DR. RONALDO JOSON, MD

Question and Answer: Dr. Reynaldo Joson on Project Xtulepinoy
2003

Why are you doing an advocacy against routine circumcision?

I want to save millions and generations of Filipino children from unnecessary circumcision, its pain and its risk of complications including death.

When did you start doing this advocacy and what initiated it?

At a personal level, in 1999, when I started realizing the senselessness of this practice. I started discouraging parents and colleagues.

In 2001, I completely stopped doing non-therapeutic circumcision, after I advised and convinced my son not to go for the tradition-driven circumcision. I felt I should not have double standards, i.e., not doing circumcision on my son and yet doing circumcision on patients other than my son. I remember vividly I turned down a request from a surgeon-colleague to do circumcision for his son on that year.

Publicly, in 2002, when I was the chairperson of the Department of Surgery of Ospital ng Maynila Medical Center, I received a letter of invitation from the Philippine Society of General Surgeons to conduct Operation Tule in Ospital ng Maynila Medical Center. I politely turned down the invitation and started an in-depth review of the issues of circumcision. Our department conducted a debate on pros and cons of circumcision and after which we decided to make a stand on NO to routine circumcision and NO to Operation Tule. Our department committed itself to spearhead an advocacy against tradition-driven circumcision as part of its social responsibility program.

Are you alone in this advocacy? If not, who are with you in this advocacy?

Initially, I was alone. Then, the Department of Surgery of OMMC was with me. Then, other surgeons and physicians all over the country joined us. Then, the whole hospital of OMMC supported us. OMMC is the first hospital in the Philippines that has openly declared its stand against tradition-driven and non-therapeutic circumcision.

I like to mention though, even before I was into my advocacy, there were already individuals who were into this advocacy already, like Dr. Michael Tan, the anthropologist, and Dr. Jaime Licauco, author of Inner Awareness.

What is/are your stand on circumcision?

We are for therapeutic circumcision such as in patients with phimosis (restrictive foreskin) with recurrent urinary tract infection, paraphimosis (too tight foreskin), and balanitis (infection of the glans penis).

We are against the performance of tradition-driven, non-therapeutic circumcision in children, both in the newborns and adolescents.

We are against the holding of Operation Tule, which promotes the performance of tradition-driven, non-therapeutic circumcision in adolescents.

We are not against the performance of circumcision on adult males who request it done for cosmetic reason.

Why are you against tradition-driven circumcision?

Primarily because it is non-therapeutic, that is, of no medical benefits, therefore, unnecessary. Doing an unnecessary circumcision inflicts on the subject, usually a male newborn or boy, unnecessary pain and unnecessary risk of complications which include the possibility or danger of death.

What is/are the origins and bases of the practice of circumcision?

The exact origins and bases of the practice of circumcision are not definitely known.

As to origins and bases of the practice of circumcision, these may be classified as religion-based or non-religion-based. Under religion-based origins, we have to study the how and why of its practice by the Christians, Muslims, and Jews. Under non-religion-based origins, we have to look at medical and non-medical reasons. Under medical reasons, we have to consider how circumcision can promote health and prevent disease. Under non-medical reasons, we have to look at the origin of the non-religious rituals.

What is the most common basis for the practice of circumcision in the Philippines?

As part of the non-medical non-religious rituals, as a rite of passage to manhood for the adolescent male children, as a result of fear of cultural stigma of being teased “supot”, as a result of peer pressure and as a result of the belief that all males should be circumcised with no specified reason. If there is a reason expressed by a parent, especially the mother, the reason is usually a myth, such as circumcision will make the boy cleaner, grow faster and taller.

Is the religion basis a strong justification or contributory factor for the rampant practice of circumcision in the Philippines?

NO. With majority of the Filipinos being Catholic and with the Catholic Church not requiring circumcision for salvation, the religion basis is not a strong contributory factor for the rampant practice of circumcision in the Philippines.

What are the evidences on the medical benefit of routine circumcision?

Using evidence-based medicine study approach, with analysis of almost 40 years of medical research on circumcision, the American Academy of Pediatrics in 1999 has come out with a stand that the benefits are not significant enough to recommend circumcision as a routine procedure.

Using number of patients needed to treat principle, routine circumcision is not warranted to prevent urinary tract infection and penile cancer. Urinary tract infection secondary to phimosis and penile cancer are uncommon if not rare.

