Penile Plunder

CHRONIC REMUNERATIVE SURGERY, although a declining speciality, still plays a role in the economic life of many in the medical profession. In this speciality, before an operation can qualify as suitable for inclusion in the established repertoire, certain criteria have to be fulfilled. Firstly, it should require a minimum of skill; secondly, it should have few immediate complications-delayed complications can always be attributed to other factors; and lastly, and above all, there should be a fee attached. Circumcision will certainly answer a maiden's prayer, is the procedure par excellence for the chronic remunerative surgeon.

Two origins of circumcision can be traced, neither of which has any bearing on the reasons why the operation is currently practiced with such fervour by many non-Semitic races. In certain African and Melanesian tribes, the operation is one of a variety of ritual mutilations that are performed in the hope of adding allure and charm to the scarified subject. Thus it resembles nose-keloid formation, neck elongation, tattooing and deliberately induced keloid formation. In this context it is relevant to point out that the operation does not find favour with all the tribes of New Guinea; a discerning minority of the inhabitants of this island deliberately stretch their foreskin by dangling weights on it, for to them a pendulous prepuce is a thing of beauty and a joy for ever. Rumour has it that they are allowed to remove the weights when they compete in the high hurdles and pole vault. The other origin of circumcision relates to the fact that in many African tribes the young male cannot be accepted into his tribe as a full-fledged man without first having proved his manhood. To do this he is tested by some ordeal, in this case circumcision, and if he does not flinch he is then accepted as an adult with all of the associated privileges. In parts of Africa and also Lebanon, pubertal girls suffer the same fate, ostensibly to help keep them faithful during their married life. No matter how one looks at the origins of the operation, it becomes apparent that it was conceived in ignorance and superstition and has been nurtured by man's inherent propensity for sadism and masochism.

The medical literature dealing with this subject seems endless, and for every paper that questions the cult of circumcision, a hundred appear glorifying it. The articles written by those in favour of the operation are almost without exception intense, humourless and terrifyingly evangelical. The arguments used to justify the operation are many and ingenious-so much that they are occasionally accepted by the intelligent physician and almost invariably by the layman. Nevertheless, when a critical assessment is made of the evidence that purports to show that the possession of a foreskin is harmful, the whole hypothesis can be seen to be based on a series of non-sequiturs. Let us take a look at the reasons that are used to justify this mutilation.

There are many physicians who are under the impression that the foreskin is completely retractile at birth. They assume that if it cannot be retracted, then the child has phimosis, and the prepuce should be lopped off forthwith. In reality the prepuce does not become fully retractile until the child is two or three years old, and phimosis is all but unknown in infancy. In contrast the circumcised child, with his glands exposed to uriniferous napkins, is very prone to develop meatal ulcers and meatal stenosis-a condition that is never seen in the intact subject. It is also stated that cancer of the penis occurs only in the uncircumcised. However, cancer of the tongue occurs only in those subjects with tongues, and the possibility of developing glossal cancer can hardly be used as a pretext to prophylactically remove this organ. As has been pointed out elsewhere, appendicitis is responsible for many more deaths than is penile cancer, but routine appendectomy is not yet the rule and is unlikely to become so. (Morgan, 1965). Moreover, penile cancer is a relatively benign form of cancer which is fairly amenable to treatment. On the basis of the present morbidity and mortality statistics for this disease in the United States, Marshall (1956) has pointed out; If a surgeon would perform one circumcision every ten minutes, eight hours a day, and five days a week, he would be able to prevent one penile cancer by working steadily for between six and 29 years. Since a significant number of penile cancers are curable, still more time and labor might be required to prevent a fatality from this disease. He goes on to state that if cancer prevention is to be an end in itself, then bilateral simple mastectomy in female infants would probably be an even more effective measure. In those countries which do not practise circumcision and in whih acquaintance with soap and water is more than casual, the incidence of penile cancer is ether no different from, or in instances is actually less than, the incidence in the U.S.A. Although penile cancer is exceptionally rare in circumcised subjects in America, Europe and Australia, it is seen not uncommonly in Javanese Muslims, not withstanding their denuded state.

