The CDC vs Penises

The latest federal medical guidelines for circumcision are now out, and they emphatically want to return to the era in which infant boys are routinely subjected to the surgical removal of their foreskins – and even adolescent and adult men encouraged to cut their penises. A couple of things need to be emphasized, it seems to me. The core argument is about lowering the risk of HIV infection:

“The first thing it’s important to know is that male circumcision has been associated with a 50 to 60 percent reduction of H.I.V. transmission, as well as a reduction in sexually transmitted infections such as herpes, bacterial vaginosis and the human papilloma virus (H.P.V.), which causes penile and cervical cancer,” Dr. Jonathan Mermin, director of the CDC’s National Center for HIV/AIDS, told The New York Times.

The evidence for this is entirely with respect to heterosexual sex, and in sub-Saharan Africa, where, unlike in the US, heterosexual sex accounts for the vast majority of HIV infections. It refers, moreover, only to those cases where men are infected by HIV-positive women – a small fraction of the total HIV cases in the US. You wouldn’t know this from Mermin’s statement – which seems to me designed to scare parents with the HIV boogeyman, rather than present them with a clear sense of the tiny potential health benefits involved. (There’s no evidence that circumcision can reduce the chances of HIV infection in gay sex, which accounts for the big majority of US HIV infections.)

To flesh out its case, the CDC cites a statistic that estimates that 10 percent of HIV infections in men can be attributed to female-to-male transmission in the US. It’s worth reiterating that these statistics are estimates, not actual numbers. And the actual number of men estimated to be at risk from this kind of infection is a mere 4,000 a year. Around 2 million boys are born in the US every year. So the future risk of an infant boy getting infected with HIV by a woman, using the CDC’s own argument, is 0.2 percent, or two in a thousand baby boys. And remember, we cannot know that these men were infected by women – it’s an inference – and self-reporting on the matter is extremely unreliable.

We have some other circumstantial data with respect to HIV transmission and circumcision in the West. The AIDS epidemic was far worse in the US – with much higher rates of circumcision – than in Europe, where the infant mutilation was far less prevalent. We’ve also seen a major shift downward in circumcision rates in the US and no sudden upsurge in infection rates. Then there’s the simple fact that we now have a non-surgical preventative daily pill that prevents HIV infection, as well as condoms, providing a way for men to protect themselves from HIV without permanently scarring their dicks.

Somehow, none of this context is spelled out in the recommendations. Neither is any non-medical concern – such as not having your body permanently mutilated without your consent. The impact on sexual sensitivity is also unmentioned – because pleasure has no place in assessing mere medical costs and benefits. The reductions in the risk of getting herpes or HPV are also minimal. If I were to offer any recommendations for the final report on this, it would be for the real and minuscule potential medical benefits of circumcision to be spelled out more clearly, and the non-medical costs to be weighed at least in part. When the potential benefits of this are so marginal, the case for doing nothing – and doing no actual harm – seems to be a powerful one.

(Cropped sidebar image by Flickr user Shira Gal)

Being Conscious Of Your Own Circumcision, Ctd

Readers continue to provide the best MGM conversation out there:

This is in response to this reader. The condition that worries the dads is called phimosis. Until my mid-twenties, I couldn’t see more than a dime-sized area of my glans when I pulled back my foreskin. I didn’t even realize my foreskin was supposed to retract until I stumbled upon information about the condition online.

I recommend the dads look at the archives of this forum. It contains many first-hand accounts of successfully overcoming phimosis with stretching exercises. After stretching my foreskin twice per day for a year, I was able to fully retract my foreskin when flaccid. My sensitivity decreased, but that was necessary. I was overly-sensitive, and now I’m able to retract to wash my glans every shower with soap and water, which any healthy uncircumcised man will tell you is simple and necessary. I don’t stretch now, years later, and my frenulum is still a bit tight when erect, but I was amazed by the improvement.

