In order to show the relative importance of the various indications, or alleged indications, for circumcision they will be discussed under three headings:- Essential, Advisable and Optional.
The operation is obligatory for infant Jewish and Moslem males as a religious rite so it is not open for discussion.
Routine circumcision at birth other than for religious reasons is a custom in several countries and in some families in this country. Most males are circumcised soon after birth in the U.S.A., Canada, Australia and New Zealand but until recently this was rare in Continental Europe. In Britain, routine operation is much more common among the well-to-do than manual workers; and it is an open secret that Prince Charles was done by a Mohel, or Jewish circumciser, and that his two brothers are also circumcised. Every parent wants to do what he thinks best for his child and this may include a sincere belief in the benefits of circumcision. Common reasons given by parents requesting the operation are "His father was done"; "It's more hygienic" and "It will prevent trouble later in life". One can sympathize with the man who has unpleasant memories of having the operation later in life and thus seeks to avoid the same situation in his sons by requesting circumcision at birth. Likewise, one can understand the request when an older son, or child of a relative, is distressed by circumcision later in childhood.
It is not uncommon for a man to be dissatisfied with the size or appearance of his penis. Quite a number of men have an intense desire to be circumcised which usually arises after seeing the circumcised organs of brothers or school fellows. In time, this initially simple wish to have the appearance of his penis improved becomes an obsession in which he feels that the continuing presence of his foreskin is affecting his sex life. If he is brave enough to confide in his doctor he will be told that his penis is quite normal, operation is not necessary, and he should see a psychiatrist and not a surgeon. Most surgeons are unsympathetic and would refuse to operate on these unfortunate individuals even as private patients. Whilst it is true that the patient's mental attitude is the cause of his sexual disability, it is equally true that circumcision cures the condition. The stand taken by doctors on this issue is quite inconsistent when one considers that a woman who thinks her breasts or nose are not quite the right shape is sent to see a plastic surgeon without any investigation of her psyche.
After infancy the foreskin should be loose enough to be drawn back so as to completely expose the whole penis head and to be pulled forward again without pain or difficulty. In the mature youth this action should be possible with the penis erect. If it cannot be retracted at all (phimosis), washing is not possible and smegma accumulates. Phimosis also makes sexual intercourse unsatisfactory and low deposition of semen in the vagina due to poor penetration may cause infertility. Occasionally the opening becomes so small that even passing water becomes difficult. If a tight prepuce is forcibly drawn back (e.g. during intercourse) it may become jammed and incapable of being pulled forward again (paraphimosis). In this painful condition the foreskin strangulates the glans and emergency treatment is necessary. So heed the warning signs that paraphimosis is going to occur when you are no longer able to draw the foreskin forward after sexual intercourse until the erection subsides or when painful little splits appear in the tip of the prepuce during sexual intercourse. Phimosis may follow injury (e.g. zip-fastener!), inflammation (see below), or it may be a developmental abnormality. Parents are often surprised to learn that their teenager needs a circumcision, having been assured he was perfectly normal earlier in life. The explanation is that before puberty the opening in the prepuce was large enough to allow the glans to pass through but during the rapid growth of the penis after puberty only that part of the foreskin which covers the glans enlarges. In consequence, the tip of the prepuce which lies beyond the glans does not grow, the opening stays the same size and the much enlarged glans will no longer pass through (puberty phimosis). A tight prepuce cannot be cured by stretching at any age because this only causes little splits which heal with scarring making the condition worse than before.
In spite of adequate hygiene one may suffer from persistent or recurrent soreness, itching or redness of the inner aspect of the foreskin and penis head p; a condition called balanitis. Occasionally there may be an acute attack with a discharge of pus which resembles gonorrhoea. Balanitis may also occur before the prepuce has fully separated from the glans in childhood when washing is not possible. A long prepuce tends to retain moisture predisposing to this condition which is often precipitated by warm weather (summer balanitis). Balanitis occurs especially in sportsmen and others who sweat a lot. One or more acute attacks or recurrent mild attacks heal with scarring of the foreskin and phimosis develops. Similarly, inflammation affecting the glans may heal with scarring and narrowing of the water pipe opening (meatal stenosis). If passing water becomes difficult an operation (meatotomy) to enlarge the opening may be necessary. A variety of germs will flourish under a damp prepuce and they are difficult to permanently eradicate until the area is rendered permanently dry by circumcision. Thrush or Monilia, a fungus infection, is quite common in the vagina of women on 'the pill' and their male consorts are liable to get 'thrush balanitis'. Due to the presence of sugar in their water diabetics are also prone to balanitis. Similarly warts under the prepuce, which are caused by a virus infection, are difficult to cure until circumcision is performed. If you suffer from balanitis seek medical advice and do not treat yourself with a strong antiseptic which may make the condition worse.
