Tuesday, May 29, 2012

A Chat About Circumcision

So what is circumcision, anyway? Don't they just take a little bit off the top?

It's surgical removal of the foreskin, frenulum and about one-third to one-half of the skin of the penis.

Wait, one-half of the skin of the penis? How can that be?

There's no precise point where the foreskin ends and the skin of the penis begins. During a circumcision, the skin of the penis is peeled back like a banana to expose the mucosal tissue of the head and shaft - tissue like the inside of your mouth. The two types of tissue can be clearly seen on the circumcised penis and the tissue covering the head and upper shaft is very different from the skin below the circumcision scar.

But it just slides back and then they clip it off or something?

No, actually it doesn't even begin to slide back until around age 2 or 3 at the earliest, and frequently much later. In a newborn, the opening of the foreskin is big enough to let urine through and the foreskin itself is tightly fused to the head and shaft of the penis - like a fingernail is fused to the nail bed. It doesn't slide back at all.

Then how do they get it off of there to cut it?

They use a blunt probe to separate them. It feels about like having a fingernail ripped off... except it's on the most sensitive part of the body. The head of the penis looks like the finger minus the fingernail too, very raw and bloody.



So then they just cut it off?

They cut a slit in the side of it and then they usually crush it with a clamp for a few minutes. Then they cut it off. Alternately, they put a plastic bell over the head, and tie a ligature around the foreskin, then cut the foreskin off.

That all sounds really painful! But they use anesthetic of course.

Uh, most often no they don't.

Oh come on! That's barbaric!

It is, isn't it. Sometimes they use a topical cream and even less often they use a shot of stuff like Novocaine. Well under half of all circumcisions are performed with any pain relief at all, and most of those are not especially effective.

It's just skin though. It can't be that important.

It's not "just skin". It's skin on the outside with a thin, flexible muscle sheath underneath and the same exquisitely sensitive mucosa as the inner edges of your lips on the inside. Right around the edge of the foreskin is a ridged band of tissue which attaches at the frenulum to the underside of the glans. (Together, that band and the frenulum are considered the primary erogenous zone in males - the head of the penis is secondary and much less sensitive.) Not to mention tens of thousands of nerve endings and specialized immune cells.

Hey, most circumcised guys say if they were any more sensitive they'd explode! How is more sensitivity a plus, here?

Probably because the term 'more sensitive' isn't defined. Men needlessly circumcised as adults have reported the sensitivity and sensation before and after as the difference between color vision and only seeing in black and white. Using this analogy, a man circumcised at birth might say "How could I possibly see any better? I can see everything so clearly as it is, and it's beautiful! If there was any more light, I'd go blind!" because without experiencing color, he cannot conceive of how it could be different, richer or better - only brighter.

Well, at least it's beneficial medically. It's much healthier to circumcise, right?

No. There is no medical reason for routine infant circumcision, and no national or international medical association recommends it. It doesn't stop urinary tract infections, it doesn't stop HIV infection, it doesn't stop cancer of the penis or of the cervix. It doesn't stop (or even significantly reduce) any disease.

Doesn't everyone need it done eventually?

Nope. In countries where nonreligious routine infant circumcision is rare (like the UK or Denmark or pretty much everywhere but the United States) at most one in 200 men is circumcised later in life, and the actual number who need it because they cannot be treated in any way but with amputative surgery is 1 in 18,000. Even here in the US, where many doctors recommend circumcision needlessly because they do not know how to treat the foreskin, the rate is less than 8 in one hundred. Circumcising all boys at birth to prevent later need for circumcision is somewhat like removing the breast tissue of all girls to prevent later breast cancer... except the risk of getting breast cancer over a woman's lifetime is one in eight, whereas the need for circumcision for any reason is at less than one-half of one percent.

I read that it prevents AIDS - doesn't it?

There have been problematic studies in Africa that show that circumcised men contract HIV from HIV positive women at a slower rate than men who have a foreskin. So saying it prevents AIDS is inaccurate; it could slow the uptake, so to speak. (Maybe. The studies were deeply flawed, and stopped early.) If an intact man decides the potentially lessened risk is worth the price of his fully functional and highly innervated foreskin, he can certainly choose to be circumcised as an adult. Most guys would probably opt for condom use over radical amputative surgery - that still requires a condom afterwards!

But, still, it could prevent, uh, something?

