Circumcision

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

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 is a surgical procedure that removes some or all of the foreskin (prepuce) from the penis. The word "circumcision" comes from Latin circum (meaning "around") and caedere (meaning "to cut").

Since March 2007 the World Health Organization and UNAIDS recognize male circumcision as an efficacious intervention for HIV prevention, while cautioning that male circumcision only provides partial protection and should not replace other interventions to prevent heterosexual transmission of HIV. According to WHO, 30% of men worldwide have had the procedure, mostly in countries where it is common for religious or cultural reasons.

Circumcision predates recorded human history, with depictions in stone-age cave drawings and Ancient Egyptian tombs. Theories include that circumcision is a form of ritual sacrifice or offering, a health precaution, 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. Male circumcision is a religious commandment in Judaism, expected in Islam, and customary in some Oriental Orthodox and other Christian churches in Africa.

Circumcision is common in the Middle East,in north América (USA and Canada ),in Australia and parts of Africa and Asia.

Genital integrity supporters condemn infant circumcision as a human rights abuse and a genital mutilation like female genital cutting, while advocates of circumcision like internationales organisations WHO,UNAIDS,UNICEF,UNFPA ,World Bank ,NIAID [2] regard it as a worthwhile public health measure, particularly in the control of HIV [3] . Circumcision may also be used to treat inflammation of the glans and penile cancer. Using circumcision to treat phimosis (see section below) is debated in medical literature.

Circumcision procedures

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

File:Circumsised penis - Flacid and Erect - High Res.jpg

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. Clamps are designed to cut the blood supply to the foreskin, stop any bleeding and protect the glans. Before using a clamp, the foreskin and the glans are separated with a blunt probe and/or curved hemostat.

• With the Plastibell, the foreskin and the clamp come away in three to seven days.

• With a Gomco clamp, a section of skin is first 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 and the clamp is tightened, "crushing the foreskin between the bell and the base plate." The crushing limits bleeding (provides hemostasis). While the flared bottom of the bell fits tightly against the hole of the base plate, the foreskin is then cut away with a scalpel from above the base plate. The bell prevents the glans being reached by the scalpel.

• With a Mogen clamp, the foreskin is grabbed dorsally with a straight hemostat, and lifted up. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result," than with Gomco or Plastibell circumcisions. The clamp is locked shut, and a scalpel is used to cut the foreskin from the flat (upper) side of the clamp.

The frenulum is cut if frenular chordee is evident.

Cultures and religions

Circumcising cultures may circumcise their males either shortly after birth, during childhood or around puberty as part of a rite of passage. Circumcision is most prevalent in Muslim countries, Israel, the United States, the Philippines and South Korea and is most prevalent in the Jewish and Muslim faiths. It is less common in Europe, Latin America, China and India. Hodges argues that in Ancient Greece the foreskin was valued and that Greek and Roman attempts to abolish ritual circumcision were prompted by humanitarian concerns.

Judaism

Circumcision is a fundamental rite of Judaism. It is a positive commandment obligatory under Jewish law for Jewish males, and is only postponed or abrogated in the case of threat to the life or health of the child. 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 Jewish law, failure to follow the commandment carries the penalty of karet, or being cut off from the community by God. Brit milah is considered to be so important that should the eighth day fall on the Sabbath, 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.

Less commonly practised, and more controversial, is metzitzah b'peh, or oral suction, where the mohel sucks blood from the circumcision wound. The traditional reason for this procedure is to promote healing, though the practice has been implicated in the spreading of herpes to the infant. Today, if it is performed, the mohel generally uses a sterilized glass tube.

Christianity

Christianity does not call for circumcision. The first Church Council in Jerusalem declared that circumcision was not necessary (Acts 15). St. Paul had Timothy circumcised (Acts 16:1-3) but in his letters he warned gentile Christians against adopting the practice (Galatians 6:12-16, Philippians 3:2-3). While in most countries, Christians do not circumcise, it is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches. Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership. Some participants in focus group discussions in Zambia and Malawi said that Christians should practice circumcision because Jesus was circumcised and the Bible teaches the practice. Male Circumcision: context, criteria and culture (Part 1), Joint United Nations Programme on HIV/AIDS, February 26, 2007.

