The Guardian, London, 28 May 2000.


Health

Rough cut

What do you do when your doctor tells you your son should be circumcised?
Sophie Radice agonises over the choices.
Sunday May 28, 2000.

One terrible evening last year, my eight-year-old son's foreskin got stuck back at bathtime when he was routinely cleaning himself. Within minutes, it had alarmingly ballooned behind a tight red ring of swollen skin and he was screaming with pain. My husband was still at work and I suddenly felt desperately inadequate. What should I do? Perhaps there was a knack to this? Was this something that happened to boys that I didn't know about?

I phoned my GP, who told me that this was an emergency and to get to hospital immediately. My son then had to endure an hour of agony which overcame his extreme embarrassment at having to hold an ice-pack on his genitals while dozens of medical staff came in to our cubicle and gave their opinion. When that failed to bring down the swelling, he was given morphine, followed by gas and air, while a consultant tried to manipulate his foreskin back into its usual position. Despite being told that we were very lucky that the 'foreskin expert' just happened to be in the hospital and this consultant had 'never encountered one that he could not get back', in the end my son was put under general anaesthetic to drain the fluid by a small incision. I was told that he had a bad attack of balanitis - inflammation of the foreskin - which is why he was complaining of having a sore willy. When he tried to clean it in the bath by pulling back his foreskin, paraphimosis occurred. This is when the retracted circle of foreskin becomes tight and swollen, and then fluid builds up behind the tight ring of skin.

Before he went into the operating theatre I was told that 'he would certainly have to be circumcised at some point and did I want it done now so he would not need another operation?' Even though I was warned that the swelling would make it slightly more tricky, my immediate response was: 'Yes, of course.' I should explain that there is a history of tight foreskins in my family, with one case of circumcision in late childhood. More importantly, I never wanted my son to have to endure this kind of agony again. The consultant added, 'If you had seen as many old men with their foreskins stuck back, as I have, then you'd have no doubts.'

Before signing the consent form, I hesitated just for a moment, however. My son had already gone under the anaesthetic, and standing next to his unconscious form, I suddenly felt that it would be terribly wrong to make this decision on his behalf. I needed to discuss it with him, my husband, my son's father, my doctor and, as it turned out, anyone who could give me an opinion, be it cultural, emotional, sexual or medical.

In the months that followed, I tried to get as much information as possible by raising what I discovered was the highly emotional and pun-ridden ('Let's get straight to the point,' said the urologist; and 'You must read this seminal work') subject of circumcision as often as I could. Both my uncircumcised husband and ex-husband were horrified that I had even considered agreeing to the operation. Meanwhile, my doctor prescribed an antibiotic cream to apply at the slightest sign of swelling and told us to take our time making up our minds.

Jewish friends and a Muslim relative felt that my son's medical problems added weight to the cultural reasons for having their sons circumcised as babies. Religious circumcision may have its origins in ancient Egypt of 3000 BC. It was adopted by the Jews and later the Muslims, possibly as a hygienic measure in a hot and sandy climate. It then became a ritual of religious observance.

Dr Schamroth of the Association of Progressive Mohalim, who performs circumcision on both Jewish and Muslim babies, says that 'it is not a nice thing to have to do to a newborn. As a doctor, I feel that there are no medical disadvantages in later life, though I don't feel there is overwhelming evidence of advantages either. My concern is to make it as untraumatic as possible, with local anaesthetic.'

Talking to friends in mixed marriages with sons was also helpful because of the lengthy debates they had inevitably had during pregnancy. Sandra Rose is married to Paul, with a son aged three and a two-month-old daughter. He is Jewish and she was brought up in a non-religious family of Christian origin. 'The thought of any kind of operation removing healthy tissue was extremely difficult to get my head around,' she said. 'When Daniel was born, we spent three days arguing about it, and in the end I found my husband's religious and emotional reasons - he wanted a son that resembled him and his forefathers - more compelling than my squeamishness. In the event, the circumcision, when Daniel was eight days old, was a deeply moving family event, and Daniel didn't even cry.'

The circumcision debate is not only between non-Jews and Jews and Muslims but international, intergenerational and in the case of my bother-in-law from Guyana - where only men of certain ancestry use circumcision as a mark - intertribal. British men of my grandfather's and father's generation were routinely circumcised at only a few days old. It is likely that circumcision was introduced in this country by doctors who felt that it would discourage masturbation, which was considered to be the cause of a number of illnesses, including epilepsy and blindness. This attitude prevailed until 1935, when the aptly named Dr Cockshut wrote in the British Medical Journal : 'I am convinced that masturbation is much less common in the circumcised - with these considerations in view, it does not seem apt to argue that "God knows best how to make little boys".' Circumcision later came to be considered more 'civilised' in that it was a sign of a hospital birth, and possibly because during both World Wars and the era of National Service, circumcised conscripts suffered from fewer infections if hygiene was poor.

