As featured in the Living and Loving, September 2007, contributions by Joanna Kleovoulou, Clinical Psychologist and Director of PsychMatters Family Therapy Centre

To circumcise or not to circumcise can sometimes be a difficult decision for parents to make. Read on to find out exactly what you need to know about this procedure before making a final decision.

To circumcise or not to circumcise is an easy decision for some parents, but for others it’s quite a baffling one. Many grown men today are quite unhappy that they were circumcised as infants, especially if it wasn’t for medical or religious reasons. Research that the foreskin isn’t just a ‘flap of skin’ as previously believed, but in fact the most sensitive part of the penis, has also come to light in recent years. If you are uncertain about what to do, read all you need to know about the advantages and disadvantages of circumcision and other handy information given below before making a final decision.

The worldwide stance on circumcision

There are many arguments for circumcision, but as with all controversial topics, there are also arguments advising against this practice. Circumcision has been a religious and cultural tradition for thousands of years in many parts of the world. The choice to circumcise is currently largely still driven by cultural preference as it is no longer considered to be a preventative health measure. Medical Associations in most parts of the world including Australia, Canada and America no longer recommend non-therapeutic, routine infant circumcision. The South African Medical Association’s stance on the topic is that there is no medical justification for routine circumcision in babies and children. This statement has lead to doctors refusing to circumcise infant boys unless it is for religious reasons or if there is a valid medical reason for the procedure to be performed. The new Children’s Act in South Africa also protects babies and children under 16 from circumcision without a medical reason.

When is circumcision medically necessary for a child?

Pretoria based General Practitioner Dr Sheraaz Ganchi says medical circumcisions are rarely necessary. “In newborns and even young pre-pubertal boys the foreskin is generally adherent to the glans (head of the penis). As the child gets older, hormonal influences allows the foreskin to become more retractile. Sometimes the foreskin can be very narrow at the tip of the penis which can impede urination or make it painful. This is referred to as a phimosis. A circumcision will thus be necessary to relieve the obstruction.” Ganchi says another reason for medical circumcision in a child would be trauma to the foreskin.

The foreskin is important after all…

Circumcision in simple terms can be described as the removal of the foreskin of the penis through surgery. The foreskin is attached to the glans (the rounded part forming the end of the penis). This loose fold of skin protects the penis from urine, faeces and abrasions from diapers during infancy. Other known functions of the foreskin includes: protective, sensory and sexual.

A study published in April 2007 in the British Journal of Urology International called ‘Fine-touch Pressure Thresholds in the Adult Penis’ discovered that the foreskin actually plays a very integral role in sexual pleasure. The study stated that intact men enjoy four times more penile sensitivity than circumcised men.

The aim of the study was to compare circumcised and non-circumcised men by mapping fine-touch pressure thresholds of the adult penis. 17 Specific sites of fine-touch sensitivity of the penis were measured on the non-circumcised penis and the remaining nine sites and two scar sites of the circumcised penis were measured. Lead researcher Morris Sorrells, MD and the rest of the team were surprised by the results. He said: “The most sensitive part of the penis is the opening at the tip of the foreskin. The results confirmed that the frenulum and ridged band of the inner foreskin are highly erogenous structures that are routinely removed by circumcision, leaving the penis with only one quarter of the fine-touch sensitivity it originally possessed. Five sites on the penis – all regularly removed by circumcision – are more sensitive than the most sensitive site remaining on the circumcised penis.”

If it has to be done, when is the best time?

Ganchi explains that circumcision forms an intricate part of the Muslim and Jewish faiths. He says most families have their children circumcised at birth or within a few weeks following birth. “The procedure can in fact be safely performed immediately after birth even before discharge from a hospital or clinic or it can be electively booked as soon as the parents are willing to have the procedure done. The same applies to medical circumcisions, which should be done at the earliest possible time,” explains Ganchi.

What are the emotional aspects affecting the decision?

Clinical Psychologist and Director of PsychMatters Family Therapy Centre, Bedfordview Joanna Kleovoulou says form a psychological and physiological perspective, all children are born as sexual beings. “It may be difficult to think of your newborn as a sexual creature, however, sexuality already begins in utero as studies have shown that male foetuses can experience erections in utero. An aspect of self can be identified with a body part, as masculinity is typically identified with the penis. When that part is wounded there is often a corresponding psychological wound to the self and a loss of esteem.” She adds that low self-esteem often evokes feelings of shame which isolates us from others and from ourselves. Kleovoulou says parents therefore need to acknowledge that part of their children’s development and deciding to circumcise needs to be taken into account.