The forum is sometimes antagonistic to doctors, with the allegation that American doctors are too willing to circumcise in phimosis cases because they don’t know any better. Some extreme phimosis cases may need circumcision, but I recommend the dads do extensive research of their own before subjecting their son to a scalpel.

Another reader is pretty antagonistic toward American doctors:

America just doesn’t know how to deal with foreskins.  We didn’t circumcise my son and his foreskin didn’t retract by age 5.  We were told that it should by age 3, and the cure for a non-retracting foreskin was circumcision.  No other advice was offered in England or America.

Then we moved to Bulgaria.

The doctor said we should pull the foreskin back to the point of gentle tension every day in the bath.  Now, it’s a bit awkward for a mother to be handling her son’s penis, so I tried to get my son to do this himself, with so-so results.  Not many months later, my son got an infection in his foreskin, from sloughed off skin cells trapped under the foreskin. He didn’t tell me in time, because he was an accident-prone kid and his solution to avoiding the doctor was to ignore the infection until he had a fever and was walking funny.

I checked on the web, consulted my home medical books, and called my American insurance company’s hotline.  All the advice was to lop off that useless (and, it was hinted, disgusting) foreskin.  But we were in Bulgaria, so we went to a Bulgarian hospital.  The doctor was built like a weight lifter and had odd English. I explained my husband’s preference was to try to save the foreskin, if possible, expecting to be told it wasn’t.  The doctor was absolutely horrified at the barbaric notion that anyone would consider removing a part of a man’s or a boy’s penis, especially for a trivial problem like a nonretracting foreskin with a treatable infection.

He forced the foreskin back, disinfected the infection, slathered antibiotic cream and told us to keep putting the cream on and that the foreskin now retracted. The procedure took under 5 minutes, cost $60 (10$ fee, 50$ tip) and solved the problem.  That was years ago.  My son remains intact.

I think it’s the cultural value that foreskins are useless at best and otherwise potential for disgusting reservoirs for grunge that makes the American and English solution to be lop it off at the slightest hint of any problem – and better yet, before there’s a problem.

And back Stateside:

I have been reading your circumcision thread and thought your readers may want a perspective from a female pediatrician who actually performs circumcisions on a regular basis.

My patient base is semi-rural, mostly white, blue collar, in the heart of Appalachia. They feel that their newborn sons are not “normal” if they are not clipped, and in fact that is sometimes the only question they ask when their son is just born – “Will he be circumcised?” Typically my partners and I will do a circumcision before the child leaves the hospital, but it can be done with local anesthesia up to two months of age in an office setting. There are different types of circumcision procedures that can be done and different doctors are trained on different procedures, but the basic principle is the same: the foreskin is loosened from the glans, a dorsal slit is performed and the foreskin is either placed in a clamp, or tied off around a plastic ring. There are pluses and minuses to each procedure, but it is mostly doctor preference regarding which one is done. And as I said, local anesthesia is given.

As part of my practice, I want my patients’ parents to make the right decision, and so I typically perform a thorough explanation of the risks and benefits of the procedure. But I do get frustrated that despite letting them know they don’t need the procedure, the parents feel it must be done.

Reading your readers stories, I am sad and a little disappointed because although I was not involved in these cases, I feel like the medical field have let them down.  And I think the reason is because the majority of males in the US are circumcised, and that creates a bias and a misunderstanding of the true nature of the foreskin and the male sex organs. If you only see circumcised boys, you may not really know when the foreskin should protract, and you would view something that is completely normal as abnormal just because it is different.

First off, ALL males are born with a natural phimosis. With time the phimosis loosens. This can vary, but there is a key ingredient needed and that is TESTOSTERONE. That is why the doctors of the various readers gave them steroid cream, but that is just not as effective as your own production of testosterone. Now some mothers with uncircumcised boys are aggressive with “cleaning”  and that traction will loosen the foreskin. Some boys are more playful, and that too will loosen foreskin, but a boy of age 3, 5, 7, 8 – even sometimes 14 – has very little testosterone flowing, so it is needed to mature the the male sex organ to function like it should. (As a side note, we recommend not pulling the foreskin down to clean, as that may cause it to rip from the glans but stick, swell and potentially cause loss of blood to the glans, which is bad.) Once the testosterone is flowing, the adolescent maleusually provides enough friction that any minor tightness will also loosen.

