Archive for the ‘phimosis’ Category

Some thoughts on Male Circumcision

November 24, 2011

This is a blog post by Nicholas Fogelson thought would be of interest to my fellow bloggers. Although I am of the Jewish faith and have been circumcised, I thought this was a balanced discussion by fellow physician. I am interested in reading your comments and opinions on this very controversial topic.

One of the interesting things about running a semi-popular blog is that from time to time the blog community decides to take up a topic and run with it, completely without any stimulation from me. This happened recently on the Academic OB/GYN Facebook page, where a group of concerned individuals carried on a serious and passionate discussion about the merits of circumcision. As such discussions tend to be, this one was dominated by the anti-circumcision activists, with occasional interjections by those that were less concerned about the issue, including myself.
Circumcision is an interesting issue because it crosses multiple boundaries. It is a social tradition in many cultures, and in some cases considered a religious mandate. It is also an ethical issue for many, with some feeling that it is an assault on an infant with long term negative impact on their psychosocial health. For some it is just cosmetic.
As a young person, I always thought that my penis looked like penises were supposed to look. It looked like my father’s and my brother’s, and anyone else’s I had ever seen. For the most part, I was blissfully unaware that a penis could look any other way, until one day in high school when my world completely changed. I happened to see a friend’s penis we were showering after wrestling practice, and in that flash of a moment all kinds of things went through my mind. Did he have some kind of growth on his penis? Could he pee out of that thing? A few other choice thoughts. I can still remember the shock to this day. All I had ever seen looked like mine, and in that moment what I saw was foreign, revolting even. You see, from my frame of reference he looked like an alien. It took me a few minutes and SNAP! it came to me like a ton of bricks – he has a foreskin. He probably doesn’t have an alien death ray then. I can relax about that one.

Of course now I realize that I also was born with a foreskin, and at some point in early life had it cut off. Despite what was no doubt a anesthesia free surgical procedure, I have no memory of ever having had a foreskin, or of any trauma of it having been removed. It never occurred to me to miss my foreskin, but apparently others do.
I hear stories from various anti-circumcision activists about how men are traumatized by their lack of foreskin, or even that some use strange devices to try to restore their foreskin in some way. I am struck with these stories, and have one burning question – when did they start missing their foreskin? From the moment they had the capability to store long term memories, they had no foreskin. Being circumcised was their frame of reference; it was their ‘normal’. The only way they could ever ‘miss’ their foreskin would be through some outside influence that convinced them of some new ‘normal’, and that they were somehow incomplete. Some of these men express anger at their parents or doctors for circumcising them as an infant, it seems to me that this anger is misplaced. It would make far more sense for them to be angry at the person who felt the need to drive a message into one’s head they were somehow incomplete, a message without which the feeling of loss never could have occurred.
I also hear stories of how the lack of a foreskin somehow interferes with sexual pleasure. I just don’t understand how this can be verified. I can say that from a personal point of view, everything down there seems to work just fine. I also don’t notice a preponderance of Jews who do not enjoy sex. Anecdote aside, one can only know what one has, and so again, anyone that feels that their sexual pleasure was supposed to be better than what it was got that idea from some other person, not from their personal experience. There’s plenty of people with foreskins that feel like their sexual pleasure was supposed to be better as well.
My biggest question in all of this is just why? Why do people care so much about this? Its really hard to say that an infant is being victimized by the procedure. Their frame of reference is being changed, no doubt, but as that frame is changed so early in their life there will be no sense of loss unless someone feels the need to convince them of it.
One could just as easily ask ‘why circumcise?”. There are plenty of data to suggest that circumcision decreases horizontal transmission of some STDs and the rate of penile cancer, though these effects are small. The anti-circumcision folks like to act like this data doesn’t exist, but this is just their ignorance. When I first thought of writing this blog post I was going to lay all this data out, but as I now write I realize that it doesn’t really matter. Those that believe or don’t care will see the strength in the data, those that are against will call it faulty or corrupt in some way. So goes academia. In the end, circumcision is a cultural practice that is done for cultural reasons, not for medical benefit. In Jewish tradition, circumcision is done as a way of honoring the covenant between God and Abraham, a covenant which commanded that all of Abraham’s sons and male servants, and their descendants, as a mark of allegiance and agreement. Though I have Jewish heritage, I am atheist. Nonetheless, I would feel a cultural desire to circumcise my son when and if I have one.
Some of my comenters, of which there no doubt will be many, will call this stance unethical. To this I say “grow up”. We are hard pressed to find ethical principles on which all humans agree, and this is certainly not one of them. A very large part of this world feels completely fine with male circumcision, and if one doesn’t, they certainly are under no pressure to circumcise their son. This is one of the many things that we don’t all agree on.
Other commenters will say “I’m not against circumcision, I’m against forcing it on newborns.” This is the same as saying that we shouldn’t do ritual circumcision at all. That’s a perfectly fine goal if one is really against the procedure, but just state it that way. Male circumcision is a cultural rite performed on newborns. Its pretty obvious that by 18 years old, very few boys are going to choose to have their foreskins removed. Their frame of reference has already been set, and they are fine with who they are. If we did that, we would be just fine, just as we are with a large part of the population circumcised. A cultural tradition would be lost, but that would also be ok. It just wouldn’t really matter.
Other commenters will say “they are dangerous and cause complications.” This is a half-truth. By in large, they are not very dangerous. That said, like any surgical procedure, there are some small risks. There have even been babies that have died from complications of the procedure. Ultimately, it is very important that anyone doing circumcisions know what they are doing and doesn’t do them wrong.
In truth, its an issue that I don’t care a great deal about, and as such am vexed on why it matters so much to others. Sometimes when someone writes a piece on the net, they are instantly labeled as an activist for that cause. People certainly label me as an activist for delayed cord clamping, which I would deny. I just wrote an article about the topic and lots of people read it. They can make up their own mind. I just wish people would treat this issue the same way. Everyone is free to circumcise their child or not, and the boy will grow up just fine either way.

