When John Lam was a teenager, his foreskin was tight and difficult to retract, a frustrating state of affairs for a kid "starting to use the equipment." At 18, he went to a urologist who said there was only one solution: circumcision.
Later, he found out that he might have been cured using medicated creams instead of surgery. Mr. Lam, who is now 34 and a hotel employee in Vancouver, wishes his penis was still intact and that the doctor had offered him a choice.
He believes that no one should make the circumcision decision on behalf of someone else, even a newborn baby. "I'm not against circumcision," he says, "but if people are 50/50, they should err on the side of not cutting."
Indeed, people almost always feel strongly about circumcision -- either for or against it. The foreskin represents a source of great debate among experts in ethics, law and medicine. Its removal brings babies and mothers to tears and infuriates complete strangers. It polarizes huge groups of people, firm in their beliefs one way or another.
Adding a new slant to the discussion, Canadian scientists are pioneering work on the anatomy of the foreskin and have found and named a new part of the penis never before documented. This work is being used as ammunition in the very active anticircumcision lobby that is being conducted in Canada through Web sites and letter-writing campaigns to politicians and pediatricians.
At the same time, other research, mostly from Africa, is posing questions about circumcision's possible protective role against HIV infection, the virus that causes AIDS.
All of this leaves some Canadians torn between a desire to have little Billy "look like Daddy" and a belief that the body should be left alone. So one thing is for sure: the foreskin, though hidden, is gaining relevance.
Dr. John R. Taylor, a retired pathologist in Winnipeg, and his colleagues were probably the first in the world to seriously investigate the anatomy of the foreskin. In 1996 they published results of a detailed study of 21 adult foreskins at autopsy. "No one could believe that there was anything new in anatomy. I couldn't believe what I was seeing," said Dr. Taylor.
What they found, and named, was the "ridged band" -- unique tissue about half an inch wide that runs around the inside tip of the foreskin. "The foreskin is not just a piece of skin," Dr. Taylor said, "but specialized tissue full of blood vessels and nerves."
In their latest work, Dr. Taylor and colleagues are exploring the function of the ridged band, which expands and contracts like an accordion during erection and intercourse, triggering sexual reflexes.
"It has a lot to do with sexual satisfaction and broader implications about fertility," said Dr. Taylor, who wants to educate doctors and parents about his findings. "Parents should be left in no doubt that circumcision always removes a large, sexually significant portion of the penis."
Dr. Aaron Jesin, a Toronto physician and mohel, who performs both Jewish ritual and non-ritual circumcisions, is not sold on the sexual attributes of the foreskin. "To me, it is a silly argument," he said. "Jewish people have lots of sex and lots of kids." Besides, he said, how can it ever be studied, whether sex is better with the foreskin intact. "How do they know? It is impossible to study!"
Only anecdotal information exists on whether sex is better with or without a foreskin. Mr. Lam, one of the rare people who was sexually active before his circumcision, says there has been "a huge loss of sensation."
Dr. Taylor has been accused of being anti-Semitic because he is vocal about the downside of circumcision. But he has no argument against circumcision done for religious reasons. It has been done routinely in Jewish and Muslim boys since ancient times when tradition holds that God commanded Abraham to have his offspring circumcised. "Circumcision is done in the Jewish faith for good, sound religious reasons," says Dr. Taylor, "and they realize it is a significant sacrifice." His message is directed more at people who aren't sure what to do.
In Canada, it is difficult to get exact figures on circumcision rates because in all but one province the procedure is paid for privately and therefore no single body keeps track of the numbers of operations done. Manitoba is the only province that covers circumcision in its public health insurance. There, about 25 per cent of boys are circumcised, down from about 35 per cent in 1997. It is thought that the overall rate of circumcision for Canada is lower than Manitoba's rate, probably between 17 per cent and 20 per cent, because it is rarely performed in Newfoundland, Nova Scotia or francophone Quebec.
Canada's rate is still high compared to England, where about 3.8 per cent of boys are circumcised by their 15th birthday. Physicians writing recently in the British Medical Journal declared that a more desirable rate would be about 2 per cent, the rate in Scandinavia. Meanwhile, the U.S. rate of circumcision is much higher, at 62.8 per cent.
Regional variations and differences between developed countries can be explained by "social mores," says Dr. Paul Munk, a pediatrician in Toronto. He calls circumcision "cosmetic surgery" because it is often done so boys can look like their father, and it is almost always paid for privately.
When it comes to medical advantages, the pendulum swings both ways. For every pro-circumcision argument, there is a counter view. For instance, one of the advantages of circumcision is that it reduces to almost nil the chance of developing cancer of the penis, though Dr. Jesin admits this cancer is very rare. Besides, says Dennis Harrison, an anticircumcision activist in Vancouver, "there are medical benefits to removing almost any part of the body. Cut off a toe and you don't get toe fungus."
