Monday, August 6, 2012

Circumcision


I am not circumcised but many are, to get my preputial prejudice out of the way.

But there's a rationale and a prejudice.  I plan here to be rational, and reasonable, but to be arguing against the idea that circumcision should be a normal practice of a civilised human society.  (There, I've probably blown that resolve already.)

The issue to me is not that there may not be medical benefits to circumcision, but that the loss of functional and physiological benefits do not justify any such medical benefits.  There may also be psychological benefits.

There are also clearly religious issues.  Two of the worlds great religions promote if not require, their male adherents to be circumcised, and in one expect many of their female adherents to be similarly excised.  I am not going to object to their practices on religious grounds.  Well I am.  I actually think they are babaric and sadistic.  But we live in a tolerant society and time, when if you claim the right to do something on religious grounds we let you, provided harm is not done.

Lets look at these benefits in that order: functional, physiological, then medical, psychological and finally religious.

By functional I refer to the physical properties of the foreskin in intercourse.  This may be considered a little salacious but is well documented in serious medical literature. (1)

The male foreskin appears to be unique in nature.  Many if not all mammals have a prepuce, a covering of the penis that on erection is retracted.  The foreskin provides the same physical protection to the unerect penis, but unlike a prepuce, is normally only retracted on intromission.  Retraction of the foreskin is then done by friction during intercourse.  The uncovered glans is now afforded the pleasures of sliding friction that encourages tumescence and ejaculation.

There is a further effect of the retracted foreskin that results in greater engorgement and thus additional sensitivity of the glans: the retracted foreskin gathers at the base of the glans, and restricts blood flow in the penis.  Blood enters the glans but because of the restriction less easily leaves, thus causing greater swelling.

These effects contribute to success in intercourse.  From an evolutionary, adaptation perspective, they serve to encourage copulation and thus increase the likelihood of reproduction.  A species that reproduces, survives.

Now there is no evidence that the absence of a foreskin reduces reproduction.  Nor that the reverse is necessarily any more true: absence of a foreskin does not improve reproductive success.  Nevertheless, one has to suppose that since we arrive equipped with a foreskin, it has contributed (and does contribute) to our reproductive success.  If that were not so, then through the many generations of our ancestors, evolution would have selected for its absence.

There is some published evidence that the absence of a foreskin changes the pleasures of intercourse.  This evidence cannot come from those circumcised at birth.  There is no comparison either group (uncircumcised or natally circumcised) can offer that is valid, our views will be far too subjective.  There is a group however that could offer some insight: those circumcised as adults, who can (maybe it will be argued subjectively too) offer comparisons of the before and after experience.  However there is no consensus in this group and it is no surprise:  It is impossible to design a thorough scientific experiment that could determine such benefits.  You cannot have a control group, and the experiment cannot be conducted blind, that is with the participants unaware that they have been circumcised!

There is, however, anecdotal evidence in the use of erection stimulating drugs, Viagra, Cialis etc.  Epidemiological studies show that there is a higher incidence of erectile dysfunction in North America than in Europe.  This can be correlated with the incidence of circumcision, which is far lower in Europe than in the USA. (2)  (Of course if this is really the case, you cannot expect the drug makers to be against circumcision!  They are clearly making a lot from erectile dysfunction.)

My final comment on the physical benefit of a foreskin, relates to its presence other then during intercourse.  For most of one's (male) life, one is content with a relaxed and unaroused penis.  Under these circumstances, the glans is covered, and protected from physical contact with clothes, and in early life from diapers.  This physical protection keeps the glans from becoming keratinised and by being hardened less sensitive.  The foreskin has a significant physical protecting role outside of congress. (3)

Now, though lets look at the physiological functions of the foreskin.

The foreskin has a large area, about 15 square inches.  The part in contact with the penis (well not continuous since the foreskin is multipli-folded) contains a large number of glands that secrete fluids around the glans.  Some of these are simply lubricating.  There are langerhorn cells as well that provide antibacterial protection in their secretions.  There are others, that contribute to smegma, a waxy lubricating substance that also contains sloughed epithelial cells.

There are also, highly significantly, a very large number of nerve endings in the foreskin.  Some have identified these in the millions.  Not only is the glans highly sensitive, because of its nerve endings, but the foreskin is as well, if not more so.  It is because of this of course, that we males find our erections so pleasurable and ultimately satisfying.  It is also for this reason that I find it hard to believe that the circumcised penis can be as enjoyable.  But I drift into subjective experiences.

