To circumcise or not

Last updated 16:47 28/03/2008

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Thirty years ago circumcision was commonplace - a short, sharp procedure which 10 percent of Kiwi males still undergo today. But critics of the practice claim that this first cut is the unkindest of all. Felicity Monk reports.

 

Josh O'Sullivan will never remember what life was like with a foreskin.

Last year, when he was three weeks old, his dad Ryan took him to be circumcised. "Dad was done,
I was done, and I was happy with that and I just think it is cleaner," says O'Sullivan. The circumcision was performed at an Auckland medical centre and cost around $500. Although he wasn't doing it for specific medical or cultural reasons, O'Sullivan felt very strongly about the importance of the procedure. "Even if my wife had said ‘no', I would have still done it."

The medical profession, he says, weren't encouraging. "The midwife sort of frowned upon it, but she let it go, and even the doctor who performed the circumcision, he tells you the pros and cons of the whole deal and it's almost like they are trying to talk you out of it." He says it was hard seeing his son in pain, but Josh is just fine now. "All my mates are like ‘good on you mate, good on you for doing it'. I know a few people who haven't had their kids done. I don't know if it's that they are lazy or don't want to pay the money. I've never seen a guy in a rugby changing room clean his foreskin after a game of rugby, you know? Even though you can tell a kid to wash under his foreskin are they going to do it? I don't know."

O'Sullivan is Pakeha, not Polynesian, Jewish or Muslim, which is increasingly rare among parents who have their boys circumcised and it's likely there could be more O'Sullivans if those in the medical profession weren't so discouraging.

When Louise Mattheson's* son Michael* was born a month ago, she and her husband were adamant they would have him circumcised. It was, as Louise puts it, "for social niceties". In her generation, most of her male friends were circumcised, her father and brothers too. "it didn't occur to me not to have it done," says the 35-year-old. But after speaking with two GPs, a paediatrician and an obstetrician, Louise and her husband have changed their minds. "We talked to more and more people and they all said: ‘No one's getting it done now.' That kind of changed things. I said to my husband, ‘Well, you are done and I want him to be like you,' but he said it was more important that Michael fits in with his peers." Louise did not want to be identified for this story. She says that when she told other parents in her social group they were planning to have their son circumcised, the response was overwhelmingly negative. "It's just not discussed at all. If you do raise it you are looked at as absolutely barbaric; they are horrified you would even consider it."

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But that attitude is relatively new - 95 percent of New Zealand boy babies were circumcised in the middle of last century and despite growing concerns about its ramifications, 10 percent still are today.

The foreskin debate has raged on for years the world over. On the one hand there are those who claim male circumcision is a matter of hygiene, a necessary preventative health measure, a religious rite that has been practised for thousands of years (it is a religious commandment in both Judaism and Islam). On the other hand there are those who argue it is a barbaric, antiquated practice on par with female genital mutilation, and, with the exception of a few medical conditions, should be outlawed.

Anti-circumcision campaigners, many of whom refer to themselves as ‘Intactivists' and members of the ‘genital integrity movement', are growing in number and volume. They belong to pressure groups with catchy acronyms: Brothers United For Future Foreskins (BUFF), National Organisation of Restoring Men (NORM, originally known as Recover a Penis or RECAP) and the National Organisation of Circumcision Information Resource Centres (NOCIRC); and they provide forums where men can pine freely for the part of them lost forever. Many of their members are men who feel their circumcisions have left them physically scarred and sexually disadvantaged and are finding ways to "feel whole again". Salvation for some comes in the unlikely form of the TLC Tugger; its motto: "Improving the world, one penis at a time." Looking not unlike a torture device, it involves a miniature silicone lampshade, an elastic band and a knee brace and it does what its name suggests; tugs the existing shaft skin forward so the head of the penis will have more coverage and resemble what it might have looked like had it been left intact.

"It's just gone bananas," says Dr Percy Pease, a paediatric surgeon at Ascot Integrated Hospital in Auckland. Pease says there are some people becoming "absolutely paranoid" about circumcision, and cites examples in the United States where men are taking their parents to court for having circumcised them as infants. "I personally don't believe in circumcision - my own son has not been circumcised - but people have their beliefs and it is their right." Pease says he circumcises about half a dozen boys a year and most are for valid medical reasons, although he does perform circumcision for cultural and religious reasons when asked. "I will happily do it because I know I can do it properly. I have seen so many botched circumcisions over the years; mostly too much skin is taken off and that is a disaster."

Complication rates of neonatal circumcision are reported to range anywhere between 0.5 and five percent, and include local infection, bleeding and damage to the penis, with worst case scenario resulting in death. In New York, between 2003 and 2004, three infants circumcised by the same ‘mohel' in a traditional ritual practised by some Hasidic Jews called oral suction (after removing the foreskin the mohel cleans the wound by sucking the blood from it), contracted neonatal herpes. One of the infants subsequently died. Last year, in London, an eight-day-old baby suffered a heart attack and died after he was circumcised in a synagogue.

