Medical Observer

May, 2000

From the moment that little boys are old enough to be left alone in school, they become subject to that interminable human affliction called peer-pressure. It starts with comparing lunch boxes, leads onto fad gadgets like Pokemon paraphernalia, and onto stickers of whatever cartoon killer robot is currently in vogue. Then comes the perplexing and occasionally horrifying comparison when a bunch of them go together to the little boys’ room and they suddenly realize that little boys are not all created equal.

Circumcising newly-born males has long seemed like standard clinical procedure in urban health facilities in the Philippines. Today, however, many questions are being raised against this practice. These questions delve into the rationality of circumcision in general and the rationality of subjecting a newly-born child to such a painful operation without virtue of anesthesia.

Rustic hazards

In the rural setting, the circumcision of boys is almost a ritual, and is often accompanied by a certain degree of fanfare. First of all, the “operation” is performed on much older boys, usually those in their pre-teens. It is, in fact, viewed largely as a “rite of passage” or a jump across the threshold separating the men from the boys.

While professional care is available in most places where rural health physicians have been deployed, a great many of these lads still prefer to queue up under a shady tree by the local creek where the “manunule” awaits with his makeshift surgical equipment and indigenous post-operative medication. This surgical gear consists of a well-honed barber’s knife; while the medication is usually a poultice made from young guava leaves that the boy undergoing the procedure first has to chew into a pulp. In other cases it is the manunule himself who chews the leaves into the “medicine.”

Needless to say, the manunule who exercises his trade at the shady brook side is not a licensed physician; but a traditional medicine practitioner, a local shaman, a trusted elder, or even the village barber.

This primitive surgery obviously subjects the boys to a great deal of risk for infection. Not only is the same knife or labaja used on several people in the span of a single afternoon without the benefit of sterilization, but the very substance intended for wound care could actually introduce infectious pathogens into the wound. It is not uncommon for boys having undergone this indigenous practice to suffer for weeks on end from swollen penises as a result of infection.

The pain and infection accompanying this unsanitary procedure gives rise to various folk beliefs – often perpetrated by the manunule himself. In F Sionil Jose’s 1979 novel Mass, Pepe, the main character suffers excessive bleeding and swelling on his penis after undergoing such an operation. The manunule told the boy that the swelling meant he would grow up to be a stud. “Big over-ripe tomato. Pepe, a few more years and I predict you will make your women happy,” the manunule states in that novel.

Innocent victims

While boys in rural settings usually regard circumcision as an initiation into manhood, probably also because it displays their prowess against the physical pain, the operation is usually performed on newborn infants in the urban hospital setting. For the past several decades, circumcision of newborn males, even before going home from the hospital, has been considered routine procedure at urban hospitals and medical centers.

Performing this operation on the newborn means the child would not be administered any form of anesthesia due to the associated risks. The operation would, therefore, cause a great deal of pain for the baby.

The rationale behind circumcising newborns is that “they will not remember the pain when they grow up.” By contrast, males who had undergone the procedure when they were five, six, or even fourteen years old remember the incident and the pain vividly well into their adult life. Oftentimes, the event is recalled and retold like a fishing story.

Noted pediatrician Alicia Tamesis, MD indicates that parents prefer that the procedure is done shortly after birth to spare the child the pain when he is older. This, however, raises some contentious issues. The fact that the child may be too young and too ignorant to comprehend and, therefore, remember pain does not mean that he does not experience pain.

“There is pain because the nervous system is already fully developed. They can experience pain,” she attested. “The question is on the memory of pain,” she continued.

Dr Tamesis ponders on whether there is a bioethical issue attached to this. “If you circumcise the child, the child does not know any better. Let’s put it this way: if you’re thinking of bioethical issues... the parents gave the consent.”

Desist!

A study conducted in the US a few years ago found circumcision so traumatic to the babies that the participating doctors chose to terminate the study prematurely rather than subject any more babies to the operation without anesthesia. Measuring the heart rate and crying pattern of the subjects, the researchers realized that not only was there severe pain, but also an increased risk of choking and difficulty in breathing.

One of the reasons anesthesia is not used, the study found, is the prevalent belief that infants feel little or no pain from the procedure. It has also been argued that injecting anesthesia can be as painful as circumcision itself, and that infants don’t remember the procedure, anyway.

Dr Arthur Gumer of Northside Hospital in Atlanta finds these arguments hard to believe. “To say that the baby doesn’t remember it is not an adequate excuse to me. Babies experience other painful procedures and we worry about that, and we do give them anesthetics for those procedures,” he argued.

In the United States, Rabbis who perform circumcision as part of the exercise of the Jewish faith are often requested to provide anaesthesia for the child. This is usually in the form of a topical anaesthetic on the skin which is inadequate for relieving pain of foreskin separation and incision.

To cut or not to cut

Why is circumcision of newborns so widely practiced in the Philippines? Dr Tamesis admits that the Philippine Pediatric Society does not prescribe it since it is entirely optional, and largely the choice of the baby’s parents. The PPS believes, though, that there is some health benefit to circumcision such as reduced propensity to infection, there being less of a structure within which dirt could accumulate. Doctors often advise parents of these children to have them circumcised, but mainly for the health benefits, and for no other reason.

Department of Health chief for Health Promotion Dr Ivanhoe Escartin points out that this practice is done largely due to Judeo-Christian influences, and not for any real health reason. Dr Escartin, who headed the National Mental Health Program before being tasked with health promotion, notes that the religious influence that placed a premium on circumcision created a social norm and preference.

A growing number of doctors are pointing out that the pressure to have children circumcised is more socio-cultural than it is medical. In fact, many argue that the presence of the foreskin is beneficial to the person’s health, and is actually necessary during sexual intercourse.

The absence of the foreskin results in desensitization of the penis, increasing the amount of friction during vaginal intercourse, and making the act altogether less pleasurable. In fact, it is believed that the practice of circumcision flourished in the US as a punishment for boys who were caught masturbating. Circumcision was meant to remove the pleasure of self-stimulation during this Victorian era in American history.

The case for integrity

To the present day, some Asian and African cultures still practice genital mutilation, or some form of circumcision for women. This is meant primarily to diminish the woman’s ability to enjoy sex, thereby keeping her “pure and chaste.” In some instances, not only the clitoris, but even some portions of the labia minora have been surgically removed. International human rights groups have cried out against this and are engaged in fervent efforts to stop the practice.

In the US, a counterpart force called the National Organization to Halt the Abuse and Routine Mutilation of Males (NOHARMM) advocates the cessation of male circumcision and all forms of genital mutilation. While circumcision of females is much more severe in its consequences, males are many times more likely to be subjected to genital mutilation.

To express concern for individual rights to one’s own body, NOHARMM developed The Genital Integrity Ribbon from a concept by human rights activist John A Erickson. Possessing both blue and pink surfaces to represent both males and females, the ribbon is an expression of the movement’s position that circumcision of healthy infants and children is not in their best interests. It is also an appeal for respect of children’s rights.

Physicians and caregivers should review the current findings and growing thinking surrounding the issue of circumcision, particularly when helping parents decide whether or not a newly born boy will have to go under the knife and be subjected to pain that adults can never really understand.