Circumcision

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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.[1] 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.[2] According to WHO, 30% of men worldwide have had the procedure, mostly in countries where it is common for religious or cultural reasons.[3]

Circumcision predates recorded human history, with depictions in stone-age cave drawings and Ancient Egyptian tombs.[4] 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.[5] Male circumcision is a religious commandment in Judaism, expected in Islam,[6][7] and customary in some Oriental Orthodox and other Christian churches in Africa.[8]

Circumcision is common in the Middle East,in north América (USA and Canada ),in Australia and parts of Africa and Asia. [3]

Genital integrity supporters condemn infant circumcision as a human rights abuse and a genital mutilation like female genital cutting[9], while advocates of circumcision like internationales organisations WHO,UNAIDS,UNICEF,UNFPA ,World Bank ,NIAID [1] regard it as a worthwhile public health measure[10], particularly in the control of HIV [2] [11][12][13]. Circumcision may also be used to treat inflammation of the glans and penile cancer.[14][15] Using circumcision to treat phimosis (see section below) is debated in medical literature.[16][17]

Circumcision procedures

File:Uncircumcised Penis.jpg
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.[18] 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.[19]
  • 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.[20][21]

The frenulum is cut if frenular chordee is evident.[22][23]

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.[24]

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.[25] 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.[26]

Less commonly practised, and more controversial, is metzitzah b'peh, or oral suction,[27][28] where the mohel sucks blood from the circumcision wound. The traditional reason for this procedure is to promote healing,[29][30] though the practice has been implicated in the spreading of herpes to the infant.[31] Today, if it is performed, the mohel generally uses a sterilized glass tube.[32][33]

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,[34] it is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches[8]. Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya[35][8], 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,[36] while Orthodox churches following the Julian calendar celebrate it on 14 January. The Russian Orthodox Church considers it a "Great Feast".[37] In the Catholic, Anglican and Lutheran churches it has been replaced by other commemorations.[38] At the Council of Basel-Florence in 1442, the Catholic Church condemned circumcision among the Copts and ordered against its practice.[34]

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.[39] Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham.[40]

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.[41] 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."[42] 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.”[43] Kamyar et al describe circumcision as an "obligatory custom" and note that it is not necessary for the circumciser to be a Muslim.[44]

Other faiths and traditions

Bahá'ís do not have any particular tradition or rituals regarding male circumcision, but view female circumcision as mutilation.[45]

The Druze have no male circumcision in their religion,[46] although, according to one source, it is practiced among those living in urban areas or outside the Middle East, mainly for hygienic reasons.[3]

There is no specific reference to male circumcision in the Hindu holy books [4], and Hindus in India generally do not practice circumcision. [5]

Sikh male infants are not circumcised.[47]

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.[48] However, Antonio de Morga's seventeenth century History of the Philippine Islands, speculates that it is due to Islamic influence.[49] 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.[50] 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.[51]

Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land,[52] where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.[53] Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature, including subincision for some aboriginal peoples in the Western Desert.[54] In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu;[55] participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.[56] 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.[57] 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.[58] 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.[59]

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.[60]

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.[61] Those opposing circumcision, however, question the legality of infant circumcision by asserting that infant circumcision is a human rights violation or a sexual assault.[62][63]

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.[62] Another argument questions why the genital cutting of males is allowed while the genital cutting of females is prohibited.[64]


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.[65]

Some medical associations accept that the parents should determine what is in the best interest of the infant or child,[66][60][67][68] but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue.[69][70] The BMA insists that a circumcision must not go ahead without the consent of both parents and the competent child.[70]

Emotional consequences

Goldman discussed the extent to which circumcision may cause emotional harm to males.[71] Some organizations have been formed as support groups for men who are resentful about being circumcised.[72]

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,[73] 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.”[74] 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.[75]


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."[66] 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."[76]

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."[77] 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.”[70] Cost-benefit analyses have varied. Some found a small net benefit of circumcision,[78][79] some found a small net decrement,[80][81] 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."[82]

Risks of circumcision

While the risk in a competently performed medical circumcision is very low,[83] complications from bleeding, infection and poorly carried out circumcisions can be catastrophic.[84] According to the AMA, blood loss and infection are the most common complications. Bleeding is mostly minor; applying pressure will stop it.[60] 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.”[85]

File:Flaccid-erect.jpg
A circumcised penis with a skin bridge.

