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1. An article in the Philippines Daily Inquirer 2. An earlier article in the Philippines Daily Inquirer 3. A three-part series in the Manila Bulletin |
First posted 01:30am (Mla time) May 17, 2006
THE weekend typhoon reminded us that summer may be ending soon, which means time is running out for that ritual of passage of “pagtutuli,” or male circumcision. I’ve written in the past about this practice, mainly to point out that its medical basis has come under question. The American Academy of Pediatrics, for example, issued a statement in 1999 saying the health benefits of the practice “are not compelling enough.” You should have seen the angry feedback I got from readers -- mainly men -- whenever I did a column questioning the need for circumcision. “It’s cleaner” was the most common argument, to which I’d say that you can be circumcised and still quite, uh, sloppy. Others argued that circumcision was needed to produce children. To which I would respond that circumcision is not practiced in mainland China so how come we now have more than a billion Chinese? (A side story: Some angry readers asked if I had been cut and I’d say, with a bit of dramatic flair, yes
I’ve been mutilated, as with most Chinese-Filipinos.) ‘Supot’ Another popular Filipino belief is that circumcision is needed, around puberty, to spur growth. I should share a little story here to refute that argument. Many years ago, the NGO I worked with got a Dutch volunteer agriculturist, Michiel, assigned to us. He arrived shortly before summer and promptly noticed all the free circumcision missions being offered. When he asked about this one time, over lunch, the NGO staff explained that an uncircumcised boy would end up “bansot,” or with stunted growth. Michiel mustered all his Tagalog to protest: “Hindi ‘yan totoo.” [“That’s not true.”] The staff broke out in hysterical laughter, realizing Michiel, who was like 6 feet 3 inches, was, as most Dutch go, uncut. And yet the Dutch are said to be the tallest people on earth. Really now, if circumcision produces tall people, why do we still have to import basketball players, some of whom are probably “supot” [uncircumcised]? “Supot.” Paper bag. Let’s face it -- we drag our sons to get circumcised to save them from ostracism. The term “supot” stigmatizes people for life, marking them as poor lovers and poor basketball players (not only are they shorter, they’re also said to be poor shots). The word is even used to insult people, as in a sign I saw the other week posted on a wall as a warning: “Supot lang ang umiihi dito.” [“Only the uncircumcised will pee here.”] The worst is when someone “supot” passes and naughty friends wrinkle their noses, claiming the poor hygiene wafts through. HIV/AIDS Some readers are probably now itching to tell me, hey, what about all these reports now that circumcision can prevent HIV/AIDS. We need to be a tad careful here. Yes, it's true [Well, maybe.]: Medical researchers have found that there generally seems to be fewer HIV infections in countries where circumcision is practiced. In Asia, the lower infection rates have been noted in the “cut league” of countries, which includes the Philippines, Bangladesh, Pakistan and Indonesia (yes, circumcision is part of our pre-colonial Muslim heritage). Generally, the studies seem to suggest some “protective” effect from circumcision, not just for males but for their female partners. The reduced risk isn’t just for HIV/AIDS. In a paper issued last month, the US Agency for International Development noted that circumcision has been known to “greatly reduce a man’s risk of penile cancer . . . and it also reduces risk of some other sexually transmitted diseases (STDs), including chancroid, herpes and syphilis. It eliminates problems such as phimosis (narrow foreskin opening) and balanitis (infected foreskin), and has been shown to significantly reduce the risk of cervical cancer among female partners of circumcised men.” How does this protective effect work? It’s interesting that the anti-circumcision camp has argued that uncircumcised males experience more sexual pleasure because the extra skin is sensitive, but now the pro-circumcision camp says the foreskin actually has more “target cells” that attract infectious microorganisms like HIV. The foreskin is also said to be more susceptible to tears and abrasions, which means easier infection by HIV and other microorganisms causing STDs. No magic bullet Where does this leave us now? USAID is careful in saying “MC” (sigh, Americans probably gave Filipinos this love for acronyms) is not a “magic bullet” and that it “it will not provide full protection against HIV.” Rather wryly, USAID also points out that circumcision “will provide little or no protection against urethral STDs such as gonorrhea and Chlamydia [known locally as “tulo”] and obviously will not prevent unwanted pregnancies.” It’s important then to keep repeating that just because Filipinos are “cut” does not mean we’re immune from HIV. The HIV epidemic in the Philippines, previously described as “low and slow,” is now considered to be “hidden and growing” so we need to continue to be vigilant and to promote a package of prevention methods, including condoms. USAID, in fact, warns that there may be a need to have programs of