Wow.
I can't believe that this issue on circumcision would be so...well, serious.
Okay, i will speak more on my observations in my 3 years of performing the said procedure (which i never had any major issues with, except for 1 case during my clerkship training, which i will highlight here).
But first off, i will "walk" you guys through with the steps in performing the said procedure.
1) We clean the site to be handled (the base of the penile shaft, where the local anaesthesia will be administered/injected, the shaft, and the head) using aseptic technique (wearing sterile gloves and using antiseptic solution).
2) We administer the local anaesthesia. First, we ask the patient to relax. This is for 2 reasons. First reason: if the patient is afraid, the penis retracts. When that happens, the procedure becomes difficult for us to perform. Second reason: if someone is nervous, the heart rate rises to much, and the local anaesthesia will surely get cleared from the site of injection faster, making the duration of its effect shorter, warranting the need to inject the anaesthesia again. When the patient is ready, we inject the anaesthesia at the base of the penile shaft. We have an option to add epinephrine to the anaesthesia to make the bleeding much less, and the effect of the local anaesthesia to be longer. But we rarely do this (at least, i never have), because the procedure is very short, and the bleeding isn't profuse or very minimal (unless the patient has a bleeding disorder, in which cases, we defer the circumcision).
Before i proceed to the next step, i will need clarify some things. Someone, after all, said that it's a lie to say that the procedure isn't painful. Well, the answer to that is yes, and no.
Actually, ironically enough, the most painful part of the procedure (if not the second most painful part), is the administration/injection of the local anaesthesia. The entry of the needle into the base of the penile shaft isn't what hurts, but the entry of the anaesthesia itself. As a rule, i never tell my patient that it will never hurt. I never lie to my patients, no matter how young they are. They have to have the right expectations, so they could brace themselves. Plus, it matters to me that the patient learn to "trust" me (i will talk more on this later). If i lied, saying it wouldn't hurt, and it hurt them, they wouldn't believe anything else i tell them afterwards. But after i tell them that injecting the anaesthesia will hurt, i tell them, firmly, looking them in the eyes, that they can bear the pain. Because that is the truth. I never had any case where my patients violently thrashed whilst i was injecting the local anaesthesia. You see, if the pain is severe and intolerable, our body's response is to move away from the pain. You can never lie still and bear it if it's too much. You will have to be restrained, or sedated (worse case scenario). These 2 have never been done in all my years of doing this procedure, and that is no lie.
Now, the next thing i need to mention (which may or may not be the next step in the procedure) is the separation of the skin from the penile head. Some patients already have this separated before the start of the procedure, while others have it all attached entirely or partially. It's case to case, from one boy to another, and depends on how they handle their major organ at home (whether they frequently take it out whilst bathing or not, for example). If there is a need to manually separate the skin from the head, there will be some pain (which, again, i will inform the patient to brace himself for). But i believe it's not so much pain as it is more of the sensitivity of the area to be handled (grasping the penile head alone is quite uncomfortable, being highly sensitive). The parents have the option not to take their son for the procedure if the separation hasn't taken place yet, to avoid this added burden/discomfort for their son before the circumcision is done.
3) The cutting of the foreskin. Before we proceed to doing this, we test the area if the local anaesthesia has already taken effect. We do this by clamping on the skin with mosquitoe forceps. If we are able to do a full bite (completely locked forcep) on the skin, without getting a violent reaction from the patient (they usually still say it's painful, but we know that it's more of the fear talking already), the anaesthesia has taken effect. You see, if there was no anaesthesia, it's impossible to do a full forcep bite on the skin without the patient wildly jumping off the treatment bed and running all the way home (a pinch on one's skin on the arm is painful enough, what more of a full bite?). At this point, if the child is still crying and muttering, and the parent panicking, i show them the fully clamped skin. Then they realize it isn't that painful as they think it is (more on this later). Afterwards, we proceed to cutting up the skin, long enough to entirely liberate the penile head.
4) Suturing the cut skin. Depending on the length of cut skin, and the amount of bleeding, this step can be long or short. I rarely have any problems in this step (except maybe when the patient keeps asking if i'm finished yet, and how many more stitches i need to be done already XD apparently, they're starting to get bored). During this time, they usually either talk incessantly with me or their parents, play with their cellphones or PSP or tablet, or watch the procedure itself. I have only 1 case where he was crying for the entire duration of the circumcision (the reason for which, i know, is not mainly because of the pain).
