Circumcision

The neutrality of this article is disputed. Please see the discussion on the talk page.

This article is about male circumcision. For the practice sometimes referred to as "female circumcision", see Female genital cutting.

Seixas Family circumcision set and trunk, ca. eighteenth century.
Wooden box covered in cow hide with silver implements: silver trays, clip, pointer, silver flask, spice vessel.

Circumcision cuts some or all of the foreskin (prepuce) from the penis. The frenulum may also be cut away at the same time, in a procedure called frenectomy. The word "circumcision" comes from Latin circum (meaning "around") and caedere (meaning "to cut").Circumcision predates recorded human history, with depictions found in stone-age cave drawings and Egyptian tombs.^[1] The origins of the practice are lost in antiquity. Theories include that circumcision is a form of ritual sacrifice or offering, a sign of submission to a deity, a rite of passage to adulthood, a mark of defeat or slavery, or an attempt to alter esthetics or sexuality.^[2] Circumcision of males is a religious requirement of the Muslim and Jewish faiths.^[3][4] It is also practiced by the majority of Americans, South Koreans,^[5] and Filipinos.^[6]

Infant circumcision has come under increasing discussion in recent decades. The American Medical Association states that medical associations in the US, Australia, and Canada do not recommend routine “non-therapeutic” circumcision, which it defines as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns.^[7] According to the AMA's 1999 literature review, in the US when parents choose elective circumcision for their child, it is largely because of social or cultural expectations, rather than medical concerns.^[7] However, a 2001 survey questionare found that 23.5% of parents listed 'health reasons'.^[8] The genital integrity movement condemns all infant circumcision, religious or secular, as a form of male genital mutilation that they consider comparable to female genital mutilation.^[9]Some argue that there are medical benefits in the procedure (i.e. fewer urinary tract infection in infant males, less penile cancer in adult males, and possibly less sexually transmissible infections, including HIV—Human Immunodeficiency Virus).^[7][10] Circumcision may be needed to treat chronic inflammation of the penis, and penile cancer^[10]. Some physicians recommend circumcision to treat phimosis, while others recommend the other effective treatments for this condition.^[11][12]

The procedures of circumcision

Uncircumcised penis, flaccid (left) and erect (right)

Circumcised penis, flaccid (left) and erect (right)

Circumcision removes the foreskin from the penis. For infant circumcision, clamps, such as the Gomco clamp, Plastibell, and Mogen are often used.^[13] These clamps are meant to protect the glans while they apply pressure to the foreskin to stop any bleeding. With the Plastibell clamp, the foreskin and the clamp come away in three to seven days. Before a Gomco clamp is used, a section of skin is crushed with a hemostat then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is then tightened, "crushing the foreskin between the bell and the base plate." The crushing limits the bleeding (provides the hemostasis). With the flared bottom of the bell fit tightly against the hole of the base plate, the foreskin is cut away with a scalpel from above the base plate, while the bell covers the glans to prevent it being reached by the scalpel.^[14]

With a Mogen clamp, used by many physicians and all mohels (Jewish ritual circumcisers), the foreskin and the glans are separated with a blunt probe and/or curved hemostat (as with the first part of the Gomco procedure). The foreskin is then grabbed dorsally with a straight hemostat, and lifted up. The Mogen clamp is then slid between the glans and hemostat. The clamp is locked shut, and a scalpel used to cut the foreskin from the flat (upper) side of the clamp.^[15][16]

According to a 1998 study, 45% of physicians used anaesthesia for infant circumcisions. Dorsal penile nerve block was the most commonly used form. Obstetricians had a significantly lower rate of anaesthesia use (25%) than pediatricians (71%) or family practitioners (56%).^[17] A 2004 Cochrane review concluded that dorsal penile nerve block was the most effective form of anaesthesia and EMLA (topical anaesthesia) was less effective. The authors noted that both anaesthetics appear safe, but neither of them completely eliminated pain.^[18] Adult circumcisions are often performed without clamps, and require 4 to 6 weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.^[19]

Cultures and religions

For information on circumcision in the Bible, see circumcision in the Bible.

Some cultures circumcise their males as a matter of tradition, either shortly after birth, in childhood or around puberty, when it may be (or form part of) a rite of passage. The practice is most notable among Jews and Muslims, and is more prevalent in the United States than in other Western nations.