The Greek Orthodox Church celebrates the Circumcision of Christ on 1 January, while Orthodox churches following the Julian calendar celebrate it on 14 January. The Russian Orthodox Church considers it a "Great Feast". In the Catholic, Anglican and Lutheran churches it has been replaced by other commemorations. At the Council of Basel-Florence in 1442, the Catholic Church condemned circumcision among the Copts and ordered against its practice.

Islam

The origin of circumcision in Islam is a matter of religious and scholarly debate. It is mentioned in some hadith, but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended (Sunnah); others that it is obligatory. Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham.

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 ^{[citation needed]}. Traditionally, Turkish circumcisions are celebrated with sweets and the "Sünnet Düğünü," or "Circumcision Feast/Celebration." It is considered a very important celebration in man's life as a passage to a manhood. However, in the middle class circumcision is more usually done in infancy. In Pakistan, Muslims may be circumcised at all ages from the newborn period to adulthood, though 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." 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.” Kamyar et al describe circumcision as an "obligatory custom" and note that it is not necessary for the circumciser to be a Muslim.

Other faiths and traditions

Bahá'ís do not have any particular tradition or rituals regarding male circumcision, but view female circumcision as mutilation.

The Druze have no male circumcision in their religion, although, according to one source, it is practiced among those living in urban areas or outside the Middle East, mainly for hygienic reasons.[4]

There is no specific reference to male circumcision in the Hindu holy books [5], and Hindus in India generally do not practice circumcision. [6]

Sikh male infants are not circumcised.

Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War. The origin of circumcision in the Philippines is uncertain. One newspaper article speculates that it is due to the influence of western colonizers. However, Antonio de Morga's seventeenth century History of the Philippine Islands, speculates that it is due to Islamic influence. 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. In early 2007 it was announced that rural aidpost orderlies in the East Sepik Province of Papua New Guinea are to undergo training in the circumcision of men and boys of all ages with a view to introducing the procedure as a means of prophylaxis against HIV/AIDS, which is becoming a significant problem in the country.

Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land, where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago. Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature, including subincision for some aboriginal peoples in the Western Desert. In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu; participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised. 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. In many West African traditional societies circumcision has become medicalised and is simply performed in infancy without ado or any particular conscious cultural significance ^{[citation needed]}. Among the Urhobo 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. For Nilotic peoples, such as the Kalenjin and Maasai, 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.

Ethical issues

The American Medical Association defines “non-therapeutic” circumcision as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. It states that medical associations in the US, Australia, and Canada do not recommend the routine non-therapeutic circumcision of newborns.

Therefore, circumcising infants is controversial. Those advocating circumcision assert that circumcision is a significant public health measure, preventing infections, and slowing down the spread of AIDS. Those opposing circumcision, however, question the legality of infant circumcision by asserting that infant circumcision is a human rights violation or a sexual assault.

Consent

Views differ on whether limits should be placed on caregivers having a child circumcised.

Somerville argues that the nature of the medical benefits cited as a justification for infant circumcision are such that the potential medical problems can be avoided or, if they occur, treated in far less invasive ways than circumcision. She states that the removal of healthy genital tissue from a minor should not be subject to parental discretion, or that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient, regardless of parental consent. Another argument questions why the genital cutting of males is allowed while the genital cutting of females is prohibited.

Others argue that there is no convincing evidence of sexual or emotional harm, and that there are greater monetary and psychological costs in circumcising later rather than in infancy.

Some medical associations accept that the parents should determine what is in the best interest of the infant or child, but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue. The BMA insists that a circumcision must not go ahead without the consent of both parents and the competent child.

Emotional consequences

Goldman discussed the extent to which circumcision may cause emotional harm to males. Some organizations have been formed as support groups for men who are resentful about being circumcised.

Legality

Traditionally, circumcision has been presumed to be legal when performed by a trained operator.