If for no other reason, this seems to me to be the cruelest cut in circumcision: The removal of highly sensitive tissue.  The operation has to be excruciatingly painful, and it is no wonder that infants scream so much during the treatment, even I understand with a local anaesthetic.  The offer of whisky-soaked gauze hardly compensates.

From a medical perspective what goes wrong with the foreskin?  The one condition most often referenced in the literature is a condition known as phimosis.  In this condition the opening of the foreskin is so tight as not to allow the passing of urine. Since this is a painful condition and life-threatening, the resolution is often circumcision, particularly since usually discovered in infants when manual stretching of the foreskin is impractical as a solution.

The most likely cause of other conditions (inflammation of the glans and foreskin) is lack of reasonable hygiene.  When the foreskin is peeled back during normal washing smegma is easily removed along with other potential bacterial and and viral infections.

Other studies have claimed that HIV/AIDS can be controlled through circumcision, suggesting that the virus can harbour within or around the foreskin and be transmitted in intercourse.  This is hard to substantiate in a physiological sense, because HIV has actually highjacked the use of semen. (4)  It exists in the semen of infected individuals, not in their external tissues.  It is transmitted through semen not by direct contact, though clearly there can be auxiliary pathways following ejaculation.

In summary so far:
- the foreskin acts as a physical protection for the relaxed penis,
- the foreskin protects during intercourse,
- the foreskin provides lubrication during intercourse,
- the foreskin enables longer penetration during intercourse, and
- the foreskin provides hygienic protection.

In the absence of the foreskin, none of these benefits can exist.  More so, the absence of a foreskin inevitably leads to a less sensitive organ, through loss of nerves and keratinisation.

How about psychological benefits.  Here I am wandering way outside my fields of expertise and of research, and will immediately claim considerable subjectivity in my remarks.

One of the first things I will claim is that without a foreskin, the individual is no longer whole, he has been deprived, often at birth.  The deprivation may not be obvious and may be reinforced as a good thing depending on the nature of his childhood experiences.  This is not the same thing as being tonsil-less or appendix-free.  Both are beneficial operations that improve quality of life.  Neither is done until necessary, and are not therefore arbitrary procedures.  This is not the case with the removal of the foreskin on or shortly after birth.  Quality of life is not threatened by the foreskin, nor is it improved by its removal.

Next, as noted above, intromission without a foreskin is harder.  Not only harder, but potentially painful, for both parties.  This it seems to me can lead to alienation between the sexes: "What I want to do with you is painful, but highly desirable.  Therefore I will grow to hate and despise you."  If this isnt a significant source of misogyny I dont know what is.  (Ayaan Hirsan Ali talks about this from a female's point of view.)  Well maybe this is getting a bit extreme, but the potential for this effect does seem to me to exist.

Whereas with a foreskin neither of these psychological effects will exist.

Which I guess brings me to religion.  Why would the founders of our religions be so in favour of circumcision?

I would first advance the iron age hypothesis, that there was a time when hygiene was difficult, and that a significant incidence of penile disease existed.  Removal of the foreskin may have reduced this incidence.  In the hands of a self-selecting priesthood, disagreement with whom may have had serious life threatening results, the use of circumcision, may have solidified tribal loyalties.  With a group of tribes from the desert, where water would have been exceptionally precious, such procedures may have been more critical for survival.  In time this became codified in the religion of that and those tribes.

In time this may further have come to be seen as a measure to control the randy impulses of the young, both boys and girls.  There may have been the thought that circumcision would reduce the (supposedly) harmful effects of masturbation *.  But certainly I see circumcision as a controlling measure by the priesthood, and as such a highly sadistic and self-serving rite.

Some will claim that the change from youth to adult needs to be marked.  The Xhosa of Southern Africa require circumcision at puberty as a rite of passage.  The Bar Mitzvah customs of jews is a similar mark of passage to adulthood, though circumcision here occurred much earlier in life.

 As a layman, I have great difficulty in seeing circumcision as a beneficial operation.  There is not a single medical college in North America, Europe or Australia that recommends circumcision as a normal procedure.  Ontario does not provide insurance coverage for the elective surgery.  The incidence of natal circumcision is still high in the USA (around 60%) but is declining; the incidence in Europe under 25%.  The incidence in China and India is well below 5%, in non Muslim and Jewish populations.

 Well, food for thought?  Others have done a better job perhaps than I, but I am now shot of this rant!  Fire your comments at me!

 * An interesting observation on masturbation follows from biological considerations.  Sperm have a limited life in storage of only a few days.  Unless implanted, they need to be replaced anyway.  Masturbation is the evolutionary adaptation that ensures this happens.  This should assuage the guilt many of us clearly feel!
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