5) Cleaning and dressing the suture site. Very self-explanatory.
6) Post-operative instructions. We tell the patient and their parents the do's and don'ts for the entire week of recuperation, how to handle the sutured site when urinating, how to clean up the wounds, the medications to be taken, and follow-up if there are any problems.
Okay, i'm done talking about the procedure. Now i will talk about my observations.
From what i can see, a boy who is brought for circumcision is feeling 1 major thing: FEAR
Now, this fear is due to a lot of reasons:
1) The anticipation of pain. Depending on the feedback he got from those who came before him, or from what he himself has heard or seen (if he was waiting in the clinic, and heard a kid crying while being circumcised, for example), he will then decide whether, to him, the pain will be a major issue or not. The questions they will ask themselves will be: "Can i bear the pain? Is it really that painful as they say? Or not that painful, like they say?"
2) Pressure. Yes, in our country, this is a major source of fear. You see, if they don't proceed with the circumcision, they will be taunted by their fellow kids who had it done. He will be called a sissy, or scaredy cat, or gay, if he couldn't muster up the courage to go through with it. Even the parents do this to their own son (specially if the boy is already quite big and still uncircumcised, like around 11 yrs old or more). It becomes an issue of pride and manhood. The questions they are asking themselves would be: "What if i don't go through with this? What will they say about me?"
3) Embarrassment. You see, showing your genitals is definitely anything but comfortable. Specially if you're in the age when you're starting to become conscious about your body. The kid is aware that he will need to strip down there, and show his private parts to a complete stranger(s): the doctor and the assisting nurse. Heck, stripping down in front of a family member can be quite embarrassing already at some point in a kid's life XD of course, it's understandable if the kid gets afraid! The questions he may be asking in his mind might be: "What will they think when they see it? How are they going to touch me there?"
With all this said, our role as doctors is to gently and patiently reassure the patient and the parents that the initial pain (from the injection of local anaesthesia and separation of skin from the penile head) is tolerable, and that the cutting and suturing itself is painless. This is the truth. And i have NEVER had any problems carrying out said procedure. All my patients went home fine. If they cried at some point during the procedure, they get off the treatment bed embarrassed at themselves from over-reacting XD none of them left the clinic, regretting they were ever circumcised. Most of them even say that it wasn't as painful as they thought it was.
From all my years of doing this, there is only one patient that whined incessantly from the beginning 'til the end (he was already crying when he was brought to the clinic, and so was his mother). We asked if they really wanted the procedure done, and the parents said yes (the father was a police officer, and he was there too, scolding his son and his wife). So we proceeded with it. From what i saw, this kid was quite a spoiled one. He kept looking at his mother during the whole procedure, crying. The mother was no help at all, since she was also crying. Of course, that made the child even more afraid, crying even louder. But the pain is obviously blunted already, since we were able to carry it out and finish it without restraining the patient. He was just lying still the whole time whilst crying loudly. Right after the sutured wound was dressed, the kid stopped crying. Are you guys seeing my point? It's the fear talking and making the kid cry, NOT the pain. Because the pain is tolerable (unless the kid has a ridiculously low tolerance for pain, which we deal with by injecting additional anaesthesia, to which the kid himself refuses to receive again, apparently not feeling the pain anymore after all XD).
The mind is a powerful thing. If it chooses to believe something, that's what it will register to the entire body. If one chooses fear, then fear will dictate everything else. But if one chooses to trust and take courage, the body will do likewise. So it's very important to talk and reassure the kid and the parents on what to expect before, during, and after the entire thing.
My stand on the necessity to circumcise is basically for health reasons. If the procedure is done, personal hygiene for males would be easier to carry out and maintain. Bacteria and fungi are fond of moist areas. If the penile head isn't liberated and not cleaned properly and regularly, it is more prone for the growth of such unwanted microbes.
I'm not posting this to force anyone to have their kids circumcised. I am mainly clarifying things, and sharing my observations, okay?
Whether you want to have it done on yourself or your child is all up to you, guys. GOD bless you all, and please, let's not have any unnecessary fighting, okay? Let's not forget to speak and relate to others with gentleness and love
I can't believe that this issue on circumcision would be so...well, serious.