Judaism

Main article: Brit milah

See also: Circumcision in the Bible

Circumcision is fundamental to Judaism. It is an essential component of Jewish practice and is a commandment obligatory under Jewish law (Halakha) for all Jewish males.^[20] It is usually performed in a ceremony called a Brit milah (or Bris milah, colloquially simply bris) (Hebrew for "Covenant of circumcision"). A mohel performs the ceremony on the eighth day after birth unless health reasons force a delay. According to the Torah (Genesis, chapter 17 verses 9-14), God commanded Abraham to circumcise himself, his offspring and his slaves as a sign of an everlasting covenant. According to Halakha, failure to follow the commandment carries the penalty of karet, or being cut off from the community by God. Brit milah is so important that should the eighth day fall on Shabbat, actions that would normally be forbidden because of the sanctity of the day are permitted in order to fulfill the requirement to circumcise. The expressly ritual element of circumcision in Judaism, as distinguished from its non-ritual requirement in Islam, is shown by the requirement that a child who either is born aposthetic (without a foreskin) or who has been circumcised without the ritual must nevertheless undergo a Brit Milah in which a drop of blood (hatafat-dam, הטפת דם) is drawn from the penis at the point where the foreskin would have been or was attached.^[21]

Less commonly practised, and at times the subject of controversy, is metzitzah b'peh, or oral suction. This is a procedure where after removing the foreskin, the mohel will suck out the blood from the wound to clean it,^[22] although today this is usually done with a glass tube.^[23]

Christianity

Catholic, Protestant, Eastern and Oriental Orthodox Christianity do not prescribe circumcision. The first Church Council in Jerusalem decided that circumcision was not a requirement (Acts 15), and St. Paul warned gentile Christians against adopting the practice (Galatians 6:12-16, Philippians 3:2-3). However, individual Christians and Christian traditions may have different customs. For example, circumcision is customary among members of the Coptic Orthodox, Ethiopian Orthodox, and Eritrean Orthodox churches in their home countries. On 1 January, the Catholic Church used to celebrate the Circumcision of Christ. This has been superseded by the Solemnity of Mary. Anglican and Lutheran churches have other feast days at this time such as the Holy Name of Jesus ^[24].

Islam

The origin of circumcision in Islam is a matter of religious and scholarly debate. It is mentioned in some parts of the Hadith, but not in the Qur'an. Fiqh scholars have different opinions about circumcision in Shariah, depending on which Hadith are accepted and how they are interpreted. According to some it is recommended (Sunnah); according to others, it is obligatory.^[25] Some have quoted the Hadith to argue that the requirement of circumcision is based on the covenant with Abraham.^[26]

The timing of Muslim circumcision varies. Turkish, Balkan, rural Egyptians and Central and South Asian Muslims typically circumcise boys between the ages of six and eleven and traditionally the event may be a joyous occasion and celebrated with sweets and feasting. However, in the middle class it is more usually done in infancy and is largely unremarked upon. In Turkey the celebratory feast is called "Sünnet Düğünü" and is considered a very important celebration in man's life as a passage to a manhood.^[27] In Pakistan, Muslims usually circumscise their boys on the 7th day of life. The birth celebration, Aqiqa takes place with the sacrifice of goat or two on behalf of the new-born child.[1]. While circumcision may be performed at all ages from newborn period to adulthood, the medical profession has encouraged medical circumcisions in the first week after birth to reduce complications "Circumcision is performed by barbers, medical technicians, quacks and doctors including paediatric surgeon[s] [and as] yet there is no consensus for the best age and method."^[28] In Iran, Dr. Paula Drew states that “circumcision, which formerly celebrated the onset of manhood, has for many years now been more customarily performed at the age of 5 or 6 for children born at home, and at two days old for those born in a medical setting.…By puberty, all Muslim Iranian boys must be circumcised if they are to participate fully in religious activities.”^[29] Kamyar et al describe it as an "obligatory custom" and note that it is not necessary for the circumciser to be a Muslim.^[30]

Baha'i

"Bahá'ís are not advised on a particular course of action in respect to circumcision of males; circumcision of females is considered mutilation." [2] .

Druze

The Druze do not practise male circumcision [3] .

Hinduism

There is no specific reference to male circumcision in the Hindu holy books, and Hindus in India generally do not practice circumcision.

Sikhism

"Circumcision holds no relevance to a Sikh." All rituals which do not hold relevance are strictly forbidden.^[31] For Sikhs, "acceptance of Nature's beautiful body is an important component of the Sikh value system."^[32]

Secular tradition

Routine circumcision practices in South Korea are largely the result of American cultural and military influence following the Korean War. The origin of the practice in the Philippines is uncertain according to one newspaper article, although it speculatively attributes it to the influence of western colonizers.^[33] That the origin is uncertain is supported by the seventeenth century text of Antonio de Morga's History of the Philippine Islands, which equally speculatively attributes circumcision to Islamic influence.^[34] In West Africa infant circumcision may have had tribal significance as a rite of passage or otherwise in the past; today in some non-Muslim Nigerian societies it is medicalised and is simply a cultural norm.^[35]

Non-Western initiatory traditions

Circumcision can be part of an initiation rite in some African, Pacific Islander, and certain isolated Australian aboriginal traditions, such as in Arnhem Land,^[36] where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.^[37] Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature, including subincision for some aboriginal peoples in the Western Desert.^[38]In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu;^[39] participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.^[40] Circumcision is also commonly practised in the Polynesian islands of Samoa, Tonga, Niue, and Tikopia. In Samoa, it is accompanied by a celebration. Among some West African animist groups, such as the Dogon and Dowayo, it is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males.^[41] Although in many West African traditional societies circumcision has become medicalised and is simply performed in infancy without ado or any particular conscious cultural significance, among the Urhobo people of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te Oshare ("the boy is now man"), constitutes a rite of passage from one age set to another.^[42] For Nilotic peoples, such as the Nandi, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set.^{[citation needed]}

