Saturday, January 17, 2009

How it all began...

Finding out that you're going to be a parent is an exciting, yet surreal, moment.
But, if you've got a boy on the way, one of the decisions you'll need to make is whether his penis will circumcised or not. This is the decision that my fianceƩ left to me last year when we found out the sex.

Anna was indifferent about it, and I just assumed our boy would be circumcised, mostly because I am myself. We also live in the United States (New Jersey to be particular) and it just seemed like something everybody does.

It wasn't until we met with the paediatrician one day and he brought the topic up. He said, somewhat bluntly, that "the Paediatrics Academy doesn't recommend this procedure. From a medical standpoint its not really beneficial, and from an ethical standpoint... well that depends on your point of view."

Driving home, this got me thinking (while Anna concerned herself more with boy names and bedroom wallpaper designs). Her opinion was that I'm the one with the penis, so I should decide what happens in that department.

So, I went on the internet, and did some homework. What happened next shocked me.

It soon became clear that circumcision was no longer something everyone "just did".
I started from the very beginning — doing a Google search for circumcision returned over six million results. At that point, I decided I would need a beer.

So, armed with a 4-pack of Bud and a curiosity as to why there are 6,000,000 webpages about it, I got stuck in.

Next, I realized how hotly debated circumcision actually is. I found it very difficult to find resources that were impartial. Most seemed to be either very "pro" or very "anti", and a lot of people have very strong opinions for their side of the fence, some even resorting to flat out abuse of the opposition.

Oh by the way, for the purposes of this blog, I will often refer to circumcised penises as "cut" and uncircumcised ones as "intact". This seemed like what each battalion preferred calling their respective units, and also I am the laziest person I know, so typing out the long versions every other sentence will soon get tiresome.

When I was eventually able to find some objective resources, I quickly learned a lot. See, I thought that if we didn't have baby Joseph (so he turned out to be named) circumcised, we'd have to intricately wash under his foreskin after every diaper change to prevent all sorts of nasty diseases. Not so. In fact it seemed like more care and attention would be required if we had him cut!

I also learned that the foreskin plays an important role in protecting the penis head, and that I could actually be missing out on some sexual sensation being cut. I think this is disputable, and almost impossible to prove.

To outline what follows: I've split my blog up into 4 sections.
In the first, I'll share what I know of the actual thing that us Americans like to cut off: the foreskin itself.
Next, I'll talk about how America is actually the only country that cuts foreskins off for non-religious reasons!
Thirdly, I will dedicate a whole section to the potential protections circumcision has to offer, as well as its potential risks.
And finally, the decision that I made for little Joe, as I smoked a thousand cigarettes while Anna pressed through labor for what seemed like an eternity, way back in the April of '08...

What is the foreskin there for?

"Its just a ghastly flap of extra skin."
That may be how you've heard a male foreskin described. But allow me to shed some light on what the foreskin really is.

Well, firstly, its not "extra". All guys are born with it, so that immediately begs the question, "if we were born with it, it must be there for a reason?" Well it is.

Foreskin comprises four-fifths of penile skin, and is full of specialized nerve receptors. These receptors play a role in sexual functions (as I will soon explain) and the way that it acts as a 'sheath' over the head (or 'glans' to be scientific) means that it protects it too.

Understanding how the foreskin plays a role in sex is something of a vague science.
So lets start with masturbation.

Don't frown; we all do it, and your son will do it too, especially when he starts 'growing up'! Doctors actually first started circumcising boys to STOP them from masturbating, because once-upon-a-time they thought it was harmful. The way the foreskin can be glided back and forth over the glans and shaft makes masturbation easier and, arguably, more enjoyable. Without the need for artificial lubrication, it seems as though boys can discover self-pleasure from a youunger age if they are intact.

In sex it is believed that this gliding action is what most stimulates the orgasmic elements of the penis. It also makes for smoother movement between the partners, and creates a pressure that enables enhanced pleasure for both.

