Sore point

Circumcision "a source of great anguish"


Circumcision - beloved by the Victorians, crucial to two of the world's great religions, arguably a health boon - can be a cause of great anguish. Richard Johnson meets men finding ways to reverse a cut they wish they'd never had

Guardian, Saturday October 29, 2005

Skin constantly renews itself. Foreskin is no different: stretch it, and it will grow. Which is why eight circumcised men are meeting in Watford town hall. They want new foreskins. "When people come to my house," says Laurie, "I don't go 'Hello there, I'm Laurie, I'm growing my foreskin', but I've often got research papers out on the table, so word gets out. I do find people are really very interested in what I'm doing."

Laurie is sharing his experience of restoration, as the process of foreskin renewal is called, with fellow members of NORM-UK. In the US, where NORM was born (and where circumcision rates are somewhere around three-quarters of the male population, far higher than in Britain), it stands for National Organisation of Restoring Men. NORM-UK is about more than that, but Laurie is on a roll. And the others don't want to interrupt him - after all, in two and a half years, Laurie has achieved glans coverage when flaccid. In the world of restoration, that is major.

NORM-UK meetings are small and intimate. Not usually as small and intimate as this one, but there's been a pile-up on the M1. There are a few handshakes, but otherwise little in the way of physical display - "People are always worried we're going to drop our trousers," says general manager David Smith. Laurie wouldn't be averse to the idea, to show off his stretching. Women stretch skin for reconstruction after a mastectomy. So why shouldn't men stretch a foreskin?

Some men can't restore - they are too tightly circumcised and have no tissue left to grow, but others can and are availing themselves of products such as the TLC Tugger, Tug Ahoy and the Your-Skin cone. Some have found their own DIY solutions, using funnels and gaskets to stretch the foreskin, and sash-window weights to provide traction.

The whole idea of restoration sounds funny, like the time that Laurie was having a go with sticky tape, the most primitive of the restoration methods. He pulled what skin he had left over his glans, and taped it down. "I only had the tape on for half an hour", says Laurie, "but it was hell. I was walking down the high street and suddenly had to dive into the nearest toilet to check my penis hadn't gone black, green or blue. Or dropped off altogether."

It sounds funny, but it isn't. Not if it's happening to you. Smith remembers sitting through the scene in the film East Is East in which the father tries to catch the son and take him to be circumcised. "I remember the cinema was in hysterics," says Smith, "and they were laughing when he was wheeled into the operating theatre, but all I could hear was the boy's screams. My wife turned to me and said, 'I've got to go - I can't watch this.'"

When the foreskin is removed, it leaves the glans exposed and that can be difficult - removing a protective layer and sometimes creating soreness. "I always had a problem with my penis giving me stimulation I didn't want," says Kevin, recalling how, as a boy, "I had to keep adjusting it through my pocket. I was near the climbing frame in the playground when, all of a sudden, everyone started chanting 'Kevin is dirty - he's always playing with himself'. I didn't like the feeling of being odd, of being deformed. Suicide would have been a good option."

Kevin is now 56 with a fully restored foreskin. But he's left with the question, why was he circumcised in the first place? His mother read the Bible and went to Sunday school. "But I was conceived out of wedlock when she was 17. And my father was a divorcee. They wanted to get married in church, so I think I was circumcised as some kind of apology to Jesus. My father wasn't circumcised himself, so I really don't understand." And that is a feeling he shares with many members of NORM-UK.

Meetings are on a first-name-only basis because members don't like to be identified. "Many men who come to meetings won't even speak to their families about the pain they're suffering - we are dealing with victims of abuse here," says Smith.

NORM-UK currently has just short of 300 members. Less than one inquiry in 10 results in membership, but it isn't strictly about the numbers. "Men often want the information to restore," says Smith, "but they want to keep it to themselves. They are frightened about being found out. When they ring me up, they say, 'Please ensure that the information is in plain envelopes and don't put me on a mailing list.'"

John D was like that. He felt abused because his circumcision was unnecessary - a course of antibiotics had already cleared up his urinary infection. "But my father agreed with the doctor, and told me I was going to have a minor operation," he says. "I remember the nurses giggling as I was taken off to theatre. They wore these big sickly grins, and said, 'We're taking you to be done up now. Hee hee hee.' I was eight, but suffice it to say that they knew what was happening to me and I did not ... I remember waking up," says John D, "after the general anaesthetic had worn off, and looking down. My beloved penis had been replaced with wrinkled skin, a collar of thorns - the black stitches - and an ugly great dome on top. I experienced shock at first, later deep anger and resentment. The stitches disappeared, but the mutilation didn't. My father said, 'I didn't think it would look like that.' It was misinformed consent."