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.[86] 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.”[87]

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.”[66][88] 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.[89] Birley (1993) stated that the use of soap to wash the foreskin and the glans can lead to balanitis.[90]

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.[91]

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.[92] 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.”[93]

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.[94][95][96] The reasons are unclear, but several hypotheses have been suggested:

  • The foreskin may harbor bacteria and become infected if it is not cleaned properly.[97]
  • The foreskin may become inflamed if it is cleaned too often with soap.[90]
  • The forcible retraction of the foreskin in boys can lead to infections.[98]

The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams.[99]


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.[100] 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.[6] At that time when people regarded masturbation as both sinful, and physically and mentally unhealthy, circumcision was promoted as a way of discouraging it. [7] 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.[101] Although this observation was challenged (the protection that Jews appear to have are more likely due to cultural factors[102]), a 2006 systematic review concluded that the evidence "strongly indicates that circumcised men are at lower risk ... syphilis."[103]

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.[104]

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[8] 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.[105] 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.[106]

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..." [9].

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.[60] 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.[10] 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."[11] A 2001 study reported that "The most important reason to circumcise or not circumcise the child was health reasons."[107] 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.[12] 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".[107]

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."[60]

Table 1: International circumcision rates
Country Year Neonatal circumcisions (%)
United States 2003 55.9%* [13]
Canada 2003 < 14% [14]
Australia 2004 10%-20% [15]
New Zealand 1995 0-5%[16]
*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.


