Issue 1 / 17 January 2011

MEDIEVAL churches used to engage in vigorous argument over which of them owned the “authentic” foreskin of the circumcised Jesus Christ, the only part of him believed not to have ascended bodily to heaven after the resurrection.

At one point, as many as 18 churches are supposed to have asserted theirs was the genuine holy prepuce, with no clear winner ever established.

Catherine of Siena even claimed in the 14th century to be wearing the foreskin on her finger as a ring given to her by Jesus when he made her his bride, though apparently nobody else could see it.

It seems the ability of foreskins to cause trouble has not waned over the centuries as this week’s MJA clearly demonstrates.

An editorial published by the journal last year advocating infant circumcision as a preventive health measure, particularly for later protection against heterosexual transmission of HIV, caused a storm of protest among letter writers.

Non-therapeutic infant circumcision could be seen as “tantamount to criminal assault”, says one of the letters published in the Journal’s Matters Arising this week, while another describes it as “a highly mutilating operation which seriously impairs penile function”.

It’s citations at 10 paces, as the letter writers and authors of the original paper launch research claims at each other in an attempt to prove their positions.

Pity the poor parents of a newborn son trying to make sense of it all.

Could early circumcision help prevent him from later exposure to HIV or are the findings only valid for African men circumcised in adulthood?

Might his circumcision actually increase the risk of transmission to his female partners if he was unfortunate enough to contract the virus?

And would the hapless parents be dooming him to a life of dulled sensation and impaired sexual performance if they went ahead?

It seems whenever penises are involved, it doesn’t take long for things to get heated and claims to become, well, a tad exaggerated.

Clearly, there is an argument against removal of any healthy tissue in the absence of a medical indication, particularly in a minor who is incapable of consent.

Cultural factors aside, there might also be an argument in the other direction if public health benefits could be demonstrated and if delaying the procedure until the patient was capable of consent was associated with a clear reduction in benefit or increase in risk.

But the intemperate nature of the arguments made by some in both the pro- and anti-circumcision lobbies doesn’t really do anybody any favours.

I suspect few circumcised men would welcome suggestions they had a “mutilated penis”, and most would probably respond to any suggestion that their sexual function was impaired with: “Nothing wrong in that department, thanks very much”.

The Catholic Church eventually became so frustrated with the arguments over the holy foreskin that last century it apparently decreed any further discussion of the elusive scrap of tissue would lead to excommunication.

Medical debate is not so easy to silence ― and nor should it be ― but it might be in everybody’s interest if we could rein in the rhetoric and discuss a complex issue in less emotive terms.

Jane McCredie is a Sydney-based science and medicine writer. She has worked for Melbourne’s The Age and contributed to publications including the BMJ, The Australian and the Sydney Morning Herald. She is also a former news and features editor with Australian Doctor. Her book, Making girls and boys: inside the science of sex, will be published by UNSW Press next month.

Posted 17 January 2011

25 thoughts on “Jane McCredie: Cut the rhetoric

  1. Tom Ruut says:

    I don’t want to go off “half cocked” on this issue but remember the experiences of two men, both doctors, who stated categorically that sex was more enjoyable before circumcision.They were both circumcised as sexually active adults.

  2. Dr Zdenek Srna says:

    Unless done for a clear medical pathology, circumcision is a form of iatrogenic disfigurement rationalized by religious pseudo-arguments and by penis envy driven feminazi agendas included. You want to circumcise as a routine – do it on girls as well.

  3. Anonymous says:

    The ‘Almighty God’ instructed His people to perform the
    procedure on All males born under ‘His umbrella’ (yes…as
    a ritual) on the eighth day of life…..
    Now if you believe this would be detrimental in any way to the well-being of the individual……..
    My reply to anyone…….GET REAL !!!
    ” Rob the Physician ” FRCS,FRACS