In America, there is now a radical anti-circumcision movement in response to a 60 per cent circumcision rate, which has gone down from nearly 90 per cent. There is also a small movement of American men who attempt to 'grow back' their foreskin by means of bands and weights. In the UK, there is little call for extreme pro- or anti-circumcision groups because a number of factors brought down the rate of circumcision to today's 10 per cent. A highly influential paper, 'The Fate of the Foreskin', was written in 1949 by a Dr Gairdner, stating that most boys' foreskins retract naturally by the age of four or five and the rest by adolescence. Also, mothers started to question the practice at the same time as the NHS (where money was always tight) was born and sexual attitudes (masturbation no longer being considered the root of all evil) became more relaxed.

At its most atavistic level, the debate can get nasty. Uncircumcised and circumcised men defend their own penile state. The circumcised are confident that they are smegma free, more aesthetically pleasing, free from cancer of the penis, urinary tract infections, premature ejaculation (I have even heard a circumcised man say that he has a bigger erection because there is no skin holding him back) and are better lovers. The uncircumcised feel they are more sensitive because the foreskin protects the glans, that women find them easier to 'handle' without lubrication. They, too, consider themselves to be better lovers.

Mr Cuckow, consultant paediatrician urologist at London's Great Ormond Street Children's Hospital, says that 'men can be far too concerned with either wanting a circumcision, or regretting one, or in the defending of non-circumcision in the context of the sexual performance. There is such a wide spectrum of normality when it comes to the penis, and sex involves such a huge range of stimuli and sensation, which are not all centred on the tip of the penis.'

Although an important consideration, my son's future sex life is not the only thing I have to think about here. Above all, I don't want him to have to endure repeated discomfort or emergency dashes to the hospital. Cuckow is reassuring. 'At the end of the day, the foreskin is a normal piece of tissue which is not pathological, but like any part of the body, it does need some looking after. Be vigilant about gentle washing and tell your son to retract his foreskin a little when he does a pee.'

In a quiet moment, I gently told my son some of the things I had learned and asked what he thought. I was surprised to hear that although he wasn't that keen on the operation, he would have it done if he could go back to the same hospital - 'because they had the best Nintendo 64 game console that I have ever seen. That's a good enough reason, isn't it?' The decision is on hold.

Circumcision: the facts

The foreskin In most boys, the foreskin (also called a prepuce) is attached to the head of the penis at birth. It keeps the glans soft, moist and sensitive and protects it from exposure and chaffing. During growth and development, the foreskin gradually separates from the head of the penis or glans and it is extremely inadvisable to pull it back forcibly, as unenlightened paediatricians used to do. Consultant Mr Wilcox of the paediatric urology department of Guy's hospital says that this 'may cause tears and scar tissue, which will mean problems in retracting the foreskin later on'.

Problems These three conditions are the most common reasons for medical circumcision but many doctors, urologists and paediatricians would now consider other treatments such as antibiotic and steroid creams as well as gentle and extremely gradual stretching exercises.

Hygiene One of the reasons many paediatric urologists think that boys have problems with their foreskins is that parents, and particularly mothers, are unwilling or embarrassed to teach boys how to properly clean themselves. In the bath, boys from the age of four or five should be taught to very gently pull back the foreskin a small way and clean as much of the glans and foreskin as they can. As they get older, they will be able to pull the foreskin back further so they can wash away urine and smegma. If the foreskin does get stuck back, then try to firmly pull it back into its normal position as soon as possible because any delay increases the chance of swelling. If this is impossible, then get to hospital as quickly as you can.

Circumcision Circumcision is the surgical removal of the sleeve of skin and mucosal tissue that normally covers the head of the penis. In very repeated cases of infection, medical circumcision may be seriously considered. It is worthwhile getting a second or third opinion from other urologists. In most medical circumcisions, which commonly occur in mid- to late childhood, a general anaesthetic is used, but with infants, a local anaesthetic cream or injection can provide a penile nerve block. Some doctors and all Orthodox Jewish mohels (the men who perform the task) prefer to avoid the small risks posed by anaesthetic agents. There is a good deal of controversy about how much the baby is traumatised by circumcision.

Timing If your child must be circumcised, think carefully about the timing. Penelope Leach recommends that parents wait until the boy is more than six: 'The younger they are, the more difficult it is for them to understand that removing the foreskin will not damage the organ.' If the boy is prepubescent or adolescent and self-conscious, he may find the whole process deeply embarrassing and humiliating. Circumcision is a minor operation, but it can be extremely upsetting.

Recovery Older boys may find the few days after circumcision extremely painful. There are many ways to help keep the pressure off, such as using a sports box or sitting on a beanbag.

Websites

<http://www.users.dircon.co.uk/~vernon/ICIRC> British no-nonsense website; mainly pro-circumcision.

<http://www.cirp.org/> American, highly researched website with anti-circumcision leanings.

<http://dmoz.org/health/> Level-headed, and aimed at parents trying to make a decision.

[CIRP Note: This news article contains both information and misinformation. Unfortunately this is typical of many circumcision news articles in the popular press.]

Citation:
(File updated 14 May 2003)

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