Manhood
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In ancient Rome too there were Jews who because of sanctions against them wished to undo their circumcision. Obviously there were successful methods even at that time, since, when the law banning 210
a i l m e n t s o f t h e p e n i s circumcision was repealed, the requirements that a circumcision had to meet were further tightened by the rabbis. The foreskin must be completely removed, so that no tissue remained for possible experiments.
Then there is the well-known discussion about King David’s
‘marble foreskin’, since Michelangelo’s celebrated statue of this Jewish patriarch shows him apparently uncircumcised. Scholars had a field day with this and finally declared that Michelangelo knew exactly what he was doing: King David lived around 1000 bc, and it was not until after 300 bc that the circumcision laws were tightened. Before that time only a small fringe of the foreskin was removed, which is exactly what one sees in Michelangelo’s sculpture, where the foreskin does not completely cover the glans . . .
Religious circumcision confronts many surgeons, urologists or plastic surgeons with a dilemma. On the one hand there is the right to physical and intellectual integrity, and the individual’s right to self -
determination, and on the other there is freedom of religion. And religions sometimes have archaic rules. A recent Dutch government proved pro-active on this point and removed ritual circumcision from the standard health insurance package.
Health circumcision
In 1870 an American orthopaedic surgeon launched the notion that a whole range of ailments, rheumatism, asthma, kidney infections, bed-wetting, alcoholism, sterility and venereal disease, could be cured by circumcision. Sayre, the surgeon concerned, was acclaimed as the
‘Columbus of the foreskin’.
At the beginning of the twentieth century an American magazine hypothesized that the low incidence of cervical cancer in Jewish women might be a result of Jewish men being circumcised. Although this hypo -
thesis was not confirmed by scientific research, there was a massive overreaction: since then virtually all American male babies have been circumcised, mostly in hospital. In 1900 a quarter of male Americans had been circumcised. This so-called health circumcision, on medical grounds, was used in Europe in the Victorian period, but at that time to prevent masturbation.
When the army medical service published reports to the effect that uncircumcised soldiers were much more susceptible to venereal disease than their circumcised colleagues, circumcision was recommended as a preventative health measure. The result of this was that by the late 1960s some 90 per cent of the male population was circumcised. In 1969 there were the first stirrings of resistance, but it was not until 211
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David’s private
parts.
1990 that there was a real sea change in America. A lobby group for circumcised men was set up and there were direct appeals to the media:
‘We don’t cut babies’ ears off because they need washing behind them, do we?’ Members could not only commiserate with each other, but could also swap experiences about all kinds of methods of restoring the foreskin. These included obtaining ‘new’ tissue by careful stretching of the remains of the foreskin, involving the use of clamps, plasters and elastic bands. Homosexuals, as so often with these kinds of problems, were the trailblazers. From San Anselmo in the United States the anti-circumcision lobby distributes its newsletter No-circ, which reports on successes achieved, like a ban on female circumcision, which is regarded as a first step in the struggle against male circumcision. In a statement the movement argues that doctors who perform a ritual circumcision are infringing the ancient medical adage primum non nocere, do not inflict harm. Even the un charter on human rights is invoked: no one shall be subjected to torture, or inhuman or humiliating treatment.
In early 2007, as a result of publications in the authoritative journal The Lancet, there were unexpected developments. A study in Kenya 212
a i l m e n t s o f t h e p e n i s headed by scientists from Johns Hopkins University (Baltimore) involved 2,784 hiv-negative men aged between eighteen and 24. The men were either circumcised or their circumcision had been postponed for two years. After two years 4.2 per cent of the second group had become infected with the hiv virus, whereas in the group of immediately circumcised men the percentage was 2.1!
