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Circumcision - A Cut Below

Circumcision has been practised for centuries for religious, cultural and hygienic reasons ... ...but it 's a controversial issue as Lucy Atkins reports

For some people the idea of allowing a scalpel anywhere near their baby's penis is unthinkable. Indeed, 'assault', 'atrocity' and 'abuse' were among the words used in a recent raging debate about male circumcision in a website forum. Some even believe circumcision of newborn boys is a violation of basic human rights.

For countless loving parents, meanwhile, circumcision is a perfectly humane practice, whether performed for religious, health or purely cultural reasons. So what are the facts? Is it healthier and more hygienic to have your son's foreskin removed? Are there ever good medical reasons to do it? Or is it risky, unnecessary and even cruel?

Although it is the norm in the States, where 60 per cent of newborn boys are circumcised, most infant circumcisions in Britain today are done for religious reasons (this is usually called 'non-therapeutic' or ritual circumcision and is an essential part of both Judaism and the Muslim faith). Only about four per cent of boys in England are circumcised for non-religious reasons before their 15th birthday.

If done in a British hospital, infant circumcision is usually performed under local anaesthetic. Older children and adults normally have a general anaesthetic. The operation consists of cutting away the inner and outer layers of foreskin that cover the bulb of the penis and then stitching the edges together. In the UK you can also have your baby circumcised by a GP using the Plastibel technique with topical anaesthetic cream. The foreskin is forcibly separated from the glans of the penis (the knob at the end) and then the blood supply to the foreskin is cut off by a plastic ring. This does not remove as much skin as a surgical circumcision.

Sounds fairly harmless. However, the main medical bodies on both sides of the Atlantic, although they do not object to circumcision for religious reasons, are firmly against the non-therapeutic circumcision of boys. According to the British Medical Association's latest guidelines, published in March 2003, "It is essential that doctors perform male circumcision only where this is demonstrably in the best interests of the child." Because, they say, surgical circumcision has "medical and psychological risks". The American Medical Association's most recent statement, in 2000, backs this up. Existing scientific data, it says, "are not sufficient to recommend routine neonatal circumcision".

Sue Anna Boddy, consultant paediatric urologist at St George's Hospital, London, could not agree more. Religious reasons aside, she says, "There are very few indications for doing circumcisions. Every operation carries risks, but the incidences of infection and bleeding after circumcision are higher than in other operations performed on babies and children." These risks include "inappropriate removal of skin, oozing blood and damage to the opening of the urethra".

The notion that circumcision is just a 'snip' may explain why many new fathers, who themselves are circumcised, want their son 's foreskin removed. For couples, particularly where one has religion on their side, this can cause stress. Katherine, who is not Jewish, is married to Daniel, who is (though non-practising). "His Jewishness suddenly seemed to appear with the birth of a son," she says. "Most of all, he wanted his son to look like him. I didn't want to be anti-Semitic but I was against it. I felt squeamish at the thought of doctors touching my newborn son." As the pregnancy wore on the debate hotted up. "There was some heavy-duty bargaining," says Katherine. "He even said I could have the name I wanted if the baby was circumcised."

Ritual circumcision, performed on newborns under strict conditions, such as the Jewish Bris ceremony, is fine, says Boddy. "Most Rabbis are very skilful," she says. Many other non-therapeutic circumcisions are performed in hospitals. But when an older child is circumcised in unhygienic circumstances (Boddy cites the case of a six-year-old who was to be circumcised "on a kitchen table!"), this is a different matter. The risk of infection or injury is high and the psychological effects may scar a child for life.

For most parents contemplating their son 's circumcision, pain is a concern. Organisations such as Doctors Opposing Circumcision say the procedure is 'painful', 'tragic' and 'contra-indicated'. "No-one has the right to forcibly remove sexual body parts from another individual," says their website. Put the words 'forcibly' and 'sexual' together and you have a clear accusation of abuse. But how painful could the removal of this flap of skin be?

Adult men who have had the operation will confirm that it is no picnic. James, 34, was circumcised a year ago because he had developed scar tissue from a recurrent infection. "I had the operation four days after my second child was born - we honestly thought it would be a little Outpatient's trip. But I had a general anaesthetic and two days later, I bled profusely. There were three comical but awful days where neither my wife nor I could walk. I was in pain for about two weeks and numb for a long time. I was amazed at how major it was."