Ethical issues

Main article: Bioethics of neonatal circumcision

Circumcising infants as a public health measure is controversial. Circumcision advocates assert that circumcision is a significant public health measure, preventing infections, and slowing down the spread of AIDS.^[43] The genital integrity movement, however, asserts that infant circumcision is a human rights violation and a sexual assault, and that the practice of circumcising infants or children should be discouraged or banned.^{[citation needed]}

Consent

Debate often focuses on what limits, if any, should be placed on a caregiver's ability to have a child circumcised. The procedure is irreversible, the immediate medical value is disputed and the result may not be in accordance with the child's wishes when he is an adult. Some believe that male circumcision is ethically identical to female genital cutting and question the perceived inconsistency of not prohibiting the former in the same manner as the latter.^[44] Some assert that circumcision causes sexual harm and emotional scarring later in life, or urge that the procedure should be left until the boy is mature enough to make the choice for himself. Others assert that circumcision is less traumatic when performed in infancy and that there is no evidence of sexual or emotional harm. They point out that restrictions on circumcision would be highly intrusive on the religious or cultural rites and practices of various communities and would interfere with the traditional right of parents to make this decision on behalf of their child. Most major worldwide medical associations accept that the parents should determine what is in the best interest of the infant or child.^{[45][7][46][47]}

Emotional consequences

An article discussed the extent to which circumcision may cause emotional harm to males.^[48] Some organizations have been founded as support groups for circumcised men who are upset with their status.^[49]Several studies suggest that circumcised infants do not forget the pain during circumcision easily, as a correlation between circumcision with ineffective anaesthesia and intensity of pain response during vaccination months later has been noted.^[50]

Legality

Main article: Circumcision and law

The mainstream medical organizations do not consider circumcision to be a legal issue as long as the decision for circumcision was made by the legal guardians, and that they have given their informed consent.

In 2001, Sweden passed a law restricting the performance of neo-natal circumcisions to persons certified by the National Board of Health. This law requires that a medical doctor or an anesthesia nurse accompany the circumcisor, and that anaesthetic is applied prior to the procedure. Most Jewish mohels have been so certified.^[51] Muslims and Jews in Sweden objected to the law,^[52] and the World Jewish Congress stated that it was “the first legal restriction on Jewish religious practice in Europe since the Nazi era.”^[53]

Medical aspects

Main article: Medical analysis of circumcision

The direct medical benefits of neonatal circumcision are still under debate, with various studies reaching different opinions. The studies have been conducted using cost-benefit analyses. The complication morbidity is compared to the potential gain in expected longevity, and the medical costs of circumcision are compared to the expected reduction in lifetime health costs. In the words of the BMA, “There is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.”^[47] Biases notwithstanding, some studies decided that circumcision has a net benefit,^[54][55] some decided that it has a net decrement,^[56] and others decided that the benefits and risks balance each other out and that other factors must be taken into consideration.^[57][58]

The American Medical Association, American Academy of Pediatrics, and the Royal Australasian College of Physicians all suggest that anasthesia be used if performing circumcision.^[7][45][59]

Risks of circumcision

Example of a "skin bridge", one of the possible negative side effects of circumcision.

Circumcision is a surgical procedure. While the risks of circumcision-related complications are very low,^[60] the complications resulting from a poorly carried out circumcision, post-operative bleeding, or infection can be catastrophic.^[61] Bleeding and infection are the most common complications of the procedure, according to the AMA, although in the majority of cases, bleeding is minor and hemostasis can be achieved by pressure application.^[7] Kaplan identified longer term complications, including urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias, impotence and removal of too much tissue, sometimes causing secondary phimosis. He stated “Virtually all of these complications are preventable with only a modicum of care. Unfortunately, most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.”^[62] Infant circumcision may cause problems such as skin bridges, when the cut skin does not heal neatly but attaches to the glans penis instead. This does not commonly require surgical correction; rather, a brief, simple, office procedure may be performed.^[63] Meatal stenosis may be a common longer-term complication from circumcision. Recent publications give a frequency of occurrence between 0.9% in Iran^[64] and 9% to 10% in the U.S.^[65] Loss of the penis itself has been documented. The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.^[66]

The American Medical Association quotes a complication rate of 0.2%–0.6%,^[7] based on the studies of Gee^[67] and Harkavy.^[68] These same studies are quoted by the American Academy of Pediatrics.^[45] The American Academy of Family Physicians quotes a range of anywhere between 0.1% and 35%.^[69] The Royal Australasian College of Physicians and the Canadian Paediatric Society bring the AMA results together with other studies with results ranging anywhere between 0.06% to 55%, and bring Williams & Kapila^[70] citing that a 2%–10% seems reasonable.^[46][66]