In Uganda a comparable study was conducted by a team from the University of Illinois, only this time with 4,996 hiv-negative men between fifteen and 49. This study also showed a halving of the risk of hiv infection. The tenor of the various reactions was more or less unanimous: because of the enormous potential of circumcision, within Southern Africa alone a reduction of 3.7 million hiv infections and 2.7
million deaths from aids, the procedure had to be seen as a preventative measure. This marked a return to ‘health circumcision’.
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chapter eight
Voluntary and Involuntary
Sterility
Forced sterilization
The controversial history of sterilization in men, vasectomy, begins with Cooper’s publication of 1832 on the severing of the seminal duct in dogs. The first sterilization was carried out in the United States at the end of the nineteenth century in order to prevent the spread of crime.
There was a fear that the usa would be inundated by mentally and socially inferior people. The procedure was also carried out in the United Kingdom, but in this case on eugenic grounds, to protect the race from self-destruction by its own descendants. At the beginning of the twentieth century Sharp reported on 450 sterilizations he had carried out in the state of Indiana on members of the Reformed Church.
In their case vasectomy was intended to suppress masturbation. It was performed without anaesthetic and took no longer than three minutes.
The severed end of the duct on the testicle side was left open so that the sperm cells could drain away freely and be absorbed by the body. In 1907 a law was introduced in Indiana that permitted the sterilization of ‘mental defectives’ and the ‘insane and feeble-minded’ for eugenic reasons. In the following decades similar laws were passed by 32 states, while twelve also legalized the forced sterilization of criminals. Up to 1960 over 60,000 sterilizations were carried out for the above
-
mentioned reasons.
In Germany in 1933 vasectomy was made to serve eugenics, based on ‘modern racial hygiene’. In the first year after its introduction 28,000 sterilizations were carried out. In 1936 Adolf Hitler discussed sterilization with the German cardinal Faulhaber, the Archbishop of Munich. Hitler had argued for the sterilization of those with hereditary defects, and is reported as saying the following: ‘The operation is simple and does not make the man unsuitable for an occupation or marriage, and now we are being thwarted by the church.’ Cardinal Faulhaber is supposed to have said: ‘Chancellor, the state is not being 214
vo l u n ta ry a n d i n vo l u n ta ry s t e r i l i t y forbidden by the church to remove these harmful individuals from the community within the framework of the laws on public decency and given a genuine emergency. But instead of physical mutilation other methods must be tried, and such a means exists: the internment of people with hereditary defects.’
Internment camps amounted to concentration camps; such an institution fell within the laws on public decency and sterilization did not. Sterilization led to sexual pleasure without reproduction and that in the view of Catholic moral theologians could not possibly be permitted. For the ordinary Catholic sexual intercourse had repercussions, as Uta Ranke describes in her book Eunuchs for the Kingdom of Heaven.
In 1935 a question came from Aachen to the Holy See as to whether a forcibly sterilized man could be admitted to a church marriage. On 16 February the reply was received that the man’s marriage must not be forbidden, since it involved an unjust coercive measure by the state.
In Sweden it has been possible since 1935, with the approval of a committee, to sterilize those whom ‘the law has
declared non compos mentis’, or who because of a psychiatric condition are deemed unsuitable for parenthood. In 1948 a law was promulgated to control sterilization on eugenic grounds; in practice many sterilizations were actually performed for socio-economic reasons. Between 1948 and 1962 14,000
sterilizations were carried out in Japan, and the number of illegal sterilizations was estimated at four times that figure.
A large proportion of people with a mental handicap are not able to give informed consent with regard to sterilization. In those cases the carer should fulfil his/her obligations towards the parents or guardian and, with those who are of age, towards those charged with the pe r -
son’s welfare. If the handicapped person is capable of informed consent and is over the age of twelve but not yet sixteen, the permission of parent or guardian is also required. Everything seems perfectly regulated, but in practice the picture is different. When the parents of a strapping lad of fourteen with Down’s syndrome asked me to have him sterilized, since their son had already made a spontaneous attempt at intercourse, I acceded to their request without hesitation. Some readers might think that a Down’s syndrome male with his 47 chromosomes cannot father children, but in certain circumstances that is perfectly possible.