In 2001, Sweden allowed only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anaesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the law, and in 2001, the World Jewish Congress stated that it was “the first legal restriction on Jewish religious practice in Europe since the Nazi era.” However, in 2006, the United States State Department reported that most Jewish mohels had been certified under the law and 3000 Muslim and 40-50 Jewish boys were circumcised each year. The National Board of Health and Welfare reviewed the law in 2005 and recommended that it be maintained.

Pain and pain relief during circumcision

According to the American Academy of Pediatrics' 1999 Circumcision Policy Statement, “There is considerable evidence that newborns who are circumcised without analgesia experience pain and psychologic stress.” In the statement, the Academy recommends the use of pain relief for circumcision. One of the supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response during vaccination months later. They acknowledge that there may be "other factors" besides circumcision that account for different levels of pain response, but stated that they did not find evidence of such. They concluded "[p]retreatment and postoperative management of neonatal circumcision pain is recommended based on these results."

Stang, 1998, found 45% of physicians used anaesthesia - most commonly a dorsal penile nerve block - for infant circumcisions. Obstetricians used anaesthesia significantly less often (25%) than family practitioners (56%) or pediatricians (71%).

J.M. Glass, 1999, stated that Jewish ritual circumcision is so quick that "most mohelim do not routinely use any anaesthesia as they feel there is probably no need in the neonate. However, there is no Talmudic objection and should the parents wish for local anaesthetic cream to be applied there is no reason why this cannot be done." Tannenbaum and Shechet, 2000, stated that an “authentic, traditional bris performed by a mohel does not use clamps, so there is no pain associated with crushing tissue.” They also asserted that due to the speed of the procedure and rarity of complication, it is “more humane not to subject the infant to a local anesthetic.”

Lander et al., found that babies circumcised without pain relief "exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the circumcision and following. Two newborns ... became ill following circumcision (choking and apnea)."[7] A 2004 Cochrane review, which compared the dorsal penile nerve block and EMLA (topical anaesthesia) found both anaesthetics appear safe, but neither of them completely eliminated pain. Razmus et al reported that newborns circumcised with the dorsal block and the ring block in combination with the concentrated oral sucrose had the lowest pain scores. Ng et al found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.

Sexual effects

The American Academy of Pediatrics (1999) stated "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." In January 2007, The American Academy of Family Physicians (AAFP) stated "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."

Boyle et al. (2002) argued that circumcision and frenectomy remove tissues with "heightened erogenous sensitivity," stating "the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings—many of which are lost to circumcision." They concluded, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well."

Medical aspects

The British Medical Association, states “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.” Cost-benefit analyses have varied. Some found a small net benefit of circumcision, some found a small net decrement, and one found that the benefits and risks balanced each other out and suggested that the decision could "most reasonably be made on nonmedical factors."

Risks of circumcision

While the risk in a competently performed medical circumcision is very low, complications from bleeding, infection and poorly carried out circumcisions can be catastrophic. According to the AMA, blood loss and infection are the most common complications. Bleeding is mostly minor; applying pressure will stop it. Kaplan identified other 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" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.”

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A circumcised penis with a skin bridge.

Infant circumcision may result in 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.

The American Medical Association quotes a complication rate of 0.2%–0.6%, based on the studies of Gee and Harkavy. These same studies are quoted by the American Academy of Pediatrics. The American Academy of Family Physicians quotes a range of anywhere between 0.1% and 35%. The Canadian Paediatric Society cite these results in addition to other figures ranging anywhere between 0.06% to 55%, and remark that Williams & Kapila suggested that 2-10% is a realistic estimate. Meatal stenosis may be a common longer-term complication from circumcision. Recent publications give a frequency of occurrence between 0.9% and 9% to 10%. The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.

Deaths have been reported. The American Academy of Family Physicians states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision. Gairdner's 1949 study reported that an average of 16 children per year out of about 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 argued that such deaths were probably due to the circumcision operation.

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.

HIV

Observational studies in the 1980's identified a strong association of circumcision status and reduced risk of HIV infection, as well as of sexually transmitted genital ulcer disease, although behavioural factors may have been a part of that association. Population based studies suggested that circumcision may protect against HIV but likewise social or religious factors may have skewed results. In March 2005, the Cochrane review found the medical evidence at that point "insufficient" to consider implementing circumcision "as a public-health intervention" but the positive results of observational studies suggested that circumcision was "worth evaluating in randomised controlled trials.”

