To cut or not to cut? The issues surrounding routine circumcision

Philippines question male circumcision

Supot! shouted a newly circumcised young boy to one of his uncut peers, while wincing at the pain brought about by his newfound manhood. His uncut friend was now running off with tears streaming down his face.

Pantoy and his friends check out his newly circumcised member. Photo by Max Pasion

This is a usual scenario come summer time when most young Filipino boys earn their manhood through routine circumcision. Those who are cut boast of their manliness, while those who are yet to experience the right of passage are left embarrassed by their condition, anxious for their time to come.

A predominantly Catholic country, circumcision in the Philippines has long become an obligation and a tradition. Following Christian doctrine, Filipinos believe that circumcision is a symbol of the covenant between man and God. Nobody dared question the practice.

Today, however, doctors are debating on the purpose of a practice that has become a fixture in Philippine tradition, regardless of medical benefits and risks.

Reasons for circumcision

There are three main reasons why doctors continue endorsing routine circumcision: For hygienic purposes; religious reasons and to avoid foreskin problems (phimosis, paraphimosis and balanitis) in susceptible males and cervical cancer in women.

Hygiene is an important consideration in circumcision. Before and after circumcision, proper hygiene must be observed. For still uncircumcised males, this means that there needs to be a more tedious cleaning process to maintain the cleanliness of the foreskin. They need to do so to make sure that unwanted bacteria and other foreign microbes do not enter the spout of the skin and breed. Unless cleaned, there are a host of possible infections that can ensue in males such as phimosis, paraphimosis and balanitis and cervical cancer in their female partners.

Phimosis is the inability of an individual to retract the penis. According to the article Conservative Treatment of Phimosis: Alternatives to Radical Circumcision (https://www.cirp.org/), it occurs in less than two percent of intact males, or seven out of 10,000 males.

Additional information is given by the article Foreskin Problems by Dr. Paul A. Alleyne for E Medicine (www.emedicine.com), which states that phimosis is caused by infection, poor hygiene, previous foreskin injury, any condition or activity that results in prolonged foreskin retraction, improper circumcision of the penis, catheterization, and vigorous sexual activity, including masturbation.

Meanwhile, the article Phimosis and Paraphimosis written by Dr. Santos Cantu Jr., also for E Medicine, defined paraphimosis as the entrapment of a retracted foreskin behind the coronal sulcus. Like phimosis, paraphimosis also occurs in the uncircumcised or incorrectly circumcised penis.

According to Urology Channel ( www.urologychannel.com), paraphimosis occurs in one percent of males over 16 years of age. This is usually caused by bacterial infection, catheterization (i.e., if the foreskin is not returned to its original position after a urethral catheter is inserted, the glans penis may become swollen, which can set off paraphimosis), poor hygiene, a swelling producing injury and vigorous sexual intercourse.

On the other hand, balanitis is the inflammation of the head of the penis (glans penis).

According to Dr. Mark Leber in his E Medicine article Balanitis ( www.emedicine.com), Balanitis is a common condition affecting 11 percent of adult men, treated in urology clinics, and three percent of children.

Diabetes is also considered as one of the most common underlying conditions associated with balanitis. There are also cases when a balanitis-complaining patient suffers from uncontrolled diabetes, so that retraction of the foreskin cannot be done.

Other causes of balanitis include poor personal hygiene, the use of chemical irritants like soap and petroleum jelly, Edematous conditions like congestive heart failure, cirrhosis and nephrosis, drug allergies, morbid obesity, penile cancer and viruses such as candidal species (most commonly associated with diabetes), anaerobic infection, human papilloma virus (HPV), gardnerella vaginalis, treponema pallidum (syphilis), trichomonal species, group B streptococci and borrelia vincentii.

In addition, Dr. Clayton Blas, a urologist and member of the  Philippine Urological Association, said that circumcision also aims to prevent cervical cancer in women. The HPV is a common sexually transmitted disease that is passed on from one partner to another through sexual intercourse. According to the National Cancer Institute's website ( cis.nci.nih.gov), the virus plays a major role in cancers of the anus, vulva (the external female genital organs, including the clitoris, vaginal lips, and the opening to the vagina), vagina and penis.

In fact, according to Neurologist Dr. Artemio Ordinario, in Israel, there are only a few cases of cervical cancer as compared to other countries. Israel, by virtue of being predominantly Jewish, requires all men to be circumcised. This is based on sacred scriptures that deem circumcision as a necessity in man's salvation.

Both based on Jewish tradition, the Christian and Catholic beliefs, however, do not consider circumcision as a necessity for salvation, but a symbol of the covenant between God and His people. This covenant was made between God and Abraham, the father of all nations.

According to the article Circumcision in the website Free Minds (www.freeminds.com), it was written in Gen 17:14-13 that Any uncircumcised male who is not circumcised in the flesh of his foreskin shall be cut off from his people; he has broken my covenant. This is the covenant of circumcision.

It is only Muslims, who by faith, are not obliged to circumcise their sons. But if they choose to have them circumcised, they may. There are some Muslims who subscribe to circumcision, even in the Philippines and other Muslim countries, as patterned from their belief that women should always wear headscarves. The article said, This is similar to the headscarf which some women wear out of fear that it is a 'command' from God … as long as you know that it is not a command from God, then the woman is free to wear it or disregard it as she sees fit.