Even today forced sterilizations take place, and not only of the mentally handicapped. The following story may serve as an illustration: Patient a, a 37-year-old man of Iranian origin, came to the urology clinic after having failed for the third time to father a child. His ejaculate repeatedly contained almost no sperm cells. After some years’
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residence in the Netherlands both he and his wife wanted to extend their family. He had fled from Iran for political reasons, having endured extended periods of torture, including electric shocks to his genitalia, which had often rendered him unconscious. Echographic examination led to a diagnosis of an epididymal cyst on the right side and on the left; the head of the epididymis was irregular; the testicles themselves showed no abnormalities. At the patient’s request the diagnostic process was continued in our clinic after two years, and it was decided to perform an exploratory operation under anaesthetic. When sections of tissue from the testes were examined the pathologist found a slight disruption of sperm production on both sides, though adult sperm cells were present. After the removal of scar tissue, non-soluble green knotted stitches were observed on both sides, consistent with a post -
vasectomy condition. The loose ends were stitched back together on both sides, without any post-operative complications. When the hospital did a follow-up check, the patient indicated that he had absolutely no knowledge of the sterilization.
Sometimes men are ignorant of the fact that they have undergone sterilization. Another illustrative case history: A 47-year-old man was referred to me by a gynaecologist in relation to the patient’s involuntary childlessness with his new partner. He had two children from a previous marriage. Three examinations by the gynaecologist showed a complete absence of sperm cells. In another hospital a section of testicular tissue had been removed under local anaesthetic. The production of sperm cells, spermatogenesis, was shown to be only slightly disrupted, which suggested an obstruction, for instance a double epididymal inflammation. When asked if he had had diseases or operations in the past, the patient’s answer was negative. It was decided to explore further under anaesthetic. No obvious abnormalities were apparent to the touch, but after incision it soon became clear that he had been sterilized: the gap between the two ends of the seminal duct was so small on both sides that it had not been felt and likewise on inspection of his shaved scrotum the tiny scars were virtually invisible. The ducts were rejoined on both sides, and there were no post-operative complications.
At a follow-up check the patient mentioned that in the years before and following his divorce his alcohol intake had been very high, and that he could remember little or nothing from that time. When asked about the case the referring gynaecologist said that he had information only from the gp of the present partner. Three months after the restorative operation microscopic examination showed over 20 million spermatozoa per millilitre, and it was soon possible to fulfil the desire for children.
When divorced people enter into a new relationship, there is of course a good chance that they will not have the same gp. If the referral 216
vo l u n ta ry a n d i n vo l u n ta ry s t e r i l i t y process in relation to an unfulfilled desire for children subsequently begins with the woman, usually only her medical records are forwarded. In this case the urologist had omitted to request possibly relevant information on the man from the gp.
The World Health Organization
In the 1970s a large-scale programme was launched by the World Health Organization in India and elsewhere to combat over-population, in which millions of men were sterilized. The same happened in China under government pressure. For some decades Chinese doctors had already been using alternatives to vasectomy, including a technique requiring only three instruments (an important factor in developing countries), the so called ‘no-scalpel’ technique, that is, no scalpel but a sharp clip, a pair of scissors and another clip for fixation of the seminal ducts.
