Mission Notes: Tuli or Not Tuli....

Circumcision has been a staple part of our medical-surgical mission held every summer time in the province of aklan. It has been a common sight to see long line of pubertal boys of all shapes and sizes, waiting for their turn to be cut. This has been considered a summer ritual in almost every part of the Philippines. I was even asked to write something about it about 3 years ago, sadly, I did not even get a thank you note for this. I remember this article as one of the 'cutters' commented on how well endowed these boys of aklan are. And just like in a baber shop, most of the times these comments lead to small discourse and here is my take on this...

Tuli or Not Tuli
Myths & Facts of Circumcision

The practice of circumcision has been in existence for more than 6000 years dating back to the snake worship in ancient Egypt, much like the snake shedding off its skin emerging shiny and new again; and so has man by cutting the foreskin has taken this as a sign of rebirth.

Through the years the practice has remained the same – the surgical removal of the sleeve of skin and mucosal tissue that normally covers the glans (head) of the penis. This double layer also called the prepuce is more commonly known as the foreskin. But through the years what has differed is the connotation attached to this practice; Religious – Judaism, Islam and Christian as part of religious rite and as a form of covenant; Moral – especially during the Victorian era when it was used as a deterrent for masturbation with the notion that it reduces sexual sensitivity compounded by the salutary effect of pain on the mind especially if it is associated with the idea of punishment; and during the last century its intent for medical and hygienic purposes.

In the Philippines, circumcision has traditionally been a rite of passage for adolescent boys. A tradition embellished with myths and association with the development of secondary sexual characteristics like growth in height, penile length and sexual prowess to name just a few. Familial and peer pressure plays a dominant role in this tradition. And this supposedly a pure male thing is further reinforced by the female population’s own belief in myths about circumcised men and its association with machismo. In this age of evidence-based medicine, this can arguably be called a needless hangover of Victorian era mindset.

Some of the medical benefits offered for its continued practice include reduction in the risk of childhood urinary tract infection, reduction in the risk of sexually transmitted diseases and HIV; and reduction in the risk of penile cancer as well as cervical cancer for the female sexual partner. All of these risk reduction benefits were all attributed to the notion that a circumcised penis is cleaner and more hygienic. However, historical and scientific data does not clearly support these supposedly medical benefits. This prompted the American Academy of Pediatrician to issue a policy statement “potential benefit of infant circumcision aren’t significant enough and therefore not recommended as a routine procedure.”

Debunking the myths starts with proper education supported by clear medical evidence that point’s circumcision does not improve male hygiene. In most of the western world this practice has already been discarded. In the US particularly, the practice has gone down to less than 60% starting in the 1990’s compared to as high as more than 90% during the early 1900’s. In the Philippines, tradition clearly plays a much bigger role than scientific evidence, that it would be an oddity to encounter uncircumcised men.

There is no clear medical evidence that would point to the readiness of a child to undergo circumcision. This is a rite of passage, a tradition that every Filipino male adolescent must undergo. Scientific evidence have already shown that there is no clear medical benefits and the only indication for its continued use is the presence of a medical condition called phimosis, which is the continued adherence of the foreskin to the glans of penis well beyond the adolescent years. Full retraction of the foreskin, completely exposing the glans, should not be taken as a sign of readiness. More than anything else the psychological maturity of the child should be the gauge of his readiness. On the average this has been set at 10-15 years of age, the early stage of adolescence, when the unpleasant experience would not cause much psychological harm. Nonetheless, the decision to undergo the procedure must come from the boy himself, an important decision on his part that may signify the degree of his rationalization and the level of maturity he has achieved. Although, this is not really completely true and acceptable, for possibly how can submitting to peer pressure and tradition resolve the inner conflicts and changes that an adolescent child faces at this stage. Experts would point out that this is the important stage of a child’s psychological development where adjustments takes place and the period when a child redefines his individuality and his complex relationships with people around him.

Supporting the child’s decision is an important part a parent can do to participate. Traditional or “pukpok” type of circumcision has largely been replaced with more modern and sterile method. The use of local anesthesia to eliminate the pain of the procedure has greatly reduced the trauma associated with the procedure. These have also resulted in largely reducing the possible complications that may arise which includes, hemorrhage and infection, the two most important. Suturing the cut edges of the foreskin or the use of electrocautery are some of the modern methods employed to control bleeding. This has largely replaced the traditional way of bleeding-control by having the boy jumps to the river right after the circumcision, the desired effect of which is the constricting effect of the cold water on the blood vessels and thereby stopping the bleeding. The sterility of the procedure performed in a hospital or clinic obviates the need for soaking or cleaning the wound with boiled guava leaves, which has been largely used for its antimicrobial property, although the unsanitary preparation of this concoction leads to more frequent infection most of the times. A 3-5 day course of broad-spectrum antibiotic is also employed to reduce the risk of infection, although this is rarely necessary if the procedure has been strictly performed under a sterile condition The other rarely seen complications include, incorrect removal of tissue resulting to disfigurement of the penis (either bowed/curved during erection); cyst, lymphedema, fistula and necrosis. Post-operative pain control can usually be achieved with administration of analgesic, paracetamol given every 4-6 hours.

Post-circumcision wound care, just like any other wound care includes cleaning with antiseptic solution like betadine and application of new sterile dressing once it becomes soiled with urine or soaked with dirt and perspiration. The use of vaselinized gauze is sometimes preferred in order to prevent the adhesion of raw wound/skin to the gauze; otherwise removal and changing of the dressing would be a very painful and difficult exercise. Bath is usually advised after 24-48 hours and daily bath with soap and water is sufficient for daily hygiene once the wound starts to dry up. Healing usually takes 7-14 days, although this could sometimes extend to 4-6 weeks if there were significant inflammation or hematoma formation. Loose fitting trousers are to be worn, not just to prevent the wound coming in contact with the clothing material but also more for the sensitive thin skin of the unprotected/uncovered glans now directly exposed and in constant contact with the clothing material. This would eventually make the skin of glans, cornified in essence a thickened and less sensitive skin, an adoptive response to the now exposed glans penis.

Arguments can be raised here and now. But it would certainly take several more lifetime before circumcision becomes just a matter of choice for Filipino men. Until such time, tuli or not tuli is not yet an appropriate question to ask a Filipino man, for needless tradition still dictates it has to be tuli.

May '04