To enable a patient to urinate standing up and function normally sexually, the end of the urethra must be reconstructed and the penis stretched. In the past children with this condition were not operated on until they were older, but today urologists prefer to perform the operation before the child enters its third year, thus limiting the psychological trauma of hospital admission as far as possible. For the manufacture of a new section of urethra use is made of the inner leaf of the foreskin. If the foreskin has already been removed, one can also use mucous membrane from the cheek or lip. Scars, the relatively short penis length and the abnormal shape of the glans mean that some boys, particularly in their adolescence, are not really satisfied with the result of the operation. The urologists who operated on them usually are, but they know that their options will always be limited. Doctors can’t really improve on the existing organ. It is important to make it quite clear to patients that correction of hypospadia will not lengthen the penis.
Adolescents or adults complaining of too small a penis in particular should be offered help by a sexologist.
A very special form of hypospadia is mika. As an initiation ritual at the onset of puberty, the male inhabitants of the island of Mangaia in the Pacific have their urethra split open from the tip to the scrotum with a narrow incision. It is no accident that mika means ‘the terrible ritual’. The procedure prevents semen from finding its way into the vagina during intercourse – a crude form of contraception! Australian Aborigines, as it happens, once had the same custom.
As a last resort in the event of several failed urethra operations, uro logists sometimes go a step further by relocating the outlet of the urethra between the scrotum and the anus. Men who have had this treatment are therefore obliged to urinate in female fashion, namely squatting.
Phimosis and circumcision
A completely different but common ailment of the penis is phimosis, contraction of the foreskin. The only reason for operating on the foreskin is a lasting contraction that leads to problems. Virtually all newborn baby boys have a slight degree of phimosis with some adhesion, which almost always disappears spontaneously. Actually the term adhesion is incorrect: what is actually meant is that in the prenatal development of the sex organ the separation of the foreskin is not yet complete, and continues after birth. In only 4 per cent of newborn males can the foreskin be fully retracted, after six months the figure is 15 per cent, and at one year approximately half.
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Hypospadia.
With phimosis, urine and smegma can accumulate between the glans and the inner leaf, causing an inflammation. Still, an operation is by no means always necessary, since it is usually possible to slide the foreskin back over the glans and to slide it back after applying some Vaseline, though using force must be avoided at all costs! If careful retraction takes place with some regularity, the aperture will become wide enough. If retraction, whether or not in combination with a corti-coid cream, is unsuccessful, there is some reason for circumcision, but not otherwise.
In Western Europe when someone does something odd or deviant, he or she may be considered deranged and ignored, punished or treated.
When a large number of people do something odd or deviant, it is called ‘culture’. That also applies to ritual or religious circumcision.
Jews and Muslims do it from religious conviction and some men even on aesthetic grounds (have you ever seen a foreskin in a porn movie?).
Circumcision is a strange phenomenon but it is by no means as innocent as is often thought. To make the point, let’s begin with a disastrous story from the Netherlands. In 2002 a young Moroccan boy underwent the ‘standard’ procedure. The operation was carried out by an ex-gp, supervised by a urologist, and in the course of it use was made of an ‘electric’ knife. Unfortunately it turned out that the opera-204
a i l m e n t s o f t h e p e n i s tors had insufficient knowledge of the potential hazards of electro -
surgical equipment. As a result the penis was partially coagulated, and went partly black. The three-year-old victim was virtually castrated and required extensive plastic surgery. Naturally the case had legal con -
sequences, both criminal and civil.
Almost all urologists are familiar with the story of David Reimer.
In his case too a large part of his penis was accidentally burned away when he was circumcised as a child. According to the psychologist John Money there was no problem, and the answer was simple. David was still so young that with some surgical cutting and patching and a large dose of hormones it was surely possible to turn David into a girl. What you’ve never known, you won’t grieve over, the psychologist must have thought. And so it came to pass: David became Brenda. Money published a triumphant account of what he saw as his brilliant inspiration and its supposedly successful outcome. The truth was somewhat different: in 2004, at the age of 38, after an extended personal ordeal David/Brenda finally took his/ her own life. The decision to turn a boy into a girl after a ‘failed’ circumcision is not unique. According to an article in the National Enquirer (22 October 1985), 200 babies die each year in America of complications arising from a circumcision.
