Department of Surgery
Ospital ng Maynila Medical Center

Letter to the Editor of Philippine Daily Inquirer

April 28, 2002

Dear Editor,

This letter is a reaction to the article written by Ms. Cathy C. Yamsuan entitled “Boys of summer grit, bear it” which was published in your paper on April 16, 2002.

We appreciated Ms.Yamsuan’s article on at least four points to which we give our reactions and at the same time expressed our views and stand which form part of the social responsibility and public health education program of the Department of Surgery of Ospital ng Maynila Medical Center.  

First, we appreciated her presentation of the differing views of two physicians, one from a urologist and another from a pediatrician.  We tend to agree with the views of the pediatrician when she said that the old-time belief that uncircumcised men are more prone to penile cancer is false; circumcision on a new born is only done if the opening for urine is too small so that they won't be prone to urinary tract infection and that peer pressure is the more frequent cause for boys to undergo circumcision because they don't want to be teased as 'supot.'  We believe that the pediatrician was more objective in her analysis of the issues and acknowledgeable in evidence-based medicine.

Second, we also appreciated Ms. Yamsuan’s presentation of a picture showing a child suffering in pain during circumcision and her clear message that the procedure is painful  if NOT done with anesthesia.  There is NO such thing as painless circumcision as the public might be led to believe because of false and erroneous advertisement. Circumcision without anesthesia is painful to any normal person subjected to it, even to newborns.  During the circumcision, the operation is made less painful because of anesthesia applied.  After the circumcision, when the effect of anesthesia has worn off, pain is also experienced and is reduced by intake of pain-killing medicines. The pain experience usually lasts for about one week after circumcision.

Third, we also appreciated Ms.Yamsuan’s presentation of the real reason why circumcision is routinely practiced in the Philippines.  It is more of a tradition and peer pressure to the so-called “rite of passage to manhood” than for any health reason. We agree with her statement: “There are millions of uncircumcised men the world over who are alive, well and are the embodiment of maleness.”

The fourth and last aspect of Ms. Yamsuan’s article which we appreciated the most is the question she posed: “Is circumcision necessary?”  For us, it is enough that she posed the question for the public to think about and to think twice in having their children circumcised.  We don’t expect her to be able to answer this question authoritatively in her capacity as a journalist.  We, surgeons from the Department of Surgery of the Ospital ng Maynila Medical Center, in a meeting held last April 25, 2002 decided to offer our help in answering the question to the public as part of our social responsibility and public health education program.  

Prior to our departmental meeting on April 25, 2002, two of our associate surgeons, Dr. Hazel Turingan and Dr. Janix de Guzman did an extensive research tracing the history of the practice of circumcision in the world and in the Philippines and gathering evidences that may support the health reasons of circumcision.  Their effort led to the following findings which were presented in our departmental meeting and which served as a basis for our department stand and policies:

1.	Circumcision was widely practiced as a religious rite since the ancient times.  Earliest evidence of practice dates from ancient Egypt. Although circumcision was commonly practiced by Jews, Muslims, and Christians as part of a religious rite before, nowadays, it is NOT a required religious rite anymore for Muslims and Christians.  
2.	The foreskin of the penis was widely thought to be associated with the causation (if not circumcised) or prevention (if circumcised) of diseases like urinary tract infection, sexually transmitted diseases, penile and cervical cancer, and other diseases.  There are NO solid evidences in the literature that show that preserving the foreskin of the penis is the direct cause of the abovementioned diseases.  Moreover, there are NO solid evidences in the literature that show that circumcision will directly prevent the abovementioned diseases.
3.	Circumcision was widely thought to be associated with heightened sexual sensation during intercourse. This has NOT been scientifically proven.  On the contrary, the presence of the foreskin has been shown to have fuller range of sexual experience during sexual activities.
4.	It is true that circumcision can promote hygiene or cleanliness of the glans penis.  However, there are other equally effective and noninvasive (non-operative) ways like daily meticulous cleansing.
5.	In the Philippines, the practice of routine circumcision is more of a tradition and peer pressure of a “rite of passage to manhood” than a religious rite and for health reasons.
6.	Though statistically infrequent, complications and ill-consequences do occur with circumcision. Bleeding, infection, painful erection, and death are some of the risks that every person has to face when he decides to have a circumcision.

Our department’s stand or philosophy is that we will NOT make any person suffer from the pain of a procedure that has NO therapeutic basis.  We will NOT allow any person to be subjected to risks of a procedure that has NO therapeutic basis.  We will adhere to the basic tenet of physicians: FIRST DO NO HARM.

Our specific departmental policies on circumcision, therefore, consist of the following:

1.	We will NOT include Operation Tule in our Operasyon Pinoy*  
2.	We will NOT conduct “circumcision” missions within or outside the hospital.
3.	We will discourage routine circumcision.  We will perform circumcision only when indicated such as recurrent urinary tract infection with phimosis (abnormally small opening of the foreskin).
4.	If circumcision is performed, the procedure should preserve the frenulum.  The procedure can be a dorsal slit or at most trimming part of the foreskin  but with preservation of the frenulum.
5.	The Department will conduct public health education on the myths and facts of circumcision as part of its social responsibility program.

Operasyon Pinoy  is a monthly surgical mission by Filipino surgeons for the indigent Filipino surgical patients, providing quality-monitored surgical services and structured training to surgical and parasurgical staff. It is the main social responsibility program for the urban poor - part of the Healthy Urban Poor – Health for All Filipino Movement of the Department.

Respectfully yours,

Joseph A. Estanislao, MD
Senior Associate Surgeon
Department of Surgery
Ospital ng Maynila Medical Center

Noted by:

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Chairperson
Department of Surgery
Ospital ng Maynila Medical Center