Using the benefit-risk ratio, an invasive and painful procedure such as circumcision is not warranted to promote hygiene of the penis and to prevent diseases such as sexually transmitted diseases and cervical cancer. There are equally effective, non-invasive and painless procedures available such as meticulous mechanical cleaning, hygienic sexual practice, avoidance of multiple partners and sexual promiscuity.

Thus, for the above reasons, routine or tradition-driven, non-therapeutic circumcision is not indicated.

Is there such a thing as “painless circumcision”?

NO. Circumcision, just like any operative procedure which involves cutting of body tissues, entails some degree of pain, both during and after the operation.
Considering that there are NO strong religious and medical reasons and considering the procedure is NOT without pain and complications, how do you intend to reduce if not stop the tradition-driven non-therapeutic circumcision in the Philippines?
To reduce the tradition-driven non-therapeutic circumcision in the Philippines is to change the tradition and the peer pressure.
The challenge really consists of three aspects. One is how to change the belief of parents who will have their male children undergo routine circumcision because of the tradition. Two is how to reduce, if not abolish the peer pressure that will make the male adolescents and adults undergo routine circumcision. Three is how to convince physicians to stop doing routine circumcision, especially those who have already acquired the habit of doing the procedure left and right and those who tend to ride on all traditions to avoid any conflict.
What do I propose to do to meet the challenges? Basically, public health education and advocacy.
Public health education will consist essentially of sending the message to the public through all forms of media that "TULE – HINDI NA KAILANGAN! MASAKIT PA!"
Advocacy will consist essentially of actively campaigning against routine male circumcision by first explaining the issues and then convincing the public, especially the parents and male children that TULE – HINDI NA KAILANGAN! MASAKIT PA! Hopefully, with the advocacy, the belief and behavior will change and peer pressure removed.
To meet the third challenge, which constitutes the physicians, advocacy will also consist of enlightening and convincing the physicians on the non-necessity of routine circumcision.
The strongest strategy in the advocacy is for the physicians to speak out against routine circumcision. The public considers the physicians as the professionals to turn to when it comes to issues on circumcision. The public still has high respect for physicians in the Philippines.
What have you done so far? How successful are you now in your advocacy?
A lot have been done already but there is still a lot to be done. We need your help and all the help from every Filipino parents and physicians.
We have done a lot of information dissemination since April, 2002, in the newspapers, radio, and television, health magazines, Internet, and public forums. We have created a website for this purpose: http://xtulepinoy.tripod.com/
We have written to practically all medical associations and the Department of Health to get their stand. We are still awaiting their stand.
We have enlightened and convinced organizations who have sponsored Operation Tule before not to do it anymore and do something else like cleft lip and palate mission and thyroid mission.
Our end-points in this advocacy are: less if not zero routine circumcision in adolescent boys, less if not zero routine neonatal circumcision, and, less if not zero Operation Tule, At the moment, we don’t have the figures, both baseline and ongoing. It is not easy to get figures on these parameters.

At present, we measure the degree of success just in terms of concrete achievements or events, such as the following:

Presence of a manifesto of surgeons against routine circumcision (January, 2003)
Presence of several medical departments and institutions against routine circumcision and have stopped holding Operation Tule (OMMC, PGH, JRMH, PCMC, ZCMC)

Presence of several organizations that have stopped sponsoring Operation Tule (REACT, Metrobank Foundation)

Number of parents convinced not to go for routine circumcision for their children. (about 1,000 as of March, 2003)

Presence of school physicians who came out with circulars on the pros and cons of circumcision to their students and parents (Xavier School)

What is your appeal for the parents, boys, and physicians in your advocacy?

For the parents,

TULE – HINDI NA KAILANGAN! MASAKIT PA!

Do not hurt your boys anymore.

For the boys,

TULE – HINDI NA KAILANGAN! MASAKIT PA!

Huwag madadala sa tukso!

For the physicians,

TULE – HINDI NA KAILANGAN!

Do not hurt the Filipino children anymore! PRIMUM NON NOCERE!

Continuing doing tradition-driven circumcision puts you at risk of a malpractice suit because of violation of bioethical principles and human rights of children.

Dr. Reynaldo Joson may be reached at rjoson2001@yahoo.com
Website: http://xtulepinoy.tripod.com/