Three randomised control trials published since 2005 confirm that adult male circumcision results in a 50-60% reduction in risk of HIV transmission (from female to male) during heterosexual intercourse. The results of the first trial were 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. The authors said, “Male circumcision provides 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.” Two further trials conducted in Uganda and Kenya were stopped early on December 13, 2006 on grounds that circumcision was so effective that it would be unethical to continue the experiment and not offer circumcision in the uncircumcised men who were acting as controls. The results showed that circumcised males in Uganda were, depending upon the analysis, 51%-60% less likely to be infected. In Kenya, circumcised males were 53%-60% less likely to be infected. A paper published in the journal PLoS Medicine in July, 2006, calculated that if all men in sub-Saharan Africa were circumcised over the next 10 years, two million new infections could potentially be avoided.

The World Health Organization (WHO) said: “Although these results demonstrate that male circumcision reduces the risk of men becoming infected with HIV, the UN agencies emphasize that it does not provide complete protection against HIV infection. Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners. Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing and counselling.”. Others have also expressed concern that some may mistakenly believe they will be fully protected against HIV through circumcision and see circumcision as a safe alternative to other forms of protection, such as condoms. An interim analysis from the Rakai Health Sciences Program in Uganda suggested that newly circumcised HIV positive men may be more likely to spread HIV to their female partners if they have sexual intercourse before the wound is fully healed. “Because the total number of men who resumed sex before certified wound healing is so small, the finding of increased transmission after surgery may have occurred by chance alone. However, we need to err on the side of caution to protect women in the context of any future male circumcision programme,” said Dr Maria Wawer, the study's principal investigator.

There is also a danger of HIV being spread from unhygienic circumcision procedures. Brewer et al. studied HIV infection rates in Kenya, Lethotho and Tanzania and found that "[circumcised] male and female virgins were substantially more likely to be HIV infected than uncircumcised virgins. Among adolescents, regardless of sexual experience, circumcision was just as strongly associated with prevalent HIV infection. However, uncircumcised adults were more likely to be HIV positive than circumcised adults." The authors concluded, "HIV transmission may occur through circumcision-related blood exposures in eastern and southern Africa."

On March 28, 2007, the World Health Organisation and UNAIDS issued joint recommendations about male circumcision and HIV/AIDS. These are:

• Male circumcision should now be recognized as an efficacious intervention for HIV prevention.
• Promoting male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men.

Newell and Bärnighausen (2007) also stated there was "firm evidence that the risk of acquiring HIV is halved by male circumcision." However, Garenne (2006) doubted its value in reducing HIV. and Talbott (2007), in a controversial paper [8] stated that cross country regression data pointed to prostitution as the key factor in the AIDS epidemic rather than circumcision. A World Health Organization AIDS Prevention Team official Tim Farley disagreed with the findings of the paper, while Chris Surridge, PLoS One's managing editor, defended its publication. In 1999 the American Medical Association had stated, "behavioral factors are far more important in preventing these infections than the presence or absence of a foreskin."

Langerhans cells and HIV transmission

Langerhans cells are part of the human immune system. Three studies identified high concentrations of Langerhans and other "HIV target" cells in the foreskin and Szabo and Short suggested that the Langerhans cells in the foreskin may provide an entry point for viral infection. McCoombe, Cameron, and Short also found that the keratin is thinnest on the foreskin and frenulum. Fleiss, Hodges and Van Howe had previously stated a belief that the prepuce has an immunological function. While their specific hypothesis was criticised on technical grounds. a study published in 2007 by de Witte and others said that Langerlin, excreted by Langerhans cells, is a natural barrier to HIV-1 transmission by Langerhans cells.

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.” 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 the penis of an uncircumcised infant requires no special care and should be left alone. It states 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. Birley (1993) stated that the use of soap to wash the foreskin and the glans can lead to balanitis.