She says long-term psychological effects associated with circumcision can be difficult to establish because the consequences of early trauma are rarely recognisable to the person who experience the trauma. “However, lack of awareness does not necessarily mean that there has been no impact on thinking, feeling, attitude, behaviour and functioning which are often closely connected. In this way, an early trauma can alter a whole life, whether or not the trauma is consciously remembered.” Kleovoulou says awareness about circumcision is changing and investigation of the psychological and social effects of circumcision opens a valuable new area to investigate. “The question parents need to ask is, “do the reasons to circumcise outweigh the potential risks?” She says much more research is needed before we can fully understand the psychological and social consequences of this life event.

The pro’s and cons of circumcision

Advantages:

  • It is much easier to maintain better hygiene on a circumcised penis than an uncircumcised one as bacteria and fungi tend to harbour under the foreskin.
  • A decreased risk of penile cancer.

Disadvantages:

Ganchi says if circumcisions are done in a hospital or medical practice by trained practitioners, the complication rate is as low as 2%. He says the most common problem of this procedure would be bleeding post circumcision. “This rarely results in death and can be adequately managed. Infection in theory is possible, but is almost nil in such a setting.” He says although pain is experienced, adequate anaesthesia, which, can last up to 8 hours and analgesics are extremely effective. Another disadvantage of circumcision is when too much foreskin is removed, the individual may experience painful erections and skin grafting may then be necessary. If too little foreskin is removed, a re-circumcision may be needed.

Says Ganchi: “In recent years traditional circumcisions have evoked serious debates. Many initiates go through this puberty rite, marking the boy’s passage to adulthood during the winter months in South Africa and other neighbouring countries. Unfortunately, severe bleeding, sepsis, risk of HIV infection and Hepatitis B due to the use of non sterile blades, penile amputations and even deaths have been reported.” He adds that the combination of a medical male circumcision together with traditional initiation will minimise morbidity and adverse effects and they will also need to be explored further as these deaths are entirely preventable.

Caring for an intact penis

Ganchi says usually no special care is required for a newborn apart from normal bathing with soap and water. He says no cotton buts should be used to clean beneath the foreskin. “The foreskin should not be retracted at all as it is adherent to the glans and such a movement may cause pain, bleeding, infection, scarring and adhesions of the foreskin. A cheesy substance called smegma lies under the foreskin of babies and pre-pubertal boys which acts as a lubricant. From the age of 5-years-old and in some boys even at adolescence, hormonal influences allow the foreskin to become loose and retractile. At this point the skin can be safely retracted and washed with soap and water during bathing,” explains Ganchi.

Does circumcision prevent HIV transmission?
According to a pamphlet on the National Organization of Circumcision Information Resource Centres website, www.nocirc.org, circumcision cannot prevent the spread of HIV. The pamphlet states that anyone who engages in high-risk behaviour, such as multiple sex partners, failure to use condoms and contaminated needles, is in danger of contracting HIV and other sexually transmitted diseases, whether circumcised or intact. Although there were studies that reported that fewer circumcised men contracted HIV than intact men, both circumcised and intact males contracted HIV during the course of the studies. Numerous studies have been performed around this topic and have shown a variety of results. “Some found higher rates of HIV in non-circumcised populations, while others either found the opposite to be true or found no difference between circumcised and intact males. One recently published study found that Langerhans’ cells, which are prominent in the foreskin, actually help to protect against HIV.”

Circumcision should not be promoted as an HIV prevention strategy as this can provide a false sense of safety and can place sexually active men and women at an increased risk.

Bradley Kieser shares his story …

I was circumcised because my parents were devout Christians. Religion came above respect for me as an individual or a future sexual adult.
I have very early memories of the pain of my penis rubbed raw on nappies and underwear before it “toughened up” (lost sensitivity).

I first became aware that I was “different” physically at a very young age. My best friend was intact. In horror we showed our different penises to his mother. She sensitively explained that some boys were cut. I felt embarrassed and hurt.

The exposed glans of a circumcised penis is interpreted by the brain’s wiring as being aroused. Constantly. This created problems for me as a pubescent and teenage boy. Moreover, as I approached puberty my cut penis had “flashbacks”, often extremely painful. Many years later I learned that a normal penis undergoes foreskin changes at that time. Amputees have similar. The worst effect of being circumcised came in married life. The accelerated loss of sensitivity over time has affected both me and my wife. There is a reason why Viagra sales directly match circumcision rates globally!

I have paid a lifelong, increasing price for my parents’ ignorance. It cannot be undone.

www.nocirc.org

www.nocirc-sa.co.za

www.circinfosite.com

www.cirp.org

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