Medical Post, Volume 37, Issue 1. Tuesday, 9 January 2001.
Medical Post, Volume 37, Issue 1. Tuesday, 9 January 2001.
Just when you thought nothing new could be said about the foreskin, two new studies, one in Canada and one in Britain, support the idea that doctors shouldn't be too hasty in recommending its removal.
The as-yet-unpublished Canadian study looked at the function of the foreskin and found the tissue to be much more important sexually than previously thought. The 
British study, meantime, found too many English boys are still being circumcised because of difficulties retracting the foreskin.
First, the Canadian study. Inside the foreskin, a band of tissue has been discovered that expands and contracts like an accordion during erection and intercourse, triggering sexual reflexes.
It has a lot to do with sexual satisfaction and broader implications about fertility,
said Dr. John R. Taylor, a retired pathologist in Winnipeg and lead researcher in the new study.
Dr. Taylor and his colleagues were probably the first in modern times to seriously investigate the anatomy of the foreskin. Descriptions of the foreskin in all the anatomy books read by medical students and nurses are much the same as 300 years ago,
said Dr. Taylor.
In 1996, he and his colleagues published in the British Journal of Urology results of a detailed study of 21 adult foreskins at autopsy. No one could believe there was anything new in anatomy. I couldn't believe what I was seeing,
said Dr. Taylor in a phone interview.
What they found, and named, was the ridged band
-unique tissue about half an inch wide that runs around the inside tip of the foreskin.
The foreskin is not just a piece of skin, but specialized tissue full of blood vessels and nerves,
he said.
He now wants to get the message out to doctors and patients that circumcision takes away something important. Circumcision always removes a large sexually significant portion of the penis.
Dr. Aaron Jesin, a Toronto physician and mohel who performs both non-ritual circumcisions in his clinic and Jewish ritual circumcisions in people's homes, is not sold on the sexual attributes of the foreskin. To me, it is a difficult argument to prove,
he said. Jewish people have lots of sex and lots of kids.
Besides, he said, how can it ever be studied, whether sex is better with the foreskin intact. How do they know? It would be hard to put together a big enough study.
Dr. Taylor has been accused of being anti-Semitic because he is vocal about the downside of circumcision. But he has no argument against circumcision done for religious reasons. It has been done routinely in Jewish and Muslim boys since ancient times when, it is believed, God commanded Abraham to have his offspring circumcised.
Circumcision is done in the Jewish faith for good, sound religious reaons,
said Dr. Taylor, and they realize it is a significant sacrifice.
His message is directed more at people who aren't sure what to do.
Beyond the newborn stage, parents often look to doctors for help when their growing boy's foreskin isn't retracting. Which brings us to the British study.
The study, published in the September 2000 issue of the British Medical Journal, looked at circumcision rates and concluded too many English boys were still being circumcised because of a misdiagnosis of phimosis. Phimosis almost always resolves as boys mature, it said. Only 0.6% of boys with phimosis actually require circumcision, and those are the ones with secondary cicatrisation of the orifice.
For the others, there are alternatives to try-for instance, topical steroids. A group of pediatric urologists in Barcelona found them to be an effective treatment for phimosis. Their study of 137 boys with phimosis (median age five) was published in the August 2000 issue Urology. The study found that six months after initial treatment with topical steroids, 90% of the boys had developed an easily retractable prepuce; for the others, compliance had been the main problem.
Dr. Paul Munk, a pediatrician in Toronto, has a low-tech prescription to mend a tight foreskin. Time, patience and basic hygiene
... as well as letting the child masturbate. Phimosis does happen occasionally,
he explained, but by the late teens the tissue usually stretches and the adhesion is released.
A laissez-faire attitude toward the foreskin is starting to catch on in many parts of the world. In Canada, the circumcision rate is dropping. It now hovers around 20%, still high compared to England's approximately 4% and Scandinavia's 2%. The U.S. rate of infant circumcision is much higher at about 63%.
In some countries where men are at high risk for HIV infection, such as in some African countries, circumcision is being floated as a preventive measure. A growing body of evidence supports the conclusion that circumcised men are at reduced risk of HIV infection, possibly by as much as 50%. In a study recently published in the journal AIDS, for instance, it was found circumcision was associated with a reduced rate of acquiring HIV infection among the study population of 5,507 Ugandan men.
The strong beneficial effect of circumcision, however, may be confounded by other factors. Most of the circumcised men in the study were Muslim, so researchers need to find out whether other practices of Muslims are significant factors.
At the moment, most experts agree it is premature to recommend mass circumcision in high-risk populations, though plenty of editorials in the literature have called for just that.
For every pro-circumcision argument, there is a counterview. For instance, another of the advantages of circumcision is that it reduces to almost nil the chance of developing cancer of the penis, though Dr. Jesin admitted this cancer is very rare. Besides, said Dennis Harrison, an anti-circumcision activist in Vancouver, There are medical benefits to removing almost any part of the body. Cut off a toe and you don't get nail fungus.
A third advantage to circumcision is a reduction in urinary tract infections in babies. A study published in the April 2000 edition of Pediatrics concluded that newborn circumcision results in a nine-fold decrease in the incidence of UTIs in a baby's first year and that circumcision is a valuable preventive health measure, particularly in the first three months of life.
However, said Dr. Taylor, it is short- sighted for parents to make a decision on that basis. It is important in circumcision decisions to think well ahead, say, 20 years,
he argued.
Here in Canada, circumcision has been ruled not medically justified. A position statement on circumcision, released in 1996 by the Canadian Pediatric Society and reaffirmed this year, recommended that circumcision of newborns should not be routinely performed. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns.
Dr. Munk called circumcision cosmetic surgery
because it is often done so boys can look like their fathers, and it is almost always privately paid for. (Manitoba is the only province where the procedure is covered under provincial insurance.)
Circumcision is also an ethical and legal hot potato. People have a fundamental human right not to have pain intentionally inflicted on them,
writes Margaret Somerville in her new book, The Ethical Canary. Dr. Somerville, a lawyer and ethicist at McGill University, is well-known for her anti-circumcision views. Legally, she explained, there may be a way to prohibit infant male circumcision while respecting religious reasons for doing it.
If Dr. Taylor has his say, doctors giving advice to parents who sit on the fence will start with the premise that the foreskin is a valuable part of their son's body. In the equation, the value of the actual foreskin is often put at zero,
he said. Put a value on it. It is a structure in its own right.
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