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 is common to all mammals—male and female. In rare cases, accumulating smegma may help cause balanitis.

Hutson speculated 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. 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 not significant problems during either of the World Wars.”

Infectious and chronic conditions

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

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

The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams.

Balanitis

Balanitis, an inflammation of the glans penis, has a variety of causes. Some of these, such as anaerobic infection, occur more frequently in uncircumcised men. There are less invasive treatments than circumcision that have been shown to be effective in treating most mild cases of balanitis. Birley, et al, found that in 90% of their cases of chronic or recurring balanitis "use of emollient creams and restriction of soap washing alone controlled symptoms satisfactorily." They also state that 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.” The, less invasive procedures are not as successful in treating balanitis xerotica obliterans, or BXO, which is much less common but harder to treat.

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.

Penile cancer

Most cases of penile cancer occur in men over the age of 70. Boczko and Freed (1979) stated that since Wolbarst's 1932 review, "there have been only eight documented cases of penile carcinoma in an individual circumcised in infancy." They described the ninth reported case, concluding that "performing it in infancy continues to be the most effective prophylactic measure against penile carcinoma." The AMA remarked that in six case series published from 1932 and 1986, "all penile cancers occurred in uncircumcised individuals." Maden et al (1993) reported that the risk of penile cancer was 3.2 times greater in men who were never circumcised and 3 times greater among those who were circumcised after the neonatal period. An editorial by Holly and Palefsky complimented the study for noting other risk factors for penile cancer, and also for providing corroborating evidence as to the association between a lack of neonatal circumcision and the development of penile cancer. However, they criticised include the study for combining data from invasive and in situ cancers. They concluded that as Maden reported that 20% of the men with penile cancer were circumcised at birth, the recommendation of circumcision for medical indications remained somewhat controversial and the risks and benefits must be weighed. The American Academy of Pediatrics made similar criticism, also noting the possibly inaccurate use of self-report to determine circumcision status. Schoen et al studied the association between neonatal circumcision and invasive penile cancer in 2000, and found that the relative risk for uncircumcised men was 22 times that of circumcised men.

The American Cancer Society states that “In the United States, men who are circumcised in childhood have a lower rate of penile cancer. It’s not known whether this is due to the absence of the foreskin or other lifestyle factors. Recent studies have found that circumcised men are less likely to be infected with HPV, even after this risk is adjusted for differences in sexual behavior. Other studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer.,” “In weighing the risks and benefits of circumcision, doctors consider the fact that penile cancer is one of the least common forms of cancer in the United States” and “Ultimately, decisions about circumcision are highly personal and depend more on social and religious factors than on medical evidence.” They state that it is important to concentrate on the main risk factors: poor hygiene, having unprotected sex with multiple partners, and cigarette smoking. They also state that the current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer.

The American Academy of Pediatrics (1999) stated 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. Similarly, the American Medical Association states 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.

Kochen and McCurdy performed a life table analysis on penile cancer rates. They assumed that penile cancer occurred only in uncircumcised males and that the rates from older groups applied to the 1971 birth cohort. They estimated a rate of 1 in 600, or 0.167% in uncircumcised males, with a median age of occurrence of 67 years. They stated, “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.”

The Medical College of Georgia is now studying the impact of the new vaccine against "HPV types 16 and 18, the two most common causes of cervical and penile cancer" [9]

HPV

Several studies have shown that uncircumcised men are at greater risk of human papilloma virus (HPV) infection. Some genital HPV strains some can cause genital warts, cervical or penile cancer [10]. One study found no statistically significant difference in HPV infection between circumcised and uncircumcised men, but did note a significantly higher incidence of urethritis in the uncircumcised.

Phimosis and paraphimosis

It is normal for an infant's foreskin to be attached to the glans. Phimosis is defined by some sources as an inability to retract the foreskin, others by that occurring after age 5, and still others by a form of the first source's definition caused by a specific disease (balanitis xerotica obliterans). Dawson and Whitfield, say "True phimosis is rare but may cause appreciable problems in either childhood or adolescence."[11] The AAP state that the true frequency of problems such as phimosis is unknown. Fergusson et al found phimosis in 16% of non-circumcised boys, while Herzog and Alvarez found it in 2.6%.[12] Rickwood and Walker raised concern that phimosis is frequently misdiagnosed by physicians confusing it with the developmentally non-retractable foreskin. Several researchers have described less invasive treatments for phimosis than circumcision, and recommend that they be tried first.

