Sex, Sleep or Scrabble

by Hammond, Phil

  My cello-chafing days may be over, but I shall continue to diagnose athlete’s armpit (fungal infection of the pit, usually in very rotund non-athletes), farmer’s bum (piles), fish fancier’s finger (bacterial finger infection caught from tropical fish nibbling) and even chimney sweep’s scrotum. The latter was famously described by Percival Pott in 1775, and is a most unpleasant tumour caused by prolonged soot exposure. It’s become much rarer now we no longer send small boys up chimneys but you’d be amazed what half an hour on the naughty step can do, especially if the carpet’s a bit rough.

  As for sick notes, they’re on the way out too. These days, we’re supposed to give out ‘fit notes’ instead, to accentuate what work you can still do. You may not be able to play the cello but you can still pluck a guitar. You may not be able to go up the chimney but that doesn’t stop you from being a clergyman. All you have to do is believe.

  Should foreskins be cut off willy-nilly?

  No. It’s odd that female circumcision is considered a barbarous abuse of human rights, but the male equivalent is seen by many as a mere trifle, and hardly worth getting worked up about. The foreskin is not a redundant quirk of evolution, but actually comprises between fifty and eighty percent of the penile skin (depending on the length of the shaft). If laid end to end, it would have over three feet of veins, arteries and capillaries and 240 feet of nerve fibres with 20,000 nerve endings. Unravelled, it measures 15-20 square inches and they’ve even developed a way of growing skins for burns’ victims from the foreskins of circumcised baby boys. From each one, they can grow enough skin to cover six football pitches.

  Personally, I’d still rather play on grass but it’s clear there is far more to a foreskin than meets the eye. So what’s it for? It expands to cover the shaft during sex, facilitates a smoother thrust and all those nerve endings make it more enjoyable. Not that circumcised men can’t enjoy sex, they just have a bit less feeling at the tip. The foreskin also protects the head of the penis and has glands that aid lubrication and produce anti-bacterial proteins like those found in breast milk.

  So why would anyone want to remove it? Good question. The first known drawing of a circumcision is on the wall of a Dynastic tomb in Egypt, which dates it at around 4,400 years old. It is still performed widely for religious reasons, for example, on eight-day-old baby boys in the Jewish faith, although Jews themselves have questioned the wisdom of doing it without anaesthetic.

  In Israel, the custom of removing the foreskin after death prior to a Jewish burial has now been outlawed. In Western culture, non-religious circumcision became big business in the Victorian era to discourage masturbation (it only works in the short term) and as a ‘cure’ for insanity, epilepsy, hysteria, tuberculosis and short-sightedness. In 1891, Jonathan Hutchinson, president of the Royal College of Surgeons of England, wrote an article entitled ‘On Circumcision as a Preventative of Masturbation’, in which he wrote: ‘Clarence was addicted to the secret vice practised among boys. I performed circumcision. He needed the rightful punishment of cutting pains after his illicit pleasures.’

  By the turn of the century, amputation of the foreskin was ‘scientifically proven’ to cure and prevent malnutrition, paralysis, bed-wetting, hip-joint disease, headache, alcoholism, criminality, club-foot, and heart disease. Unbelievably bad science. Some recent studies have shown that circumcision may help prevent cancer of the penis and reduce the risk of sexually transmitted infections, but good personal hygiene, not smoking and having safe sex are far more important. We could cut lots of bits of our anatomy off if we couldn’t be bothered to clean them properly or didn’t want them to get infected or cancerous, but generally we leave them be and enjoy them. So why pick on the foreskin?

  In America, the only country in the world to circumcise the majority of its sons without religious reason, the foreskin has truly become a fashion victim, and although rates have dropped from eighty-five per cent in the sixties to sixty per cent now, it’s still big business in a recession. Some women believe that because circumcised men feel less they have more staying power, and that a circumcised ‘regular guy’ penis looks nicer, but this is hardly a reason to go chopping off half a man’s penile skin. In Finland, where foreskins are valued, there is no removal at birth and the chance of needing a circumcision later on for a very tight, infected foreskin is just 1 in 16,667.

  In the UK, we still remove thousands of foreskins a year for medical reasons but most of these could have been saved by other methods, such as the use of steroid creams to ease a tight ending and antibiotics for infections. Half of all medical circumcisions are performed in the under tens, and a third in the under six, with most religious circumcisions still done in the first few days of life. Some men feel angry that they were genitally mutilated as children without their consent, and deprived of a very useful part of their anatomy. As Dr John Warren, an outspoken champion of the foreskin puts it: ‘Not having one is like listening to an orchestra without violins. Something is definitely missing.’ There are some rare medical reasons for circumcision, such as a skin condition called BXO or a scarring and narrowing of the foreskin which makes it impossible to pull back, but aside from these, we should just keep it clean and let the foreskin be. If only that had been the Beatle’s B-side.

  Can I do my own circumcision?

