A Botched Circumcision

Disclaimer: This post has no disturbing images, but may be uncomfortable to the sensitive reader.

It was my first day of Urology and I was sitting in on a colleague’s examination of a young man in obvious pain. I had missed the history-taking, and wondered why he was walking so tenderly and carefully to the examination bed. As he painfully undressed and started unwinding his bandages, I vaguely guessed whether he had had a late repair of hypospadias, or perhaps had sustained zipper-trauma. Suffice to say, I was not prepared for what I saw.

The young man had been genitally mutilated. There was little external penile skin, and the less than a millimeter of glans was visible. His external urinary meatus was not visible.

Xhosa initiates – just an image, not the patient!

He had been for his Abakwetha Circumcision Ceremony, also known as initiation (into manhood) and going “to the bush” – because it is about more than circumcision: the young men are also given several tasks of surviving independently without a lot of food or water.

In South Africa, healers who perform traditional circumcisions have to be registered and trained, but many have evaded this law. Many young men still frequent these “illegal” traditional healers. I wrote before about the injuries and deaths in our country due to traditional circumcision.

When a circumcision is not performed by a trained person, it is usually not in the sterile environment required, and thus these young men are prone to infections – including necrotising fasciitis, which the patient in question had developed recently. Surgical debridement had cost him even more of his precious skin. Untrained individuals also do not use sutures, and thus wound healing becomes fibrotic and the skin becomes stiff and retracted.

Last year during my rural family medicine rotation, I wrote about my day assisting in circumcisions. These were hospital-based, thus with all appropriate equipment, expertise and sterility. Some people were dismayed by my “participation”. The more I have been reading up about it, the more I realise that what we have been told about circumcision may not be entirely true. Still, I do not feel guilty about those procedures, because none of the young men were under-age and they had all given informed consent. Furthermore, had we not provided the opportunity to be circumcised at the day hospital, they would have had it done “in the bush” and could have been exposed to all the horrible complications.

Nevertheless, over the past year I’ve become more aware of protest against circumcision – especially against circumcision before a child can make an informed decision by himself (which I understand), but also against adult, non-medically indicated circumcisions.

I thought the comic, Foreskin Man, was pretty interesting. It makes for reasonable comic book reading and is available online for free here. The bias is quite obvious, where the person circumcising is always depicted in horrible or evil ways, and the antagonists are heroic, beautiful people. It also has a tendency to come across as antisemitic. But I think if one is aware of potential biases it is still worth a look-over.

As with all debates, there is also the sub-group of ridiculously emotional activists (or “intactivists”, as they like to call themselves) who turn the debate into a subjective mess. I try to ignore them so I can focus more on figuring out what is ethically and medically acceptable.

On that note, I must go. I will write a more focused post soon regarding what I have learned so far regarding latest evidence, as well as cultural considerations. In the meantime, if you are interested, check out this “foreskin IQ” questionnaire. You might be amazed at some of the answers.