Fatal complications have been reported. The American Academy of Family Physicians states that death is rare, and cites an estimated death rate with circumcisions of infants of 1 in 500,000.^[69] Gairdner's 1949 study reported that during the 1940's an average of 16 children per year, out of an estimated 90,000, died following circumcision in the UK. He found that most deaths had occurred suddenly under anaesthesia and could not be explained further, but hemorrhage and infection had also proven fatal. Deaths attributed to phimosis and circumcision were grouped together, but Gairdner guessed that such deaths were more likely due to the circumcision operation. ^[71]

Metzitzah b'peh without a sterile glass tube or pipette was implicated in the transfer of HSV from mohels to eight Israeli infants, one of which suffered brain damage^[72] [4]. When three New York City infants contracted herpes after metzizah b'peh by one mohel and one of them died, New York authorities took out a restraining order against the mohel.^[22] However, the mohel's attorney argued that the New York Department of Health had not supplied conclusive medical evidence [5] linking his client with the disease .^[73] In September 2005, the city withdrew a restraining order against the mohel and turned the matter over to a chasidic rabbinical court.^[74] In February 2006, Dr. Thomas Frieden, the Health Commissioner of New York City, wrote, “There exists no reasonable doubt that ‘metzitzah b'peh’ can and has caused neonatal herpes infection.…The Health Department recommends that infants being circumcised not undergo metzitzah b'peh”.^[75] In May 2006, the Department of Health for New York State, issued a protocol for the performance of metzitzah b'peh.^[76] Dr. Antonia C. Novello, Commissioner of Health for New York State, together with a board of rabbis and doctors, worked, she said, to “allow the practice of metzizah b'peh to continue while still meeting the Department of Health's responsibility to protect the public health.”^[77]

HIV

The most recent data indicate that circumcision is correlated with reduced risks of HIV transfer, although the topic remains the subject of ongoing research and debate in the medical community. There are also fears that some may mistakenly believe they will be protected against HIV through circumcision and see circumcision as a safe alternative to other forms of protection, such as condoms.^[78]

Research by the World Health Organization published in the US Public Library of Science Medicine journal in July, 2006, showed that men who had been circumcised had a significantly lower risk of infection with the AIDS virus, and calculated that if all men were circumcised over the next 10 years, some two million new infections could be avoided.^[79]

In March 2005, a Cochrane review of the medical evidence concluded that, “Although the positive results of these observational studies suggest that circumcision is an intervention worth evaluating in randomised controlled trials, the current quality of evidence is insufficient to consider implementation of circumcision as a public-health intervention.”^[80] Initial population based studies suggesting that circumcision might play a protective role were criticised because confounding factors such as religion may have skewed the results; the reviewers therefore commented that the results of randomised controlled trials then underway would be critical.^[80]

The results of the first randomised controlled trial was published in November 2005. It found a 60% reduction in the rate of new HIV infection (from 2.1 per 100 to 0.85 per 100 in the intervention group and claimed that male circumcision provided a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa. ^[43] Results of two further randomised trials of the effect of circumcision on HIV infections will become available in 2007.

If circumcision does protect against HIV transmission, the mechanism by which it does so is unclear. One possibility relates to Langerhans cells, a part of the human immune system. Szabo and Short suggest that Langerhans cells in the foreskin may provide an entry point for viral infection.^[81] Three studies identified high concentrations of Langerhans and other HIV target cells in the human prepuce.^[82][83][84] Additionally, McCoombe, Cameron, and Short found that the keratin is thinnest on the foreskin and frenulum.^[85] Conversely, some authors believe that the prepuce has an important immunological function, and that its removal increases the chances of infections.^[86] This hypothesis has been criticised on technical grounds.^[87]

HPV

Several studies have shown that uncircumcised men are at greater risk of human papilloma virus (HPV) infection.^[88][89] While most genital HPV strains are considered harmless, some can cause genital warts or cancer. One study found no statistically significant difference between men with foreskins for HPV infection than those who are circumcised, but did note a significantly higher incidence of HPV lesions and urethritis in uncircumcised men.^[90]

Hygiene

The American Academy of Pediatrics observes “Circumcision has been suggested as an effective method of maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene.”^[45][91] It states that the "relationship among hygiene, phimosis, and penile cancer is uncertain" and further remarks that "genital hygiene needs to be emphasized as a preventive health topic throughout a patient's lifetime."

The Royal Australasian College of Physicians emphasizes that a non-circumcised infant's penis requires no special care and should be left alone, stating that attempts to forcibly retract the foreskin, e.g. to clean it, are painful, often injure the foreskin, and can lead to scarring, infections and pathologic phimosis.^[92] It is recommended that, while there is no special age where the foreskin should be retractable, once the foreskin becomes retractable, the child should gently wash it with soap and water. It has been suggested, however, that excessive washing of the foreskin and the glans will make infections such as balanitis more likely.^{[citation needed]}

Circumcision reduces the amount of smegma produced by the male.^{[citation needed]} Smegma is a combination of exfoliated epithelial cells, transudated skin oils, and moisture that can accumulate under the foreskin of males and within the female vulva area. It has a characteristic strong odor and taste, and is common to all mammals—male and female. While smegma is generally not believed to be harmful to health, the strong odour may be considered to be a nuisance or give the impression of a lack of hygiene. In rare cases, accumulating smegma may help cause balanitis.