Okay, i will speak more on my observations in my 3 years of performing the said procedure (which i never had any major issues with, except for 1 case during my clerkship training, which i will highlight here).
But first off, i will "walk" you guys through with the steps in performing the said procedure.
1) We clean the site to be handled (the base of the penile shaft, where the local anaesthesia will be administered/injected, the shaft, and the head) using aseptic technique (wearing sterile gloves and using antiseptic solution).
2) We administer the local anaesthesia. First, we ask the patient to relax. This is for 2 reasons. First reason: if the patient is afraid, the penis retracts. When that happens, the procedure becomes difficult for us to perform. Second reason: if someone is nervous, the heart rate rises to much, and the local anaesthesia will surely get cleared from the site of injection faster, making the duration of its effect shorter, warranting the need to inject the anaesthesia again. When the patient is ready, we inject the anaesthesia at the base of the penile shaft. We have an option to add epinephrine to the anaesthesia to make the bleeding much less, and the effect of the local anaesthesia to be longer. But we rarely do this (at least, i never have), because the procedure is very short, and the bleeding isn't profuse or very minimal (unless the patient has a bleeding disorder, in which cases, we defer the circumcision).
Before i proceed to the next step, i will need clarify some things. Someone, after all, said that it's a lie to say that the procedure isn't painful. Well, the answer to that is yes, and no.
Actually, ironically enough, the most painful part of the procedure (if not the second most painful part), is the administration/injection of the local anaesthesia. The entry of the needle into the base of the penile shaft isn't what hurts, but the entry of the anaesthesia itself. As a rule, i never tell my patient that it will never hurt. I never lie to my patients, no matter how young they are. They have to have the right expectations, so they could brace themselves. Plus, it matters to me that the patient learn to "trust" me (i will talk more on this later). If i lied, saying it wouldn't hurt, and it hurt them, they wouldn't believe anything else i tell them afterwards. But after i tell them that injecting the anaesthesia will hurt, i tell them, firmly, looking them in the eyes, that they can bear the pain. Because that is the truth. I never had any case where my patients violently thrashed whilst i was injecting the local anaesthesia. You see, if the pain is severe and intolerable, our body's response is to move away from the pain. You can never lie still and bear it if it's too much. You will have to be restrained, or sedated (worse case scenario). These 2 have never been done in all my years of doing this procedure, and that is no lie.
Now, the next thing i need to mention (which may or may not be the next step in the procedure) is the separation of the skin from the penile head. Some patients already have this separated before the start of the procedure, while others have it all attached entirely or partially. It's case to case, from one boy to another, and depends on how they handle their major organ at home (whether they frequently take it out whilst bathing or not, for example). If there is a need to manually separate the skin from the head, there will be some pain (which, again, i will inform the patient to brace himself for). But i believe it's not so much pain as it is more of the sensitivity of the area to be handled (grasping the penile head alone is quite uncomfortable, being highly sensitive). The parents have the option not to take their son for the procedure if the separation hasn't taken place yet, to avoid this added burden/discomfort for their son before the circumcision is done.
3) The cutting of the foreskin. Before we proceed to doing this, we test the area if the local anaesthesia has already taken effect. We do this by clamping on the skin with mosquitoe forceps. If we are able to do a full bite (completely locked forcep) on the skin, without getting a violent reaction from the patient (they usually still say it's painful, but we know that it's more of the fear talking already), the anaesthesia has taken effect. You see, if there was no anaesthesia, it's impossible to do a full forcep bite on the skin without the patient wildly jumping off the treatment bed and running all the way home (a pinch on one's skin on the arm is painful enough, what more of a full bite?). At this point, if the child is still crying and muttering, and the parent panicking, i show them the fully clamped skin. Then they realize it isn't that painful as they think it is (more on this later). Afterwards, we proceed to cutting up the skin, long enough to entirely liberate the penile head.
4) Suturing the cut skin. Depending on the length of cut skin, and the amount of bleeding, this step can be long or short. I rarely have any problems in this step (except maybe when the patient keeps asking if i'm finished yet, and how many more stitches i need to be done already XD apparently, they're starting to get bored). During this time, they usually either talk incessantly with me or their parents, play with their cellphones or PSP or tablet, or watch the procedure itself. I have only 1 case where he was crying for the entire duration of the circumcision (the reason for which, i know, is not mainly because of the pain).