Quite aside from the risks of the operation, circumcision, it is claimed, reduces sexual pleasure. The foreskin is designed to protect the penis, to ease penetration and to stimulate friction and thus arousal. It has its own lubrication and sensory nerve endings said to be equivalent in sensitivity to the fingertip. With circumcision, around 60 percent of the foreskin is removed, and what remains is a very simple system of free nerve endings equivalent in sensitivity to the heel of the foot. Women have a vested interest too. Studies have shown that they are more likely to experience orgasm if their partner has a foreskin.

Champions of the foreskin are emerging from unexpected quarters. Jews Against Circumcision, led by Rabbi Moses Maimonides, are "a group of educated and enlightened Jews who realise that the barbaric, primitive, torturous and mutilating practice of circumcision has no place in modern Judaism", states its website. In the United States there is a small but growing trend of Jewish families who, instead of having a bris, a religious ceremony in which a boy's foreskin is removed at eight days old, are opting for a brit shalom; a cut-free ceremony.

Doctors Opposing Circumcision (DOC) is an organisation of physicians who disagree with non-therapeutic neonatal circumcision and "recognise that no one has the right to forcibly remove sexual body parts from another individual".

In 2001 the Swedish parliament passed a groundbreaking new law aimed at addressing Sweden's burgeoning Muslim population. It was in response to concern over the number of disfigured infants turning up at hospital emergency wards after botched backyard operations. Now in Sweden, circumcision can only be performed by a registered doctor or nurse and adequate pain relief must be provided. After the first two months of life circumcisions can only be carried out by a physician. (Swedish Jews and Muslims objected to the law, and in 2001, the World Jewish Congress stated that it was "the first legal restriction on Jewish religious practice in Europe since the Nazi era".)

In New Zealand circumcision can be legally performed by any registered medical practitioner; however there are those who believe it should only be carried out by a physician using both general and local anaesthetic.

"This operation is not clean and sweet, I tell you," says Auckland University of Technology senior lecturer in pathology Ken McGrath. He believes child circumcision contravenes basic human rights.

"New Zealand is a signatory to all of the international conventions through the United Nations. We have signed the Universal Declaration of Human Rights which says that every individual - of any age - has a right to bodily integrity. We are also a signatory to the International Convention on the Rights of a Child, which says that children should not be subjected to any harmful or torturous procedures that are unnecessary.

"I saw [circumcisions performed] in my early training years and it sickened me; it is a hack and slash job, there is blood everywhere. I don't know if you have ever looked at it closely, but no two men are ever alike because no one can predict how it will turn out. And it looks like the penis has been attacked with pinking shears; it is very rare to find a neat job. There are far more complications as a result of the surgery than there are in just leaving kids alone."

Retired Auckland gynaecologist John Thomson reckons he's circumcised some 6000 babies in his time. He used to use a local anaesthetic and recommended parents bring in their newborns as soon as they could. "I simply used to do it because people wanted it. But I now fully believe, from a medical point of view, that there is no detriment [in circumcision] or very, very rarely any detriment, but the medical benefits are tremendous long term."

The Paediatric Society of New Zealand's position is that there is no medical reason for routine male circumcision. But the medical fraternity is as divided in New Zealand as it is elsewhere. Those who advocate it say it is medical negligence not to do it and refer to studies that have shown circumcision can help prevent phimosis (a condition whereby the foreskin is unable to be retracted due to scarring and contraction), urinary tract infections, penile cancer, prostate cancer, cervical cancer in women (due to the transmission of the HPV virus) and sexually transmitted diseases and HIV in males. Recently three trials carried out in Africa found that male circumcision provided a 50 to 60 percent reduction in heterosexual HIV transmission. In March last year the World Health Organisation and UNAIDS recommended that male circumcision should now be recognised as an efficacious intervention to prevent HIV (but emphasised that it does not provide complete protection against the virus).

Many in the health profession have since claimed that these trials were deeply flawed, having been terminated too early for all the incidents of infection to be documented. Many cultural factors were not taken into consideration, says McGrath, such as the practice of ‘dry sex', which is common in sub-Saharan Africa. This is where women place drying agents (anything from herbs, dry soil, shredded newspapers to cotton, salt and detergents) in their vaginal canal to absorb lubrication. Dry vaginas are seen as desirable, as is the increased friction during sex, particularly for circumcised men (and women) who may find it harder to feel stimulated. But the lack of lubricant can result in abrasions in the delicate membrane tissue, making it easier for the HIV virus to enter.

"I predict in 10 years' time this will turn out to be a tragedy because you can guess what's going to happen," says McGrath. "The young fellas in Africa are going to say, ‘All I have to do is go down to the doctor and have the end trimmed and I don't have to worry about condoms or precautions any more.' Some people are predicting a marked surge in infections as a result of this. I think it is very immoral, the whole thing."

No one seems quite sure how and when the practice of ritual circumcision came about, and depending on who you're asking, it was a ceremonial sacrificial act to the gods, a mark of tribal identification, a rite of passage, or a means of humiliating and marking defeated enemies and slaves.