But is it the same for babies? Teresa, 32, who is British, had her five-day-old son Thomas circumcised using the Plastibel technique, because her circumcised husband felt strongly that it would be more hygienic. She says, "The operation was a total non-event. Thomas was not strapped down; he didn 't cry and fell straight to sleep afterwards. I'd heard some horror stories, and asked a lot of questions beforehand, but it felt totally humane: he was given about three doses of anaesthetic cream then a tiny plastic ring was put over the end of his penis. It took about three days for the ring to drop off and the foreskin came with it."

Boddy says that from a urologist's perspective there is "no physiological difference" (other than size) between the penis of an infant and that of a grown man. "The only difference is that an infant can have better pain relief and will recover more quickly." The Plastibel technique is not necessarily better, she explains: the anaesthetic cream will not really be absorbed, so does little in the way of pain relief. An infant will, however, forget pain more quickly.

According to the American Academy of Pediatrics, there is considerable evidence that newborns who are circumcised without analgesia do experience pain and physiological stress. Studies have shown that a newborn baby's responses to circumcision pain include changes in heart rate, blood pressure, oxygen saturation and cortisol levels. One report also found that circumcised infants react more strongly to pain when they subsequently have their routine immunisations than uncircumcised babies do.

The level of this pain is unclear. Many parents who have their newborns circumcised without anaesthetic in religious ceremonies say, strongly, that any pain is minor and fleeting. Sarah, an Orthodox Jew, has had three infant sons circumcised in a Bris ceremony at her synagogue. "None of them howled when it was done," she says. "They were all happy minutes later. I never saw any of them wince when they peed afterwards, or show any sign of distress once it was over."

The religious and ethical arguments over circumcision are complex - to put it mildly. Is it, for instance, more cruel to leave a Jewish boy uncircumcised when the rest of the males in his community have been? And wouldn't a blanket ban on circumcision deny Jews and Muslims their fundamental right to practise their religion?

But, religion aside, one thing is clear: most of us are woefully ill-informed about penises. The notion that a circumcised penis is easier to clean or more hygienic than an intact one is, says Boddy, "nonsense". Parents do not, she says, ever need to pull their son's foreskin back to clean under it. Indeed, we should all "just leave it alone". She points out that boys (even young boys) touch and manipulate their penises constantly and that although this may embarrass their mothers, it actually helps keep them clean because it "keeps things moving". In other words, the male obsession with touching their parts may actually have an evolutionary use after all.

Many boys, says Boddy, are misdiagnosed with phimosis - a condition in which the foreskin cannot be retracted. "This is actually normal," she explains. "Your son's foreskin may not be fully retractable for up to ten years." Balanitis (an infection under the foreskin) is another reason given for circumcision. If the balanitis causes scar tissue and the foreskin becomes "pathologically phimotic", circumcision may be required. This is, emphasises Boddy, extremely rare.

And frequently misdiagnosed. One recent British Medical Journal study found that up to 6000 English boys a year are having their foreskins removed unnecessarily at a cost to the NHS of ?3 million. Boddy explains: "It is entirely normal for a boy's penis to balloon when he pees. Tightness below the tip is also normal, as are minor infections or occasional redness." None of these requires circumcision.

Furthermore, she explains, a natural substance known as smegma can cluster and swell in 'pearls' under the foreskin. These can look a bit like pus when they emerge. "This is often confused with balanitis," she says, "but can be cured with a bath or possibly some antibiotics." Your doctor may not be aware of this and may refer you to a general surgeon, who may not be aware of it either. If your doctor has diagnosed your son with balanitis or phimosis and says he should be circumcised, you should, Boddy advises, ask to see a paediatric surgeon or urologist before you agree. There is, she adds, "virtually never any medical reason to circumcise a boy under five".

The foreskin is actually quite useful. It keeps the end of the penis moist and preserves sensitivity. Indeed, as any man who has trapped it in his zip will tell you, it contains a rich variety and concentration of specialised nerve receptors. In May 2002, a study in the British Journal Of Urology reported that circumcision appears to result in decreased erectile function and penile sensitivity. Many men who have been circumcised as adults say they notice less sexual pleasure. Some have even tried to have their foreskins restored using plastic surgery.

The male penis, then, is an emotive, confusing subject. Mix in religion and the notion of 'hurting' babies and you have a minefield. The BMA is calling for the Royal College of Paediatrics and Child Health and the British Association of Paediatric Surgeons to produce an information leaflet; meanwhile, specialists such as Boddy spend a lot of time trying to pass on their expertise. So, should you circumcise your son? The answer is simple: unless you have a powerful religious or medical reason to do so, you should leave his penis intact.
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