Notes

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.
  1. ↑ Surgery:
  2. ↑ (March 28, 2007). "New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications". World Health Organization. Retrieved 2007-08-13.
  3. ↑ 3.0 3.1 Insert 2. Information Package on Male Ci rcumcision and HIV Prevention. World Health Organization (2007). Retrieved 2007-08-15.
  4. ↑ Wrana, P. (1939). Historical review: Circumcision. Archives of Pediatrics 56: 385–392. as quoted in: Zoske, Joseph (Winter 1998). Male Circumcision: A Gender Perspective. Journal of Men’s Studies 6 (2): 189–208.
  5. ↑ Gollaher, David L. (February 2000). Circumcision: a history of the world’s most controversial surgery. New York, NY: Basic Books, 53–72. ISBN 978-0-465-04397-2 LCCN 99-40015. 
  6. ↑ Circumcision. American-Israeli Cooperative Enterprise. Retrieved 2006-10-03.
  7. ↑ Beidelman, T.. (1987). "CIRCUMCISION". The Encyclopedia of religion Volume 3: 511–514. Ed. Mircea Eliade. New York, NY: Macmillan Publishers. LCCN 86-5432 ISBN 978-0-02-909480-8. Retrieved on 2006-10-03.
  8. ↑ 8.0 8.1 8.2 Customary in some Coptic and other churches:
    • "The Coptic Christians in Egypt and the Ethiopian Orthodox Christians— two of the oldest surviving forms of Christianity— retain many of the features of early Christianity, including male circumcision. Circumcision is not prescribed in other forms of Christianity... Some Christian churches in South Africa oppose the practice, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership and participants in focus group discussions in Zambia and Malawi mentioned similar beliefs that Christians should practice circumcision since 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 decision that Christians need not practice circumcision is recorded in Acts 15; there was never, however, a prohibition of circumcision, and it is practiced by Coptic Christians." "circumcision", The Columbia Encyclopedia, Sixth Edition, 2001-05.
  9. ↑ Milos, Marilyn Fayre and Donna Macris (March-April 1992). Circumcision: A medical or a human rights issue?. Journal of Nurse-Midwifery 37 (2 S1): S87–S96.
  10. ↑ Schoen, Edgar J (1997). Benefits of newborn circumcision: is Europe ignoring medical evidence?. Archives of Disease in Childhood 77 (3): 258-260.
  11. ↑ Newell, Marie-Lousie and Till Bärnighausen (February 24, 2007). Male circumcision to cut HIV risk in the general population. The Lancet 369 (9562): 617–619.
  12. ↑ Bailey, Robert C and Stephen Moses, Corette B Parker, Kawango Agot, Ian Maclean, John N Krieger, Carolyn F M Williams, Richard T Campbell, Jeckoniah O Ndinya-Achola (February 24, 2007). Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. The Lancet 369 (9562): 643–656.
  13. ↑ Gray, Ronald H and Godfrey Kigozi, David Serwadda, Frederick Makumbi, Stephen Watya, Fred Nalugoda, Noah Kiwanuka, Lawrence H Moulton, Mohammad A Chaudhary, Michael Z Chen, Nelson K Sewankambo, Fred Wabwire-Mangen, Melanie C Bacon, Carolyn F M Williams, Pius Opendi, Steven J Reynolds, Oliver Laeyendecker, Thomas C Quinn, Maria J Wawer (February 24, 2007). Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. The Lancet 369 (9562): 657–666.
  14. ↑ Holman, John R. and Keith A. Stuessi (March 15, 1999). Adult Circumcision. American Family Physician 59 (6): 1514–1518. ISSN 0002-838X PMID 10193593.
  15. ↑ Rempelakos A and et al (Jan-Mar 2004). Carcinoma of the penis: experience from 360 cases. J BUON 9 (1): 51-5.
  16. ↑ Dewan, P.A. and Tieu H.C., and Chieng B.S. (August 1996). Phimosis: Is circumcision necessary?. Journal of Paediatrics and Child Health 32 (4): 285–289. PMID 8844530.
  17. ↑ Beaugé, Michel (September/October 1997). The causes of adolescent phimosis. British Journal of Sexual Medicine 26.
  18. ↑ Holman, John R. and Evelyn L. Lewis, Robert L. Ringler (August 1995). Neonatal circumcision techniques - includes patient information sheet. American Family Physician 52 (2): 511–520. ISSN 0002-838X PMID 7625325.
  19. ↑ Peleg, David and Ann Steiner (September 15, 1998). The Gomco Circumcision: Common Problems and Solutions. American Family Physician 58 (4): 891–898. ISSN 0002-838X PMID 9767725.