  4. Peter Arnold says:

    There are too many factually misinformed opinions, accompanied by strong emotions, in the usual discussion of this subject. Let’s look at some facts:
    1. We Jews have been circumcising, at the age of 8 days, for millennia. We would not have continued this practice if our baby boys had died or been seriously injured.
    2. At 8 days of age and sucking the traditional wine-soaked cloth, the infant yells for about 5-10 seconds.
    3. We adults all know the momentary pain of a slice with a razor blade – it’s over in seconds.
    4. At 8 days of age, no medical anaesthesia is needed, neither local nor general.
    5. At 8 days of age, the complication rate, after ritual circumcision, is minimal.
    6. At a later age, months or years, circumcision is painful – as Nelson Mandela has attested.
    7. At a later age, anaesthesia is desirable, but, if general, carries its own risks.
    8. So few sexually experienced adult men have undergone circumcision, that any critic’s assumption of impaired sexual function or sensation is conjectural.
    9. No valid medical comparison can be made between male circumcision and female genital excision.
    As for the legal side, while I look forward to comments by members of that profession, I offer the following ‘bush lawyer’s opinion’:
    1. Parents are the legal guardians of a newborn – it is they who have legal authority, not the baby.
    2. If parents act in what they consider the baby’s best interests, as they do when choosing its food or clothing, and they do no short- or long-term harm, the baby has no later grounds for complaint.
    3. Society’s warrant for interfering in child-rearing practices is restricted to serious child abuse, and as DOCS well knows, is difficult to justify and implement.
    4. To bring infant circumcision into this domain demeans the serious challenges faced by DOCS.
    5. To postpone circumcision on the grounds that the child must have reached the age of consent is to expose the child to either the childhood and adult risks associated with the uncircumcised state (whatever those risks are) or to the risks associated with general anaesthesia.
    I look forward to comments by Muslim colleagues on the facts relating to circumcision at ages later than 8 days.

  5. Pete B says:

    Following on from the comment above, which is something I have deduced from patient feed-back as well, it is not too hard to understand why that might be, when one compares the sensitivity of exterior cornified squamous epithelium with what is essentially a mucus epithelium under an intact prepuce. Another strong impression I have gained, both from GP and working in a mens’ health clinic, and this relates to the same issue I think, is that there is a greater representation of those who suffer premature ejaculation in the circumcised group. Which is initially a surprise, but when one considers that with the result of the loss of mental distraction from local sensation, the ejaculatory drive then becomes more a mental thing, and the mind tends to be ahead of the body…..?

  6. woolly93 says:

    Barbaric practice. The are much better ways to prevent HIV…

  7. Vikki says:

    Clearly debate remains emotive on this issue, especially when religion becomes involved. Circumcision may have been appropriate in cultures where personal hygiene was restricted by of lack of water. Attributing it to God’s instruction may have ensured compliance, however it also ensured that in some religions and cultures it became a ritual which prevailed long after its original purpose ceased to exist. I believe that, without medical indication, circumcision should no longer be practised. If a male wishes to undergo the procedure once he is able to give informed consent it should be classed as cosmetic surgery and the client charged accordingly. Dr Srna’s comparison with female circumcision is totally inappropriate. Female circumcision served no purpose other than to decrease a woman’s sexual pleasure and reduce the risk of a man’s ‘female property’ straying. An example of men manipulating religion to their own ends, it is totally barbaric and was NEVER justifiable. Paradoxically both male and female circumcision are often sought by the mother of the child.

  8. Anonymous says:

    Circumcision by the medical profession should be limited to:
    1. infant with severe phimosis and associated complications (obstructive s/s, infection, pain etc). This should be paid by Medicare.
    2. Parent wished their infant or teenage son circumcised for religious reasons should be done by a rabbi/mullah, and not by a doctor.
    3. Parents who want their son circumcised for other reasons should bear the costs, like breast enhancement for cosmetic reasons, and risk the blame of their son in the future.
    There is little evidence to prove any significant medical benefit for the infant who has no say in the procdure. And this is not fair to the kid.

    When religion, wishful thinking, and commercialism is involved, this will deinitely be confusing to everyone, except for the infant.

    What has sex got to do with it anyway?

  9. Robert Loblay says:

    Twenty eight years ago I watched my nephew have the traditional day 8 circumcision. He screamed inconsolably for what seemed like an hour. It was barbaric. We decided that rather than having our own son circumcised we would opt for teaching him about proper hygiene and safe sex. Now that he is grown up, notwithstanding what we now know about HIV, we are happy with our decision.