Don't get me wrong. Circumcised men can still lead normal and very enjoyable sex lives. I do. But the prospect that it could be better if I had a foreskin certainly makes me wonder...

While not masturbating or having sex, the foreskin sits in its usual forward position, protecting the glans.
This protection keeps the glans soft and sensitive. Cut the foreskin off, and thousands of nerve endings are removed and the glans becomes tough and dry, in a process called keratinization.
So you see, the foreskin does serve a purpose. Several important ones, in fact.

Who in the world circumcises...

As far as I can see, there are three main reasons why a boy would be circumcised:
1. Religious reasons
2. Medical reasons
3. Cultural reasons

In terms of reason 1, the mainstream religions that require their males to be circumcised are Judaism and Islam. Therefore, all Jewish and Muslim men are 'cut'. Furthermore, this means that the majority of men in the Middle East are circumcised.

Sometimes, a boy may have a medical condition where a circumcision is required. The most common such condition appears to be phimosis, where the foreskin cannot be pulled back.
Although these problems are rare, they are usually the reason behind most circumcisions in first-world countries other than the U.S.

Cultural reasons...
Ask me to define 'culture' and I'd struggle to be very precise at all.
But let me give you an example: Nelson Mandela.
It was a custom for him to undergo a circumcision at the age of 16, as a sign of transition from boy to man. Mandela even had to bury his own severed foreskin in the ground as part of the ritual.
In the Philippines, boys undergo a similar cultural tradition when they hit puberty, and have their foreskins cut off too.

Now I want to make something clear:
The USA is the only developed country that circumcises most of its boys for non-religious and non-medical reasons. Our European, Asian, Australian and South-American friends do not routinely circumcise.
However, the U.S. rate of circumcision has dwindled to just 57% with the lowest rates in the south and west and higher rates in the midwest.

Later, I will make very important comparisons between the USA, a country where 80% of males are 'cut', and countries where 80% of males are 'intact'.

To conclude this section, I can summarise by telling you that on the global scale, approximately 80% of males are 'intact'.
At the time of going to print, the world's population was 6¾ billion.
So assuming there are around 3.4 billion men on the planet, that means about 2.7 billion of them have foreskins!

Now let’s get down to business…

Circumcision has some pros, but are they sufficient enough to warrant cutting your son's foreskin off?
It would be unfair, impartial and futile for me to deny that circumcision carries some benefits. The extent of these benefits however, are not as great as I once thought. Especially in a country like mine where hot water runs out of our taps, and people can purchase condoms from their local store.

Let's explore the apparent advantages, one by one:

STI (Sexually Transmitted Infection)

  • Its never been more essential to use a condom or other reliable contraceptive.
  • Whether a man is 'cut' or 'intact' actually appears to have little or no affect on his exposure to STDs. Studies are often conflicting and complex, but the most recent one showed that circumcision offers a tiny 1% reduction. Every study however notes that there are much more significant factors, such as use of condoms and promiscuous behavior, in the acquisition of STDs, than whether the man has a foreskin or not.
  • As mentioned earlier, I would also like to compare a mostly-circumcised region to a mostly-uncircumcised region. The USA has a greater incidence of STDs than several Western European countries, despite having most of its males 'cut' compared to most of their males 'intact'.

UTI (Urinary Tract Infections)

  • Females are far more prone to UTIs than males.
  • Again, the risk of UTIs in developed countries like the U.S. are markedly reduced compared to the third-world, yet one-third of adult Americans reported getting a UTI at some point in their lives. This is in a country where 80% are circumcised...
  • In the UK however, where 80% of males have foreskins, only 1 in 30 boys reported having a UTI by the age of 16.
  • The effect of circumcision on risk of UTIs is also minimal, and risk in adulthood is more commonly associated with increased and vigorous intercourse with a new partner.