The frenulum (also called frenum or frænum) is a band of skin containing a blood vessel and some sensory nerves which joins the inner aspect of the prepuce to the glans on the under surface of the penis. Drawing back the prepuce pulls upon the frenulum and in full penetration during sexual intercourse the frenulum is quite taut. If the frenulum is short or tight, full penetration may cause discomfort which may last for several days; or the structure may tear causing a painful wound for a longer period. Occasionally smart bleeding occurs which requires emergency treatment. Surgical division of the frenulum usually cures the trouble and this can easily be done under local anaesthesia. Sometimes circumcision has to be done as well to relieve the tension in the frenular area. A lad should be instructed to check that his frenulum is satisfactory before he leaves school. He should be able to completely retract his prepuce so that it lies flat along the shaft of his erect penis without causing pain or markedly bending the glans downwards.
Phimosis and persistent balanitis are the most common medical reasons for circumcision in this country. Have yourself circumcised if you suffer from these troubles because they will get worse with time and may lead to more serious complications in later life. A vicious circle develops in which balanitis produces phimosis which prevents washing the penis and leads to further attacks of balanitis, due to lack of hygiene, with more scarring. If phimosis is the primary condition then balanitis will sooner or later be a complication and the same cycle of events results. Men who get cancer of the penis usually give a history of 20-40 years of phimosis and/or chronic balanitis so these troubles have more than just a nuisance value. It is not generally known that the tendency to penis troubles is inherited so if a man has trouble with his prepuce or frenulum he should seriously consider having his sons circumcised at birth as a preventative measure.
Balanitis and its complications may occur in this country but are even more likely to occur in individuals who are going to live in a warm climate. In hot and humid countries the inhabitants are aware of the problem and practice routine circumcision in childhood as a preventative measure. Merchant seamen, particularly engine-room staff, are also at risk and although circumcision is not a condition of employment it is a sensible precaution and advised by some firms. Whilst one cannot predict that anyone will have trouble abroad or at sea, it is probably better to lose a normal prepuce at a suitable time under optimum conditions in the U.K. than find that the operation has become necessary when conditions are primitive, the time is inconvenient, the foreskin is inflamed and medical aid is not readily available. The normal penis heals rapidly after circumcision but healing may be delayed and the wound become infected in tropical conditions, particularly in the presence of balanitis. To be unable to work because of an attack of tropical balanitis is embarrassing enough - but no one will believe that it is not really a dose of V.D.! Chefs and other kitchen workers are a further example of those at risk - with the added complication that food hygiene can be compromised if one is constantly rubbing at the irritated foreskin.
As we have already seen in over half the male population the prepuce shortens during development leaving the glans partially or completely exposed but in the remainder the long infantile form persists. The persistence of a long foreskin must be regarded as a failure of normal development because of the greater incidence of troubles associated with this state. Foreskin length is an inherited characteristic; thus if a man finds his long prepuce is a nuisance then his sons are likely to grow up also wishing they had been circumcised when they were small. A long foreskin retains moisture so that the inner aspect of the prepuce and the glans become white, sodden and malodorous. Balanitis develops in the devitalized tissues and even if the inflammation is mild, phimosis may follow in a few years. A long prepuce may be an anatomical cause of premature or early ejaculation, a condition in which a man 'comes' too quickly during sexual intercourse and sometimes even before he has entered the vagina. It seems that the glans is too sensitive due to a combination of over-protection from an excess of foreskin and some degree of balanitis. A long foreskin may also be a nuisance during intercourse due to its sheer bulk. An excess of prepuce may cause social embarrassment or to quote one youth "I'm fed up with the comments about my elephant's trunk in the school showers". The troubles which may be associated with a rather long foreskin suggest that it is a redundant or unwanted piece of skin and it would be better to complete the development process by shortening it surgically. It is interesting to record that a man with a long prepuce living in the U.K. runs a much greater risk of foreskin troubles than he would of developing say tetanus, T.B., polio or other diseases against which he will, however, probably have been protected by immunisation.