  10. Vikki says:

    I agree with woolly93. Education re sexual practices and personal hygiene and unrestricted availability of condoms would be far more appropriate than circumcision. The Catholic Church’s stand on the use of condoms is unconscionable. Religions of all hues have much to answer for.

  11. Dr ARC says:

    I agree 100% with Dr. Peter Arnold’s comments. My experience some years ago with an adult patient who requested a circumcision was that his sensation during intercourse, after his surgery was heightened, not diminished.
    The incidence of penile carcinoma in the circumcised Jewish population is incredibly low compared with the uncircumcised gentile population.
    I also remember as a medical student, having to catheterise an uncircumcised patient and removing copious, foul smelling smegma from the penis was very unpleasant indeed.
    For my money, circumcision is the only way to go!
    One further aspect to consider is the aesthetic appearance of the circumcised penis. I know which I prefer!

  12. Bruni Brewin says:

    I am with woolly93. We are supposed to move forward in life from the past. Science has considerable proof that ‘The Dark Ages’ came about by a natural climatic phenomena. However, the superstitious thinking of the day was that it was punishment for the decadent ways of the people.
    Even religion is/was not safe from those that profess to be its custodians. It was the thinking of the day and how easy to say ‘a higher deity’ professed it should be so. End of argument – who dare to question such authority?
    It makes a mockery of the need to have ‘evidence proof’ in so many other areas of our life, yet that everything handed down or written was indeed was undisputable.
    Instead we rely on ‘faith’ and take things for granted to be the indisputable ‘truth’ despite perhaps many interpretations differentiating the meanings. Whose truth? We could accept that many things written so long ago were perhaps the thinking of the day and with our modern knowledge interpret what we can make sense of that is still valid today.
    As Jane McCredie put so well: Cut the rhetoric.

  13. Anonymous says:

    I was circumcised in infancy and have no recollection of it. In due course I married and fathered 4 boys, all of whom were circumcised, without any ill effects. My sex life was enjoyable and, so far as I am aware, so is theirs. No genitourinary tract infections have occurred in any of them (or me). Grandchildren continue to arrive. The anti circumcision campaign, like so many 20th century fads, is so much politically correct nonsense.

  14. beryl shaw says:

    I have two sons, both now adult. One had too much skin removed at circumcision, leaving him with problems in his adult life – at one point he was reading to find out if the remaining skin could indeed be stretched.
    The younger one bled after his circumcision – in hospital – only noticed by me when he was brought for a feed and the blood had already soaked right through a toweling nappy. I only found out weeks later that the surgeon had been called to suture the wound – and that indeed, he could have bled to death if I hadn’t found it. That silence was also abuse, in my mind. How dare they not report it to his parents?
    And I believe this idea of uncircumcised men being open to infection is nonsense. My exhusband was uncircumcised and extremely careless about cleanliness, but never had any infection as a result.
    Yes, I believe circumcision is mutilation – we wouldn’t remove girls’ breasts – or boys’ testes at birth because of the proven number of cancers in these organs.

  15. Richard says:

    Anything proposed as a medical intervention has to pass the test that the benefit conferred outweighs the harm (and usually we like the outweighing to be substantial.)
    As far as benefit is concerned, the most that the proponents of circumcision can claim is that it reduces the transmission rate of HIV. That is, the risk of transmission from a single episode of unprotected sex is less than for an uncircumcised man. This is nothing like the protection conferred by most viral vaccines, and unanswered is the question of whether circumcised men, believing themselves to be protected, are more likely to have multiple partners and practice unprotected sex, so voiding what limited protection they do have.
    On the harm side of the balance, the proponents of circumcision are guilty at the very least of a failure to recognise that acceptance or rejection of circumcision is rooted in culture. In societies which have traditionally practiced circumcision, it is seen as a “normal” thing to do, and the result as aesthetically pleasing. In societies which do not, it is seen as a bizarre tribal mutilation on a par with facial scarification or lip plugs, and the result as disfiguring.
    A highly effective way to eliminate male breast cancer would be routine neonatal removal of male breast tissue. There would be no loss of function. Whey don’t we do it?
    To those who have claimed the circumcised penis to be more attractive, I would ask: “Why did Michelangelo sculpt David with an uncircumcised penis?”

