'Circumcision caused my son’s suicide'
"Know that I went peacefully and am now in a state of peace that was impossible following this mutilation. I died in 2015, not now."
Lesley Roberts was stunned as she read the devastating final email from her beloved son Alex Hardy.
The email had been timed to arrive on 25 November 2017, 12 hours after he killed himself. Less than an hour before the email arrived, Lesley had opened her front door to find a police officer standing there, explaining her son was dead.
Alex was an intelligent and popular 23-year-old with no history of mental illness. Lesley could not understand why he would have wanted to take his own life.
His email explained how the foreskin of his penis had been surgically removed two years before. This is commonly known as circumcision, but Alex had come to believe it should be regarded as "male genital mutilation".
He never mentioned this to his family or friends when he was alive. Lesley did not even know her son had been circumcised.
In the following months, she tried to find out more about circumcision. Why had it affected Alex so badly, and why did he feel killing himself was his only option?
Alex was the eldest of Lesley's three sons and had been very much longed for, having been conceived after fertility treatment.
Lesley says her "dreams came true" when she became a mother in July 1994.
"He was everything I could have wished for," she says. "Gorgeous, easygoing, and adoring of his younger brother Thomas who arrived following more treatment almost three years later."
He also adored his baby brother James, who was born when Alex was 13. The walls and windowsills of Lesley's home in Cheshire are covered in photos of all of them.
Alex sailed through his education and was particularly gifted at English, so much so that his old school established the Alex Hardy Creative Writing Award in his memory.
"Alex was passionate about history but as his English teacher I saw in him a true talent for writing," says Jason Lowe, who is now head teacher at Tarporley High School.
It was while on a school skiing trip to Canada, aged 14, that Alex fell in love with the country. He had enjoyed skiing as a child and the trip reignited his passion. So, when Alex reached 18, he decided to defer university and live in Canada for a year.
"He fell in love completely with Canada and made so many friends and got a promotion at work," says Lesley.
"After one year he rang me and said 'Mum, I'm deferring my place for university'. The same thing happened after year two."
Two years turned into three, then four, and by the time of his death Alex had been living in Canada for five years and had obtained residency.
"He was known as the 'super-smart Brit' with impeccable manners," says his mother. "The super-intelligent guy from the UK who helped people with their Canadian residency applications."
Lesley visited her son several times, both alone and with his brothers and stepfather. They were a close family, but Alex did not tell any of them he was secretly suffering with a problem with his penis.
"I had issues with a tight foreskin," he eventually wrote in his final email, "but from my late teens it created issues in the bedroom as it meant my foreskin would not retract over the glans as intended which caused some awkward moments."
In 2015, still silently suffering, Alex consulted a doctor in Canada. He was given steroid cream to stretch his foreskin, but went back to the doctor after just a few weeks because he did not think the treatment was working.
The medical name for Alex's problem is phimosis. It simply means his foreskin was too tight to pull back from the head of his penis, or the "glans" as Alex referred to it in his email. This is perfectly normal for boys in the early years of their life. As boys get older, their foreskin usually starts to separate from the head of the penis.
Phimosis does not always cause problems, but if it does, problems can include difficulty urinating and pain during sex. In England, the NHS advises topical steroids and stretching techniques – and circumcision as a last resort.
Over in Canada, where circumcision is more common, Alex was referred to a urologist.
"He immediately suggested circumcision," Alex wrote. "I asked about stretching and he completely lied to my face and said it would not work for me.
"I was mostly trusting as I felt he was the expert who knew best in this regard so with a pinch of salt I accepted it."
Lesley has since read online reviews of this urologist which have made her question his competence. One patient said she had been unable to work since having surgery for kidney problems, and he had "destroyed" her quality of life.
"I'm a mother of three young children who are scared every day I will die as they see me suffering in so much pain," she wrote.
"I can see how he misdiagnosed others, botched surgeries, and ruined lives," said another review. "He's dangerously incompetent."
Another review of Alex's urologist read: "They left a surgical instrument in my bladder but I only got notified three months later. Run away before you get hurt!"
Lesley, who was "horrified" by these reviews, has asked for the urologist to be investigated. She has been told an inquiry is ongoing.
The College of Physicians and Surgeons of British Columbia told the BBC it "cannot disclose the existence of a complaint against a physician, and only may do so if the complaint leads to formal discipline".