Having shown that a tight prepuce is a definite indication for circumcision one would expect that a rather loose one would be an advantage. A loose, short foreskin usually causes no trouble during sexual intercourse but it may ride to-and-fro during everyday activities trapping pubic hairs. A long, loose foreskin may be a nuisance if it will not remain retracted as a collar behind the glans during sexual intercourse but tends to slip forward re-covering the glans. The man virtually masturbates inside his foreskin during intercourse and his partner complains of lack of stimulation.
Severely physically handicapped males may be unable to wash their own genital area, while the mentally handicapped may be incapable of learning and appreciating the need to do so daily. It is therefore desirable to relieve them of this problem, and the resulting risk of serious infection, by performing a complete circumcision. Where the degree of handicap is obvious in infancy then this is naturally the best time to perform the operation, otherwise in the early teens. If the severely handicapped boy is to live in a residential institution (even on a weekday only basis) he should be circumcised before starting there so as to avoid unnecessary embarrassment when his genitals are cleaned for him by strangers.
Cancer of the penis affects men in the 40-70 age group and being fairly rare only causes 80-100 deaths every year in the U.K. It is treated by partial or complete amputation of the penis and about half of the victims survive for 3 years. Men who develop this cancer give a history of phimosis and/or balanitis over a period of years. Smegma seems to be the cancer producing agent which accumulates before the foreskin becomes retractable in the child, or later in life when hygiene is not practised due to phimosis or ignorance. Complete circumcision in the first three years of life completely prevents this disease and a lesser degree of protection is afforded if circumcision is incomplete or done later in life. Whether it would be justifiable to circumcise all new born boys to protect the small number who will later in life get penile cancer is a matter for debate. It has been suggested that it is better to lose a little bit than risk losing the lot!
The low incidence of cancer of the neck of the womb or cervix in Jewesses has been known for a long time and investigation has shown that it is associated with circumcision of their menfolk and is not a racial immunity. Statistics in Moslems and other groups practising circumcision in various parts of the world have produced conflicting results and overall the operation seems to be less effective in preventing cancer in non-Jewish people. Jewish and the other circumcised groups may not be strictly comparable because whilst all Jews are thoroughly circumcised soon after birth the others may have been incompletely circumcised at various times after birth, or into their teens. Also unreliable answers about circumcision status may be given by men (and/or their wives) when they are not Jewish or Moslem. It is now known that a number of factors are involved in cancer of the cervix and circumcision is of secondary importance compared with the other variables - personal hygiene, age at first intercourse, and number of partners. Good personal hygiene may well be the relevant factor and this is ensured by circumcision; but herpes virus infection has recently been implicated in the causation of cervical cancer.
The prostate gland lies at the base of the bladder and supplies part of the liquid which forms the semen ('come'). Cancer of the gland may occur in later life and it causes about 3,000 deaths a year in the U.K. Circumcision may be a preventative measure since the disease is less common in Jews than Gentiles and herpes virus has now also been implicated in the causation of this disease.
Those who argue that soap and water are all that is required for penile hygiene and that circumcision is quite unjustified are ignoring the evidence that many males forget or ignore this part of their toilet. Parents must show the boy how to retract his prepuce at bath time until he is old enough to do this for himself. Due to fear, ignorance or embarrassment in dealing with his 'privates' they often fail to give this instruction; and subsequently to ensure that he keeps this part clean. Circumcision renders the penis permanently clean and avoids the washing and inspection which may draw unnecessary attention to his penis at an early age. As we have already seen, where the hygiene problem is the result of physical or mental handicap then circumcision becomes not just optional but highly desirable.