Obviously there are some exceptions to this rule, and a circumcision may need to be performed for medical reasons, but that is the exception. I would highly question any physician who tells you a prepubertal boy needs a circumcision if they are urinating with no problems. I also feel very sorry for the man that had a circumcision as an adult with just a local anesthetic that is cruel. No child or adolescent would get a circumcision out of the newborn period without general anesthesia, so why would we do that to an adult?

One more thing: I am surprised that nobody has mentioned circumcisions that had complications. Commonly I see penile adhesions where the foreskin has reattached itself to the glans of the penis, sometimes making it appear as though the child has never been circumcised.  Unfortunately I actually had a mother re-circumcise her son due to this very issue, despite my explaining that this was completely unnecessary, as the boy was two and thus had no testosterone, and that it will get better with time. Unfortunately she became obsessed with it and insisted it be done. I will never forget that boy. (Interestingly enough, prepubertal girls have a similar condition in which the labia minor fuse together, because there is no estrogen blocking the opening of the vagina and even the urethra, but of course we would never perform procedures to separate that.)

So that’s my two cents, for what it’s worth. I found you a few years ago and have thoroughly enjoyed reading your blog.

And we never cease to enjoy these incredible contributions from readers. Update from another:

(Interestingly enough, prepubertal girls have a similar condition in which the labia minor fuse together, because there is no estrogen blocking the opening of the vagina and even the urethra, but of course we would never perform procedures to separate that.)

Actually, this is exactly what my daughter’s pediatrician recommended when she was less than a year old; we were told to put estrogen cream on it (don’t worry if your infant develops breasts, that’ll be temporary … never mind the people freaking out about exposing their children to tiny amounts of estrogenic compounds in BPA plastics and possible links to the obesity epidemic). And if that didn’t work, we were told surgery might be necessary. Thank god for the Internet. The problem went away on its own at about 18 months. Never caused any trouble.

Being Conscious Of Your Own Circumcision, Ctd

More readers share their stories:

My heart goes out to your reader. We opted not to circumcise our son, only to have him develop the same non-retraction problem at age three. We tried a variety of topical treatments and visited a number of doctors. We were told that the problem might resolve with time, but if it didn’t, we’d be looking at circumcision of an even older child. That seemed untenable to us, so we went ahead with the procedure, which required a visit to an outpatient facility, general anesthesia, and several hundred dollars out of pocket.

He’s now almost seven and doing just fine, but it was a sad experience for all of us. To this day he talks about the time “when Mommy was crying so hard.” I’d tried to put the antibiotic ointment on his incision and he ran away screaming. I was emotionally worn out and worried about infection but also hoping and praying that he wouldn’t get a complex from having a wound on his penis that his parents had to slather with ointment several times a day.

As much as my husband and I couldn’t stomach the thought of a newborn undergoing this procedure, what our son experienced was more traumatic. Would we have done it differently had we known? Probably, but that’s the problem – there’s no way to know ahead of time if your child will develop this issue.

Another got his penis sliced much later than age three:

Having read about your reader’s dilemma regarding his child’s circumcision, I’d recommend that he go ahead and do it. I had issues with phimosis in adolescence and actually needed a circumcision, but I had to wait until I had health insurance to get one. I remained a virgin through college because I was too afraid of something bad happening during sex, which I will forever regret, even though I am happily married now.

One of the first things I did after getting healthcare coverage through a job was to get a circumcision. I was 24 then, and I can attest as to how terrible it is. Imagine getting multiple shots of local anesthetic on your johnson, feeling the sutures being sewn because the anaesthetic is wearing out, and having the whole thing witnessed by four nurses, presumably because of the sheer novelty of an adult circumcision. The recovery is equally horrendous, with painful mid-sleep boners and the skin of my glans getting chapped and flaking off. I took three days off work when I was told one would suffice.