"I will wish with my last breath and with all of heart that my darling son had run away," says Lesley.
Much to his regret, Alex was not able to research the urologist – or circumcision – properly at the time because his laptop was broken.
He had tried researching the topic in a public computer space but felt uncomfortable, and also felt it was "too much of a taboo" to discuss with friends.
So Alex booked what he believed was a minor procedure and had the surgery in 2015, at the age of 21.
"It quickly became apparent that what had just happened was a catastrophe," Alex wrote in the email to his mother.
He attached a much longer public statement in which he explained, in great detail, the physical problems he had suffered after being circumcised.
He described experiencing constant stimulation from the head of his penis, which was no longer protected by his foreskin.
"These ever-present stimulated sensations from clothing friction are torture within themselves; they have not subsided/normalised from years of exposure," he wrote.
"Imagine what would happen to an eyeball if the eyelid was amputated?"
"He was in so much pain that it hurt to do normal physical activity," says Lesley. "He was a keen skier and snowboarder so you can imagine the pain he was in."
Consultant urological surgeon Trevor Dorkin, who is a member of the British Association of Urological Surgeons, advises his patients that the head of their penis will be more sensitive after circumcision.
However, this sensitivity usually reduces.
"I always say to guys 'it's going to feel more sensitive to start with' because all of a sudden you haven't got this protection over the head of the penis and it will feel different," says Mr Dorkin, who has carried out more than 1,000 circumcisions.
"But in the vast majority of the cases the man adjusts to that, the brain adjusts to that, it adjusts to the signals that are coming back through the nerves from the head of the penis."
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Alex also wrote about experiencing erectile dysfunction, and burning and itching sensations, particularly from a scar which sat where his frenulum was removed. The frenulum is a band of tissue where the foreskin attaches to the under surface of the penis. Some men refer to it as their "banjo string".
"It's one of the more erogenous zones so it's thought to be important in sexual function," says Mr Dorkin.
"The foreskin, the head of the penis and the frenulum is a very, very sensitive area.
"But again when you do circumcision sometimes the frenulum is not preserved and it doesn't necessarily have an effect on overall sexual function and enjoyment."
But Alex felt his frenulum had been important.
"Through its absence I can certainly verify it is the most erogenously sensitive area of the penis and male body overall," he wrote.
"If someone were to amputate your clitoris you may begin to be able to understand how this feels."
He wrote about experiencing cramps and contractions in his muscles and "uncomfortable" sensations which extended deep into his abdomen.
Lesley does not know whether or not Alex had sex after his circumcision.
"Where I once had a sexual organ I have now been left with a numb, botched stick," he wrote. "My sexuality has been left in tatters."
He asked: "Nature knows best – how can chopping off a section of healthy tissue improve nature's evolved design?"
Like many people, Lesley admits she knew very little about the foreskin or circumcision before her son died.
"I didn't know anything apart from I believed it was a very routine surgery," she says.
The foreskin is sometimes dismissed as a "useless flap of skin", but Mr Dorkin says it does have a purpose.
"It covers the head of the penis," he says. "In terms of what's it for, it provides a bit of protection to the head of the penis. It's thought to have some sort of immunological function perhaps."
Circumcision rates vary a lot depending on where you are in the world and which culture you grew up in.
According to the World Health Organization, 95% of men are circumcised in Nigeria but only 8.5% of men in the UK are.
Most of the men circumcised in the UK are either Muslim or Jewish, as circumcision is regarded as an important part of their religions.
According to the 2011 census, Muslims accounted for 4.8% of the population in England and Wales, while 0.5% were Jewish.
People who question circumcision are sometimes accused of being anti-Semitic or Islamophobic, but Lesley stresses her son was neither.
"For me, this has nothing to do with religion at all. I respect all people of faith or indeed no faith, as Alex did," she says.
In Canada, where Alex had moved to, an estimated 32% of men are circumcised.
Alex felt male circumcision has been normalised to the extent that most people do not question it, while female circumcision has become known as female genital mutilation (FGM) and is now illegal in many countries.
He felt male circumcision should be known as "male genital mutilation" – a view shared by a growing anti-circumcision movement.
"If I were a female (in Western nations) this would have been illegal, the surgeon would be a criminal and this would never have been considered as an option by doctors," Alex wrote.