Several studies have identified phimosis as a risk factor for penile cancer. A letter to the British Medical Journal stated it would be irresponsible to expose a patient to risk for longer than necessary.

Paraphimosis is an acute condition when a tight foreskin is stuck behind the glans and cannot be returned to its original position, curbing the blood flow to the glans. In children, it is sometimes caused by a caregiver trying to forcibly retract the infant foreskin.

Urinary tract infections

Twelve studies have indicated that neonatal circumcision reduces the rate of Urinary tract infections in male infants by a factor of about 10. The March 1999 AAP statement notes that premature boys are usually not circumcised because of their fragile health status. Studies have found that 1 in 10 premature infants will have a urinary tract infection during the first month of life. [13] Some UTI studies have been criticised for not taking this 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%. 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.”

The Canadian Paediatric Society questions whether increased UTI and balanitis rates in uncircumcised male infants may be caused by forced premature retraction. Lerman and Liao, state that apart 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."

Policies of various national medical associations

United States

The American Academy of Family Physicians (2007) recommends that physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering circumcision for newborn boys.

The American Academy of Pediatrics (1999) found both potential benefits and risks in infant circumcision. It felt that there was insufficient data to recommend routine neonatal circumcision, and recommended that parental decisions on circumcision should be made with as much accurate and unbiased information as possible, taking medical, cultural, ethnic, traditional, and religious factors into account. The AAP also recommended using analgesia as a safe and effective method for reducing pain associated with circumcision, and that circumcision on newborns only be performed on infants who are stable and healthy.

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

The American Urological Association (2007) recommends "that circumcision should be presented as an option for health benefits."[14]

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Circumcision: Information for Parents" in November 2004, and "Neonatal circumcision revisited" in 1996. The 1996 position statement says that "circumcision of newborns should not be routinely performed," (a statement with which the Royal Australasian College of Physicians concurs,) and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many paediatricians no longer perform circumcisions."

United Kingdom

The British Medical Association's position (June 2006) was that male circumcision for medical purposes should only be used where less invasive procedures are either unavailable or not as effective. The BMA specifically refrained from issuing a policy regarding “non-therapeutic circumcision,” stating that as a general rule, it “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.”

Australasia

The Royal Australasian College of Physicians states there is no medical indication for routine neonatal circumcision (emphasis as in the original). It states, "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"

History of 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 has been suggested that the custom of circumcision gave advantages to tribes that practiced it and thus led to its spread regardless of whether the people understood this. It is possible that circumcision arose independently in different cultures for different reasons.

File:Circumcision Precinct of Mut.png

Ancient Egyptian carved 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 B.C.E.

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, Topkapı 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 B.C.E.) 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 B.C.E., lists the Egyptians, Jews, Edomites, Ammonites, and Moabites as circumcising cultures. Herodotus, writing in the fifth century B.C.E., 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

There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The success of the germ theory of disease made surgery safer, and made the public deeply suspicious of dirt and bodily secretions. So smegma was viewed as unhealthy, and circumcision was seen as good penile hygiene.[15] At that time when people regarded masturbation as both sinful, and physically and mentally unhealthy, circumcision was promoted as a way of discouraging it. [16] All About the Baby, a popular parenting book of the 1890s, recommended infant circumcision for this purpose. (However, a survey of 1410 men in the United States in 1992, Laumann found that circumcised men were more likely to report masturbating at least once a month.)

In 1855, the Quaker surgeon, Jonathan Hutchinson, observed that circumcision appeared to protect against syphilis. Although this observation was challenged (the protection that Jews appear to have are more likely due to cultural factors), a 2006 systematic review concluded that the evidence "strongly indicates that circumcised men are at lower risk ... syphilis."