Why circumcise? Opinions vary about the origin of ritual circumcision. The first indications of the existence of ritual circumcisions date back about five thousand years, when they formed an important element in heliolitic culture, in which sun worship was central. Nothing is known about the significance of circumcision at that time. In The Eternity Machine, Johannes and Peter Fiebag describe how gods once lived among men. Clearly these gods were susceptible to earthly maladies and required the humans who served them to be as pure as possible. Women with periods were not allowed to prepare meals and men too must be scrupulously clean. Circumcision was an obvious way of preventing dirt under the foreskin. The fear of pollution of the ancient gods fuelled the idea that the ‘gods’ may have been extraterrestrial. Via these primeval tales of hygienic gods the idea of circumcision crept into modern religions like Judaism and Islam. In this modern age, we tend to be sceptical of such mythologies.
Worldwide, then, circumcision takes place mainly on a ritual -
religious basis. Shortly after the Second World War the Dutch Marxist A. Soep published an interesting ethnological study on this subject. He had forsaken Judaism, as is clear from the introduction to his very thorough, Marxism-based study, which is an indispensable reference work for specialists. Soep locates the first circumcision in ancient Egypt. The Egyptians originate from the countless nomadic tribes of Central and North Africa, and when they settled in the Nile delta they brought their 205
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cults and accompanying rituals with them. The Jews and Muslims in turn adopted ritual circumcision from the ancient Egyptians. In Soep’s view the Egyptians saw circumcision mainly as a political-psychological symbol of superiority in respect of the uncircumcised nomadic peoples, including the Hebrews, who later formed the Jewish people.
According to the us nocirc website (www.nocirc.org), the oldest known depiction of a circumcision is an Egyptian print (Wellcome Institute Library), dating from 2420 bc. The print was found in the tomb of Anchmahor in Saqqara, from the sixth dynasty of the Old Kingdom. The circumcision is being carried out by an hm-k3 ( ka priest) and the relief consists of two scenes: in one, a boy is being held by the assistant of the ka priest, who is seated on the ground and is saying to the assistant: ‘Hold him tight, so that he doesn’t faint.’ The assistant replies: ‘I shall do as you say.’ In the second scene the assistant is absent. The boy is still standing and places his hand on the head of the priest, who is sitting in front of him and rubbing something on his penis. The boy says: ‘Rub it in very well.’ The priest replies: ‘I will make you comfortable.’ Probably the ointment has anaesthetic properties, suggesting that the right-hand scene precedes the left-hand one.
Many anthropologists believe that circumcision is fundamentally a relic of human sacrifice. Sacrifices were made
to the gods to be assured of their protection and beneficence. Complete devotion meant complete sacrifice. In order not to have to sacrifice a complete human being, a part of the principal organ, the organ of creation, a sacred force of nature, was sacrificed. With many peoples the removed foreskin was also burnt, as were human sacrifices. In this way the sacrificing of the foreskin became a symbol of the bond established between God and human beings. In Christianity circumcision was replaced by baptism, while Jews and Muslims have retained it. In Islam circumcision is seen mainly as a symbol of purity: a man must be circumcised before he can take part in religious ceremonies. In his book Soep devotes a great deal of attention to the various initiation ceremonies and the accompanying circumcision (and in some cultures clitoridectomy) in relation to the significance of puberty as the transition from a child to a sexually mature young man/woman – a kind of rebirth.