5) Cleaning and dressing the suture site. Very self-explanatory.
6) Post-operative instructions. We tell the patient and their parents the do's and don'ts for the entire week of recuperation, how to handle the sutured site when urinating, how to clean up the wounds, the medications to be taken, and follow-up if there are any problems.
Okay, i'm done talking about the procedure. Now i will talk about my observations.
From what i can see, a boy who is brought for circumcision is feeling 1 major thing: FEAR
Now, this fear is due to a lot of reasons:
1) The anticipation of pain. Depending on the feedback he got from those who came before him, or from what he himself has heard or seen (if he was waiting in the clinic, and heard a kid crying while being circumcised, for example), he will then decide whether, to him, the pain will be a major issue or not. The questions they will ask themselves will be: "Can i bear the pain? Is it really that painful as they say? Or not that painful, like they say?"
2) Pressure. Yes, in our country, this is a major source of fear. You see, if they don't proceed with the circumcision, they will be taunted by their fellow kids who had it done. He will be called a sissy, or scaredy cat, or gay, if he couldn't muster up the courage to go through with it. Even the parents do this to their own son (specially if the boy is already quite big and still uncircumcised, like around 11 yrs old or more). It becomes an issue of pride and manhood. The questions they are asking themselves would be: "What if i don't go through with this? What will they say about me?"
3) Embarrassment. You see, showing your genitals is definitely anything but comfortable. Specially if you're in the age when you're starting to become conscious about your body. The kid is aware that he will need to strip down there, and show his private parts to a complete stranger(s): the doctor and the assisting nurse. Heck, stripping down in front of a family member can be quite embarrassing already at some point in a kid's life XD of course, it's understandable if the kid gets afraid! The questions he may be asking in his mind might be: "What will they think when they see it? How are they going to touch me there?"
With all this said, our role as doctors is to gently and patiently reassure the patient and the parents that the initial pain (from the injection of local anaesthesia and separation of skin from the penile head) is tolerable, and that the cutting and suturing itself is painless. This is the truth. And i have NEVER had any problems carrying out said procedure. All my patients went home fine. If they cried at some point during the procedure, they get off the treatment bed embarrassed at themselves from over-reacting XD none of them left the clinic, regretting they were ever circumcised. Most of them even say that it wasn't as painful as they thought it was.
From all my years of doing this, there is only one patient that whined incessantly from the beginning 'til the end (he was already crying when he was brought to the clinic, and so was his mother). We asked if they really wanted the procedure done, and the parents said yes (the father was a police officer, and he was there too, scolding his son and his wife). So we proceeded with it. From what i saw, this kid was quite a spoiled one. He kept looking at his mother during the whole procedure, crying. The mother was no help at all, since she was also crying. Of course, that made the child even more afraid, crying even louder. But the pain is obviously blunted already, since we were able to carry it out and finish it without restraining the patient. He was just lying still the whole time whilst crying loudly. Right after the sutured wound was dressed, the kid stopped crying. Are you guys seeing my point? It's the fear talking and making the kid cry, NOT the pain. Because the pain is tolerable (unless the kid has a ridiculously low tolerance for pain, which we deal with by injecting additional anaesthesia, to which the kid himself refuses to receive again, apparently not feeling the pain anymore after all XD).
The mind is a powerful thing. If it chooses to believe something, that's what it will register to the entire body. If one chooses fear, then fear will dictate everything else. But if one chooses to trust and take courage, the body will do likewise. So it's very important to talk and reassure the kid and the parents on what to expect before, during, and after the entire thing.
My stand on the necessity to circumcise is basically for health reasons. If the procedure is done, personal hygiene for males would be easier to carry out and maintain. Bacteria and fungi are fond of moist areas. If the penile head isn't liberated and not cleaned properly and regularly, it is more prone for the growth of such unwanted microbes.
I'm not posting this to force anyone to have their kids circumcised. I am mainly clarifying things, and sharing my observations, okay?
Whether you want to have it done on yourself or your child is all up to you, guys. GOD bless you all, and please, let's not have any unnecessary fighting, okay? Let's not forget to speak and relate to others with gentleness and love
