Circumcision: yes or no?

What is circumcision?

Male circumcision is a procedure during which the foreskin, which covers the glans of the penis, is cut off.

Who practices circumcision?

In South Africa, circumcision for cultural or religious reasons is practised by most isiXhosa groups, Jews, Muslims, and sePedi, and is common among seSotho, tshiVenda, Tsonga and Ndebele people, according to Majaja et al, in a study conducted by the HSRC in 2009. (Of all SA’s cultural groups, circumcision is least common among isiZulu spreakers.)

In South Africa, adolescent or young adult males – specifically isiXhosa – are circumcised by traditional practitioners during an initiation ritual, while Jewish and Muslim babies are circumcised by religious elders days after birth.

Is it legal?

Circumcision is enjoying good press from the South African government since the Orange Farm study has shown that circumcised men are much less likely to be infected by the HI–virus (from HIV-positive partners) than uncircumcised men.

The government is actively encouraging adult men to become circumcised, says Dr Sean Doherty, senior consultant in urology at Chris Hani Baragwanath Hospital in Johannesburg. “At Bara, the Khula Ndoda circumcision centre offers free walk–in circumcisions to men who agree to be tested for HIV,” he says.

So it may seem strange that the South African Children’s Rights Act 2005 includes the following lines:

Circumcision of male children under the age of 16 is prohibited, except when is performed for religious purposes in accordance with the practices of the religion concerned and in the manner prescribed; or circumcision is performed for medical reasons on the recommendation of a medical practitioner. (Section 12.8).

Legal opinion on the interpretation of this law varies, with anti–circumcision activists saying elective circumcision amounts to genital mutilation, and parents should be prosecuted. Proponents argue that the HIV transmission figures amount to persuasive enough “medical indications” for parents to be allowed to choose to circumcise their young child.

Another reason parents cite in favour of circumcision is that penile cancer rates are lower among circumcised men, says Dr Doherty – nearly irrelevant in developed countries, where it is extremely rare. However, in the developing world about 10% of cancers in men are of the penis. However, circumcision is only protective in this case if it’s done as a child.

There is no evidence to suggest that a circumcised penis is less sensitive than an uncircumcised one or affects an adult male’s sex life. Taking into account these pros and cons, Dr Doherty’s advice is always to leave a boy intact if there’s no medical or cultural need to circumcise.

Regardless, elective circumcision remains a widespread practice among South African parents. If you do choose to circumcise your son, you should be aware of the debate around circumcision, and the details of the procedure and aftercare.

What are the medical reasons for circumcision?

He says a medical indication for circumcision is phimosis (when the foreskin is tight and cannot be retracted behind the head of the penis) and paraphimosis (when a pulled–back foreskin becomes stuck behind the head of the penis, and swelling and discomfort then occurs).

However, don’t be concerned if you cannot pull your son’s foreskin back all the way. (And don’t yank – you could do damage!) ‘You can gently retract the foreskin in the bath to clean the tip of the penis, but never force it back,’ says Dr Doherty.

Many boys’ foreskins are tight, and children’s foreskins are naturally attached to the head – a ‘prepupal adhesion’, in medical–speak – until about age 5. You don’t need to circumcise your son under these circumstances. Your child’s normal erections will usually stretch the skin sufficiently so that the foreskin can retract with ease by the age of sexual maturity.

When is the best time to circumcise?

If you want to circumcise your son, medical practitioners wait until a baby is older than 6 months, as the risks of general anaesthesia reduce after this time.

But religious practice usually demands that a child is circumcised within days of being born, and in such cases it is performed without general anaesthesia. This is possible because ‘there is very little blood supply to the foreskin in a newborn,’ says Dr Doherty. ‘In other words, there is very little bleeding after the circumcision and no stitches are required.’

Older children will require stitches, for which they need to keep still – and because that is impossible for a child to do under local anaesthetic, the preferred method is under general anaesthetic.

How is it done?

Circumcisions can be done under local or general anaesthetic, in an operating theatre or in consulting rooms, and by a general practitioner or a specialist such as a urologist, says Dr Doherty.

‘I use the dorsal slit method,’ says Dr Doherty. ‘A vertical incision is made into the foreskin on the upper (dorsal) side of the penis. If your circumcision is to relieve phimosis or paraphimosis, you could stop there, and leave the foreskin intact apart from the incision. But because this leads to an unusal appearance, I usually continue to cut away the foreskin around the head of the penis, and then cut away the mucosa on the inside under the glans, to complete the circumcision.’

‘You may also have heard of the clamp method. In this case, a hollow cup is fitted over the head of the penis, the foreskin is pulled over the cup, and a clamp tied around the cup and skin. Over a period of 5 days, the lack of blood supply to the foreskin means it gradually dies off and falls off.’

‘Another form of clamp circumcision is when the foreskin is pulled over the head of the penis and clamped there,’ he adds.

Aftercare

Your child will emerge from theatre with a bandage around his penis. ‘We advise parents to leave the bandage on for 3 days, but kids being kids, it’s usually off by the time you’ve reached the car,’ jokes Doherty. ‘This is not a problem. Just keep the area clean and covered – and remember to keep your follow–up doctor’s appointment in 10 days or so to track the healing progress.’

‘Expect to see some blood, swelling and bruising,’ says Doherty. ‘But take heart that your boy will look normal again by 6 weeks post–operation.’

Doctors usually use absorbent stitches which dissolve by themselves over a period of 6 weeks.
You will be advised to give your child pain relief (such as Panado) for 3 days, and then as needed. You should also gently rub an antibacterial cream (such as Bactroban) on the wound, loosely tie nappies so that you don’t put pressure on the penis while it heals, and rinse the penis with warm water for cleansing.

BUT CALL YOUR DOCTOR IF:

• Blood around the penis is bright red and is soaking through the dressing onto the nappy.
• Your baby has not passed urine or produced a wet nappy for 24 hours after the procedure or shows signs of fever.

60% less chance of contracting HIV if males are circumcised.
Clinical research done by the Clearinghouse on male circumcision, says this statistic refers to medically performed circumcisions.