There are lots of horror stories about circumcision. Like the time in Baltimore in 1964 that it went so badly wrong that the doctors decided to change the child's sex. Or the time in London in 1991 when a 16-year-old was circumcised so badly that he bled all night and died. But these cases are extraordinary, and far from typical. Even for adults, circumcision is reckoned a safe and easy operation. Opponents of the procedure, however, don't see it like that.

John E is blind. But it's not his blindness that keeps him from meetings. "It's the fact I feel I've been more devastated than everyone else," he says. "They've got their lives in order. And they've got sexual partners. I haven't. My life has been ruined by circumcision, although I hate that word. I prefer 'foreskin amputation'. It's not an operation - there's no medical benefit. It's a rite. A faith crime."

In the Bible, circumcision was God's covenant with Abraham and the Jewish people. Of all of the commandments in Judaism, the brit milah (literally, covenant of circumcision) is probably the most universally observed. And although circumcision isn't actually mentioned in the Qur'an, it is mentioned in other Islamic texts. Most Muslims believe it's fundamental because Allah ordered Muhammad to follow the way of Abraham.

Asked if NORM-UK has Jewish and Muslim members, Smith replies, "Yes we do, but it is difficult to estimate the number because if someone joins us we do not ask their religion, nor are we really interested."

Religious circumcisions are frequently performed without anaesthetic, and are painful, even when performed on newborn babies. Adults can testify to the pain for themselves and can give their informed consent - but children can't. If, as opponents claim, circumcision is traumatic, and can result in lifelong damage - including psychological problems and a reduced sex drive - why are religious circumcisions still allowed?

NORM-UK says, actually, they aren't allowed: the UN Convention on the Rights of the Child declares that violence to children cannot be justified on grounds of "religion, culture or tradition". Children are not the possessions of their parents to do with as they please - or submit to surgery unless absolutely necessary. We make an exception for circumcision because it's mentioned in Genesis.

Dr Zuhair Zarifa, from Docklands in east London, is one of the few surgeons prepared to advertise the fact that he will circumcise males for religious or ethnic reasons. "Why not?" he says. "The operations are permitted by the General Medical Council. And they will happen whether I do them or not. It's much better for the operations to happen in my surgery under clinical conditions with anaesthetic, where I can provide all the necessary aftercare."

Even nonpractising Jews tend to circumcise their sons. It was, after all, the first command given to Abraham and the defining physical mark of the Jewish people. Circumcision involves "Hatafat Dam Brit" - a drop of blood that seals a covenant. Which does, for some, suggest that removing the foreskin goes beyond what is required by God. But, according to Rabbi Dr Jeremy Rosen, that is to miss the point.

"People are always trying to find rational reasons for Jewish laws," says Rosen. "They ask if our dietary laws improve hygiene. They ask if observing the Sabbath helps mental relaxation. And they ask if circumcision prevents STDs. But even if these rational reasons stood up to objective scrutiny, they wouldn't be a reason for keeping - or abandoning - our laws. One keeps to these rules out of religious commitment. I have no medical expertise," adds Rosen, who runs the London branch of the liberal Yakar Educational Foundation, "but I am convinced that circumcision is harmless, and not traumatic. But even if it is, we Jews have done pretty well on it over the years - and so indeed have Muslims."

Circumcision on females was made illegal in the UK in 1985. The same protection is not extended to males precisely because it would involve taking on two of the world's great religions. Most forms of female circumcision are, certainly, more damaging than male circumcision, but the distinction in law between male and female circumcision just can't be justified objectively. It is a double standard.

Circumcision was not practised in Britain until the 18th century and it really only gained popularity in the 19th century, after claims that it stopped the vile habit of masturbation. By stopping masturbation, Victorians thought circumcision would cure everything from epilepsy and hip trouble to asthma and alcoholism. In the first world war it was hailed as a defence against venereal disease, and by the second world war it had become an emblem of status; most of the middle and upper classes were eagerly circumcising their sons. Only in the late 1940s, with the introduction of the National Health Service, did numbers begin to fall - it is now estimated that around 20% of the current male population in the UK are circumcised.

But whenever a new disease becomes a matter of social concern, circumcision is wheeled out as the cure. A recent paper in the British Medical Journal found a link between an intact foreskin and HIV infection - but a paper in the British Journal Of Urology found exactly the opposite. There is clear medical evidence that circumcision reduces the incidence of cancer of the penis, and of the cervix for the women whose partners are circumcised, but even this is disputed by NORM-UK. It argues that the research is out of date and that a lack of cleanliness is more important to the transmission of disease than the lack of a foreskin.