  16. Gavin says:

    Can HIV spread in a monogamous society?

  17. Dr Mike - Darwin says:

    People of the Middle East clearly determined that circumcision was beneficial to long lasting health in baby boys. The Middle East was a desert place, with little water for washing, soap only for the rich. So sand would irritate the uncircumcised. And also phymosis and paraphymosis would have been a possible death sentence if infection occured. These conditions no longer exist — But HIV does, and even in Australia several cultures require circumcision. Better done medically than out “bush”. Mike.

  18. Ronald Brett McCoy says:

    I went to read the letter published this week at MJA and it’s a subscriber only, unlike the original editorial which is freely available. Hardly fair in terms of presenting balanced views. Sort of makes this editorial a bit useless if you can’t read both of them.
    Ronald McCoy

  19. Schmuck says:

    If having a foreskin is deleterious to health, why has natural selection not eliminated it? The supposed health benefits of circumcision are facile rationalisations of a practice grounded in superstition, not science. By all means allow adults capable of giving informed consent to have themselves circumcised, but don’t inflict on infants something which some will grow up to resent as a mutilation, or as a mark of adherence to beliefs they do not share.

  20. Richard says:

    “Rhetoric,” in the words of the literary critic Ivor Richards, “is the study of misunderstandings and their remedies.”
    Judging by the comments on this blog, there is plenty of misunderstanding, and a need for more, not less, rhetoric!
    In my humble opinion the main source of this misunderstanding is a failure to recognise the centrality of the penis to self image, and to tribal identity. The decision to circumcise is not, save in a tiny proportion of cases, a medical one, but is cultural or religious.

  21. Peter Elliott says:

    Well, circumscion was devoloped by people living in a sandy, sweaty and humid enviroment – just like Surfers Paradise main beach – to protect against balanitis. It works well, and having seen the misery that balanitis can cause, circumscion gets my vote.

  22. Dr Attila Danko says:

    “It seems whenever penises are involved, it doesn’t take long for things to get heated and claims to become, well, a tad exaggerated.”
    Actually, it seems whenever vaginas are discussed the hysteria becomes far stronger, as witnessed by the recent furore about making a ritual nick as a low harm alternative to female circumcision in communities where that is the culture. Vaginas have far more protection in law.
    The fact that any form of female genital mutilation, no matter how mild and preserving of the clitoris, is specifically proscribed by law when male genital mutilation is not, shows where the hysteria and hypocrisy is on this issue.
    Male and female circumcisions are mutilations without consent. Both are done for primarily cultural reasons. Both have unacceptable risks of mortality and morbidity. There are even studies that show reductions in HIV with female genital mutilation!
    I cannot believe we still have people who push genital mutilation of any sort because of their cultural beliefs, dressed up and justified by studies done with in Africa where the results were likely to support their perverse cause.
    Bear in mind that the real world results even in a high prevalence area like Africa are likely to be not quite as positive when the well supplied Western doctors funded by the circumcisionists have gone home and the operation is performed with less than perfect resources.
    When you are defending the human right not to be mutilated, whether you are male or female, it is not surprising that people feel, well, a little heated.

  23. Unemotiveman says:

    Fair call, Jane.
    I like your own value-free assessment:
    “Clearly, there is an argument against removal of any healthy tissue in the absence of a medical indication, particularly in a minor who is incapable of consent.”
    Good argument.
    Ban unnecessary genital surgery for all Aussie kids without discrimination.

  24. Sue Ieraci says:

    You seem to be right, Jane. Your call to “cut the rhetoric” has resulted in – well – rhetoric….

  25. anon says:

    I never knew that so many men were so obsessed by foreskins (or absence of them, or whatever).

    If studies of circumcision and HIV transmission in Subsaharan African men really do apply to Australian populations (and that’s a big IF), I am still struggling with the view that this finding necessarily applies to a newborn child. Surely such a preventative procedure could wait till the child is a tad older and the theoretical risks are more imminent – until they can consent to their own surgery perhaps?

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