "rights" is flawed. Societal opinion is irrelevant when dealing with the removal of healthy, functioning body parts on an individual.
 
Parents who think it is simply right to make such a decision for their baby need to realize that if, after growing up, their son wants to be intact, he faces an impossible-to-change future.

Contrast with facing a more painful and difficult procedure if he does want one. That's precisely why in medical decision-making terms, it's a tie.

That is simply irrational . . . A reduction or loss is not relevant to one who has no memory of having a left arm.

Okay, if we're going to try to stay rational, I'd try to avoid the camel's-nose-under-the-tent approach to comparative anatomy and would simply state that, in the rest of the world which is not penis-obsessed, the foreskin is not considered as important as, say, an arm.

The real issue being debated here is whether parents have a right to make this decision for their children. That's perhaps a civil rights issue, beyond the scope of my purpose (exploding medical myths). As I've already stated that they make much more weighty decisions all the time, so for me the subject is moot. (And, yes, parents do make other cosmetic surgery decisions for their dependent children.)

For doctors, the issue here is not how to obtain consent from an infant but rather how to properly inform the consenting parents. I would tell parents that circumcision is (1) not necessary for the future health of their son; (2) has a small risk of bleeding, infection, or unintended disfigurement; (3) causes temporary pain; (4) removes a sensitive area of the penis; (5) overall does not affect sexual or urinary function; (6) may decrease the transmission of HIV and HPV; (6) may decrease risk of penile cancer (which is rare, anyway). Medically, there is neither a compelling reason to do a circumcision on an infant, nor is there a compelling reason to dissuade parents who desire it for their son.
 
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