Today, as  I promised, Circumcisions 

Circumcisions have been done for thousands of years. Many different cultures from around the world do it. There must be some really strong reason for it to have started so long ago, for it to have lasted so long, and for it to become so widespread.

When I say old, I mean really old. How many people know that the star constellation Ursa Major (that is the Big Bear, in, you guessed it, Latin) is called the Big Bear in cultures as far separated as Africa and Native American Indians? According to Scientific American, human beings started their existence in Africa about 200,000 years ago. The original human tribe included about 40 women, according to DNA studies of mitochondria, which only passes from mothers to children. It started in Africa. We are literally all cousins. One of the youngest human gene pools is Native Americans, which passed from Asia to North America over the Bering Strait about 12,000 years ago and populated the Americas. Yet, Africans and Native Americans both call this constellation the Big Bear. Since it looks like a bunch of stars, and nothing like a bear to me, I presume that the original humans must have named it the Big Bear, and it has been called that ever since.

Similarly, Circumcisions have been around for a very long time. And the origins of the custom are lost into the mists of historical time. It is practiced in a lot of places. Nobody knows the original reason, but it must have been a very good one to justify the risks and the pain. It must have been a very good reason to justify the persistence of the culture, and the very widespread "popularity" of the culture.

Whatever the ancient reasons are, we still do it. The reasons we do it now are pretty clear. It is done because out fathers are circumcised, and their fathers as well, going back to the beginning. Religion demands it for it's own reasons. And social custom demands it because "all of the other boys are done". A few years ago it was determined to a scientific likelihood that circumcision was not necessary. But now, more and more interestingly,   science has determined that HIV is much less likely to transmit if the boys are circumcised. So now, in Africa, where HIV is a heterosexual disease, a lot of the boys are getting circumcised again. Like I've said many times, science seems to cycle. Science is not immune to fads. And the foundation which underlies any particular science can change, rendering moot all of the knowledge built on that particular foundation.

Theologically, there is a story in the old testament. King Abraham at some point made a covenant with God. A modern lawyer would call a covenant a contract. King Abraham's one and only covenant with God was this: Circumcise your sons, and your children will populate the Earth. This is Genesis 17:1-13. Biblical genealogy puts King Abraham at about 4000 years ago. Since then the Jews have populated some Earth, the Christians followed about 2012 years ago, and the Muslims about 800 years ago. The Muslims believe that Abraham himself built the mosque at the very center of Mecca. All three religions are called "Abrahamic" since they are descendants of Abraham. And they all circumcise their boys. So, circumcision is very very old indeed. At least as old as the very first book of the Bible and the Torah.

Circumcision is also very popular in China and Asia, although it is not done for religious reasons, it is one of the most common operations done there.

So, when the San Francisco "intactivists" tried to ban circumcision within city borders, the result was predictable . The measure was thrown off the ballot in 2011, by the Courts. The reason for removing it from the ballot was that it was in violation of California State Law, in which the state alone could regulate medical procedures. But, if the courts didn't strike the ballot, the weight of human history would not be in favor of a ban. Circumcision would continue no matter who tried to stop it.

What is a circumcision?

A human penis is created with a sheath, or tube, of loose skin that covers the penis from it's base to above the head. Of course there is a hole for urine. Circumcision involves cutting the sheath so that the head is exposed. How much to cut is not covered in any textbook that I have ever read. It is simply taught from teacher to student as a procedure. And it has been this same teaching that has been done since the beginning of history. The part of the sheath that is cut off is simply called the foreskin. My preference is to simply cut off enough to get the head exposed. I will leave some sheath in place. I will usually have a discussion with the parents describing my technique and preferences. It seems to me that some boys are over circumcised and this leaves a penis with no extra skin at all. I tell my patients that more can always come off, but you cannot put it back on later. I am not quite minimizing the circ, but I am not skinning the penis either.

Nevertheless there are some surgeons out there that have the feeling that they can diagnose "excess foreskin", even in newborns. And they tell the mothers that the circumcision was "botched" and the penis should look like the fathers, despite the fact that it is much smaller. If I can, I will tell the mothers that they should leave the penis alone and let it grow. It will fill in normally and then look like daddy's. Although it is unlikely that a mother is going to get a look at her grown son's penis to do a comparison. I think that these surgeons are mistaken, to say the least. They have a right to their opinion, and so do I. I think they should leave these boys alone.

So my preference is to do just enough to get the head exposed. This means the edge of the incision should be just below the rim of the head. By the time the boy is a grown up, the sheath will look normal. But there will be enough sheath left to make erections and intercourse comfortable for both partners.

When I do it, I use a cookie cutter type device that is called a Gomco. Our hospital uses a new one every time. With this device, making the circ round is a no brainer. There are other devices. The Mogen is a popular device. It pinches with a vertical instrument side to side. It is hard to overcirc with a Mogen, but the result cannot be round. And in rare cases, it has been known to partially amputate the head.

Anesthesia for the circ is another question entirely. Anesthesia meds have some risk. Not using them means no risk from the meds, and no painful shots into the penis. We use other means, including a quick placement of the Gomco. Once that is on, there is no pain from the scalpel at all.

In case you haven't figured it out yet, a circumcision is the job of the Ob/Gyn, at least where I work. Jews would sometimes prefer that a specially trained religious person called a Mohel do it, on the eighth day of life, with a ceremony done at home called a Bris.

When I do it, I try to honor any cultural traditions that exist as best I can. We can make a mini ceremony out of it, including the ritual wine if the parents and grandparents want. I find it personally valuable to honor whatever traditions that people may have.

Before I even begin, I try to see why the parents want it. If there is any hesitation, I will try to ask if the father is done. If not, it is possible that maybe it shouldn't be done at all. But at our hospital, the vast majority of the boys are circumcised.

Thanks sincerely,

Dr John Marcus Ob/Gyn.
Ridgewood NJ 07450

201-447-0077