behavioral “disinhibition” among circumcised males who might return to high-risk behavior thinking they’re adequately protected by circumcision. Since circumcision is already being practiced here, I’d go a step further and look at how we might want to borrow from a program in Kenya, where circumcision, which is practiced as a traditional ritual, now integrates preventive health education. In the Philippines, circumcision is only one of summer’s rituals of passage. It used to be that after young men had recovered from circumcision, their older male relatives would bring them to a brothel for their “binyag,” a second, more profane form of baptism. Times have changed and we should be rethinking these rituals. Circumcision may be a good time to explain that the passage from boyhood to manhood isn’t just a matter of being brave during the cutting ritual, or of going off to conquer women in brothels. There is a folk belief that the circumcised male should “protect” his wares from the female gaze, lest this swell and redden like tomatoes. That belief could well be used to explain that manhood is a matter of learning to be responsible, and of respecting women. Tomato metaphors aside, I’ve found in the Philippines that it’s especially useful to remind young men to see, in every woman, their own mother or sister. That kind of thinking may yet be a more effective preventive action against HIV/AIDS and STDs than circumcision.
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[Inquirer, 23/5/02]
M. L. Tan
"Routine male circumcision is NOT necessary!" The capital letters and the exclamation point are in the original statement, a letter from Dr. Reynaldo Joson who chairs the Department of Surgery at the Ospital ng Maynila Medical Center. Joson wrote me asking if I could help me campaign against this pagtutuli, especially since it has become a summer ritual sponsored by all sorts of groups from the Catholic Women's League to Kodak Philippines (Smile, you've just been cut!). The "Operation Tuli" banners always intrigue foreigners because really, we are one of the few countries left in the world that insist on, well, let me use a strong term, mutilating our males. I actually wrote about the circumstitions or myths around circumcision back in 1999. (I'm borrowing the term "circumstitions" from someone named Hugh, a New Zealander who has a website on this controversy. Will give you the address at the end of this article.) At that time, the American Academy of Pediatrics had just issued a statement stating that "the foreskin plays very little or no role in the spread of sexually transmitted diseases", which was the rationale for routine infant circumcision in the States. Among western countries, it's been mainly the Americans who have clinged on to the practice, with strange reasons. At one time, American doctors thought circumcision could prevent masturbation. Remember that in the 19th century and, I suspect for some moralists in the 21st century, there was this myth that masturbation had harmful effects. Some doctors even thought you could masturbate to death – no wonder they had this mad search for preventive methods. Then there was this idea that uncircumcized males were "unclean" and that the "dirt" causes diseases in their partners. In fact, Filipinos tend to tease uncircumcized men by wrinkling their noses when they pass by, insinuating that the stench from the "dirt" is so overwhelming. This is of course total nonsense – junior's state of hygiene depends less on a piece of skin than what you do, or don't do, with it. I worry, for example, about how Filipinos avoid taking a bath after sex because they think this causes pasma. I think that belief creates more problems of sexual hygiene than being uncut. In the last few years there has been speculation that circumcision might prevent HIV/AIDS. One theory is that the uncircumcized male's foreskin provides more surface area for the virus to enter but I think this is not very scientific – the virus' entry into the body, and its causing an infection, involves more of blood vessels than skin. The bottom line is that Filipino circumcized men are being infected with HIV/AIDS so it may actually be dangerous to propagate the idea that a cut penis protects you from AIDS. Circumcision in the Philippines persists because of many other folk beliefs. Let me refute them. First, circumcision does not make help to make a person taller. Once puberty sets in, you will grow with or without circumcision, your height pretty much a function of genetics and nutrition. Second, circumcision does not make you more fertile – how many children you have depends on you're the quantity and quality of your sperm, and your sense of sexual responsibility. Third, circumcision doesn't give you a longer penis – having a pedro or a pedrito involves a bit of genetics. Nutrition, as far as I know, does not play a significant role. (Some of our readers will remember how they had [to] bring out a magnifying glass with that superhunk of a partner). Finally, circumcision doesn't make you a better lover – that you pick up from experience and reading Inquirer columnists. Moreover, Margy Holmes (who you should also read, even if she isn't in the Inquirer) will tell you the research shows that the foreskin is exquisitely sensitive and that supot males have more