Transcript of BBC Health Matters, 8:15 GMT 21 Aug. 1996

Presenter: ...question: to cut or not to cut. Is it kinder to leave the foreskin of the penis well alone, or is it nobler for reasons of religion or health to lose it? We follow one man as he undergoes the operation, and we meet another who would like to have his circumcision reversed to restore the lost foreskin.

Dr. John Warren: It's not just any old bit of skin. It has very specialized nerve endings; it has a ridged structure rather like the fingertip, so it isn't just a protective shield for the glans. It is a very important part of the erogenous equipment of the male in its own right, I think, and when it's lost then something irreplaceable has been taken away.

Presenter: Dr. John Warren runs a support group for men who like himself yearn for uncircumcision. We'll hear more from him later. But first I've been to a private clinic in London to meet a man anxious to relinquish his foreskin.

voice: You're here to have a circumcision...unintelligible... You're going to have it done underlocal anesthetic. That means you'll still be awake.

A short description of the operation follows.

Presenter: The man waiting for the operation is Mr. Jones. Not his real name, but then circumcision is rather a personal matter. At the age of 61 Mr. Jones is being circumcised for religious reasons: he's converting to the Jewish faith.

Mr. Jones: To become Jewish, to go through a form of conversion I will need to becircumcised.

Presenter: Why is that?

Mr. Jones:Well it's the covenant entered into between Abraham and the Almighty.

Presenter: In a sense is a sacrifice that you're being asked to make?

Mr. Jones:No, I don't see it as a sacrifice. I see it as a commitment.

Presenter: But at this point, just before you go in to have the procedure carried out, how do you feel about it? After all you've lived with your penis as it is for 61 years you've just said. It's going to change. When you comeout it'll be different.

Mr. Jones:Yeah, but I shall still have the penis. They're not going to... at least I hope he hasn't had so much to drink that he'll take that as well.

Presenter: (laughs)

Mr. Jones:No, I don't think it's going to make too much of a difference from that point of view. I feel a little apprehensive obviously, but everyone's gone out of their way to emphasize what a minor matter it is from a surgical point of view. Although it has a great significance from (unintelligible).

Presenter: The procedure is being carried out by a Jewish doctor, John Cohen. He begins by giving Mr. Jones an injection to numb the groin area, and the operation is quickly underway.

Dr. Cohen: I've just made a first incision, and the patient didn't feel it, because of the local anesthetic, and I'm just about to make a circular cut around the foreskin and just excise it, and then we will see how we go from there. (To Mr. Jones: Are you all right? You know where you are? Fine. OK, we're doing very well so far.) I'm just removing the foreskin and it's now removed completely, and I'm now going to just clip some blood vessels so that it heals up nicely.

Presenter: That really was at a stroke, that took all of 10 seconds to cut away the foreskin.

Dr. Cohen: Yes, but then one hopefully knows what one is doing. And what one's cutting.

Presenter: Now the fact that as you've removed the foreskin, cut that away, what you can then see is the end, the tip, of the penis. This is the glans, and this is usually then covered unless you're circumcised. Does it matter that this part is exposed?

Dr. Cohen: The sensitivity is different, because of course you don't have a foreskin. Some people claim that their sexual sensations are enhanced and others say that it's diminished. I think that it's likely that it's different.

What I'm doing now is tidying up the skin edges. Bleeding is the commonest problem, but hopefully by taking your time over it and not rushing to secure the blood vessels and tying them that we prevent that happening. It's an occasional but fortunately very rare complication.

OK, we're just putting the stitches in now, the skin stitches, and we've nearly completed the process of making it look good. And making it look right.

(To the patient) What do you want to do with the foreskin? Do you want it? OK,it is yours, if you want it.

Mr. Jones:It is part of my weight-reducing campaign, so you can have it.

Dr. Cohen: Whereas the last patient we think would like to take it home with him. He says perhaps he would like to bury it in the garden. The orthodox Jewish tradition was that a foreskin would be buried. It's a part of the body which is holy.

Presenter: So, in twenty minutes it's all over. Mr. Jones will be allowed to go home later in the day, and in a couple of days the dressings will come away, the stitches will dissolve, and the patient can resume his normal activities, including his regular visits to the synagogue.

Circumcision on a man of his age is unusual. Jewish babies are circumcised when they're eight days old. In Muslim communities the age of circumcision varies, but often starts around the age of eight while in many African societies it's carried out at puberty, as a rite of passage.