Even today all the sons of observant Muslims and Jews and the sons of tribes in Africa, Australia, Melanesia and Polynesia (except for New Zealand) are circumcised. In Polynesia the purpose of circum -
cision is to make the organ look clean and powerful, and because it is believed that with a circumcised penis one experiences a more powerful orgasm. Until 1990 virtually all baby boys were also circumcised in the United States shortly after birth. Jewish boys are circumcised when eight days old, Muslims as early as possible, but mostly before or 206
a i l m e n t s o f t h e p e n i s during puberty. Worldwide, approximately one man in six is circumcised, and over 13 million circumcisions are carried out annually.
As pointed out above the tradition goes further back than the patriarch Abraham in the Bible, who at the age of 99 had himself circumcised with a sharp stone at God’s command and then did the same to his son and all the males in his household. The story is told as follows in Genesis 17:10–14 and 23–27:
This is my covenant, which ye shall keep, between me and you and thy seed after thee; Every man child among you shall be circumcised.
And ye shall circumcise the flesh of your foreskin; and it shall be a token of the covenant betwixt me and you.
And he that is eight days old shall be circumcised among you, every man child in your generations, he that is born in the house, or bought with money of any stranger, which is not of thy seed.
He that is born in thy house, and he that is bought with thy money, must needs be circumcised: and my covenant shall be in your flesh for an everlasting covenant.
And the uncircumcised man child whose flesh of his foreskin is not circumcised, that soul shall be cut off from his people; he hath broken my covenant.
And Abraham took Ishmael his son, and all that were born in his house, and all that were bought with his money, every male among the men of Abraham’s house; and circumcised the flesh of their foreskin the selfsame day, as God had said unto him.
And Abraham ninety years old and nine, when he was circumcised in the flesh of his foreskin.
And Ishmael his son was thirteen years old, when he was circumcised in the flesh of his foreskin.
In the selfsame day was Abraham circumcised, and Ishmael his son.
And all the men of his house, born in his house, and bought with money of the stranger, were circumcised with him.
In a monthly magazine on the religious upbringing of children, one theologian interpreted this as follows:
Abraham becomes God’s partner and so can no longer stay out of the firing line. The symbol of this is circumcision. The coven -
ant cuts into Abraham’s flesh, where he is most vulnerable, it ‘sets a limit’ to his manhood. Circumcision is a continual reminder of 207
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the covenant with God. It symbolizes the fact that God’s future will never be realized with male strength and potency alone.
Another wrote:
The circumcision is not only the outward token of the covenant, but also means ‘Be thou perfect’, as God says to Abraham in Genesis 27:1. Literally, the Hebrew word translated as ‘perfect’ means: complete, all of a piece, whole. Not that Abraham is no longer allowed to make mistakes and it is not a matter of physical perfection. It is something like: ‘Let your behaviour be such that you can stand before God in all honesty.’ But being at one with God sometimes also means that you must give up something; it costs you; it hurts! That aspect is found in circumcision.
Among the Arabs circumcision existed even before Muhammad: the new religion simply adopted the ritual. For that matter, there is not a single text to be found in the Qu’ran relating to circumcision, and in the writings of the exegetists one has to wait for two hundred years after the death of the Prophet, when El Bokhari (810–870), a Persian jurist and theologian, reports Muhammad as having said: ‘Five acts make up our tradition: circumcision, the removal of the pubic hair, the depila-tion of the armpits and the clipping of the moustache and nails.’ This is part of the Sunna, the book recording the acts and pronouncements of the prophet Muhammad and his followers. In fact circumcision is not compulsory for Muslims, but is a voluntary act following the example of the Prophet, amounting to a moral obligation, which means in practice that every male Muslim is circumcised. It is a rite of passage on the road to full membership of the religious community, with the associated rights and duties. This is probably the main reason why the circumcision is carried out only when the boy is slightly older, usually between the ages of two and twelve.
The Jewish author Philo of Alexandria (ad 25–50) was the first to put forward hygienic motives for circumcision. In hot dry climates sand, insects, larvae and suchlike are difficult to remove, and this may result in inflammation. The fear of paraphimosis also played a part.
Paraphimosis may occur when in a mild form of phimosis the foreskin is retracted as far as the corona of the glans penis and cannot return.
