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Is circumcision in males necessary?

By Reynaldo O. Joson, MD And Rafael R. Castillo, MD

Until recently, no one - including doctors - ever bothered to take a closer look at this issue. We always thought it was a long-answered question and that it was really medically necessary to have all males circumcised. But is it?

Circumcision in males usually consists of removing part of the prepuce or foreskin of the penis. Its practice has various origins, both religious and non-religious, medical and non-medical. The reasons for the practice of circumcision in males have evolved from Biblical practice.

There is still the religious basis, especially for the Jews and Muslims (but this is not absolute anymore because there are now Jews and Muslims who object to male circumcision).

There is still the medical basis, particularly, in the belief that circumcision can prevent urinary tract infection, penile and cervical cancer, and sexually transmitted diseases. The sexual arguments for circumcision is based on the belief that circumcision offers more sexual enjoyment to both male and female partners.

However, the predominant driving forces for circumcision in males are tradition and peer pressure. Male newborns are circumcised because of the parent's belief of the traditional practice. Male adolescents and even adults are also circumcised because of the traditional need ("passage rite to manhood") and peer pressure (afraid to be teased as "supot").

An objective, scientific, and dispassionate look is therefore necessary to answer the question: Is circumcision in males really necessary?

On the basis of medical reasons, routine circumcision in males is NOT necessary. The American Academy of Pediatrics has done extensive critical analysis of all published papers on the topic and has come out with a stand in 1999 that routine circumcision in males is not necessary.

On the issue of urinary tract infection, penile and cervical cancers, circumcision may have a potential benefit in terms of prevention but its actual value is minimal because of the low occurrence of these dreaded consequences. In other words, the risk is extremely low if circumcision is not done and thus, routine circumcision is not warranted.

On the issue of sexually transmitted diseases, prevention should focus on the behavioral factors - that is, avoiding promiscuity and careless sex - rather than relying on circumcision. On the question of hygiene, promotion can be done with meticulous mechanical cleansing without having to resort to the invasive and painful procedure of circumcision.

The most common and most clear cut medical indication for male circumcision is now limited to patients with urinary infection secondary to phimosis (extremely small opening of the prepuce or foreskin of the penis).

Paraphimosis (tightness of the foreskin that tends to strangle the penis) can be another medical indication if it occurs. Other than these situations, medical-wise, circumcision in males is not necessary.

In the Philippines, the Christian religions do not require routine circumcision anymore. For the Muslims and Jews, it may still be advocated but it is no longer an absolute requirement. There are even websites put up by Jewish and Muslim authors crusading against circumcision.

The debatable issue on sexual enjoyment may be a myth after all. Although there are no conclusive findings yet, a most recent scientific article on the issue shows that more sexual enjoyment is felt by the female partners with non-circumcised than with circumcised men. The enjoyment is scientifically validated in terms of more copious vaginal secretion, less vaginal discomfort, and more frequent vaginal orgasm - multiple at that.

In countries like the Philippines, the predominant driving forces for circumcision in males at present are tradition and peer pressure. Though the traditional factor may be religious in origin, in the Philippines (at least for the Christians), it is usually non-religious in nature and now more related with social customs and practices.

Furthermore, the traditional factor is usually vague in the sense that the parents and the male children are not able to pinpoint the exact reason for wanting a circumcision to be done. Peer pressure in the Philippines is strong and consists of the male children afraid to be teased of being "supot". Traditional practices and peer pressure are really had to go against.

If we are not obliged by religious reasons and if we are now convinced that circumcision is not needed for medical reasons, the question is - How do we go against the tide of tradition and peer pressure to reverse the present of routine circumcision? That is the challenge being presented to those who think that the male Filipino children should be saved from the physical pain of unnecessary circumcision.

I have an adolescent son who asked me last year if he needed to be circumcised. I emphatically said "No!"

I told him it is not needed and it is painful. I emphasized to him not to be carried away by the teasing of "supot" and not to be overpowered by peer pressure. I even taught him how to counter the teasing of "supot" by saying uncircumcised men are intact, unaltered and preferred by women in terms of sexual enjoyment and comfort and that circumcised men are altered and not original. Up to now, he has remained to be uncircumcised.

As a surgeon, during the past 20 years, I have convinced quite a number adolescent males who came to my clinic not to have circumcision anymore. Those who are convinced are happy and thankful to me. Those who are not convinced seek other surgeons to do the circumcision for them.

The challenge really consists of two aspects: First is how to change the belief of parents who will have their male children undergo routine circumcision because of the tradition.

Second is how to reduce, if not abolish, the peer pressure that will make adolescents and adults undergo routine circumcision.

How can we meet the challenge? Basically, by public health education and advocacy.

Public health education will consists essentially of sending the message to the public through all forms of media that "Tuli - Di Kailangan! Masakit!"

Advocacy will consist essentially of actively campaigning against routine male circumcision by first explaining the issues and then convincing the public, especially the parents and male children that circumcision is not necessary.

The strongest strategy in advocacy is for the physicians to speak out against routine circumcision. The public considers the physicians as the professionals to turn to when it comes to issues on circumcision.

Initially, the voice of the physicians will be important in the advocacy against routine circumcision. In a book expounding on the issue, the author wrote: "One doctor said that he talked to every parent and male child who come to him for this purpose (circumcision), explaining the consequences and saying that it was unnecessary, but found they insisted upon having it done, so he complies. His justification was that he did it in a hygienic way and lost nothing by it. On the contrary, he gained money. But he overlooked the fact that he is acting unethically...abdicating his role as a model of enlightenment for others; one can only assume that he is simply pursuing his own interests. The negative effect of this is that when we try to convince the parents and their children that this operation is not necessary, they immediately reply that doctors do it, therefore it must be a good thing."

However, not only are the doctors the key opinion molders in this issue. The voice of the parents and even the children will be stronger - in fact, strongest. If they are convinced about the non-necessity of circumcision, they should also voice out their stand on it for the sake of their children, grandchildren, great grandchildren, and great, great grandchildren.

 

Dr. Joson is chairman of the Dept. of Surgery at Ospital ng Maynila Medical Center. He is a member of the CHARTER Bureau, a non-stock, non-profit research foundation, headed by Dr. Rafael Castillo and based at the Manila Adventist Medical Center - formerly Manila Sanitarium & Hospital.