The organisation doesn't want to see circumcision banned altogether. It accepts there are a few medical conditions where it is necessary. The others can be treated by simple, nonsurgical means."We need to educate the medical profession," says Smith, "because they seem unaware of the alternatives to circumcision. They are certainly unaware of the problems that it is causing."

John D is typical of NORM-UK members in that circumcision when he was a young boy changed his entire persona. "I became less sociable, and I started talking to myself. I was fearful of changing rooms. I had no close relationship with the opposite sex until I was 41, and I still haven't been able to reach orgasm through sexual intercourse. Over the years, I've had real problems with depression, and I'm sure I could trace it back to that day."

These are not the issues foremost in doctors' minds. Take a look at the General Practice notebook, an online medical encyclopaedia used by GPs, and its listing for phimosis - a condition where the foreskin won't retract. Most infants are born with a foreskin that can't be retracted and the foreskin is often tight until after puberty. Phimosis disappears in almost all cases given time. A fully retractable foreskin occurs on its own in 99% of 18-year-olds. But the notebook recommends circumcision.

The notebook makes no mention whatever of the noninvasive solutions to the problem - such as stretching, steroid cream or a simpler operation. Similarly, there are nonsurgical solutions to balanitis, a condition where the foreskin retracts too tightly, causing the glans to swell. "It sounds silly," says John D, "but balanitis can be cured by putting the penis in a bowl of sugar. The swelling goes down, and the foreskin returns to its resting position."

Zarifa isn't sure about the bowl of sugar - but he insists that doctors always explore noninvasive options first. "The truth of the matter is that stretching can be quite painful," he says. "And it's quite an undertaking for a small child. For some boys, the pain of the stretching is as bad as the pain of the circumcision. And I would say that 40-50% of boys who use steroid cream end up having a circumcision in the end. But it's always the last option."

The BMA supports conservative solutions where possible. But unnecessary circumcisions are still happening. And, as the Commons health committee noted, they are happening "because doctors don't understand the natural history of the foreskin".

Circumcision for babies and for older people is dismissed as "the snip", but it can still result in serious bleeding, or an adverse reaction to the anaesthetic. "And you cannot cut off normal, healthy, sexually-functioning tissue without cutting off normal, healthy, sexual functioning," says Marilyn Milos, a nurse and director of the National Organisation of Circumcision Information Resource Centres in the US. "It's a sexual issue, and it's a human rights issue." The foreskin isn't a useless flap that evolution should have got rid of long, long ago - it's skin that is rich with blood vessels, highly innervated, and uniquely endowed with stretch receptors. These contribute greatly to the sexual response of the intact male. The stretching of the foreskin over the glans activates nerve endings, enhances sexual excitability, and contributes to the ejaculatory reflex. There's no escaping it - the foreskin is sexual tissue.

Laurie can laugh now, but he missed his foreskin (it was removed when he was two). He was getting on for 60, and rapidly losing the feeling in his penis. "To be honest," he says, "sex was like pushing a rolling pin in. And I'm not referring to size when I say 'rolling pin' - you can get little rolling pins. I just could not feel a thing." His glans had been badly desensitised after years of rattling around - so much so that he could have an orgasm and not even feel it. That is when he approached NORM-UK.

During heterosexual intercourse with a circumcised man, the penis removes natural lubrication as it moves in and out of the vagina. "So my poor wife was buying artificial lubricant by the gallon," says Laurie. During heterosexual intercourse with an uncircumcised man, the glans moves but the foreskin stays put. And so does the lubrication. The woman doesn't feel friction at all - what she does feel is a variation in pressure.

Laurie is delighted. "And so is my wife," he says. "The skin grew in jumps. I did a lot of work for a long time and nothing happened, like with the sticky tape, but suddenly I woke up one morning and thought 'Where's that come from?' " The new foreskin didn't have the nerve endings it once did, but the glans recovered all its sensitivity. "For 40 years my wife and I had to use lubrication. Not any more. We're delighted."

David Smith is NORM-UK's one paid employee. He started admitting he worked for the charity only after his parents died - he couldn't bear the questions. (The Charity Commission put the organisation on probation for 12 months to ensure that it was not a cover for pornography.) Smith's wages come out of a grant from Lloyds TSB. But, apart from him, the trustees are all volunteers. Running NORM-UK is a big job: liaising with Great Ormond Street to correct the circumcision "fact file" on the hospital website, setting up meetings with the Family Planning Clinic, and doing mail-outs to midwives, recommending the alternatives to circumcision.

Meet the members of NORM-UK and you'll understand that it's more important to look at the complications of circumcision, and its physical and psychological side effects. In time, campaigners hope that routine circumcision will come to be seen as yet another deluded fad, along with bleeding, electro-convulsive therapy and the frontal lobotomy.

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