  20. ↑ Pfenninger, John L. and Grant C. Fowler [1994] (July 21, 2003). Procedures for primary care, 2nd, Mosby. ISBN 978-0-323-00506-7 LCCN 2003-56227. 
  21. ↑ Reynolds, RD (July 1996). Use of the Mogen clamp for neonatal circumcision. American Family Physician 54 (1): 177–182. PMID 8677833.
  22. ↑ Griffin A, Kroovand R (1990). Frenular chordee: implications and treatment. Urology 35 (2): 133-4. PMID 2305537.
  23. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named Shechet
  24. ↑ Hodges, Frederick, M. (2001). Religious circumcision: a Jewish view. The Bulletin of the History of Medicine 75 (Fall 2001): 375–405.
  25. ↑ Glass, J.M. (January 1999). Religious circumcision: a Jewish view. BJU International 83 (Supplement 1): 17–21. PMID 10766529.
  26. ↑ Shulchan Aruch, Yoreh De'ah, 263:4
  27. ↑ Nussbaum Cohen, Debra (October 14, 2005). City Risking Babies' Lives With Brit Policy: Health Experts. The Jewish Week. Retrieved 2007-04-19.
  28. ↑ Nussbaum Cohen, Debra; Larry Cohler-Esses (December 23, 2005). City Challenged On Ritual Practice. The Jewish Week. Retrieved 2007-04-19.
  29. ↑ Talmud Bavli Tractate Shabbos 133b: Rav Pappa said, “A mohel who does not perform metzitzah endangers the baby and is dismissed.”
  30. ↑ Halperin, Mordechai; (translated by Yocheved Lavon), "Metzitzah B’peh Controversy: The View from Israel", Jewish Action 67(2), Orthodox Union, Winter 2006, pp. 25, 33–39. Retrieved 2007-02-15.
  31. ↑ Gesundheit, B. and et al. (August 2004). Neonatal Genital Herpes Simplex Virus Type 1 Infection After Jewish Ritual Circumcision: Modern Medicine and Religious Tradition. Pediatrics 114 (2): e259–e263. ISSN 1098-4275.
  32. ↑ Metzitza Be'Peh - Halachic Clarification. Rabbinical Council of America (June 7, 2005). Retrieved 2007-04-06.
  33. ↑ Hartog, Kelly, "Death Spotlights Old Circumcision Rite", The Jewish Journal of Greater Los Angeles, February 18 2005. Retrieved 2006-11-22.
  34. ↑ 34.0 34.1 Burton, Richard (1882-1884). "Nur Al-Din Ali and the Damsel Anis Al-Jalis, footnote FN#26", The Arabian Nights, tales from a thousand and one nights (HTML) (in English). Retrieved 2007-07-07. “ [FN#26] In one matter Moslems contrast strongly with Christians, by most scrupulously following the example of their law-giver: hence they are the model Conservatives. But (European) Christendom is here, as in other things, curiously contradictory: for instance, it still keeps a "Feast of the Circumcision," and practically holds circumcision in horror. Eastern Christians, however, have not wholly abolished it, and the Abyssinians, who find it a useful hygenic precaution, still practise it. For ulcers, syphilis and other venereals which are readily cured in Egypt become dangerous in the Highlands of Ethiopia.”  Cite error: Invalid <ref> tag; name "CoF" defined multiple times with different content
  35. ↑ Mattson CL, Bailey RC, Muga R, Poulussen R, Onyango T (2005) Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza province Kenya. AIDS Care 17:182–194.
  36. ↑ Greek Orthodox Archdiocese calendar of Holy Days
  37. ↑ Russian Orthodox Church, Patriarchate of Moscow
  38. ↑ For example, "The Calendar of the Church Year" in The (Online) Book of Common Prayer (Episcopal Church in the United States of America), http://www.bcponline.org/ retrieved 11 October 2006.
  39. ↑ Al-Munajjid, Muhammed Salih. Question #9412: Circumcision: how it is done and the rulings on it. Islam Q&A. Retrieved 2006-07-01.
  40. ↑ Al-Munajjid, Muhammed Salih. Question #7073: The health and religious benefits of circumcision. Islam Q&A. Retrieved 2006-07-01.
  41. ↑ Hamdullah Aydın, M.D. and Zeynep Gülçat, Ph.D., "Turkey," in The International Encyclopedia of Sexuality, http://www2.hu-berlin.de/sexology/IES/turkey.html#5 retrieved 8 July 2007.
  42. ↑ Iftikhar Ahmad Jan, "Circumcision in babies and children with Plastibell technique: An easy procedure with minimal complications - Experience of 316 cases," Pak J Med Sci 2004, 20(3) 175-180.