When circumcision is not demanded as a ritual, however, parents have to choose whether to have their sons circumcised. In some countries, like Finland for example, circumcision is almost unheard of. In Britain the rate is less than ten percent. In Australia it's 25%, while in America 90% of all teenagers today have been circumcised. In these societies circumcision is done for what might be called social reasons. When pressed parents often mention hygiene. They say it's easier to keep the penis clean without a foreskin. And a clean penis, the argument goes, is a healthy penis. There is evidence that circumcised men are less likely to develop penile cancer, though this is a very rare condition. The partners of circumcised men, too, are thought to be at less risk of cervical cancer. The counter-argument is that it's perfectly possible to keep an uncircumcised penis clean with normal routine washing around the foreskin, so critics say that it is an unnecessary operation.

What's more, there is a backlash forming against widespread routine circumcision. In America a campaign calling itself UNCIRC is gathering momentum. And in Britain Dr. John Warren is active in a group of men who for a variety ofreasons resent the loss of their foreskin.

Dr. Warren: In Britain, where circumcision is not usual, they may feel uncomfortable about it psychologically if they're in a crowd of men in a changing room or something like this they may feel very self-conscious about it. So that there is the appearance and the cosmetic issue. But then more serious than that is that they may complain of loss of sensation in the penis. And there have been recent studies which show that the inner foreskin is very specialized. Men who still have their foreskin will say that the inner foreskin is rather more sensitive than the glans. It's possible that this loss of sensation may also be contributed to be changes in the glans. Nobody's really researched sensation in the glans with or without a foreskin, but men who have been circumcised as adults say that the feeling in their glans changes afterwards. Gradually they lose the sensation which they used to know before. They come and ask about this, and when you ask them why do they want to restore their foreskin, what is the problem, well over half complain of loss of sensation and things like increased time to reach orgasm.

Presenter: So what is it then that you can suggest? What can they do about it?

Dr. Warren: Well obviously the best thing is not to circumcise children in the first place in our view. But for those for whom it's too late, and who have lost their foreskin, they may be interested in foreskin restoration, which is carried out non-surgically. There have been attempts to replace the foreskin by skin-grafting, but in our experience, I've talked to some men who have had this done, the results have never been very satisfactory. And of course there are scars too. The man with a circumcision already has one scar, but if he has a skin-graft, then he has more scars.

Presenter: All right, then, what is the non-surgical way?

Dr. Warren: Well, a group of men in California started experimenting in the early eighties with non-surgical methods of restoration, and it's of course been known for a long time that if you stretch tissues, they grow, and this has been exploited by tribespeople who put weights on their ears and make the ears grow right down to the shoulders and by some tribespeople who expand their lips with putting disks into them and this sort of thing. So it's a well known fact that skin and subcutaneous tissues will actually grow and increase if they're stretched consistently over a long period, and it is this technique which is used to develop more skin on the penis to replace the lost foreskin.

The simplest thing is techniques using surgical tape, which pulls the penile skin forward over the glans and holds it in position, and that's a very simple, cheap thing to do, and not at all uncomfortable. And then other devices and appliances have been developed. Obviously weights can be used, and there is now someone in America making a purpose-built metal, stainless steel weighted device for this purpose, which is attached to the penis, the penile skin, by surgical tape. The purpose is not to enlarge the penis, but to extend the skin.

Presenter: Such attempts to uncircumcise may seem somewhat excessive, irrational even. Dr. Warren, who is a respected family doctor as well as a campaigner, doesn't agree.

Dr. Warren: Most of the men I meet who are interested in this are remarkably sane. And of course nobody makes them do this. They try it out quite voluntarily, having heard about it, thinking well maybe there'll be some good in this, maybe it'll be helpful, and if they don't like it they can stop. But the remarkable thing is having tried it a great many do persevere with it because obviously, they feel benefit quite early on and they wouldn't carry on if they didn't.

Presenter: Personal question, but is this something you've tried yourself?

Dr. Warren: Oh yes. Yes, I've been doing it for nearly three years. My wife and I both feel that we've been robbed in that I was circumcised when I was an infant, and we're doing our best to undo some of the damage.

Presenter: Dr. John Warren and his fellow uncircumcisers, whether in Britain or America are still in the minority, but his personal conviction that routine circumcision is inappropriate may give pause for thought. And Dr. Cohen, though he was perfectly happy to circumcise Mr. Jones for religiousreasons, urges a careful weighing of risks and benefits.

Dr. Cohen: The main risk associated with circumcision is bleeding. And there are in Britain a very small number of deaths each year from bleeding associated with circumcision, so this is not something to be undertaken lightly. The risks of not having a circumcision, there are some conditions associated with not being circumcised, for example cancer of the penis is virtually unknown in men who are circumcised. There is some circumstantial evidence about HIV and genito-urinary infections as being less prevalent in men who are circumcised. I don't believe that everyone should be circumcised, I think the advantages are not necessarily proven, but if you are Jewish or Muslim, or belong to certain African groups, then it is part of your tradition, and I think you'd be very unwise to depart from centuries, generations of tradition.

Presenter: That was our final word from Dr. Cohen. It's good-by from Health Matters and from me, Barbara Myers.

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