Believe it or not, an American city, San Francisco, is voting to proscribe one of the central rituals of an entire religious community, the Jewish people, who have been circumcising male infants since the time of Abraham. Many Muslims, of course, also practice circumcision for religious reasons, while millions of other American parents have eagerly supported this procedure for their infants for hygienic or health reasons. To add fuel to the fire, a Mohel may be fined $1000 or be committed to a year in jail if this vote is affirmative. Mark Stern, a lawyer for the American Jewish Committee, said, “This is the most direct assault on Jewish religious practice in the United States. It is unprecedented in Jewish life.” The proponents of the bill insist that circumcision is “mutilation and barbaric.”
IS THE JEW BARBARIC?
Are Jews who recommend or undergo circumcisions barbaric people? Russell Crowe said, “Circumcision is barbaric and stupid. Who are You to correct nature?” Is the “You” the Jew? Do anti-Semites think that Jews are barbaric? How about Voltaire in 1694? “The Jews are nothing but an ignorant and barbaric people.” What about Martin Luther in 1483? The Jews are “bloodthirsty, revengeful, barbaric, and murderous.” And Benjamin Franklin, “There is a great danger for the United States of America. This great danger is the barbaric Jew.” But do not be concerned,” Russell Crowe continues. “I have many Jewish friends. I love my Jewish friends. I love the apples and the honey and the funny little hats, but stop cutting your babies,” he declared. Who gave these narcissistic people a moral authority that they alone can determine what is best for Jews, Muslims, and others who prefer the benefits of circumcision for their male children?
FEMALE GENITAL MUTATION
The anti-circumcision activists argue that female genital mutilation is illegal in this country, and therefore argue that boys should get equal protection under the law no matter the religious beliefs of their parents. Female genital mutilation is illegal because it is a cruel practice, medically harmful, and performed for the explicit purpose of preventing female sexual satisfaction. In contrast, there is little or no credible medical evidence that male circumcision is harmful or that it prevents sexual satisfaction. Its purpose is for health reasons and for religious belief.
Anti-circumcision activists have been speaking out against circumcision for decades, but in the last several years the San Diego-based advocacy group has prepared anti-circumcision legislation for 46 states. The head of the group says that “his circumcision as an infant resulted in diminished sexual sensitivity as an adult.” Is this double-speak? How would he know the difference? Does he know for a fact that his limitations or an inability to have sexual gratification is a result of his circumcision? Does he conclude that for thousands of years, no Jews or Muslims or billions of other people have had no or limited sexual satisfaction? There are some data to suggest the opposite – that removal of the foreskin allows greater gratification. Can he argue this?
THE RIGHT TO CIRCUMCISE
Many of the proponents of the ban on circumcision argue that an infant is obviously not in the position to make the decision for himself, and the decision for circumcision should not occur until after age 18 years. But every parent knows that thousands of decisions are made about their children’s health prior to the age of 18, which include many surgical procedures, often for cosmetic reasons.
CIRCUMCISION AND HUMAN PAPILLOMAVIRUS (HPV) INFECTION
An article was published on January 6, 2011, written by Maria Wawer, et al. from Johns Hopkins University and Rakai, Uganda, printed in Lancet. Male circumcision has been linked to a reduction of HPV infection in men and a reduced risk for cervical neoplasia in women with circumcised partners. In this study, HPV-negative men were randomly assigned to undergo circumcision immediately or after a delay of 24 months. The results showed a significant reduction of 28% in the prevalence of high-risk HPV infection in female partners of circumcised male. Male circumcision also reduced the incidence of high-risk HPV in women. The authors suggest the reduced penile HPV carriage may explain the way in which circumcision helps prevent HPV infection in women. The authors conclude that their findings indicate that male circumcision should now be accepted as an efficacious intervention for reducing the prevalence and incidence of HPV infections in female partners.
The foreskin is composed of an outer layer that is keratinized and an inner lining that is a mucosal surface. The inner layer of the foreskin becomes a repository for shed cells, secretions, and urinary residue that tends to accumulate. The warm, moist mucosal environment under the foreskin favors growth of microorganisms. Parents are told not to retract the foreskin of male infants, which makes cleaning difficult. Even if optimal cleansing is performed, there is no evidence that it confers protection. Rather, the foreskin tends to trap and transmit microorganisms both to the man himself and his sexual partners.
Paraphimosis is a condition in which the skin that normally folds over the penis, the foreskin, tightens and retracts and cannot return to its normal position over the head of the penis. If not corrected, the penis will swell and the blood flow to the head may be cut off, damaging the tissue. It is usually caused by inflammation or infection of the foreskin and may be associated with poor personal hygiene. Paraphimosis can only occur in uncircumcised men. Treatment includes circumcision on an emergency basis.
Phimosis occurs when the distal foreskin cannot be retracted over the glans penis. In the infant, the foreskin normally cannot be retracted over the glans and should not be forced. With normal growth and stretching of the foreskin, it will become retractable in 90% of children by the age of 6 years. However, local irritation or infection (balanoposthitis) can cause an abnormal constriction of the foreskin, preventing it from retracting normally. Often there is pain and swelling, which is often associated with infection of the glans. The urinary stream may, in some cases, be diverted or there may be blood in the urine. Occasionally, a urinary tract infection is associated. A circumcision is indicated particularly when there is balanitis, balanoposthitis, urinary tract infection, or obstruction.