Another possible medical advantage to circumcision has worldwide public health implications. A growing body of evidence supports the conclusion that circumcised men are at reduced risk of HIV infection, possibly by as much as 50 per cent. It is thought that the sensitive cells of the foreskin may provide a vulnerable place for the HIV infection to enter the body during sex with an infected partner.
In a study recently published in the journal AIDS, it was found that circumcision was associated with a reduced rate of acquiring HIV infection among the study population of 5,507 Ugandan men. The strong beneficial effect of circumcision, however, may be confounded by other factors. For instance, most of the circumcised men in the study were Muslim, so researchers need to find out whether other practices of Muslims, such as postcoital washing, are significant factors.
At the moment, many scientific angles still need to be addressed before mass circumcision is recommended in populations at high risk for HIV infection.
Another advantage to circumcision is a reduction in urinary-tract infections in babies. A study published in the journal Pediatrics in April, 2000, concluded that newborn circumcision results in a ninefold decrease in the incidence of UTIs in a baby's first year and that circumcision is "thus, a valuable preventive health measure, particularly in the first three months of life." However, says Dr. Taylor, it is shortsighted for parents to make a decision on that basis. "It is important in circumcision decisions to think well ahead, say, 20 years."
The Canadian Paediatric Society, whose job it is to balance the evidence and come up with a conclusion, says circumcision is not medically justified. A position statement on circumcision released in 1996 by the Canadian Paediatric Society and reaffirmed this year recommends that circumcision of newborns "should not be routinely performed. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns."
Circumcision is also an interesting legal conundrum. Canadian law does protect vulnerable persons from operations on their bodies unless deemed medically necessary, so it can be argued that parents have no right to subject babies to the procedure.
Circumcisions are not always done on newborns. Some of the procedures, such as Mr. Lam's, are done in older children or young adults, often because of a condition called phimosis, which means the inability of the foreskin to retract. But the recent British Medical Journal article on circumcision rates says too many boys are still being circumcised because of a misdiagnosis of phimosis. Phimosis requiring circumcision only affects a tiny percentage of boys: 0.6 per cent.
There are alternatives to try before cutting off the foreskin. A group of pediatric urologists in Barcelona, Spain, studied the effectiveness of using topical steroids in childhood phimosis and found it is a safe, simple and inexpensive treatment.
Dr. Munk's prescription to mend a tight foreskin is low-tech and relaxed. "Time, patience and basic hygiene," he recommends. "Phimosis does happen occasionally," he explains, "but by the late teens the tissue usually stretches and the adhesion is released."
If Dr. Taylor has his say, parents making decisions about their sons' foreskins will start with the premise that it is a valuable part of the body. "In the equation, the value of the actual foreskin is often put at zero," he said. "Put a value on it. It is a structure in its own right."
Observing a circumcision
Saju Begum is having her newborn son circumcised at St. Michael's Hospital in Toronto. In the Muslim faith, boys must be circumcised before they turn 18 -- and most are done shortly after birth.
The sleeping baby is strapped into a plastic tub. He is comfortable and warm because, from the waist up, he is wrapped in blankets. Pediatrician Dr. Ricardo Olivares injects a needle full of anesthetic twice on either side at the top of the baby's penis to freeze the area.
The baby wakes up and starts to cry, but is easily pacified by a rubber nipple full of sugar water from the chattering nurse. With a sharp instrument, the doctor scrapes the foreskin, which is surprisingly thick, away from the head of the penis.
A circular Gomco clamp is inserted onto the penis and the foreskin -- amounting to about half the covering of the penis -- is pulled through the clamp, all the way around. Then the doctor cuts the ring of skin off against the base of the clamp. There is some bleeding, but not a lot.
The baby, who has momentarily lost his pacifier, is screaming. He settles back down when the nurse puts the nipple back in his mouth. His exposed gland is wrapped in sterile gauze and covered in vaseline, and his diaper is put back on.
Dr. Olivares says he let a reporter watch the procedure because the more people know about it, the easier it is to make a decision. "It is healthy to question the validity of procedures and not just take the doctor's word for it."
As with any surgery, there is a small risk of complication. About one in 500 babies reportedly suffer from damage to the penis, either from human error or clamp malfunction. The U.S. Food and Drug Administration Center for Devices and Radiological Health received 105 reports of injuries involving circumcision clamps between July, 1996, and January, 2000. "These have included laceration, hemorrhage, penile amputation and urethral damage," says an FDA bulletin.
A Jewish ritual circumcision is very different from a hospital circumcision, says Dr. Aaron Jesin, a mohel and general practitioner in Toronto. Mohels perform ritual circumcisions on the baby's eighth day of life, usually in a home, rather than a clinical setting. They do not use Gomco clamps, but rather pinch the foreskin until it loses feeling and then cut, an operation that Dr. Jesin says causes no bleeding and only takes a few minutes. "The reason I do them is so that parents have free choice and they don't have to run around looking for someone to circumcise their son. There are also medical advantages," he says.