pleasurable sexual sensations than their "cut" brothers. So where does this leave us – tuli or not tuli? (I just had to reuse that column title from 1999.) Let's hear from our medical experts. Joson wrote his colleagues at the Pamantasan ng Lungsod ng Maynila's Department of Family and Community Medicine for their stand and they agree: "Routine circumcision has no therapeutic basis." The doctors do not recommend infant circumcision and they worry that circumcision done with "bare" health facilities, such as in charity medical missions, may cause more harm than benefit. At the same time, the doctors recognize the strong cultural pressures to continue the practice. Circumcision is a ritual of passage, with an entire barkada of boys on the verge of puberty going through the guillotine together. The doctors recognize, too, the stigma attached to being supot, and have this interesting observation: the pressure to circumcize is said to be "psychologically ingrained and culturally embedded in the collective psyche of Filpino women". No wonder sometimes it's mothers who drag their sons, screaming and begging for mercy, to the chopper. The doctors worry that if they stop circumcizing, there may be more problems because Filipino boys will end up in the hands of traditional practitioners, who will perform the lethal procedure with a bamboo sliver or broken glass, spitting on a wad of guava leaves after the coup de grace. It looks like circumcision's going to be around in the Philippines for some time. Our doctors will just have to keep speaking out, explaining the risks and disadvantages involved with circumcision including infections, bleeding, reduction of sexual pleasure. At the same time, they will have to keep on explaining that so-called benefits such as increased height, fertility, virility and a long dong are all myths. Meanwhile, I do recommend you visit www.circumstitions.com, which is both informative and entertaining. (The website's slogan is: A trombone can play more notes than a bugle.) The site includes an entire section on the Philippines. Do note that the site has some photos of cut and intact manoys so prudes should just keep out. Uy, finish reading the Inquirer first. |
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To the original articles:
Part 1
Part 2
Part 3
Part I, published May 26, 2002
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Is circumcision in males necessary? Part I
Until recently, no one — including doctors — ever bothered to take a closer look at this issue. We always thought it was a long-answered question and that it was really medically necessary to have all males circumcised. But is it?
Circumcision in males usually consists of removing part of the prepuce or foreskin of the penis. Its practice has various origins, both religious and non-religious, medical and non-medical. The reasons for the practice of circumcision in males have evolved from Biblical practice.
There is still the religious basis, especially for the Jews and Muslims (but this is not absolute anymore because there are now Jews and Muslims who object to male circumcision).
There is still the medical basis, particularly, in the belief that circumcision can prevent urinary tract infection, penile and cervical cancer, and sexually transmitted diseases. The sexual arguments for circumcision is based on the belief that circumcision offers more sexual enjoyment to both male and female partners.
However, the predominant driving forces for circumcision in males are tradition and peer pressure. Male newborns are circumcised because of the parent’s belief of the traditional practice. Male adolescents and even adults are also circumcised because of the traditional need (“passage rite to manhood”) and peer pressure (afraid to be teased as “supot”).
An objective, scientific, and dispassionate look is therefore necessary to answer the question: Is circumcision in males really necessary?
On the basis of medical reasons, routine circumcision in males is NOT necessary. The American Academy of Pediatrics has done extensive critical analysis of all published papers on the topic and has come out with a stand in 1999 that routine circumcision in males is not necessary.
On the issue of urinary tract infection, penile and cervical cancers, circumcision may have a potential benefit in terms of prevention but its actual value is minimal because of the low occurrence of these dreaded consequences. In other words, the risk is extremely low if circumcision is not done and thus, routine circumcision is not warranted.
On the issue of sexually transmitted diseases, prevention should focus on the behavioral factors – that is, avoiding promiscuity and careless sex — rather than relying on circumcision. On the question of hygiene, promotion can be done with meticulous mechanical cleansing without having to resort to the invasive and painful procedure of circumcision.
The most common and most clear cut medical indication for male circumcision is now limited to patients with urinary infection secondary to phimosis (extremely small opening of the prepuce or foreskin of the penis).
Paraphimosis (tightness of the foreskin that tends to strangle the penis) can be another medical indication if it occurs. Other than these situations, medical-wise, circumcision in males is not necessary.