When all was said and done, I had a scarred dick that lost a lot of its sensitivity, but that was mitigated by the lost fear of actually using my penis.

So having experienced circumcision as a grown man, I can attest that it is a barbaric experience. Performing it on a newborn child does not change that. I do not plan on having my children circumcised, if I have any. Still, if it is an issue of medical necessity – which it can be – the sooner it gets dealt with, the better. Once puberty hits and shame becomes inevitably correlated with private parts, a lot of damage can be done.

Another suggests a novel solution:

Why do stories on circumcision never discuss the “dorsal slit” procedure, which leaves the foreskin intact? This simple procedure combines the health benefits of circumcision with all the pleasure of remaining intact. While I do not advocate routine mutilation, this neatly resolves the issue for anyone with retraction problems.  Those seeking middle-ground might consider this compromise.

A colleague of a reader seems to have done just that:

The image that came to me when I read your post was when I was working in a very busy neonatal unit. The head of the department did the circumcisions if the child did not have a pediatrician yet. I came on to work one morning and was so shocked when I pulled back the diaper to reveal something – to my eyes – that was horribly wrong. It looked like a mutilation, and I have seen lots of circs (performed by the pediatricians on their patients – this was the first one I saw that the neonatologist had performed).

I immediately went to find him and asked him to come and take a look. I thought he would really want to know – thinking that there was swelling or infection or some thing gone awry. He made a rather sniping comment – that I had been to Paris and seen the best or something to that effect. What I learned about this doctor is that he did not like to do circumcisions and so he performed a “mini circ” – essentially just nipping a bit off. Everybody is happy.

Being Conscious Of Your Own Circumcision, Ctd

The start of another fascinating thread:

I feel for the couple with the seven year old whose foreskin won’t retract.  We went through that with both of our boys.  My husband is cut, but I put my foot down and demanded that both of our boys be left intact.  The older of the two started having problems with his foreskin when he was around four (he’s eight now).  It wouldn’t retract and the doctor thought it was very tight.  The urologist gave us some steroid cream and said, basically, “good luck, it probably won’t work; see you back in two weeks to schedule the circumcision.”

Two weeks later his foreskin was retracting like it was supposed to. Yea! Problem solved.

Fast-forward two years to when our youngest was two. Same problem. We went to a different urologist (for insurance reasons). He spent less than two minutes looking at my son’s penis and said: “He’s fine, leave it alone. A lack of retraction isn’t an issue until he is at least eight or older.”

Guess what: both foreskins now retract normally.  I’m very glad I pushed for alternatives and didn’t immediately agree to a circumcision.  So definitely get a second opinion before you cut.

A second:

I’m sure you’ll have some doctors who can speak to the medical aspect of your reader’s question, but I may be able to offer a useful personal perspective. I wasn’t circumcised when I was born, but I did get circumcised when I was 15 for medical reasons that sound similar to your reader’s son’s.

In my case, the foreskin was fused with the bottom of the head, which meant I couldn’t pull it back very far (and the few times I tried, growing up, were quite painful). I just thought that was normal. I heedlessly peed into the damn thing for years and never got any infections to indicate something was amiss. I think I just nodded when doctors would ask if I was careful to pull the skin back when I used the bathroom. At a physical when I was 15, I finally understood the question, so the doctor sent me to a urologist who proscribed a circumcision. Things were pretty swollen and grody for a few weeks; after that everything worked fine.

One thing that gets elided in the hyperbole “male genital mutilation” is the distinction between a medically-indicated procedure and a purely cosmetic one. It doesn’t make medical sense to circumcise all boys at birth, but being circumcised is not a particularly onerous condition.

My dad may have gone through some of what your reader is going through when we decided I needed to get circumcised. He was adamant that I not be circumcised at birth – partly for the reasons you bring up on this site, and partly because he was very not cool with the idea of some doctor cutting on his newborn’s dick without anesthetic (which was the standard in the mid-’80s, when I was born). When I later had to get circumcised, he expressed some guilt: in an attempt to not mutilate his son, he mutilated his son!