It has been suggested that circumcision arose in peoples living in arid and sandy regions as a public health measure intended to prevent recurring irritation and infection caused by sand accumulating under the foreskin.^[93] Darby, after checking the official war histories of Britain, Australia and New Zealand and other records, and finding no mention of ‘balanitis’ or ‘foreskin’ or ‘circumcision’ dismissed this idea as a “medical urban myth,” concluding that “‘sand under the foreskin,’ balanitis, and circumcision were notsignificant problems during either of the World Wars.”^[94]

Infectious and chronic conditions

One study found that boys with foreskins tend to have higher rates of various infections and inflammations of the penis than those who are circumcised.^[95] The reasons are unclear, but several hypotheses have been suggested:

• The foreskin may harbor bacteria and become infected if it is not cleaned properly.^[96]
• The foreskin may become inflamed if it is cleaned too often with soap.^[97]
• The forcible retraction of the foreskin in boys can lead to infections.^[46]

The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams.^[98]. There are less invasive treatments than circumcision for posthitis.^{[citation needed]}

Balanitis

Main article: Balanitis

Balanitis, an inflammation of the glans penis, has a variety of causes.^[99] Some of these, such as anaerobic infection, occur more frequently in uncircumcised men, while others, such as fungal infection, have no statistically significant differences in frequency of occurrence between circumcised and uncircumcised men.^[100] There are less invasive treatments than circumcision that have been shown effective in treating most mild cases of balanitis.^[99] Birley, et al, also agrees that for many mild forms of balanitis there are less invasive procedures, but does state that there are times when circumcision “might be of benefit in a patient whose balanitis relapses despite these measures, and remains the principal treatment for specific conditions such as lichen sclerosus and plasma cell balanitis.”^[101] Also, less invasive procedures are not as successful in treating balanitis xerotica obliterans, or BXO,^{[102][103][104]} which is harder to treat.^[105]

Lichen sclerosus et atrophicus (LSA) produces a whitish-yellowish patch on the skin, and is not believed to be always harmful or painful, and may sometimes disappear without intervention. Some consider balanitis xerotica obliterans to be a form of LSA that happens to be on the foreskin, where it may cause pathological phimosis. Circumcision is believed to reliably reduce the threat of BXO.^[106]

Penile cancer

Main article: Penile cancer

Penile cancer is cancer of the penis, i.e. on the glans or the foreskin. Most cases have been found to occur in men over the age of 70.^[107] Kochen and McCurdy performed a life table analysis on penile cancer rates. Their basic assumptions were that these cancers occur exclusively in uncircumcised males and that age-specific rates calculated from older groups were applicable to the 1971 birth cohort.^[108] Their overall analysis finds an estimated occurrence rate in uncircumcised males of 1 in 600, or 0.167%, with a median age of occurrence of 67 years old. However, they close their predictions section with the following “Since the uncircumcised male is uniquely susceptible, virtually all of these cancers are preventable by neo-natal circumcision. The number of lifetime incident cancers that could be prevented annually by circumcision can be estimated with birth statistics available for 1971. In that year, there were 1,822,910 recorded live male births. If none had been neonatally circumcised, our analysis predicts that one in 600, or more than 3,000 would have penile cancer in their lifetimes.”^[108]

However, a small risk is associated with non-classic vigorous circumcisions that leave scarring.^[109]

In 2005, the American Cancer Society said that while studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer, it is important to concentrate on the main risk factors: poor hygiene, having unprotected sex with multiple partners, and cigarette smoking.^[110] They further state that the current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer.^[111]

The American Academy of Pediatrics states that studies suggest that neonatal circumcision confers some protection from penile cancer, but circumcision at a later age does not seem to confer the same level of protection. Further, penile cancer is a rare disease and the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low.^[45]

The American Medical Association states similarly that although neonatal circumcision seems to lower the risk of contracting penile cancer, because it is rare and occurs later in life, the use of circumcision as a preventive practice is not justified.^[7]

Phimosis and paraphimosis

Pathological phimosis is a condition of a very tight foreskin that makes retraction over the glans painful or impossible. Rickwood suggested that the term 'phimosis' should be restricted to cases in which the prepuce loses suppleness and becomes scarred.^[112] Paraphimosis is an acute condition where the tight foreskin is stuck behind the glans and cannot be moved back, curbs the blood flow from the glans. In children, it is sometimes caused by a caregiver trying to forcibly retract the infant foreskin.^[71]