As hospitals proliferated in urban areas, childbirth, at least among the upper and middle classes, was increasingly under the care of physicians in hospitals rather than with midwives 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.

By the 1920s, advances in the understanding of disease had undermined much of the original medical basis for preventive circumcision but doctors continued to promote it as good penile hygiene and as a preventive for balanitis, phimosis, and penile cancer. ^{[citation needed]}

Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada and to a lesser extent in the United Kingdom and New Zealand. The British Royal Family had a long tradition requiring that all male children be circumcised” (Alfred J. Kolatach’s The Jewish Book of Why, Middle Village, New York; Jonathan David, 1981). Although it is difficult to determine historical circumcision rates, one estimate[17] 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, the United Kingdom's newly-formed National Health Service removed infant circumcision from its list of covered services. One reason 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 in England and Wales had died because of circumcision, a rate of about 1 per 6000 circumcisions. 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 where private insurance does not replicate services already paid from the public purse), individual provincial health services began delisting circumcision in the 1980s.

In South Korea, circumcision grew in popularity following 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.

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..." [18].

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. 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.[19] 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."[20] A 2001 study reported that "The most important reason to circumcise or not circumcise the child was health reasons." 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.[21] 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".

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.

The AMA remarked that, in one study, physicians in "nearly half" of neonatal circumcisions "did not discuss the potential medical risks and benefits of elective circumcision prior to delivery of the infant son. 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."

Table 1: International circumcision rates

Country	Year	Neonatal circumcisions (%)
United States	2003	55.9%* [22]
Canada	2003	< 14% [23]
Australia	2004	10%-20% [24]
New Zealand	1995	0-5%[25]
*The percentage refers to infants born in non-Federal hospitals; see p 52, Table 44 of the reference.
**Samoans, Tongans and Niueans in New Zealand continue to practice circumcision, but not in public hospitals, to which these data refer.

Prevalence of circumcision

Estimates of the proportion of males that are circumcised worldwide vary from one sixth (12.5%) to one third (33.3%). According to one author, the practice is "a falling trend internationally", although another notes indications of increasing demand in Southern Africa.

Australia

According to the Sydney Morning Herald, the infant circumcision rate in Australia was 12.9% in 2003. The rates varied with Queensland (19.3%), New South Wales (16.3%) and South Australia (14.3%). The lowest rate was in Tasmania (1.6%). Non-therapeutic infant circumcision is no longer provided in public hospitals in New South Wales, Tasmania, and Western Australia, with a similar ban taking effect in Victoria in September 2007.

Denmark

In 1986, only 511 out of approximately 478,000 Danish boys aged 0-14 years were circumcised. This corresponds to a cumulative national circumcision rate of around 1.6% by the age of 15 years. [26]

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."

United Kingdom

A national survey on sexual attitudes in 2000 found that 11.7% of 16-19 year olds, and 19.6% of 40-44 year olds said they had been circumcised. It also found that, apart from black Caribbeans, overseas born men were more likely to be circumcised. Rickwood et al reported that the proportion of English boys circumcised for medical reasons had fallen from 35% in the early 1930s to 6.5% by the mid-1980s. An estimated 3.8% of male children in the UK in 2000 were being circumcised by the age of 15 [27]. The researchers stated that too many boys, especially under the age of 5, were still being circumcised because of a misdiagnosis of phimosis. They called for a target to reduce the percentage to 2%.

United States

Statistics from different sources give widely varying estimates of infant circumcision rates in the United States.

Nelson, 2005 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.

The 2003 Nationwide Hospital Discharge Survey stated that circumcision rates declined from 64.7% in 1980 to 59.0% in 1990, rose to 64.1% in 1995, and fell again to 55.9% in 2003. On page 52, it is shown that the western region of the United States has seen the most significant change, declining from 61.8% in 1980 to 31.4% in 2003. The decline in the western region has been partly attributed to increasing births among Latin Americans, who usually do not circumcise.

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.

Schoen, 2006, claimed 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."

There are various explanations why the infant circumcision rate in the United States are different from comparable countries. Some obstetricians have been accused of using circumcision as a quick and easy way of making money. Many parents’ decisions about circumcision are preconceived, and this may contribute to the high rate of elective circumcision.

