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.
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.
Labels: bris, brit, circumcision, foreskin, milah