It has also been stated that carcinoma of the cervix develops almost entirely in women who are married to uncircumcised men. The almost complete absence of this form of cancer in Jewesses and nuns is thought to confirm this point. In reality, there is little to support the theory that circumcision of the husband prevents the circumcision of the spouse. Lilienfeld and Graham (1958) have pointed out that around 30% of American women do not know if their husbands are circumcised or not. Elsewhere it is suggested that the French do not have the same trouble (Morgan, 1965) Moreover, it has also come to light that around 10 to 15% of American men do not know their own circumcisional status, some making claims that they have had the operation when they have not, and vice versa. This difficulty is related neither to myopia nor to the combination of gross obesity and a short memory. This it is advisable not to accept as gospel studies which are based on such inaccurate statistical evidence. Jones and McDonald (1955), Boyd and Doll (1964) and Stern and Dixon (1961) have all been unable to demonstrate that circumcision in anyway prevents the development of carcinoma of the cervix. The only adequately controlled series that relied visual inspection to ascertain the circumcisional status is that of Aitken-Swan and Baird (1955). They used 54 cancer patients and 54 controls, and were unable to demonstrate any difference between the two groups. Relevant also is the fact that Parsees who are of Persian origin but now live in India, have a very low incidence of cancer of the cervix. These people have extremely high standards of hygiene, but do not practice circumcision. (Khanolkar, 1950).

When the real reasons for having the operation performed are considered, the situation becomes ludicrous in the extreme. Circumcision in the U.S.A. is the rule rather than the exception. The American public has come to view circumcision in the same light as the other essentials of life-namely, superhighways, refrigerators and television sets. As well deprive these citizens of their birthright as suggest that they retain their prepuce. It has become imperative to lop it off to keep up with the Joneses, for in the affluent society status and a foreskin are incompatible. And besides in a matriarchal civilization such as exists in the New World, the female of the species has intuitively and erroneously concluded that the denuded phallus has greater appeal and is more aesthetic than its intact counterpart. The argument is also put forward that the circumcised organ is more hygienic, for the prepuce collects nasty secretions. So does the ear; but the removal of this rather ugly appendage is frowned upon, and in one famous instance cutting it off lead to war-the so-called war of Captain Jenkin's Ear. One can be grateful that this worthy mariner did not lose his prepuce under similar circumstances, for it islikely that the battle would still be raging.

Since there are no valid reasons for circumcision, it would also seem desirable to see whether the operation can have undesirable effects, Infantile circumcision is not the harmless operation that many would have us believe, and is associated with a far from negligible mortality and morbidity (Gairdner, 1949). Haemorrhage and sepsis are infrequent complications but may be serious. Staphylococcus skin infection (Ritter's disease) is seen only in circumcised infants (Pequet et al., 1965), as is meatal stenosis. When the operation is carried out without any complications, this being the usual state of affairs, are we entitled to assume that the circumcised phallus can fulfil its function as adequately as its intact brother at arms? The subcutaneous tissue of the glans is provided with special sensory receptors that are concerned with appreciating the pleasurable sensations that occur during coitus. They are stimulated normally only when the glans is exposed. In the circumcised subject these receptors are constantly stimulated and lose their sensitivity. During the act of coitus, the uncircumcised phallus penetrates smoothly and without friction, the prepuce gradually retracting as the organ advances. In contrast, when the circumcised organ is introduced during coitus, friction develops between the glans and the vaginal mucosa. Penetration by the circumcised man has been compared to thrusting the foot into a sock held open at the top, while on the other hand, penetration by the intact counterpart has been likened to slipping the foot into a sock that has previously been rolled up. (Whiddon, 1953) Coitus without a prepuce in analogous to a colour-blind person viewing a Renoir of Van Gogh painting.

We should ask ourselves whether it is really likely that Nature in all her wisdom and pragmatism, would really permit every male child to be born into this world with a useless appendage, the presence of which, according to some, almost inevitably leads to serious consequences, including death.

Finally, it has been said that the only valid reason for circumcision depends on the fact that those circumcised British and Commonwealth servicemen who suffered the sandstorms of the Western Desert in the last war were somewhat more comfortable than their uncircumcised brothers. Perhaps this is the reason why the operation finds favour with the Aborigines of the Northern Territory. Let us hope that in this instance Australia has the good sense to follow in the footsteps of the Old World and thereby keep her manhood unmutilated.

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