The AAP state that the true frequency of such problems is unknown.^[45] Fergusson et al found phimosis in 16% of non-circumcised boys,^[95] while Herzog and Alvarez found it in 2.6%.[6] Rickwood and Walker raised concern that phimosis is frequently misdiagnosed by physicians confusing it with the developmentally non-retractible foreskin.^[113]Several studies have identified phimosis as a risk factor for penile cancer, leading Willcourt to state that it would be irresponsible to expose a patient to risk for longer than necessary.[7] Other researchers find less invasive treatments for phimosis, and recommend that they be tried first.^[114][115]

Urinary tract infections

Twelve studies have indicated that neonatal circumcision reduces the occurrence rate of Urinary tract infections in male infants by a factor of about 10.^[116] The March 1999 AAP statement notes that premature infants are usually not circumcised because of their fragile health status.^[45] Studies have found that 1 in 10 premature infants will have a urinary tract infection during the first month of life. [8] Some of the UTI studies have been criticised for not taking these and other factors into account. A Swedish study found that the cumulative incidence of UTIs in boys under 2 years of age was 2.2%.^[117] The AMA cites evidence that the incidence of UTI’s is “small (0.4%-1%)” in uncircumcised infants, and “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI…One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition.”[9]

The Canadian Paediatric Society poses the question of whether increased UTI and balanitis rates in non-circumcised male infants may be caused by forced premature retraction.^[46] According to the Lerman and Liao, aside from its effects on UTI infection rates, "Most of the other medical benefits of circumcision probably can be realized without circumcision as long as access to clean water and proper penile hygiene are achieved."^[118]

Policies of various national medical associations

The medical associations noted below find the current data insufficient to recommend neonatal circumcision. They agree that parental choice remains a legitimate reason to perform the procedure.

United States

The American Academy of Pediatrics recommends the following:^[45]

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. It is legitimate for parents to take into account cultural, religious, and ethnic traditions, in addition to the medical factors, when making this decision. Analgesia is safe and effective in reducing the procedural pain associated with circumcision; therefore, if a decision for circumcision is made, procedural analgesia should be provided. If circumcision is performed in the newborn period, it should only be done on infants who are stable and healthy.

—Circumcision Policy Statement, American Academy of Pediatrics

The American Medical Association supports the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics.^[7]

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society posted Circumcision: Information for Parents in November of 2004,^[119] and Neonatal circumcision revisited statements in 1996, undergoing revision as of 2004:^[46]

Circumcision is a “non-therapeutic” procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social or cultural reasons. To help make the decision about circumcision, parents should have information about risks and benefits. It is helpful to speak with your baby’s doctor. After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.

—Circumcision: Information for Parents^[119], Canadian Paediatric Society

We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors.

—Neonatal circumcision revisited^[46], Canadian Paediatric Society

United Kingdom

As of June of 2006, the British Medical Association's position was as follows:^[47]

Circumcision for medical purposes
Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate.Male circumcision in cases where there is a clear clinical need is not normally controversial. Nevertheless, normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal. The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. Doctors should be aware of this and reassure parents accordingly.

Non-therapeutic circumcision
Male circumcision that is performed for any reason other than physical clinical need is termed non-therapeutic (or sometimes “ritual”) circumcision. Some people ask for non-therapeutic circumcision for religious reasons, some to incorporate a child into a community, and some want their sons to be like their fathers. Circumcision is a defining feature of some faiths.

There is a spectrum of views within the BMA’s membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly. The Association has no policy on these issues. Indeed, it would be difficult to formulate a policy in the absence of unambiguously clear and consistent medical data on the implications of the intervention. As a general rule, however, the BMA believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.

—The law and ethics of male circumcision - guidance for doctors, British Medical Association

Australasia

The Royal Australasian College of Physicians position is as follows:^[120]

The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision. (emphasis as in the original document)

If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment.

In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents.

—ROUTINE CIRCUMCISION OF MALE INFANTS AND BOYS - SUMMARY STATEMENT, Royal Australasian College of Physicians

Sexual

Main article: Sexual effects of circumcision

The American Academy of Pediatrics states "a survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men. There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males. Masters and Johnson noted no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men."^[45] The American Academy of Family Physicians (AAFP) states "The effect of circumcision on penile sensation or sexual satisfaction is unknown. Because the epithelium of a circumcised glans becomes cornified, and because some feel nerve over-stimulation leads to desensitization, many believe that the glans of a circumcised penis is less sensitive. Opinions differ about how this decreased sensitivity, which may result in prolonged time to orgasm, affects sexual satisfaction. An investigation of the exteroceptive and light tactile discrimination of the glans of circumcised and uncircumcised men found no difference on comparison. No valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction."^[69]

History of circumcision

Main article: History of male circumcision

It has been variously proposed that circumcision began as a religious sacrifice, as a rite of passage marking a boy's entrance into adulthood, as a form of sympathetic magic to ensure virility, as a means of suppressing (or enhancing) sexual pleasure, as an aid to hygiene where regular bathing was impractical, as a means of marking those of lower (or higher) social status, as a means of differentiating a circumcising group from their non-circumcising neighbors, as a means of discouraging masturbation or other socially proscribed sexual behaviors, to remove "excess" pleasure, to increase a man's attractiveness to women, as a symbolic castration, as a demonstration of one's ability to endure pain, or as a male counterpart to menstruation or the breaking of the hymen. It is possible that circumcision arose independently in different cultures for different reasons.