  I really wouldn’t try. Circumcision is not just a simple snip, but a complex procedure that requires considerable skill. And the smaller the penis is, the easier it is to cut off more than you intended. Complications range from amputation of the entire penis, damage to the glans and urethra, haemorrhage, infection and poor cosmetic results. If anyone I loved genuinely needed one, I’d make sure it was done in hospital, under general anaesthetic, by an experienced paediatric surgeon.

  Anaesthesia is rarely an issue in religious circumcision, most of which is done outside hospital on conscious newborn infants. Ritualistic circumcision is bad enough, but doing it without any form of analgesia is barbaric. Medical circumcisions are never justified under the age of three and rarely before five years. Religious circumcisions on newborns are especially risky as the penis is so small. They should only be performed with adequate pain relief and preferably when the child is old enough to choose whether he wants his penis skin cut off. Most, I suspect, would say no.

  Can you regrow your foreskin?

  Some men feel so incomplete after a circumcision that they attempt to regrow their foreskins with an elaborate system of taping and weights. This may provoke gales of laughter down the pub but if you type ‘foreskin restoration’ into your search engine, you’ll be deluged with illustrated diaries testifying to its success. There are even entries from bemused, embarrassed but ultimately won-over wives. I would start at the NORM website (the National Organization of Restoring Men www.norm.org) where you can now download the restoration bible, The Joy of Uncircumcising, as an e-book.

  Is it possible for a black man to have a pink penis?

  Yes, if he’s a coal miner who’s popped home for lunch. There’s also a condition called ‘vitiligo’ that causes the skin to lose its pigment and can occasionally affect the penis. There is no cure. Sunbathing makes it worse because the skin of the affected part has no melanin, so won’t tan and is liable to burn very easily. On the plus side, there are some pretty good camouflage creams around (they won’t make your penis disappear) and even if you do nothing, it won’t drop off. But whatever colour your penis has turned, it’s always worth showing it to a doctor to confirm the diagnosis.

  I’ve got scrotal swelling. Dr Google says it might be elephantiasis. What do you think?

  I’d need to see your scrotum, preferably with you attached, but generally common things are common, and elephantiasis is very rare, especially in Somerset. Far more likely to be a fluid-filled sac (hydrocele) or a bag of worms (varicocele). Either way, you need to show it to a health professional soon. As our practice nurse puts it: ‘When you hear hooves on a bridge, think first of a horse, not a unicorn.’

 
; Can you check both testicles at once, to save time?

  You can, but men aren’t great at multi-tasking and there’s a risk you’ll spin them in opposite directions. Around 1,500 men develop testicular cancer each year in the UK, and it’s the most common cancer in young men. The incidence has doubled in the last twenty years for some unknown reason, but it has a very good cure rate and your sex life and fertility are usually not affected. All you have to do is spot the lump and get help.

  Examine your testicles during or after a shower or bath, when the scrotum is relaxed and the balls are hanging proud. Look for any swelling, and then roll the testicles, one at a time (or both if you’re ambidextrous), gently between the fingers and thumb. They should feel smooth and rubbery. At the back and top of the testicle is the curly sperm tube (epididymis). Compare sides but, like breasts, it’s not uncommon to have one slightly bigger than the other or one hanging lower (usually the left)

  A cancer may start like a grain of sand on the surface of the testicle itself and then grow into a more obvious lump. Show any new lump or tenderness to your GP pronto. The sooner it’s picked up, the easier the treatment.

  Why do doctors lose interest in your testicles when you hit fifty?

  Doctors become less excited by scrotal lumps when you hit fifty, because they’re much less likely to be cancerous. However, there’s plenty that can still go down in the ageing scrotum. One of the first slides I was shown as a medical student, was of a man pushing his scrotal hernia around in a wheelbarrow. It was prize marrow-sized and then some. Generally, anything approaching a melon will rekindle the interest pretty quickly.

  FOR HER

  What should I expect from an internal examination?

  No surprises.The Royal College of Obstetricians and Gynaecologists has an ‘Intimate Examinations Working Party’, which convened in 1997 and then updated itself in 2001. Four members of the six-man party are women, and they have produced thirty-seven pages of guidelines for embarrassing examinations that you can download at the college website www.rcog.org.uk

  In a nutshell, it’s your body, no one can poke and prod you without your consent. You should be told what’s being proposed and why, and you can opt out at any time. You should be treated with dignity, respect and a warm, gentle speculum, in private (but you can ask for a chaperone and a translator). If you would like a female doctor, they will try their best to arrange it. Examination banter should avoid anything jocular; no pet names, no commenting on suntans or through-draughts, and no discussing sexual response until the gloves are off.

  Other guidelines worth knowing include:

  • ‘All sensible measures to reduce the extent and duration of nudity should be taken.’

  • ‘Gloves should be worn on both hands during vaginal and speculum examinations.’

  • ‘In the course of routine pelvic examination,

  care should be taken to avoid digital contact with the clitoris.’

  • ‘Every effort must be made to ensure that such examinations take place in a closed room that cannot be entered while the examination is in progress and that the examination is not interrupted by phone calls, bleeps or messages about other patients.’

