Circumcision: a medical student’s view

15 Square has had a long, happy and fruitful association with Keele University’s School of Medicine. Medical students at Keele are given the opportunity of a placement with a local charity or other organisation concerned with some aspect of health care or provision.

Last autumn one of the students who chose to be placed with 15 Square wrote this excellent report on her placement with the charity.

Visiting 15 Square on placement this year has been an incredibly eye-opening and educational experience.

Beforehand, I had not considered nor ever been prompted to consider, what circumcision could mean for different individuals other than it being a “minor procedure” that was performed in some cultures. Indeed, I didn’t really picture it in my mind as surgical, but as an act akin to removal of a skin tag or freezing of a verruca.

I have since learned how extremely invasive, painful and scarring the procedure can be and how the consequences can be devastating, shaping individual’s entire lives as they come to terms with the physical and psychological damage that can linger long after the scars have healed.

Male circumcision is embedded deeply into some religions and cultures, where it has sat protected and unchallenged for centuries and such has desensitised society to the detail of what occurs.

Whilst, as a whole, the Western world is united in recognising female genital mutilation as criminal, we are guilty (myself included prior to my placement with 15 Square) of viewing circumcision as a minor and outright different act.

I questioned myself why I had never considered it to be in the same bracket and it was wholly ignorance of the procedure itself, the significant change it can have on the male genitals and the life-long effects it can have on the men who have had it.

Cultural and religious circumcision is almost always carried out immediately after birth, when it is thought the child can’t recognise the pain as much as when more developed. Whilst this may be true to some extent, the removal of a significant piece of anatomy without any consent is akin to nothing else practised. Countless males have contacted 15 Square to express how they felt an incredible sense of loss when they realised that a part of them had been removed unnecessarily and expressed that they felt robbed of something that was theirs. This has led to resentment
towards parents, particularly as it is often not openly discussed and many young boys don’t realise that they have had the procedure until they are older.

Outside of cultural and religious circumcision lies clinical circumcision. The majority of clinical circumcisions are performed in order to “fix” phimosis (inability to retract the skin covering the head of the penis1). Hundreds of worried parents of boys with phimosis have contacted 15 Square to ask for advice about what alternatives there are to circumcision (of which there are many) after being told by a doctor that the only option is circumcision which is simply not the case. Many parents recognise that circumcision is a drastic measure to take but feel they can’t get doctor’s to seriously consider other options first and that’s only when doctors are even aware of other options which, according to much of the correspondence with 15 Square, they aren’t. What may seem like an easy referral for surgery and “quick fix” should not be the first port of call when it results in an irreversible change for the individual concerned.

For some already circumcised, finding out afterwards, that there were alternatives that were not explored first, can be devastating. One such individual wrote to 15 Square after having a circumcision for phimosis and said “to learn now that there were alternatives is quite possibly the most depressing day of my life.” He had, as most would, trusted his GP when told that the only option for his phimosis was circumcision and only discovered afterwards via 15 Square’s website that there were other options for him that should have been exhausted before using circumcision as a final resort. Alternatives as simple as applying steroid cream to the penis and gently stretching of the foreskin daily in a warm bath is enough to fix phimosis for many whose doctors have been reluctant to prescribe the cream or recommend the stretching, sometimes referring straight for circumcision without even examining the patient.

As a future clinician, I found increasingly alarming how often the testimonials reported that their GP was unwilling to engage in any kind of discussion about alternatives, some going as far to say that “it is that (circumcision) or nothing.” Though ignorant myself about male circumcision prior to this placement, I would have expected that by the time I was practising, I would have good awareness of different treatment options for males presenting with phimosis as it is common to experience to varying levels of severity at some point in life, with some requiring treatment. Through reading hundreds of letters from males, it is evident that the most commonly repeated phrase and cause of frustration for the patients was that the doctor said there was no alternatives to circumcision for their phimosis. Of course, it cannot be assumed that alternatives are suitable in every case and that each and every time the doctor was wrong to say it was the only option. In some cases, men may well have presented to GP’s with such severe phimosis that GP’s have felt that circumcision was important in order to (ironically) save as much penile tissue and function as possible.

Furthermore, it’s important to acknowledge that decisions made about referral to circumcision will have been made with the patient’s best interests in mind but it doesn’t stop the fact that many of these receiving the circumcision are not receiving it as a ‘last-resort’ (as it should be viewed according to NHS-choices)but as a first-resort and indeed only-resort and this has to be attributed to the doctor’s lack of knowledge and understanding or lack of belief of the effectiveness, of these alternative methods.

So, do these alternatives work? Amongst the hundreds of messages received from men saying they were offered only circumcision for their phimosis, which they now regret, are the stories of men also told that circumcision was the only option for them but went on to have a fully functioning retractable foreskin again through the alternative use of steroid cream when possible, warm baths and gently retracting the foreskin daily.

This strongly suggests that many doctors are recommending circumcision to men who are not in drastic last-resort situations and through resisting the recommended circumcision and using other techniques, have gone on to have full foreskin retractability again, contacting 15 Square to share their stories. As would any patient presenting with a complaint that may ultimately need surgery, it can be assumed that most men with phimosis would want to try other methods before being referred for surgery, due to the increased risk that comes with any surgery including adverse reaction to anaesthetics and infection risk.

Therefore, it shouldn’t be that men are leaving appointments with nothing else but a circumcision referral letter, atleast without discussing and exploring the less drastic alternatives first. According to many men who have contacted 15 Square however, this is not the case and the alternatives are not being explored.

For most, circumcision is not an easy subject to discuss for a plethora of reasons.

For society in general, it is related to the privacy and intimacy of the area itself – discussing genitals is not really a round-the-table-dinner topic for the average family, regardless of culture or religion. In Medical School training, however, reluctance to discuss the intimacies of the body and any previously held inability to discuss should be, and generally are, quickly overcome such is the nature of the course. Therefore, it seems that perhaps it is the fact that circumcision is such a cultural practise that halts the conversation and discussion around it, for fear of offending or seeming to judge a cultural practise that many, myself included, had never stopped to question.

Coming to terms with a circumcision can be difficult for male’s who have consented to circumcision as adults, regardless of whether they feel it was necessary or not as it comes with an obvious change to physical appearance but additionally, changes to sensation and sexual function can be experienced too. However, it can also be extremely difficult for those who had circumcisions in infancy as they report battling with feelings of intense resentment and confusion as to why it was carried out.

Coming to terms with the fact they feel something was removed from them unnecessarily can have lasting effects. Anger towards parents who organised for the procedure to be done weighs heavily amongst the correspondence with some never recovering from that sense of loss. One such man wrote – “I can’t change the fact I was mutilated. A constant reminder every day. The scars, the physical and emotional pain.”

15 Square continues to be a vital lifeline for so many individuals and through having access to its archive I have been able to fully appreciate how, what is posed as a “minor procedure” can be life shaping and extremely significant for many who receive it.

My eyes have truly been opened to the subject and I have felt compelled to discuss it with my peers in order to get more of a discussion going about something that many of us will encounter at some point in our careers but, like myself before this placement, may not have considered the significance of physically and psychologically for those receiving it. I feel like we, as future healthcare professionals, owe it to all those who were not allowed or encouraged to explore alternatives before being circumcised, to make sure we are fully informed about the other options that are out there so that fewer men feel that they have been unnecessarily altered going forward.

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