Balanitis and balanoposthitis are infections of the glans and foreskin. It is most commonly found in uncircumcised males and frequently presents during the preschool years. Balanitis may be caused by entrapment of organisms under a poorly retractable foreskin—gram-negative or gram-positive bacterial organisms may be causative, and recently, group A beta hemolytic strep has been implicated. Monilia infections (yeast) are also associated with balanoposthitis in infants.
In the adolescent, syphilis as a cause must also be considered. Chronic balanitis and/or phimosis may result in balanitis xerotica obliterans, a sclerotic disease of the foreskin.
Signs and symptoms include swelling, erythema, penile discharge, pain on urination, bleeding, and occasionally ulceration of the glans. Additionally, a careful examination of the base of the penis should be performed to look for a strand of hair, which may cause strangulation and edema.
MANAGEMENT OF BALANITIS/BALANOPOSTHITIS
Initially, topical soaks, topical antibiotic ointments, and oral antibiotics are used, but circumcision is indicated if there is no resolution.
This entity of infectious origin, which results in necrotizing fasciitis, may present initially as cellulitis, balanitis, balanoposthitis, or as scrotal pain and swelling. Prompt surgical consultation and operative incision and drainage of the infected tissue with excision of the necrotic tissue is paramount. This, of course, includes emergency circumcision in the uncircumcised male.
BENEFITS OF CIRCUMCISION
The benefits of circumcision include (1) decrease in many types of infection involving a tight foreskin; (2) decrease in “strangulation” of the penis; (3) lower incidence of inflammation of the head of the penis, (4) reduced urinary tract infections, (5) fewer problems with erections, (6) a decrease in certain sexually transmitted infections, such as HIV, HPV, genital herpes, syphilis, and other microorganisms in men and their partners, (7) almost complete elimination of invasive penile cancer, (8) a decrease in urological problems generally, and (9) prevention of the foreskin getting “stuck in the zipper.”
Problems involving the penis are not rare in pediatric practice. A retrospective study of boys age 4 months to 12 years found that if they were not circumcised, they exhibited significantly greater frequency of penile problems, 14% versus 6% (with P
<0.001) compared with those who are circumcised. A study by Wiswell (1980-1985) looked at 136,000 boys born in U.S. Army hospitals, where 100,000 were circumcised, and there was less than 0.01% complications, which were mostly minor with no deaths. But of the 36,000 who were not circumcised, the problems were more than ten times higher and there were two deaths (Wiswell and Hachey, 1993).
Various types of injuries and trauma can involve the foreskin. One extremely painful example is when the foreskin “gets caught” in the zipper of the boy’s pants, resulting in an extremely painful emergency situation requiring emergency circumcision.
THE WORLD HEALTH ORGANIZATION
The WHO and several Centers for Disease Control support circumcision as a preventative measure against HIV transmission.
PERSONAL OBSERVATIONS AND EXPERIENCE
Many years ago, when I was chief resident at a county hospital, our team investigated the efficacy of circumcision. We catalogued all the disorders of the penis from patients who had come through our emergency room and compared the circumcised versus the uncircumcised males. Over a three year period, there were 300 young boys with phimosis, paraphimosis, balanitis, balanoposthitis, urinary tract infections, staph infections, Monilia infections, and 12 episodes of sepsis emanating from a penile infection. All of these children were not circumcised. In the circumcised group, there was obviously no incidence of phimosis or paraphimosis. There were six boys with local infection, but none were severe and none evolved into systemic illness or sepsis.
SOCIETAL AND POLITICAL PRESSURE
There are recent alarming reports of harassment by medical professionals of new mothers (especially Jews) in an attempt to stop them from having this procedure carried out. There has been a trend by pediatric organizations to skirt the truth in favor of what could be viewed as “New Age political correctness,” spurious “human rights” rhetoric, or perhaps fear of litigation stemming from a very, very unlikely surgical mishap.
The story of pre-war Germany, of the erosion of rights of Jews and other minority groups, of book burnings, of Kristallnacht, of the Holocaust, of the Reichstag trial, of the Night of the Long Knives, of the Nuremberg rally, and of the unfolding disaster throughout the world is old news. I am not an alarmist nor a conspiratorial theorist, but is it possible, slightly possible, or even remotely possible that we are beginning to experience the events of the 1920s and 1930s in Germany – where governmental rules were “codified and classified and recorded to ensure the proper conduct of current and future generations.” Did you hear that Delta Airlines is banning Jews from traveling on their airplanes to Saudi Arabia?
The printed word is powerful. Words by political figures, actors, commentators, and others describing circumcision as barbaric suggests to some (or many) that Jews, therefore, are barbaric. Consider the virtual direct line from the Protocols of the Elders of Zion to spasms of nihilistic violence to anti-Semitism to the Holocaust.” (According to colleagues in Asia, Africa, and the Middle East, this book is their only source of knowledge about Jews.)
We need to rediscover the reverence, gratitude, and amazement that were available in Homeric times. We should cultivate these qualities to provide a bulwark against the nihilism that threatens our world in the 21st century. We need to have a rush of feeling about something, not against something. We need a resurgence of democracy and of victory once and for all against prejudice and racism. We need a rebirth of the American Dream – of the human dream.
Edward Wilson of Harvard University said, “We have Stone Age emotions, Medieval institutions, and God-like technology.” Perhaps, that is the source of our problems.