For many Filipino boys at or around the ages of 9 and 12, this summer may be the time when they join the ranks of manhood through the ritual of circumcision – cutting the foreskin of the penis. The old traditional "tule", still practiced in some areas, is commonly carried out by one of the community elders (often a traditional healer) using either a barber’s razor or a very sharp bolo. A boy’s foreskin is stretched out over a stick (generally a cleaned-up branch of a guava tree), the bladed instrument is placed over the skin, and a sharp blow on blunt side of the blade cuts the skin and underlying tissue open to create a dorsal slit that exposes the head or glans of the penis. The boy is then instructed to spit out the guava leaves that he had been chewing onto to the wound and then asked to jump into a stream, pond or any handy body of water for the final cleansing.

These days however, at least in the case of most middle and upper class boys, circumcision is done as a medical procedure by a physician – usually but not always with formal surgical training. Aseptic technique is observed whether in clinic or operating room setting, bleeding is minimized and prophylactic antibiotics take the place of the chewed guava leaves. In a growing number of cases, male circumcision is done immediately after birth so that the child is arguably spared the psychological but not necessarily the physical pain of genital surgery.

The medical rationale for circumcision has always been vague and unsupported by formal scientific studies. Nevertheless the obvious hygienic advantage of eliminating the nuisance of "smegma" – secretions that accumulate within the folds of an uncircumcised penis – has always seemed to be a self-evident way of keeping clean. Despite a few studies that seemed to support this hygienic advantage – e.g., apparent lower incidences of cervical cancer among spouses of circumcised men – a consensus was beginning to emerge that the procedure probably carried more risks than benefits. In fact the procedure especially that for newborns had been rapidly falling into disfavor in many western countries, including the United States.

But now, recent findings have confirmed that circumcision does provide significant protection against the heterosexual transmission of the human immunodeficiency virus (HIV) that causes the dreaded acquired immunodeficiency syndrome (AIDS). The last issue of the highly respected medical journal, The Lancet, published the findings of three recent African studies (from Kenya, Uganda, and South Africa) that unequivocally showed that HIV risk for uncircumcised men was more than twice that of their circumcised counterparts. The evidence was so compelling that two of the studies (in Kenya and Uganda) were discontinued less than halfway into the scheduled timetable. This was because the authors felt that there was enough reason to consider male circumcision as a possible public health intervention in the fight against HIV especially in highly endemic countries.

In addition to the three scientific reports on the HIV and circumcision studies, last week’s The Lancet issue also carried several articles on the subject thoroughly discussing social, cultural, ethical and other concerns surrounding the provision of male circumcision as a public health service.

In terms of incidence and prevalence, HIV/AIDS appears to be a minor health concern for the Philippines at the moment. This is why most of the concerns addressed by The Lancet articles are probably irrelevant to this country’s setting. Moreover, there seems to be no need to develop a major circumcision campaign in view of the fact that the procedure is already deeply ingrained in our customs and traditions.

Nevertheless, knowing that being "tule" (circumcised) does have at least some health benefits should help to convince those who are still "supot" (uncircumcised) to have it done soon. At the very least, they would no longer have to hide themselves whenever they go to public showers such as sports locker rooms and swimming pools.

In the United States, Celebrex (Pfizer’s brand of cox-2 inhibitor pain killer) is the only one that remains in the market. A recent editorial in the New York Times points out that the American Heart Association recently recommended that drugs like Celebrex which potentially increase risks of cardiovascular disease should be considered as a last resort remedy to alleviate severe chronic pains whatever the cause. In fact, as described in the Times’ editorial, the Association has recommended the following order of preference in chronic pain management: "pain treatments should start with non-medicinal approaches, like physical therapy and exercise, weight loss to reduce stress on joints, and hot or cold packs. Only if those don’t provide enough relief should drugs be used, and the doctor should take a step-by-step approach in prescribing medications, from the safest to the riskiest. The first medication would usually be acetaminophen or aspirin at the lowest effective dose, or certain other low-risk drugs. Only if those fail should doctors progress to riskier drugs, starting with naproxen and then perhaps ibuprofen, both available over the counter. A cox-2 inhibitor should be prescribed only as a last resort. The overall message is that one should use the lowest effective dose of the safest drug for the shortest period of time. That is always good advice, but it tends to be forgotten in an age when drugs are so heavily promoted."