HEALTH / Common procedures: Circumcision

CIRCUMCISION is removal of most of the foreskin or prepuce, the tube of skin that covers the head or glans of the penis. Ritual circumcision in the first few days after birth (with only a local anaesthetic, or none at all) rarely causes serious complications. But there are a very few tragedies from uncontrollable bleeding, infection or scarring.

Circumcision later in life is a straightforward surgical procedure done under general anaesthetic; the greater part of the foreskin is removed and the cut edge carefully sutured. The wound takes a week to heal, and there is a very small risk of complications.

Worldwide, it is common for newborn boys to be circumcised for religious reasons; in Africa, the procedure is carried out later in childhood as part of an initiation ceremony into adulthood. There is no reliable evidence on the effects of the operation on sexual sensation or performance. In Britain, circumcision is done less often now than earlier this century, but recent surveys have shown that around 6 per cent of teenage boys have been circumcised. Doctors estimate that only 1-2 per cent actually need the operation for medical reasons. So why does one in every 17 boys still have an operation that medical experts agree is unnecessary?

Part of the explanation is cultural; a father who was circumcised as a child has no practical experience of life with a foreskin, and he and his partner may accept that 'all the boys in our family are circumcised' and persist with the tradition. They may justify their decision by a belief that a circumcised penis is easier to clean; their doctor may give further support by telling them that cancer of the penis is unknown in men who have been circumcised but still occurs in other men and can be fatal. These beliefs do have some slight basis in fact. The medical facts about the foreskin were recently reviewed in the British Medical Journal. Before birth, as the foreskin develops, it is fixed to the head of the penis beneath it. At birth, the foreskin can be pushed back over the head of the penis in only a small fraction - 4 per cent - of boys. By the age of five this proportion has risen to 90 per cent or more, and by the age of 17 it is close to 99 per cent.

Parents and doctors unaware of this pattern of normal development may believe that a boy with an unretractable foreskin should have it removed, even if it is causing no problems. In practice, even if the foreskin seems firmly stuck down, it usually becomes free without any surgical interference. In a few cases, however, the head of the penis becomes inflamed - balanitis - or the foreskin may be so tight that it interferes with urination - phimosis. In these circumstances circumcision may be recommended.

What about the cancer risk? Cancer of the penis is so rare in Britain that little can be said about its causes - except that there does seem to be a link with smoking (as there is for cancer of the uterine cervix in women). Current medical teaching is that the disease is associated with poor personal hygiene. Certainly boys who have not been circumcised need to be taught to wash under the foreskin as a routine. Shortly after birth their parents may need some instruction from the midwife or health visitor about what is and isn't normal. If this were done thousands of unnecessary operations might be prevented.