Cutting question tinged with danger

IT'S a boy. The birth of a son brings joy, but to some families his sex will soon bring a dilemma: circumcision. To boys born into Jewish or Muslim families, removing the foreskin is generally not an option - it's a necessity. In many Hong Kong families, however, the decision to opt for an operation that could result in severe pain is based on neither medical nor religious grounds. One belief of parents is that it is more hygienic to be circumcised. They reason that if their son's foreskin is too long, they might as well have it removed to eliminate the risk of transmitting diseases to his future wife. Others believe when their son complains of penile soreness, it is time to snip the foreskin because it is probably too tight. Others authorise the procedure with the ill-founded belief that uncircumcised boys are usually weak and unhealthy. Some traditional Chinese families have it done routinely, according to Dr Yeung Chung-kwong, senior lecturer in surgery and chief of paediatric surgery at the Chinese University of Hong Kong. It is not known how many circumcisions carried out in Hong Kong hospitals are medically unnecessary. Because public hospitals usually turn away over-anxious parents due to stretched resources, circumcisions deemed medically unnecessary are done in private hospitals, where statistics are unavailable. Myths have surrounded the operation since it was introduced into Western medical practice during the Victorian era. British doctors believed that because the operation would reduce sexual pleasure, it would discourage masturbation. In the United States, the operation is still performed on more than 80 per cent of newborns. Today, the same myths exist for some Hong Kong mothers. Before asking for the operation to be performed, these mothers have also convinced themselves it carries no risk. But Dr Yeung said he had seen cases referred to the university's teaching hospital, the Prince of Wales Hospital, which showed how circumcision could go wrong. 'Some of these children who were offered the operation either should not have been operated on at all, or they didn't need the operation,' he said. Dr Yeung warned the operation, if done improperly, could even result in death. 'I have come across a child who had the operation in a regional hospital in Britain,' he said. 'He bled to death after the surgery. This is not an operation which is totally free of complications. I haven't seen death in Hong Kong and, although uncommon, I have seen very serious, nasty complications such as severe bleeding and infections.' In some cases skin grafts are required because the operation, hurriedly and improperly performed on a screaming child in a clinic, results in stoppage of blood flow to the foreskin, causing necrosis, or death of the foreskin tissue. The overwhelming consensus of paediatric surgeons and urologists is that circumcision is seldom required on medical grounds, except for a few rare conditions. According to Dr Yeung, one of these conditions is genuine phimosis. This is a narrowing at the edge of the foreskin which may result in it remaining non-retractable by the age of five or six, or a 'ballooning up' of the foreskin while urinating because of obstruction to urinary flow at an early age. But medical opinions differ on the best time to treat boys with this condition. While some doctors recommend circumcision by the age of three, others suggest this could be premature. Studies have shown retraction is a gradual process: only four per cent of male babies have foreskins which can be fully retracted. The situation will, however, improve over time. By the age of five, the figure is 90 per cent. Dr Yeung said a second medical condition requiring circumcision was to treat recurring, serious attacks of balanoposthitis, or inflammation of the foreskin and head of the penis. Mild versions of this condition occur about once in every 25 cases of boys in pre-school years, and can easily be treated with an antibiotic cream. Dr Yeung said he would also recommend the operation to children who ran a higher risk of developing urinary tract infection (UTI). American studies have shown a higher incidence of UTI in uncircumcised babies in the first year of life. Because UTI can cause kidney damage and even failure, doctors argue circumcision will do more good than harm. 'But this argument is only true in part,' said Dr Yeung. 'Circumcised boys will have a lesser chance of developing UTI, but does it mean they will not develop the disease at all? 'Is it possible that despite the operation, a child can still develop kidney problems? I think the Americans are jumping to conclusions.' Instead of recommending circumcision in all children to lessen the incidence of UTI, Dr Yeung said he offered it to children diagnosed to have underlying pathalogical problems making them more prone to develop UTI or kidney damage, and those who had recurring UTI. He said the Chinese University was conducting a study on the controversial issue by documenting the advantage of circumcision in the prevention of future UTI and kidney damage in selected boys. 'Whether to circumcise your child is not a decision to be made lightly . . . we have seen problems before,' he said. Dr Yeung said boys who were suffering from hypospadias - a developmental abnormality in which the urethra (the tube which leads from the bladder to the exterior) opens on the under-surface of the penis - should not be circumcised because surgeons would need to use his foreskin for reconstructive surgery. An inexperienced surgeon may also mistakenly treat the condition of 'buried penis' - when the outer skin is shorter than the inner one - by circumcision. The problem with these children is that their foreskin is not too tight, but too short. Thus, removing their foreskin will cause the penis to be buried even deeper. 'These conditions are commonly seen in Hong Kong and ill-planned circumcisions will make subsequent reconstructive surgery very difficult,' Dr Yeung said. 'Different doctors differ in their practices in Hong Kong. Some will probably recommend circumcision in newborns, others won't. 'There should be general guidelines for them to follow.'