Penile cancer

  • Cancer scares the shit of people. And rightly so.
  • In 'cut' men, the cancer usually forms on the actual circumcision scar itself, whereas in 'intact' men, it usually forms on the foreskin if the man has particularly poor hygiene. But penile cancer is very rare, affecting less than 1 in 100,000 men.
  • The American Cancer Society declared that having a foreskin does not increase the risk of penile cancer any more than having unprotected sex with multiple partners and smoking cigarettes.
  • The American Medical Association (and Australia's equivalent body) also declared that circumcising an infant in hope of preventing penile cancer is "unjustified".
  • Again, comparing the prevalence of penile cancer in the USA to a non-circumcising region such as Scandinavia, showed no difference at all.

Cervical cancer

  • Cervical cancer is most commonly caused by the HPV virus and a promiscuous sexual history. Not all strains of HPV can be transmitted and not all are dangerous; believe it or not, 80% of sexually-active Americans will carry some form of HPV at some point in their lives.
  • In 2006, the HPV Vaccine for girls was approved, which showed protection against 70% of cervical cancer-causing HPV strains and 90% of strains which cause genital warts.
  • The affect of male circumcision on female cervical cancer is "insignificant" according to one study, especially if the 'intact' man practises good hygiene and the woman keeps her sexual behavior at a low-risk. Bigger factors which affect a woman's risk to cervical cancer are having multiple sex partners, having sex before the age of 18, and having sex with a man who has had previously had sex with someone with the cancer.

HIV (Human Immunodeficiency Virus)

  • You, like me, may have come across headlines sensationally declaring circumcision reduces a man's risk to HIV by up to 60%. This is all very well in some African countries, where there is an epidemic and contraception is rarely (or never) available nor used.
  • In the U.S., prevalence of HIV is much lower though, and contraception is always available and usually used. Attitudes towards maintaining relationships instead of having multiple sex partners is also different in the West than in Africa.
  • The USA has the highest prevalence of HIV/AIDs than any developed country, at 0.6%. We also have a male population that is 80% circumcised.

    In France, its 0.4%. In the UK its 0.2%. Its only 0.1% in Finland, Ireland, Sweden and New Zealand, and 0.01% in Germany. Most men in those countries are 'intact'.
  • My point is that circumcision is being used as a seemingly "desperate" measure in Africa to help curb the HIV epidemic. But in the developed world, its irrelevant.

To sum up, I concluded that the advantages of circumcision are minimal and insignificant, and that if a man cleans his foreskin area regularly and properly, and sensibly uses contraception, then he is no more at risk of any health problem.

I also read the testimonies of 'intact' men who actually decided to get cut as adults.
Ouch right? Well, one common theme was that the operation itself was painless and that the recovery from it was entirely manageable.

So if men can easily undergo circumcision as adults without a traumatic experience, then why not let our babies make the decision for themselves when they're old enough?

This would bring me onto the ethical issues of circumcising baby boys, but like our ped said to us, that depends on your point of view.

So, what happened to our little Joe?

Researching circumcision was an absorbing experience for me.
So absorbing in fact, that six months later I decided to write all about my findings, and now I have posted them here online. So, what did Anna and I decide to do for Joseph?

You know, in spite of concluding circumcision is unnecessary, I still had to come to terms with the idea of my son being "different" than me.

It wasn't that I wasn't sure how to teach him how to take care for his equipment if we didn't circumcise, since there are several websites out there with advice for parents on how to care for both 'cut' and 'intact' boys.

I guess I just didn't want Joe to be worried that he's different from me, or his friends. The fact that more and more boys aren't being cut nowadays helped us realize he shouldn't have any horror stories with teasing in locker rooms. Then, something clicked.
I figured Joe wouldn't be like me anyway. His would be tiny and bald, mine would be big and hairy. So what about being cut or not? And I never really paid much attention to my dad's penis anyway!

One day I'll explain all this to him. I'll explain that my foreskin was cut off because back then they thought it was harmful to keep it on.
But in the 21st-century, its completely fine to keep a boy's penis intact, so long as you're willing to teach him to take care of it when he's older.

Joe turns 1 this spring, and he's not had any problems with his foreskin.