Many women think that their baby sons look neater and tidier after circumcision. In their husbands some think the circumcised penis is more handsome and do not regard the operation as a mutilation. They may well be 'turned on' by the sight of the naked glans but the absence of smell and smegma may be contributory factors. Women are more willing to participate in fellatio (oral sex) if their partner is circumcised. The glans without its masking foreskin tends to produce a more prominent bulge in tight clothing which some females find sexually stimulating.
A male reaches his climax or orgasm ('comes') in about half the time it takes a female to achieve orgasm. The ideal is for the female to have one or more orgasms before the male reaches his climax. It is not uncommon, particularly for inexperienced men, to have difficulty in delaying orgasm to meet the needs of their partner. Various measures, including circumcision, may be used to delay orgasm. After circumcision the glans becomes dry, tougher and less sensitive. Most men find that after the operation orgasm is delayed but much more intense and their partners notice that they 'last longer'.
After circumcision the glans increases in girth, since it is no longer constricted by the prepuce, and the margins of the base of the glans become more prominent. In the uncircumcised man the rolled back foreskin masks the margins of the glans hence circumcision makes these parts more prominent during intercourse. The circumcised penis thus makes better contact with the vagina increasing stimulation and pleasure for both partners.
Whilst there is no exact relationship between stature and the size of the penis there is a general tendency for the shorter man to have a smaller penis. In Britain growth of the penis is complete by about the seventeenth birthday and the average man then has an organ which when erect is 6" (15 cm) long and 5" (12.5 cm) in circumference at the base. The importance of penis size as a factor in sexual adequacy has been exaggerated but it must be apparent that to give the same amount of stimulation the man with a short penis must insert a greater proportion of his organ than his better endowed neighbour. A limiting factor in penetration is how far a prepuce can be drawn back without causing discomfort. The size of the penis cannot be increased but circumcising a small organ may be a useful measure in enabling a man to give greater satisfaction to his partner.
Circumcision does not prevent V.D. but men who are circumcised, or have naturally short foreskins, are less likely to become infected than those with long foreskins. The protection afforded is due to the toughening of the glans and the dry conditions which are unfavourable for the growth of germs. Circumcision does not affect the incidence of gonorrhoea and syphilis, but of the other sexually transmitted diseases genital herpes, genital warts and thrush balanitis are much more common in uncircumcised males. Circumcision may be necessary as part of the treatment of thrush balanitis and genital warts. There is no effective treatment for herpes simplex virus and if it is confirmed that it plays a part in the causation of cancer of the cervix then, in the face of increasing promiscuity, circumcision at birth may be advocated as a preventative measure. Recent research has indicated that circumcised males are slightly less likely to contract AIDS than their uncircumcised brethren in similar circumstances (this is due to the drying and toughening of the circumcised glans and the reduced risk of tearing of the frenulum). It has also been shown that circumcised infants are less likely to suffer from non-specific urethritis (inflammation of the urethra, or water pipe), which can lead to permanent damage to the kidneys in more severe cases.
A small number of boys show signs of distress if they are different from their brothers in respect of their circumcision status. This is particularly true at the time when a young uncircumcised boy starts to notice the difference between himself and his older circumcised brother or brothers. The resulting psychological disturbance can lead to various problems including enuresis (bed-wetting). Parents may therefore wish to consider the advisability of having younger sons circumcised at birth if their older brothers have already been circumcised. Similarly if one son needs a circumcision for medical reasons then his parents may want to consider having all his brothers, both younger and older, circumcised at the same time to keep them alike and avoid possible future problems.
Between 10% and 16% of males in this country are circumcised and most of them are satisfied that the operation has produced a trouble-free penis of acceptable appearance which functions well during intercourse. In circumcision for medical reasons (usually phimosis) there may be incomplete removal of the prepuce and the penis looks the same as in the 20% or so of men who have naturally short foreskins. The patient is usually quite satisfied because the operation has cured his trouble and the preputial remnant does not cause any bother. A minority are dissatisfied with their circumcision because the penis looks untidy due to the remnant of prepuce, or an ugly wound scar, and occasionally because the operation has failed to cure the balanitis for which it was performed. If an individual finds his circumcision functionally or aesthetically unsatisfactory he can be re-circumcised to give a better 'end' result. If the problem is physical rather than aesthetic then revision surgery should be available under the N.H.S.
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