Whether there is any true preventative value in amputating the foreskin may never be known, as all of the studies that have ever been done are very ambiguous. What is known is the fact that we don't remove healthy, normal, functional body parts on baby girls, or any other part of baby boys on the off chance it will prevent some nebulous health problem. Presumably if we amputated the toes of newborns we would have far fewer cases of athlete's foot each year, and toe cancer as well. But of course we don't do that - we treat the body if it gets sick, we don't amputate normal bits to prevent possible problems. The foreskin is much the same, and, as the American Academy of Pediatrics has found, the complications and risks of the circumcision procedure outweigh any potential benefits.

It doesn't do any real harm though, beyond the initial healing period.

Assuming you mean other than the harm of removing the foreskin itself, which causes the glans of the penis to become dry and desensitized every time, and the meatus (the opening of the urethra) to scar up and frequently narrow, requiring surgery to fix it about ten percent of the time, yes, it causes harm. It could easily be said that circumcision essentially turns the penis permanently inside out, and it has about the same effect as it would if we cut off eyelids, or nostrils, or lips. Complications are rampant, and include death. Even if circumcisions were free, it would still cost more to circumcise than to leave the penis alone.

OK, so there are no medical reasons, but it's cleaner, isn't it?

It's not cleaner or dirtier to be circumcised or not circumcised. Either way parents should teach their children (of either sex) to wash their genitals the same way they teach them to wash their ears. The foreskin requires no special care.

But I have to keep it clean for him before he's old enough! That sounds complicated!

It's not complicated at all! Here's the three steps to cleaning the intact child too young to attend to his own bathing:

1. Wash the outside of the penis like a finger.
2. Don't try to pull the foreskin back or retract it.
3. The End.

Won't other kids make fun of him?

It's very unlikely, seeing as how only one-third of the boys born in America today are circumcised (33% in 2009, according to the Centers for Disease Control) and worldwide around 85% of men and boys are intact. If anything, he is more likely to be teased if he is circumcised! Besides, kids make fun of lots of things. Best to raise a child to be happy with his normal body, rather than cut healthy parts of it off.

I think the foreskin makes the penis look... weird.

That's mainly because a circumcised penis is what you are used to seeing. We don't carve up other healthy, normal parts of our kids' bodies without their consent because they offend our personal aesthetics - the genitals should be the same.

He'll just want it done when he gets older though.

If men actually preferred being circumcised versus being whole and intact, then most of the men in the world would be circumcised as adults. But the thing is, they aren't, because they don't. Cultures where circumcision is common circumcise sexually immature infants and children, or adolescents on the cusp of puberty - all people who cannot give consent. Now, that said, should your son decide he wants to be circumcised he can be, and the operation is much less traumatic and less prone to complications as an adult with a mobile foreskin and an adult-sized penis.

There has to be a reason why people are doing this then?

Well, really there are many "reasons", but the main reason babies and children are genitally cut in any culture and for either sex is because their parents were genitally cut, and thus think of their altered state as normal. It's crazy when you think about it, but there you have it.

Yeah, what about when the father or older brother is circumcised? Shouldn't they look the same?

There are so many inborn differences between fathers and sons and between brothers. Some will have brown eyes, some will have blue, some will have their mother's nose and their grandfather's hands. A child will never be a carbon copy that looks just like his father and it is silly to insist that the son have cosmetic surgery on his normal penis so it will look like Dad or the child's older brother. What if the father is missing a finger or has scars from an accident or any other surgery? Tattoos? We don't mark the son similarly then! If older brothers are circumcised it's easy to tell the boys that when the older brother was born his penis looked like the younger boy's penis but back then the parents thought it was a good idea to cut off his foreskin (and that they thought that was a good idea when Daddy was born, too, if that's relevant) but now we don't do that anymore. It really is that simple.

It's traditional in my family to circumcise the boys.

In America (unless you're Jewish or Muslim) your "family tradition" is likely about two or three generations old at most and involves your father, possibly his father, and you. The real tradition is to have a whole, normal penis, not one with an amputated foreskin. Newborn circumcision was unknown in the U.S. outside of Jewish families until the beginning of the 20th century, and the circumcision rate peaked in the 1970s at about 90%. It's been dropping ever since, and is now right around 33%. Many Jewish and Muslim families are opting to leave their children intact and let them decide whether they want to be circumcised, as well.

So let me see. No medical reason, in fact it can actually cause more harm... hmm, not any cleaner, and and we don't perform cosmetic surgery on any other normal body parts without consulting the owner of the body... Well gosh. There's really no reason to do it at all!


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