Medicaid funding for infant circumcision used to be universal in the United States; however, sixteen states no longer pay for the procedure under Medicaid [28]. 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.

See also

• Brit milah
• Circumcision scar
• Foreskin restoration
• Genital integrity
• Holy Prepuce
• Preputioplasty, alternative to circumcision in the treatment for phimosis
• Zeved habat

References

ISBN links support NWE through referral fees

Some referenced articles are available on-line only in the Circumcision Information and Resource Page’s (CIRP) library or in The Circumcision Reference Library (CIRCS). CIRP articles are chosen from an anti-circumcision point of view, and text in support of this position is often highlighted on-screen using HTML. CIRCS articles are chosen from a pro-circumcision point of view. If documents are not freely available on-line elsewhere, links to articles in one or other of these two websites may be provided.

External links

Circumcision opposition

• The Circumcision Information and Resource Pages by Geoffrey T. Falk
• Doctors Opposing Circumcision presided by George C. Denniston, MD, MPH
• National Organization of Circumcision Information Resource Centers by Marilyn Milos, RN

Circumcision promotion

• Benefits of circumcision: medical, health and sexual by Professor Brian Morris
• Circumcision: a lifetime of medical benefits by Edgar Schoen, BSc., M.D.
• Circumcision Information by Gerald N. Weiss, M.D.

Circumcision techniques

• Description of an adult circumcision from the American Academy of Family Physicians.
• Description of a Plastibell circumcision from the Medical College of Georgia.

Further reading

• Billy Ray Boyd. Circumcision Exposed: Rethinking a Medical and Cultural Tradition. Freedom, CA: The Crossing Press, 1998. (ISBN 978-0-89594-939-4)
• Anne Briggs. Circumcision: What Every Parent Should Know. Charlottesville, VA: Birth & Parenting Publications, 1985. (ISBN 978-0-9615484-0-7)
• Robert Darby. A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain. Chicago: University of Chicago Press, 2005. (ISBN 978-0-226-13645-5)
• Aaron J. Fink, M.D. Circumcision: A Parent's Decision for Life. Kavanah Publishing Company, Inc., 1988. (ISBN 978-0-9621347-0-8)
• Paul M. Fleiss, M.D. and Frederick Hodges, D. Phil. What Your Doctor May Not Tell You About Circumcision. New York: Warner Books, 2002. (ISBN 978-0-446-67880-3)
• Leonard B. Glick. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. New York: Oxford University Press, 2005. (ISBN 978-0-19-517674-2)
• David L. Gollaher. Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000. (ISBN 0465026532)
• Ronald Goldman, Ph.D. Circumcision: The Hidden Trauma. Boston: Vanguard, 1996. (ISBN 978-0-9644895-3-0)
• Paysach J. Krohn, Rabbi. Bris Milah. Circumcision-The Covenant Of Abraham/A Compendium of Laws, Rituals, And Customs From Birth To Bris, Anthologized From Talmudic, And Traditional Sources. New York: Mesorah Publications, 1985, 2005.
• Brian J. Morris, Ph.D., D.Sc. In Favour of Circumcision. Sydney: UNSW Press, 1999. (ISBN 978-0-86840-537-7)
• Rosemary Romberg. Circumcision: The Painful Dilemma. South Hadley, MA Bergan & Garvey, 1985. (ISBN 978-0-89789-073-1)
• Edgar J Schoen, M.D. Ed Schoen, MD on Circumcision. Berkeley, CA: RDR Books, 2005. (ISBN 978-1-57143-123-3)
• Edward Wallerstein. Circumcision: An American Health Fallacy. New York: Springer, 1980 (ISBN 978-0-8261-3240-6)
• Gerald N. Weiss M.D. and Andrea W Harter. Circumcision: Frankly Speaking. Wiser Publications, 1998. (ISBN 978-0-9667219-0-4)
• Yosef David Weisberg, Rabbi. Otzar Habris. Encyclopedia of the laws and customs of Bris Milah and Pidyon Haben. Jerusalem: Hamoer, 2002.

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