The Chinese doctors claimed that with the aid of this technique haemorrhaging was less frequent than in conventional vasectomies, an important factor in a country where at the time sterilization of men was more or less obligatory after the birth of the first child, and in addi -
tion was less time-consuming. Another Chinese technique was based on quickly pricking the outer surface of the seminal duct, after which a blunt-ended needle was inserted in the duct on both sides. On one side a blue dye (methylene blue) was injected and on the other a red one (Congo red). If after the procedure the man’s urine was red, the operation had most probably been a success! When the needles appeared to be properly in position on both sides, a caustic fluid was injected, causing a build-up of scar tissue which blocked the seminal ducts. Initially phenol was used, and later carbolic acid with cyanoacrylate. The advan tage of this method of sterilization was the speed with which it could be performed. In any case the procedure was irreversible. To this end the Chinese had started using polyurethane and later silicones, but the use of polyurethane in the seminal duct was not initially permitted by the who since there was a chance it might be carcinogenic. The use of silicones, however, was sanctioned by the who at the end of the 1980s, in the first instance for plugging the Fallopian tubes via the vagina and the uterus. When asked, the Chinese were not able to give the exact composition of their silicones, so a Dutch company and Dutch urologists were called in. A joint workshop was held, which was also attended by Indonesian urologists. Chinese men from an area in the province of Shandong were used as test subjects. This method was of great interest to the Indonesians, since many Muslims have religious objections to conventional sterilization. Basically their religion forbids 217
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Chinese instru-
ments for use in
vasectomy.
the violation of the body, and any contraceptive procedure should be reversible. The Dutch doctors were of course focused on a potentially easily reversible form of sterilization: removing a plug is much easier than a lengthy, expensive operation in which the ends have to be sewn back together.
At the workshop it soon became clear that the Chinese had not succeeded in achieving sterility in 100 per cent of the men treated with plugs, an outcome which would never be acceptable in Western culture in countries where sterilization was on a completely voluntary basis.
Failed sterilizations have sometimes led to (successful) claims for damages, though this virtually never happens today, since every doctor performing an operation will inform the patient about the impossi bility of guaranteeing absolute sterility. Carrying out a vasectomy entails an obligation to perform to the best of one’s abilities, not an obligation to guarantee a certain result: an important legal distinction.
The ty
pe of vasectomy which involves the removal of a section of seminal duct is at present considered one of the most practical ways of achieving sterility. With Nepal, the Netherlands, Yemen, Bulgaria and India, the United Kingdom is among the few countries in the world where more men than women have been sterilized. Countries where vasectomy is considered completely unacceptable include the Dominican Republic, El Salvador, Honduras, Jamaica and Tunisia. What kind of people opt for vasectomy? Mainly men over 30, with a high educa-tional level, an above-average income and a complete family. Many of them feel that it is now ‘their turn’ to contribute to contraception.
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vo l u n ta ry a n d i n vo l u n ta ry s t e r i l i t y Though the operation may be regarded as simple by some, the great variety of techniques used suggests a different picture. The great majority of surgeons use local anaesthetic, beginning with the nerves in the seminal cord. In the 1960s it was not unusual for a man to go straight back to work after the procedure, but today patients are recommended to take things easy, at least on the day itself. An experienced doctor can perform the procedure in less than fifteen minutes, though it is sometimes difficult to locate the seminal duct, particularly if the scrotum is rather compact. Matters are complicated if the man involved disregards advice and arrives by bike in winter. For reasons of temperature regulation the layer of muscle beneath the skin of the scrotum is tautened, making it more difficult for the urologist to take hold of the seminal duct.
Bearing in mind the possibility that the procedure may one day have to be reversed, it is sensible to carry out the vasectomy high in the scrotum. To check whether the operation has been successful, the ejaculate is examined under the microscope after three months for the presence of spermatozoa (there is no point in doing this any sooner). In those three months it is advisable to ejaculate as often as possible: after vasectomy the patient is not immediately sterile, since downstream from the point of ligature spermatozoa are still making their way towards the outside world. The criterion for sterility is the absence of sperm cells; according to urological guidelines it is sufficient if after three months there are only a few cells visible, provided that these are immobile. On problem is that if a patient submits ejaculate that has spent some time out of the body, the spermatozoa will invariably have failed to survive. One thing is certain: if after a vasectomy living sperm cells remain visible, alarm bells should start sounding. In 2004 the us Food and Drug Administration (fda) approved a new vasectomy Presentation of