In the Philippines, the Christian religions do not require routine circumcision anymore. For the Muslims and Jews, it may still be advocated but it is no longer an absolute requirement. There are even websites put up by Jewish and Muslim authors crusading against circumcision.
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Part II, published May 28, 2002
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Is circumcision in males necessary?
Part II The debatable issue on sexual enjoyment may be a myth after
all. Although there are no conclusive findings yet, a most
recent scientific article on the issue shows that more sexual
enjoyment is felt by the female partners with non-circumcised
than with circumcised men. The enjoyment is scientifically
validated in terms of more copious vaginal secretion, less
vaginal discomfort, and more frequent vaginal orgasm —
multiple at that. In countries like the Philippines, the predominant driving
forces for circumcision in males at present are tradition and
peer pressure. Though the traditional factor may be religious
in origin, in the Philippines (at least for the Christians),
it is usually non-religious in nature and now more related
with social customs and practices. Furthermore, the traditional factor is usually vague in the
sense that the parents and the male children are not able to
pinpoint the exact reason for wanting a circumcision to be
done. Peer pressure in the Philippines is strong and consists
of the male children afraid to be teased of being “supot”.
Traditional practices and peer pressure are really had to go
against. If we are not obliged by religious reasons and if we are
now convinced that circumcision is not needed for medical
reasons, the question is – How do we go against the tide of
tradition and peer pressure to reverse the present of routine
circumcision? That is the challenge being presented to those
who think that the male Filipino children should be saved from
the physical pain of unnecessary circumcision. I have an adolescent son who asked me last year if he
needed to be circumcised. I emphatically said “No!” I told him it is not needed and it is painful. I emphasized
to him not to be carried away by the teasing of “supot” and
not to be overpowered by peer pressure. I even taught him how
to counter the teasing of “supot” by saying uncircumcised men
are intact, unaltered and preferred by women in terms of
sexual enjoyment and comfort and that circumcised men are
altered and not original. Up to now, he has remained to be
uncircumcised. As a surgeon, during the past 20 years, I have convinced
quite a number adolescent males who came to my clinic not to
have circumcision anymore. Those who are convinced are happy
and thankful to me. Those who are not convinced seek other
surgeons to do the circumcision for them. |
Part III, published May 29, 2002
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Is circumcision in males necessary?
The challenge really consists of two aspects: First is how
to change the belief of parents who will have their male
children undergo routine circumcision because of the
tradition. Second is how to reduce, if not abolish, the peer pressure
that will make adolescents and adults undergo routine
circumcision. How can we meet the challenge? Basically, by public health
education and advocacy. Public health education will consists essentially of
sending the message to the public through all forms of media
that "Tuli - Di Kailangan! Masakit!" Advocacy will consist essentially of actively campaigning
against routine male circumcision by first explaining the
issues and then convincing the public, especially the parents
and male children that circumcision is not necessary. The strongest strategy in advocacy is for the physicians to
speak out against routine circumcision. The public considers
the physicians as the professionals to turn to when it comes
to issues on circumcision. Initially, the voice of the physicians will be important in
the advocacy against routine circumcision. In a book
expounding on the issue, the author wrote: "One doctor said
that he talked to every parent and male child who come to him
for this purpose (circumcision), explaining the consequences
and saying that it was unnecessary, but found they insisted
upon having it done, so he complies. His justification was
that he did it in a hygienic way and lost nothing by it. On
the contrary, he gained money. But he overlooked the fact that
he is acting unethically….abdicating his role as a model of
enlightenment for others; one can only assume that he is
simply pursuing his own interests. The negative effect of this
is that when we try to convince the parents and their children
that this operation is not necessary, they immediately reply
that doctors do it, therefore it must be a good thing." However, not only are the doctors the key opinion molders
in this issue. The voice of the parents and even the children
will be stronger - in fact, strongest. If they are convinced
about the non-necessity of circumcision, they should also
voice out their stand on it for the sake of their children,
grandchildren, great grandchildren, and great, great
grandchildren. Dr. Joson is chairman of the Dept. of Surgery at Ospital ng
Maynila Medical Center. He is a member of the CHARTER Bureau,
a non-stock, non-profit research foundation, headed by Dr.
Rafael Castillo and based at the Manila Adventist Medical
Center - formerly Manila Sanitarium & Hospital. |
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