  • ‘There is no scientific evidence to support the use of rectal examination as means of assessing the cervix in pregnancy or labour and, as most women find it more distressing than vaginal examination, it cannot be recommended.’

  • ‘Fully informed written consent must be obtained for all still or video photography. The woman’s privacy and modesty must be protected and every effort must be made to ensure that the video and photographic images have no sexual connotations.’

  • ‘Informed consent must be obtained for any intimate examinations that are undertaken under anaesthesia. It is good practice for all personnel in the operating theatre to treat the patient with the same gentleness and respect that they would apply were she awake, avoiding personal comments and protecting the patient’s modesty wherever possible.’

  The fact that the college has seen it necessary to articulate what to many would seem blindingly obvious is because some really bad stuff has happened in the past. It’s rare but there will always be the odd dodgy doctor or well-meaning emotional cripple, and these guidelines should help you spot them and speak up. Be wary of any doctor with a missing glove.

  Are bakers good at examining breasts?

  Yes, although I wouldn’t go to Warburtons for a second opinion. Breasts are active all the time, particularly during the fertile years when they have to be at the ready each month, in case of pregnancy. As a result, breasts change in consistency and general lumpiness throughout each cycle, which makes it very confusing if you’re trying to check for lumps.

  The best method (taught to me by a breast specialist, not a baker), is to raise your arms above your head and have a close look once a month, in a big mirror. If one breast has always been a different size or shape from the other, there’s nothing to worry about. But any new differences, particularly dimpling or distortion of the skin or nipple, need checking out. Then, gently knead your breasts against your chest wall. Cancerous lumps generally feel very hard or irregular and need checking out urgently. Squidgy or soft lumps are rarely cancer, but are worth checking out if they don’t move with your cycle.

  Does a mammogram have to squeeze my breasts so hard?

  Well, it was invented by a man. Women with larger breasts tend to find it more of a squash but all breasts are tender when compressed between two hard plates. More distressing is that, although mammograms pick up most cancers where a lump can already be felt, they only pick up about half of unfelt cancers. And they can suggest you’ve got cancer when you haven’t.

  But this is true of all tests. Even in the best hands, we miss some cancers and worry or even treat some patients unnecessarily. The risks of getting breast cancer wrong are lessened if you have the triple assessment of a specialist opinion, imaging with X-rays/ scans and a biopsy of the tissue.

  Can I examine my ovaries?

  Not easily. The ovaries are well tucked away and although your partner could theoretically check them out for you, in the same way that you might give his testicles the once over, just the thought of trying to locate the ovaries would send most men into meltdown. Which is why we have doctors.

  The trick is knowing when to get your ovaries checked out and that’s very hard. The symptoms of ovarian cancer can be vague and difficult to recognise early on, and when I trained I was told that ovarian cancer was ‘a silent killer’ and had no symptoms at all. This usually isn’t true – it’s just that the symptoms are not heard, or put down to something else, like irritable bowel or pre-menstrual syndrome. Persistent swelling in your stomach needs an urgent specialist referral.

  Early symptoms of ovarian cancer may include:

  • pain in your pelvis, lower stomach, or side;

  • a full, bloated feeling in your stomach;

  • difficulty eating, or feeling full very quickly;

  • needing to pass urine more urgently and frequently than normal.

  Later symptoms may include:

  • swelling in your stomach;

  • pain in your lower stomach;

  • pain during sex;

  • constipation;

  • irregular periods.

  Advanced symptoms (for any cancer) may include:

  • nausea;

  • weight loss;

  • breathlessness;

  • loss of appetite;

  • tiredness.

  If you think any of this could be you, get checked out (and particularly if a close relative had ovarian cancer). An internal examination awaits, and possibly blood tests, scans or scopes. It’s a bugger to diagnose and treatment is no picnic, but the sooner it’s picked up the better.

  There is no national screening programme yet, but you may be eligible for screening if you have two or more close relatives (such as your mother, sister, or daughter) on
the same side of your family, who had ovarian cancer diagnosed at a young age (under fifty years). See your GP.

  Is there any way of making a cervical smear less embarrassing?

  Women do their own Chlamydia swabs and I’m sure it won’t be long before you do your own smears. I know one DIY nurse but it’s probably still a bit fiddly for everyone to do it. Most women have an embarrassing smear story. In these days of targets, some doctors and nurses will try to spring a surprise smear on you when you’ve popped down with a tickly cough. You don’t have to have one, and certainly not if you’re wearing dodgy pants or hiding a strawberry. But you can if you want. Nurses aren’t fazed by much. They’ll even give you the strawberry to take home.

  When I ask an audience for their smear experiences, women are surprisingly forthcoming. One spoke of freshening up with glitter spray by mistake, and presenting the GP with ‘a night of a thousand stars.’ Another told of the horror of being asked by an overly-smiley nurse to ‘pop her little panties down and flop her legs like a frog.’ And one woman became allergic to small talk after a nurse commented on the cut of her tunic during the smear, then sniffed and said: ‘Oooh. That’s a nice perfume.’