"I do not believe in championing one gender over another but I feel strongly that gender equality should be achieved for all."
Campaigners for "genital autonomy" believe it is wrong to circumcise a baby or child – whether they are male or female – because the patient cannot give consent, and these campaigners regard circumcision as a human rights issue.
Having lived with an intact penis for 21 years, Alex believed men circumcised as babies or young children would "tragically never be able to fully comprehend what has been taken away". He estimated he had been stripped of 75% of the sensitivity of his penis.
However, experiences of men circumcised as adults differ dramatically.
Some men actually prefer sex afterwards because they no longer have the pain of a tight or inflamed foreskin.
Some report a significant loss in sensitivity and greatly reduced sexual pleasure.
Some report being less sensitive but say there is no change in their overall enjoyment of sex.
Some are very happy with their decision to get circumcised.
Some, like Alex, deeply regret having it done.
Alex sought further medical help following the circumcision as well as psychological help, but never shared his problems with his family or friends.
"I was with him during those two years and I think I would be lying if I said I didn't think something wasn't right," says Lesley.
"I did say 'Is something bothering you? Are you OK?' and he would absolutely reassure me that he was."
Lesley, who used to be a teacher, now hopes to go into schools and speak to young men about sharing their problems, even if they are very personal.
"I think we all know that men don't particularly tend to talk about their problems in the same way that girls do but I think circumcision is very much a taboo subject," she says.
"Alex was reserved. He certainly wouldn't have said 'I've got a tight foreskin and it really hurts'. And he didn't. And I didn't know."
Only a week after Alex died, a friend opened up to Lesley about his own circumcision.
"He told me he wouldn't normally have mentioned it but he had a circumcision as an older man, 10 years ago, and he was in constant daily pain," says Lesley. "It just seems it's more common than you think."
Mr Dorkin says serious problems following a circumcision are rare, but not unheard of.
"You do hear of horror stories where a circumcision has been done poorly and there's damage done to the head of the penis itself," he says.
Sometimes too much skin is taken and this can result in what's known as "burying" or shortening of the penis, where it gets pulled back into the body.
"Surgeons at the end of the day are human and there is potential for human error and technical error during any operation," he says.
"One of my mentors told me every case is a tricky case, that's got to be your approach to surgery. You never take anything for granted in surgery."
There have been cases of children and men dying after being circumcised.
Four-week-old Goodluck Caubergs bled to death after a nurse circumcised him at his home in Manchester, while one-month-old Angelo Ofori-Mintah bled to death after being circumcised by a Jewish rabbi in London.
Since 1995 at least 1,100 boys have died in South Africa after ritual circumcisions. Some penises fall off after becoming infected and rotten, while some have to be amputated.
In Canada, where Alex was living, newborn baby Ryan Heydari bled to death after being circumcised by a doctor in Ontario.
"I'm not qualified to say that circumcision is always bad, because it isn't," says Lesley.
"It certainly was in my son's case and I think we need more research. We need to look into the risks, what can really go wrong, and we need to be more aware of them."
If a circumcision is necessary, Mr Dorkin says it is important to tell patients about potential complications.
"Particularly when you are doing the operation in a guy who is in his late teenage years or early adulthood, it's a very sensitive area and sexual function is important, so you have to explain the risks to them," he says.
"Alex said he was not made aware of all the risks," says Lesley. "If he had, I feel sure he would not have had the surgery.
"Alex wasn't alone. I now know he wasn't the only one that this hasn't happened to. And that can't be right."
The UK charity 15 Square, which tries to educate people about circumcision, says Alex is not the only man to have killed himself after being circumcised.
"It happens more frequently than people realise," says chairman David Smith.
There are no statistics on men who have killed themselves after being circumcised. Alex died over a year ago but his story has not been told until now. An inquest into his death was held in the UK but it was not reported by the media.
Lesley, who is normally private and reserved like her son, only agreed to share Alex's story because it was his dying wish.
"If the following information can benefit anybody then it has served its purpose," he wrote.
"I did not feel comfortable raising the issue when I had a choice, so if my story can raise awareness to break this taboo within society regarding men's health then I am happy for release of my words."
"Alex said in his letter 'We stand on the shoulders of those who came before us'," says Lesley.
"This is the last thing I'm doing for my precious son."
For details of organisations which offer advice and support, go to BBC Action Line.