Ancient Egyptian caved scene of circumcision, from the inner northern wall of the Temple of Khonspekhrod at the Precinct of Mut, Luxor, Egypt. Eighteenth dynasty, Amenhotep III, c. 1360 BC.

Köçeks at a fair
Köçek troupe dancing at Sultan Ahmed III's 14-day celebration of his sons' circumcision in 1720. Miniature from the Surname-i Vehbi, Topkapi Palace, Istanbul.

Circumcision in the ancient world

The oldest documentary evidence for circumcision comes from ancient Egypt. Tomb artwork from the Sixth Dynasty (2345-2181 BCE) shows men with circumcised penises, and one relief from this period shows the rite being performed on a standing adult male. The Egyptian hieroglyph for "penis" depicts either a circumcised or an erect organ. The examination of Egyptian mummies has found some with foreskins and others who were circumcised.

Circumcision was common, although not universal, among ancient Semitic peoples. The Book of Jeremiah, written in the sixth century BCE, lists the Egyptians, Jews, Edomites, Ammonites, and Moabites as circumcising cultures. Herodotus, writing in the fifth century BCE, would add the Colchians, Ethiopians, Phoenicians, and Syrians to that list.

In the aftermath of the conquests of Alexander the Great, Greek dislike of circumcision led to a decline in its incidence among many peoples that had previously practised it. The writer of the 1 Maccabees wrote that under the Seleucids, many Jewish men attempted to hide or reverse their circumcision so they could exercise in Greek gymnasia, where nudity was the norm. First Maccabees also relates that the Seleucids forbade the practice of brit milah (Jewish circumcision), and punished those who performed it–as well as the infants who underwent it–with death.

Medical circumcision in the 19th century and early 20th century

Several hypotheses have been raised in explaining the American public's acceptance of infant circumcision as preventive medicine. The success of the germ theory of disease had not only enabled physicians to combat many of the postoperative complications of surgery, but had made the wider public deeply suspicious of dirt and bodily secretions. Accordingly, the smegma that collects under the foreskin was viewed as unhealthy, and circumcision readily accepted as good penile hygiene.[10] Second, moral sentiment of the day regarded masturbation as not only sinful, but also physically and mentally unhealthy, stimulating the foreskin to produce the host of maladies of which it was suspected. In this climate, circumcision could be employed as a means of discouraging masturbation.[11] All About the Baby, a popular parenting book of the 1890s, recommended infant circumcision for precisely this purpose. Interestingly, a 1410-man survey in the United States in 1992, Laumann found that circumcised men were more likely to report masturbating at least once a month.

With the proliferation of hospitals in urban areas, childbirth, at least among the upper and middle classes, was increasingly undertaken in the care of a physician in a hospital rather than that of a midwife in the home. It has been suggested that once a critical mass of infants were being circumcised in the hospital, circumcision became a class marker of those wealthy enough to afford a hospital birth.[12]

By the 1920s, advances in the understanding of disease had undermined much of the original medical basis for preventive circumcision. Doctors continued to promote it, however, as good penile hygiene and as a preventive for a handful of conditions local to the penis: balanitis, phimosis, and penile cancer.

Routine infant circumcision was taken up in the English-speaking parts of Canada, the United States and Australia, and to a lesser extent in New Zealand and the United Kingdom. Although it is difficult to determine historical circumcision rates, one estimate[13] of infant circumcision rates in the United States holds that 30% of newborn American boys were being circumcised in 1900, 55% in 1925, and 72% in 1950.

Circumcision since 1950

In 1949, a lack of consensus in the medical community as to whether circumcision carried with it any notable health benefit motivated the United Kingdom's newly-formed National Health Service to remove routine infant circumcision from its list of covered services. One factor in this rejection of circumcision may have been Douglas Gairdner’s famous study, The fate of the foreskin, which revealed that for the years 1942–1947, about 16 children per year had died because of circumcision in England and Wales, a rate of about 1 per 6000 performed circumcisions.^[71] Since then, circumcision has been an out-of-pocket cost to parents, and the proportion of newborns circumcised in England and Wales has fallen to less than one percent.

In Canada (where public medical insurance is universal and there is no private insurance), individual provincial health services began delisting circumcision in the 1980s.

In South Korea, circumcision was largely unknown before the establishment of the United States trusteeship in 1945 and the spread of American influence. More than 90% of South Korean high school boys are now circumcised, but the average age of circumcision is 12 years [14].

In some South African ethnic groups, circumcision has roots in several belief systems, and is performed most of the time on teenage boys:

"...The young men in the eastern Cape belong to the Xhosa ethnic group for whom circumcision is considered part of the passage into manhood... A law was recently introduced requiring initiation schools to be licensed and only allowing circumcisions to be performed on youths aged 18 and older. But Eastern Cape provincial Health Department spokesman Sizwe Kupelo told Reuters news agency that boys as young as 11 had died. Each year thousands of young men go into the bush alone, without water, to attend initiation schools. Many do not survive the ordeal..." [15].

