Circumcision critics go against tide

“I don’t know why I did it. Even after reading this Web site, the constant mocking from my friend prompted me to go to a hospital,” wrote one 14-year-old boy at www.pop119.com. The reason for the teasing? He wasn’t circumcised.
The Web site, run by Kim Dae-sik, a physics professor at Seoul National University, was created to counter the assumption that circumcision is medically necessary. Despite countless hours in the lab and behind the desk, Mr. Kim still finds time for his crusade to rid the country of what he calls its ignorance about circumcision and its unquestioned practice.
As Mr. Kim clicks through Web pages while checking his Web site for new messages, he says, “I must say it has gotten better. Back in 1998 when you searched the Internet, the only thing that one could find on circumcision was mostly questions on when to conduct the operation.
“Nowadays, you have people questioning the very practice of it,” he says with a grin.
It was mere curiosity that led Mr. Kim on this unlikely path. “Back in college, I had lots of foreign friends who didn’t have circumcision. For me it was a culture shock,” says the professor. He recalls how he found out by chance that circumcision may not be as common as he thought, during the time he was studying for his master’s degree at the University of California at Berkeley in 1989.
His interest in the subject led him to produce a study that appeared on Sept. 25, 2001, in the British Journal of Urology, a well-known medical publication by the British Association of Urological Surgeons, the European Society of Peadiatric Urology and the Societe Internationale d’Urologie.
In his study, which he conducted with Dr. Pang Myeong-geol, a researcher at the Institute of Reproductive Medicine and Population at Seoul National University, Mr. Kim concluded that outdated notions about circumcision and Korean physicians’ lack of knowledge on the purpose of circumcision were the leading factors contributing to the extraordinarily high circumcision rate in the country.
The survey the professor conducted among 5,434 males, from infants to 92 years old, on their circumcision status and their age at circumcision suggested that circumcision in Korea started about 1945 (out of 1,400 males that were born before 1945, only one person was circumcised prior to 1945), and the procedure became widespread in the 1960s.
The study also estimated that more than 90 percent of males under 18 in Korea are circumcised.

Mr. Kim suggests in his study that circumcision is identified with wealth, or high living standards, as most of the surveyed doctors thought that developed nations such as Scandinavia and Denmark routinely conduct circumcision on a mass scale like Korea. However, both countries have a circumcision rate of slightly less than 2 percent.
Additionally, 267 practicing medical doctors were surveyed to gauge their basic knowledge on circumcision. The results only confirmed his belief that the firmly entrenched practice was based on shaky grounds.
“I would call it selective ignorance,” Mr. Kim says. “I have doctors calling me and telling me that without being an expert I should keep my mouth shut. But it just takes simple questions to make them nervous. You can tell they are fumbling for words.”
Mr. Kim’s study noted that male circumcision is mainly practiced in Muslim and Jewish communities for religious reasons, so given that neither religion has a big foothold in the country, the authors surmised that Koreans undergo circumcision because they believe it has medical benefits.
One purpose of circumcision is to treat a condition called phimosis, in which the foreskin, or prepuce, is unable to retract from the glans. When Mr. Kim asked his survey respondents for the definition of phimosis, few could pick the right one.
“When you have only about 28 percent of the surveyed doctors selecting the right answer for the definition of phimosis, it just tells you there is something wrong,” he says.
Some doctors concede that circumcision should not be done perfunctorily anymore. “Two years ago, we had about 100 kids doing the operation. Last year we had a 20 percent drop as people took more interest in the matter,” says Chun Hoon-seok, who heads the Manomedi Urology Clinic in the Gangnam area. “It’s nothing concrete, but it may be the beginning of something.”
The doctor says that unless the foreskin that covers the glans is unretractable, an operation is not needed. “Other than that, there should be no reason to do it,” Dr. Chun says.

The American Academy of Pediatrics released a policy statement on circumcision after an analysis of 40 years of available medical research in March 1999. In it, the organization stated that there was no absolute medical indication for routine circumcision.
“Some research suggests that circumcised men may be at a reduced risk for developing syphilis and HIV infections,” the organization said. “However, the AAP policy states that behavioral factors continue to be far more important in determining a person’s risk of contracting sexually transmitted diseases than circumcision status.”
Even if there are few medical reasons to get circumcised, Koreans may opt to go under the knife just to avoid looking different from other men. Those who don’t get circumcised by the time they reach adulthood are subject to peer pressure, Mr. Kim says.
At one point, it was more than peer pressure that prompted the operation: The Korean Army used to perform the procedure on its uncircumcised conscripts, but no longer.
“When we did our research, we went to public bath houses, and we noticed that people who had not done it looked somewhat embarrassed,” says Mr. Kim.
Dr. Chun estimates that costs for a circumcision, typically done during the winter break, which is longer than the summer break in Korea, range from 100,000 won ($83) to 200,000 won, depending on the clinic. Circumcisions are not covered by health insurance.
The best time for children to undergo the procedure is 11 or 12 years old, Dr. Chun says. Having it performed earlier would make it more difficult for doctors to conduct.
“A little bit of cooperation from the kid is needed as he needs to be able to suppress some degree of pain that is still felt during the operation, even with sedation,” he says.
It’s Mr. Kim’s dream to see that no child will have to suffer such pain for no good reason. These days, he feels that he’s making progress toward that goal.

Indeed, one quick search over the Internet suggests that there may be a change in attitude toward a practice that has been rarely questioned in the past.
In an Internet community named Ponammo, which is an acronym for the Korean pogyeong anhannamjamoim (which translates roughly as “a community for guys who aren’t circumcised”), about 2,671 members have formed a group. Membership has to be confirmed by the person in charge of the online community, during which the prospective member must answer personal questions and must acknowledge whether he has been circumcised or not.
However, altering the public’s perception of the benefits of circumcision will be tough, if the comments of these Korean men are any indication:
“Um, what about sexually transmitted diseases? What about hygiene?” Mr. Ha, a college student who declined to be named by in full, says in an irritated tone.
“At least visually, those who have done it look cleaner,” says Kim Han-tae, who works in the male fitting room at the Samsung Public BathHouse in Dowhadong. After a pause and some throat clearing, Mr. Kim adds, “Eh, and I think there is less odor.”
For now, whether the Seoul National University professor’s efforts will lead to an exodus from a commonly held belief is anybody’s guess.
But he promises to keep up the good fight. “It’s a mass hypnotization,” he says. “But my own son is not going to get it.”

What doctors know

These questions were used in Kim Dae-sik’s survey of 267 Korean doctors to assess their knowledge about circumcision. Each answer choice is on the left, and the percentage of doctors who chose it is on the right. The correct answer is in bold.

Circumcision
1. What is the circumcision rate in Sweden and Denmark?
~90% 21.7
~50% 31.1
~10% 37.5
1-2% 9.7
2. Which of South Korea’s neighbors, and including South Korea, have >50% circumcision rate?
South Korea, North Korea, Japan and China 7.9
Only in South Korea and Japan 51.7
Only in South Korea 40.0
Only in south Korea and North Korea 0

Phimosis
1. What is physiological phimosis?
Prepuce (foreskin) itself 4.1
Unretractable prepuce 28.8
Glans is covered by prepuce 56.9
Prepuce is too long 10.1
2. What is the percentage of phimotic males at ~20 years old?
~90% 12.4
~70% 37.1
~40% 34.5
~2% 16.1

by Brian Lee