This was ridiculous, of course: I was (and am) grateful that I wasn’t circumcised at birth, just as I’m grateful my idiosyncratic problem was so easily treatable, just as I’m content now to live without foreskin. And I told him as much, with more respect than I was usually able to muster at 15. For one thing, I was very much looking forward to sex, and with a mostly immovable foreskin there can be complications. At 15, I would have hitchhiked to the hospital and panhandled for my copay if it meant I could have sex sometime in the future.

It is important to note that I was able to consent to the procedure. I knew what was going on and I was very clear as to the reasons we were doing it. But I can’t imagine I would have harbored any ill-will if I’d been circumcised a few years earlier for the same reason.

More stories to come. Follow the whole thread here.

Being Conscious Of Your Own Circumcision

A reader writes:

I always read your circumcision posts with great interest because both my husband and I are both circumcised and we elected NOT to have our boys (ages seven and eleven) circumcised.  We have no regrets.  Unfortunately, we are now faced with a very unexpected dilemma:  our seven-year-old’s foreskin does NOT functionally retract, and this has caused some problems with urination.  We are also told that this will cause a bigger problem as he matures.  Currently, our urologist has him applying steroid cream treatment four times a day, but this has produced no positive results.  We are NOW faced with very real fact of circumcising our seven-year-old son.  This was the last thing we ever expected and, believe it or not, have never heard of such a condition.  The information available to us via our doctor and online research is both limiting and overwhelming, respectively.

So, as a shot in the dark, I wonder if you and your gifted readers could shed any light on this condition and/or any solutions other than circumcision.

That problem with retraction was apparently why my own willy was mutilated when I was an infant. I have no medical expertise on this … but I bet the Dish collective mind has some. Meanwhile, another reader underscores the difference between circumcising a newborn and a child:

I’m pro-circumcision, but when I saw the story you linked to yesterday about the four-year-old boy in Florida whose father went and obtained a court order to authorize a circumcision, my reaction was “No fucking way!”  My own gut reaction surprised me.  So I stopped and thought further: Wait, why would I be opposed to this boy’s circumcision and not to an infant, when the health benefits cited by the American Academy of Pediatrics would still apply either way?

To answer that question I thought back to an incident at my dentist’s office just this week.

As my dentist and his assistant were working away at my problem tooth I could hear from the next room over a child who was very unhappy about being at the dentist.  The whining and complaining eventually turned into blood curdling screams as his procedure was getting under way.  I’ve never been in the presence of someone being tortured, but I can only imagine that the sounds coming from this child are similar.

I have a small child myself.  It’s heart wrenching to see him in pain or fear when getting an inoculation or exam at the doctor.  All I wanted to do was run into that next dentist’s room, stop whatever was going on, give him the boy a hug and tell him it’s all over.  But that would be wrong.  We (parents) put our kids through these things because we know in the end that the benefits of the shots and the dental work outweigh the pain and psychological trauma the kids experience when it happens.

So what of circumcision then?  Do the benefits outweigh the pain and psychological trauma?  Even as someone who is pro-circumcision, I knew immediately that the benefits for this boy will not outweigh the pain and psychological torture he would suffer by going through the procedure at that age.  A newborn infant heals quickly, cannot even reach his genitals, and has no mental understanding of them.  None of those conditions applies by the time a boy is four.  He should be left alone.  The benefits of circumcision are less notable in a modern clean civilization such as ours – and non-existent when looking at it in the context of what that boy will have to endure.  I pray that no urologist will actually perform this procedure at that father’s request.

While I’m not moved enough to change sides on the overall debate (I still think parents should have this option for their newborns), the whole incident has be thinking and questioning it all.  This would not have happened without the Dish, as I would not have even known about this story with you.  Thanks again for making me think.  Keep the circumcision debate going.