Prior to 1989, the American Academy of Pediatrics had a long-standing opinion that medical indications for routine circumcision were lacking. This stance, according to the AMA, was reversed in 1989, following new evidence of reduction in risk of urinary tract infection.^[7] A study in 1987 found that the prominent reasons for parents choosing circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns.[16] A 1999 study reported that reasons for circumcision included "ease of hygiene (67 percent), ease of infant circumcision compared with adult circumcision (63 percent), medical benefit (41 percent), and father circumcised (37 percent)." The authors commented that "Medical benefits were cited more frequently in this study than in past studies, although medical issues remain secondary to hygience and convenience."[17] A 2001 study reported that "The most important reason to circumcise or not circumcise the child was health reasons."[18]A 2005 study speculated that increased recognition of the potential benefits may be responsible for an observed increase in the rate of neonatal circumcision in the USA between 1988 and 2000.[19]In a 2001 survey, 86.6% of parents felt respected by their medical provider, and parents who did not circumcise "felt less respected by their medical provider".[20]

The major medical societies in Britain, Canada, Australia and New Zealand do not support routine non-therapeutic infant circumcision. Major medical organizations in the United States do not recommend routine circumcision, but instead state that parents should decide what is in their child's best interests. Neonatal circumcision remains the most common pediatric operation carried out in the U.S. today.

Prevalence of circumcision

Main article: Circumcision worldwide

Estimates of the proportion of males that are circumcised worldwide vary from one sixth^[121] to one third.^[122]

Arab/Muslim countries

Almost all Muslim boys and men are circumcised in Arab/Muslim countries.

United Kingdom

Rickwood et al estimated that 3.8% of male children in the UK are currently (2000) being circumcised by the age of 15.[26], having fallen from about 6.5% in the mid 1980s. The authors considered half of these circumcisions unnecessary, and called for a target to reduce to the level of 2%. Dave et al, reporting on a national survey in 2000, found that 11.7% of 16-19 year olds, and 19.6% of 40-44 year olds said they had been circumcised [27].

Denmark

Denmark has a circumcision rate which has been stable for the last fifty years amongst male children at about 2%. For example, only 511 out of approximately 478,000 Danish boys aged 0-14 years were circumcised in 1986, corresponding to a cumulative national circumcision rate of around 1.6% by the age of 15 years. [28]

South Korea

It has been estimated on the basis of an academic medical survey that some 78% of South Korean men may be circumcised and it has been stated that "South Korea has possibly the largest absolute number of teenage or adult circumcisions anywhere in the world. Because circumcision started through contact with the American military during the Korean War, South Korea has an unusual history of circumcision."^[123]

United States

Statistics from different sources give different pictures of infant circumcision rates in the United States. Deferral of discussion until after birth, combined with the fact that many parents’ decisions about circumcision are preconceived, contribute to the high rate of elective circumcision.^[7]

A recent study, which used data from the Nationwide Inpatient Sample (a sample of 5-7 million of the nation's total inpatient stays, and representing a 20% sample taken from 8 states in 1988 and 28 in 2000), stated that circumcisions rose from 48.3% in 1988 to 61.1% in 1997.^[124]

Figures from the Nationwide Hospital Discharge Survey (for the 2003 survey based on a sample of 320,000 inpatient stays in 426 non-Federal short-stay hospitals),^[125] state that circumcision rates declined from 64.7% in 1980 to 59.0% in 1990, then rose to 64.1% in 1995, and fell again to 55.9% in 2003. Overall, the West saw the most significant change, declining from 61.8% in 1980 to 31.4% in 2003.^[126] The decline in the West has been partly attributed to increasing births among Latin Americans, who usually do not circumcise.^[127]

It has been noted that the statistics from these national samples differs from higher rates that have been documented in individual centers. One explanation is that "the published results of national statistical surveys represent only coded diagnoses obtained from birth centers; the reported figures do not include males who are circumcised at a later date for religious, medical, or personal reasons or who received newborn circumcision that was not coded."^[128]

A national survey of adult men found that 91% of men born in the 1970s, and 83% of men born in the 1980s were circumcised.^[129]

Some obstetricians have been accused of using circumcision as a quick and easy way of making money [29]. Medicaid funding for infant circumcision used to be universal in the United States however sixteen states no longer pay for the procedure under Medicaid [30]. One study in the Midwest of the U.S. found that this had no effect on the newborn circumcision rate but it did affect the demand for circumcision at a later time.^[130]

Canada

The incidence of child circumcision in Canada has been declining steadily. The National Institute for Health Information reports that the percentage of newborn boys circumcised in hospital was 9.2 percent in 2005.[31]

See also

• Brit shalom
• Circumcision advocacy
• Circumcision scar
• Foreskin restoration
• Genital integrity
• Holy Prepuce
• Preputioplasty
• Zeved habat

References