This causes the glans and the foreskin to swell through engorgement with blood and the formation of oedemas, resulting in pain and panic.
Doctors talk of a ‘Spanish collar’, after the starched ruff collars worn by prominent Spaniards in the sixteenth and seventeenth centuries.
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Paraphimosis can be resolved by squeezing the glans and the foreskin with the whole hand and with steadily increasing pressure carefully emptying the swollen tissue. If that does not work, the doctor can use the so-called Dundee technique: making multiple punctures with a fine needle and then suspending the swollen tip in a cup of sugar, so that the fluid from the tissue is quickly absorbed. This trick has been copied from vets, who use it on cows with swollen and prolapsed uteri, which have been through a protracted delivery and cannot be pushed back inside.
As described previously the glans is the end of the corpus spongiosum, the erectile tissue compartment surrounding the urethra. In erection the glans swells, but the internal pressure remains lower than that in the corpora cavernosa. The glans is lined with a sensitive mucous membrane and is normally sheathed with foreskin, which consists on the inside of mucous membrane and on the outside of skin. Since the vagina is also lined with mucous membrane, the penis can easily slide back and forth. Both the glans and the foreskin contain numerous fine nerve endings, which heighten sexual pleasure. This means that the foreskin is also an important sexual organ, the simple rubbing of which can lead to an ejaculation. If it is removed, a sexually significant part of the penis is lost, and continuous friction causes a layer of callus to form.
Any Jewish man may carry out a circumcision, but the ritual ( brit milah) is mostly performed by the mohel. It is a religious obligation, and should normally take place on the eighth day after birth. General principles of treatment if there are medical problems are laid down in the Shulchan Aruch. Circumcision is, for instance, forbidden if there are The ‘Spanish
collar’.
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any indications for haemophilia; if in any family two sons have died or if two sisters of the mother have each lost a child from bleeding after
circumcision, the following son must not be circumcised. This rule is regarded as the very first indication of haemophilia, a disease that we know today is inherited through the maternal line.
The sandak, a kind of godfather, holds the child on his lap during the ceremony. The mohel pulls the whole foreskin up to the glans and pushes the skin into the slot of a protective plate, after which the foreskin is cut along the line of the slot without anaesthetic. Formerly the wound was sucked clean orally by the mohel ( mezizah), but when it was found that syphilis, tuberculosis and diphtheria (and nowadays aids too) could be passed on in this way, a suction instrument was introduced for the purpose. The wound used to be treated with mohel flour, a powder made of ground oakwood; nowadays it is bandaged.
Incidentally, last century it was the custom among the Falaches, a Jewish sect in what was then Abyssinia, to circumcise even still-born male babies before they were put in their coffins, so that when they were resurrected they would be immediately recognized as Jews.
For both Jews and Muslims circumcision is surrounded by prayers and rituals. Among Indonesian Muslims circumcision is called sunat.
Sometimes a dukun (village doctor) or bong (imman) performs the ceremony, but usually the procedure is carried out by a layman. In Java the foreskin is sometimes cut only lengthways: a flat piece of bamboo is pushed between the glans and the foreskin, after which the foreskin is severed. Because the glans is initially uncomfortably sensitive after circumcision, the boys are put under cold running water. To protect the glans from grazing they wear half a coconut shell over their penis which hangs from a string round their waist.
The television film The Winds of War showed how after the invasion of Poland in 1939 foreigners, including Americans, travelled back to Berlin through the German lines. Jews and people with Jewish-looking faces and Jewish names were singled out. In cases of doubt the Nazis looked to see whether the men were circumcised or not. In the film an American minister travelling with the group protested: ‘All Americans are circumcised, me too.’ Under the Nazi threat many foreskin-restorations were carried out in this period. In fact, these are age-old practices: as long ago as the second century bc there were Jewish apostates who were anxious to imitate the ways of their Hellenistic overlords and to participate in sporting events in the athletics school in Jerusalem.
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