In the late 19th century Victorian doctors discovered that prescribing circumcision as a cure for everything short of a runny nose conveniently sated their moral hysteria. Heaven forbid a little boy touched his bits. They began advocating for mass infant male circumcision to cure or prevent, among other things, paralysis, insanity, epilepsy, tuberculosis, dislocated hips, club foot, crossed eyes and masturbation. John Harvey Kellogg, the American doctor who invented Corn Flakes and who should have probably stuck to cereal, was a big fan of the masturbation theory, writing: "The operation should be performed by a surgeon without administering an anaesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment."

At that point circumcision was rare in New Zealand. Interestingly, it doesn't appear to have been practised by Maori once they arrived in Aotearoa. In fact, among pre-European Maori, an exposed gland was considered a source of shame and ridicule.

But with World War I, New Zealand leapt on the circumcision bandwagon. In an article titled A Review of Circumcision in New Zealand, McGrath writes: "No other country has embraced near-universal neonatal circumcision more quickly or so completely, nor has any other country (apart from Britain, which never reached the same rate) dispensed with the practice just as suddenly, largely within one generation."

Major wars are often accompanied by rocketing STD rates and it's thought that circumcision gained momentum during World War I when the army medical branches decided that hygiene was an answer to the problem. The foreskin was viewed as a veritable Petri dish of bacteria and its removal was seen as a way of getting a soldier healthy enough to return to battle, while also reducing his sexual capacity and therefore risk of re-infection. It was during World War II that we embraced the procedure with fervour. By 1942 about 95 percent of all baby boys were circumcised; the procedure was performed almost without question from any parties involved.

In the 1960s medical practitioners had begun to suggest it was best to just leave a baby and his foreskin in peace. Many avoided mentioning the subject to parents, thinking that if they didn't bring it up, the parents wouldn't either. But our mums and dads were a stubborn lot. Many still believed circumcision was essential for hygiene and they wanted their sons to look like their fathers and brothers.

Christchurch Hospital's paediatric surgeon and paediatric urologist Spencer Beasely's advice to parents considering a circumcision for their son is this: be fully informed and aware of the advantages and disadvantages of the procedure, and if you proceed, the circumcision should be done by a competent surgeon, in a safe environment and with adequate analgesia. "Usually" he says "this means in an operating theatre, with general anaesthesia and local anaesthesia."

That's not quite how it played out for John when he was circumcised as an eight-year-old in Auckland in the early 90s. John, who is Tongan, was informed one morning by his mum and dad that today he was to be circumcised; their church had just called up inviting families with uncircumcised sons to have the procedure done. He was taken, along with some of his cousins, to a house in Ponsonby where a Tongan doctor was performing the procedure.

"We were in there lining up and waiting for our turn and you are watching another guy getting it done and it's like ‘oh shit'," says the now 25-year-old. "They just lie you down and try to calm you and talk to you." John says none of them were given any kind of pain relief, but they did get a lolly. The procedure was performed using a scalpel and was "painful but over pretty quick". Then the parents were instructed to take their newly circumcised sons to the beach for salt-water swims in the days following.

"My uncle took me under the Harbour Bridge, and I was a bit scared of swimming because of the sharks. I was going ‘oh jeez; with my thing cut off and whatnot, it's a good way of attracting them... ‘I still hang out with my cousins a lot and we have the odd times when we sit around and laugh about how we all got circumcised that day." If John has sons he says he will have them circumcised too.

Currently, circumcision on social, cultural or religious grounds is unavailable through the New Zealand public health system, but it is performed privately by some doctors for as little as $180. The price depends on the method and the type of anaesthetic used. Last year 321 Southern Cross members claimed for circumcisions; the average cost was $2339. Which is why Massey's Director Pasifika Professor Sitaleki Finau is pushing for circumcision to become publicly funded.

Talking on the phone from Niue, where he has been seconded as the Director of Health for two years, Finau says circumcision has health benefits for men and women and is considered a rite of passage, usually carried out on boys between the ages of seven and 15. But the Ministry of Health says that's not going to be happening any time soon. "The Ministry of Health does not support public funding for provision of circumcision for non-medical reasons," is the response of Dr Pat Tuohy, Chief Adviser, Child Youth and Health.

Says McGrath: "We spent 50 years turning it [circumcision] off and we don't want to see that sort of nonsense again."

 

A PRACTICE IN DECLINE

 

Today, it is estimated that between 25 and 30 percent of boys born worldwide each year are circumcised. The procedure is most common in the Middle East, the US and parts of Africa and Asia.

Global circumcision rates, on the whole, appear to be in decline. In the United States more boys are circumcised without specific medical or religious reasons than in any other country. In 2005 about 60 percent of US-born males were circumcised.

In Latin America and many parts of Asia the procedure is rare. In Australia some 15 percent of boys born each year are circumcised, in the UK it's about five percent and in Scandinavia it's less than two percent.

 

- Sunday Star Times

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