Bottom Line: Circumcision is probably the most common surgical procedure performed on men for thousands of years. For many boys the decision is made by their parents and is done for religious reasons. For others it is a matter of looking like dad and grandpa and the parents don’t want any differences in the genitals of men in the family. Others have the procedure for hygenic purposes. To circumcise or not may be a difficult decision for those who are not motivated bh religious reasons. I hope this article helps with that decision.

The Circumcision Decision

September 23, 2011

The first concern most men will have about their genital organs occurs right after birth when he undergoes a circumcision….and, unfortunately, the young boy has no part in the decision whether to lop off that precious piece of real estate!

Removal of the foreskin of the penis is one of the oldest surgical procedures known, dating back well over 5000 years. Hieroglyphs picturing ritual circumcision were found in ancient Egypt, and the religious significance of circumcision is described in the Old Testament.

Perhaps because of its long history, circumcision in the U.S. has been generally considered routine surgery. In the mid-1980s, up to 89 percent of newborn males were circumcised in some parts of the U.S.
There are many valid reasons for choosing circumcision, including cultural, religious and ethnic traditions. But in March 1999, the American Academy of Pediatrics (AAP) issued a policy statement that said they no longer recommend routine neonatal circumcision. It stated that although there are some potential medical benefits of newborn male circumcision, those benefits are so slight that they contribute little or nothing to the decision-making process.

So what does this mean for parents-to-be getting ready to make the circumcision decision? Mainly parents are on their own. The AAP does not make any specific recommendation. Parents need to talk with their physician and then carefully weigh the risks versus the benefits of the procedure.

Medical Risks and Benefits

Parents should be assured that the great majority of circumcisions are trouble-free. But circumcision is surgery, and all surgeries run the risk of complications. The most common complications, which occur in only about 1 percent of circumcisions, are: bleeding, which can easily be controlled with pressure, and minor infection, which can be treated with antibiotics.

The medical benefits of circumcision are small. Uncircumcised boys have a higher risk of developing urinary tract infections (UTIs) than circumcised boys, particularly in the first six months of life However, the overall risk of a UTI is still less than 1 percent. Generally, physicians will recommend circumcision for any boy who has two UTIs in the first year of life. A circumcision performed months or years after birth is done surgically under anesthesia, and seems to be associated with fewer complications and less pain and trauma.

Circumcision also has small but measurable benefit in preventing penile cancer, a very rare disease that strikes only about 1 in 100,000 men. Uncircumcised men are three times more likely to develop penile cancer than circumcised men.

Uncircumcised men are also reported to be at greater risk for developing sexually transmitted diseases such as syphilis and HIV infections than circumcised men, but behavioral factors, such as not practicing safe sex, are far more important risk factors.

Overall, the increased risk of developing UTIs, sexually transmitted diseases, or penile cancer is extremely low, regardless of circumcision status.

A Kinder Cut

For those parents who elect to have a circumcision performed on their newborn infant, it is important that the parents select an experienced surgeon to perform the procedure. The AAP recommends that pain relief with a local anesthetic should be used during the procedure. Safe and effective forms of analgesia for circumcision are easily accomplished using a local or topical anesthetic consisting of a gel or cream applied to the foreskin before the procedure. This method has been found to provide adequate pain relief during the 5-10 minute procedure.

Parents considering circumcision should talk with their doctors, and make sure that they are comfortable with whoever will be performing the procedure. Specify in advance what type of anesthesia will be used, and notify the doctor if there are any bleeding disorders in the family.

Parents who choose not to circumcise need to receive instructions on how to care for an uncircumcised penis. The foreskin should never be forced to retract, nor should objects such as swabs or cotton balls be used to clean underneath it. Although most boys will have retractable foreskins by age 3, in some cases, it may take 7 to 10 years. Parents must be patient and allow the process to happen naturally. All boys who are not circumcised need to be instructed on proper hygiene of the foreskin. Failure to do so can result in inflammation of the penis and a foreskin that is even more difficult to retract and clean. Occasionally, this condition, phimosis, or tight foreskin requires a circumcision as an adult.

So if you are considering the “prime cut” for you or your newborn son and have any questions, I suggest you contact your doctor.

Dr. Neil Baum is a urologist and can be reached at 504 891-8454 or on his web site