Anticircumcision campaign

In an effort to ban routine circumcision in the country, Dr. Reynaldo Joson, former chairperson of the Department of Surgery of  Ospital ng Maynila Medical Center, launched an antiroutine circumcision campaign based on the belief that it is unnecessary for salvation and as a medical procedure.

I want to save millions and generations of Filipino children from unnecessary circumcision; its pain and its risk of complications including death, said Dr. Joson in an interview posted on his  website (www.xtulepinoy.tripod.com).

Dr. Joson acknowledges that there are only three reasons for circumcision-religious, medical, and non-medical-but that they are not enough to justify the procedure. He added that there are no clear medical benefits in circumcision except if it is done for the purpose of therapeutic circumcision.

In therapeutic circumcision, the procedure carried out to cure or prevent phimosis, paraphimosis and balanitis in susceptible males. The procedure is the same but the rationality of the procedure-why it is being performed-makes the difference.

Dr. Joson said that the only reason why routine circumcision is still being done in the country is because of the social stigma caused by being called supot. The ways he sees it, circumcision is only done solely for the promotion of the social and mental well-being of the male individual.

Since there are no medical benefits for circumcision and neither is it necessary for salvation, saving males from the medically and religiously unnecessary procedure-this painful tradition-should be done. (The situation) should be changed to save the boys from being forced into circumcision just because of the cultural stigma of supot, he explained.

Dr. Joson said that proper hygiene is enough to prevent foreskin diseases from developing. Similarly, Dr. Blas said that cleaning the penis with soap and water every day would already suffice as a proper cleaning method.

According to anti-circumcision advocates, meanwhile, many of the reasons for circumcision in this country are all myths. Some of these myths contain that without circumcision a boy will not grow tall; that his penis would not grow bigger; that during intercourse, a circumcised male performs better; among others. There is no scientific evidence that would prove any of this.

In fact, Dr. Joson wrote a letter to Letty Jimenez-Magsanoc, editor-in-chief of the Philippine Daily Inquirer last year, saying, The presence of the foreskin has been shown to have fuller range of sexual experience during sexual activities.

On the issue of cervical cancer and other sexually transmitted diseases stemming from uncircumcised individuals, Dr. Joson maintained, There is no solid evidence in literature that show preserving the foreskin is the direct cause of the diseases, and that circumcision will directly prevent their occurrence.

Furthermore, Dr. Joson said that with circumcision, there are risks that can sometimes lead to death. According to Dr. Blas, risks such as bleeding, infection and painful erections can increase if individuals are circumcised when they are too young (some are circumcised in infancy) or if they were not physically strong at the time of the procedure.

To cut or not to cut?

Most young doctors, according to Dr. Blas, are no longer for routine circumcision. Like him, some doctors still perform routine circumcision upon the request of the parents or the child, or both, but refuse to join annual Operation Tule campaigns.

Several medical institutions have stopped conducting Operation Tule such as the  Ospital ng Maynila, the first hospital to do so; the Perinatal Center of the  Philippines Children's Medical Center;  Philippine General Hospital; and the Zamboanga Medical Center.

However, the Catholic Church has yet to act on the issue. Dr. Joson submitted a letter to  Cardinal Sin regarding the endorsement of therapeutic circumcision in place of routine circumcision but he has yet to receive word on the matter.

Ultimately, Dr. Joson said the only person who should decide whether or not to undergo circumcision is the boy himself. With research findings that routine circumcision is not warranted anymore, there is now an option not to have a circumcision done if it is not medically needed, he ended.

Cutting the edge

Traditionally, when a young Filipino boy reaches his adolescent years, he is forced to undergo circumcision. There are two versions of having a circumcision. One is through doctors and the other one, through a manunule. However, both have one purpose-to cut.

Prior to the procedure, all young boys are asked Kapon ka na ba? Kapon means that the boy has tried retracting his penis before. If the boy says No, then the doctor or manunule advises that he does so before going through the procedure. This makes the procedure easier since it would involve stretching the foreskin before cutting it. This would be extremely painful for a boy who has never retracted his penis.

When the boy is ready, using sterilized surgical knives, a medical practitioner (usually a doctor) creates a slit on the upper side of the foreskin surrounding the head of the penis. This is followed by the removal of the sleeve of the foreskin. After the procedure, medicines are given to the patient for the wound to heal.

However, in rural areas, there are specialists who do the traditional pukpok under the tree, near the river to perform the same procedure. Before the pukpok, the manunule or pukpok asks the one to be circumcised to chew guava tops. The manunule then uses a sharpened labaja or barber's knife to cut the foreskin. The manunule then places the boy's chewed guava tops on the genital as a way of medication. The new man, as they are usually called, then jumps into the river for cleansing. Jumping into the river would then constrict the blood vessels and stop the bleeding of the wound. Though it is unsanitary, the procedure is accepted and has been practiced for decades in rural areas.

On the other hand, some doctors prefer performing circumcision in infancy, for an easier procedure where the subject does not resist and the skin is still soft. There is no truth, however, to the rumor that if boys are circumcised in infancy the foreskin grows back. In instances where the foreskin is believed to have grown back, the reason doctors point to is wrong cut during the procedure.

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