Sunday July 30, 2006
Some thoughts on circumcision
BY Dr CS LOH
THE practice of circumcision dates back several thousand years. It’s a practice that is well documented in ancient Egyptian hieroglyphics. Currently, it remains a religious ritual of Islam and Judaism.
The foreskin has long been recognised as the principle location of erogenous sensation, and human sexuality had been seen by many civilisations as sinful and dirty. Hence, most historians regard the practice of circumcision by major civilisations past and present as an act of purification of the individual and society.
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Circumcision is a practice that is well documented in ancient Egyptian hieroglyphics. |
The foreskin is the retractable fold of skin that covers the head of the penis (glans penis). It is believed by anatomists to play a protective role for the delicate head of the penis during early childhood.
In fact, during early childhood, the foreskin is adherent to and inseparable from the head of the penis. During this time, the opening of the foreskin is commonly quite tight and the foreskin may not be fully retracted to reveal the entire head of the penis.
By prepubertal age, separation of the foreskin from the head of the penis, together with foreskin growth, make it possible to retract the foreskin completely. A pinhole opening at any stage of the child’s development is abnormal and the foreskin should at no time balloon up during urination.
From puberty onwards, the head of the penis and the groove just behind the head (coronal sulcus) starts to secrete an oily smelly secretion (called smegma) with sexual arousal and erection. This secretion can be copious and accumulates inside the folded foreskin. It is advisable to wash off this secretion during shower with soap and water after fully retracting the foreskin. Otherwise, it builds up into clumps of cheese-like material and may lead to infection and even promote cancer.
Phimosis and paraphimosis
A foreskin opening which is too small to prevent full exposure of the head of the penis is abnormal and prevents washing of the head of the penis. This condition is termed phimosis and can be developmental or form as a result of scarring after infection, injury or certain skin conditions affecting the foreskin.
Some foreskin openings are slightly tight and though retractable, form a constriction behind the head of the penis when the foreskin is retracted. It is very important to remember to replace the foreskin back to cover the head or else the constriction over a prolonged period of time (several hours) will lead to progressive swelling of the head of penis, making it impossible to replace the foreskin and causing severe pain.
This condition, termed paraphimosis, may require surgical intervention as a matter of urgency.
In fair skinned races, the head of the penis in uncircumcised men is covered by a delicate pink-coloured skin.
However, if the man has been circumcised, especially in childhood, the exposed skin of the head of the penis thickens and develops a more pigmented colour. Smegma secretion is also reduced.
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Most historians regard the practice of circumcision by major civilisations past and present as an act of purification of the individual and society. |
Circumcision and prevention of STDs
Of more recent interest is the role of circumcision in the possible prevention or protection from sexually transmitted diseases in later adulthood. Historical studies from London indicated that the Jews were less susceptible to syphilis, whereas the Gentiles were less susceptible to gonorrhoea.
However, many more recent studies using modern diagnostic technology and more rigorous diagnostic criteria have yielded mixed results. Most scientists believe that circumcised men are more resistant to genital ulcer diseases such as syphilitic chancre, chancroid and genital herpes whilst at the same time more susceptible to urethritis.
More recently, the debate has shifted to circumcision and protection against HIV infection. Despite many studies, results are inconclusive and the jury is still out on this debate, which may require a large scale population study in a high HIV prevalence area like East Africa to resolve.
Circumcision and sexuality
What about circumcision and sexuality? Nowhere is this debate hotter than in the United States. Based on the hypothesis almost a century ago that circumcision was medically desirable, circumcision was very widely promoted by doctors and remains very popular in the United States today.
Currently, approximately 60-70% of American men are circumcised.
Because of this high incidence and the openness to debate of sexual issues, one gets the impression that the United States is a land of sexually unhappy men, many of whom feel that they had been sexually mutilated beyond their volition.
Protagonists of circumcision argue that the foreskin is rich in sensory nerve endings that convey erogenous sensation and reduction of these by circumcision delays ejaculation. Understandably, any scientific study on this issue would be difficult to design and carry out, as there are so many other factors that can influence outcome.
Antagonists argue that circumcision leads to more female discomfort during intercourse. The theory goes that the foreskin protracting and retracting during intromission and withdrawal of the penis acts like a lubricating layer and reduces direct friction and abrasion between the head of the penis and vaginal wall.
Many women with sexual experience with both intact and circumcised men claim to prefer uncircumcised men in survey studies. However, one has to be mindful that such surveys are open to bias influences and we have to cast doubt on the validity of findings from studies of this nature.
One thing is clear: if circumcision leads to so many unhappy men and women, this is manifestly not the observation in Muslim and Jewish societies. The cynics would argue that views on circumcision and sexuality are intercurrent and influenced by other societal values and varies from culture to culture and within a society, from time to time based on many prevailing factors and considerations.
Advice to parents
So, what do you do as a parent when your child is advised a circumcision? Circumcision is strictly indicated medically in certain medical conditions in which the health of the child overrides other considerations.
These include recurrent foreskin infection (balanitis), tight pinhole phimosis causing the foreskin to balloon up during urination and a male child with recurrent urinary tract infection.
An unretractable foreskin in most small children is normal and it is fairer to the child to let him decide at a later date. In adult men, foreskins affected by certain diseases including sexually transmitted diseases, skin diseases and tumours are rightly treated with circumcision, although on many occasions, more conservative surgery short of total foreskin excision works equally well.
Such decisions can only be made on a case-by-case merit based on the history and clinical findings. Foreskin and glans penis hygiene should be promoted.
There is however, a situation in which the foreskin should be preserved for posterity, ie, a child with hypospadias. In this condition, there is incomplete development of the urine passage causing it to open downwards anywhere along the shaft of the penis before it reaches the tip. The foreskin can be invaluable as rebuilding material for reconstruction of the missing terminal portion of the urine passage.
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