  43. ↑ Drew, Paula E..; F. A. Sadeghpour and anonymous "Iran". The International Encyclopedia of Sexuality. Ed. Robert T. Francoeur. New York, NY: Continuum Publishing Company. Retrieved on 2006-10-18.
  44. ↑ Kamyar M. Hedayat, MD and Roya Pirzadeh, MD, "Issues in Islamic Biomedical Ethics: A Primer for the Pediatrician," Pediatrics Vol. 108 No. 4 October 2001, pp. 965-971, http://imamreza.net/eng/imamreza.php?print=3107 retrieved 11 October 2006.
  45. ↑ WHEN YOUR PATIENT IS A BAHA'I. National Spiritual Assembly of the Bahá'ís of New Zealand. Retrieved 2007-01-30.
  46. ↑ Who Are the Druze?. SEMP Biot #176. Suburban Emergency Management Project (February 17, 2005). Retrieved 2007-01-30.
  47. ↑ Guidelines for health Care Providers Interacting with Patients of the Sikh Religion and their Families. Metropolitan Chicago Healthcare Council (November 2000). Retrieved 2007-05-01.
  48. ↑ Rebollido, Rommel G., "Passage to manhood", General Santos, Sun Star Publishing, Inc., March 21, 2005. Retrieved 2006-07-01.
  49. ↑ de Morga, Antonio [1609] (1907). "11", History of the Philippine Islands, Translated by Alfonso de Salvio, Norman F. Hall, and James Alexander Robertson. LCCN unk82-42869. Retrieved 2006-07-01. “These Borneans are Mahometans, and were already introducing their religion among the natives of Luzon, and were giving them instructions, ceremonies, and the form of observing their religion.…and those the chiefest men, were commencing, although by piecemeal, to become Moros, and were being circumcised and taking the names of Moros.” 
  50. ↑ Ajuwon et al., "Indigenous surgical practices in rural southwestern Nigeria: Implications for disease," Health Educ. Res..1995; 10: 379-384 Health Educ. Res..1995; 10: 379-384 Retrieved 3 October 2006
  51. ↑ "PNG circumcision campaign hopes to halt HIV," (htm). ABC Radio Australia citing the Papua New Guinea Post-Courier (2007-02-08, 14:21:13,).
  52. ↑ Aaron David Samuel Corn (2001). "Ngukurr Crying: Male Youth in a Remote Indigenous Community". Working Paper Series No. 2. University of Wollongong. Retrieved 2006-10-18.
  53. ↑ Migration and Trade. Green Turtle Dreaming. Retrieved 2006-10-18.
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  55. ↑ RECENT GUEST SPEAKER. Australian AIDS Fund Incorporated (2006). Retrieved 2006-07-01.
  56. ↑ Weird & Wonderful. United Travel. Retrieved 2006-07-01.
  57. ↑ Circumcision amongst the Dogon. The Non-European Components of European Patrimony (NECEP) Database (2006). Retrieved 2006-09-03.
  58. ↑ Agberia, John Tokpabere (2006). Aesthetics and Rituals of the Opha Ceremony among the Urhobo People. Journal of Asian and African Studies 41 (3): 249-260.
  59. ↑ Masai of Kenya. Retrieved 2007-04-06.
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  61. ↑ Auvert, Bertran and Dirk Taljaard, Emmanuel Lagarde, Joëlle Sobngwi-Tambekou, Rémi Sitta, Adrian Puren (November 2005). Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Medicine 2 (11): 1112–1122. PMID 16231970.
  62. ↑ 62.0 62.1 Sommerville, Margaret (November 2000). "Altering Baby Boys’ Bodies: The Ethics of Infant Male Circumcision", The ethical canary: science, society, and the human spirit. New York, NY: Viking Penguin Canada, 202–219. LCCN 2001-369341. ISBN 0670893021. Retrieved 2007-02-12. 
  63. ↑ Van Howe, R.S. and J.S. Svoboda, J.G. Dwyer, and C.P. Price (January 1999). Involuntary circumcision: the legal issues. BJU International 83 (Supp1): 63–73.
  64. ↑ Lightfoot-Klein, Hanny (2003). Similarities in Attitudes and Misconceptions toward Infant Male Circumcision in North America and Ritual Female Genital Mutilation in Africa.. The FGC Education and Networking Project. Retrieved 2006-07-01.
  65. ↑ Benatar, David and Benatar, Michael (2003). How not to argue about circumcision. American Journal of Bioethics 3 (2): W1-W9.
  66. ↑ 66.0 66.1 66.2 American Academy of Pediatrics Task Force on Circumcision (March 1, 1999). Circumcision Policy Statement. Pediatrics 103 (3): 686–693. ISSN 0031-4005 PMID 10049981.
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  69. ↑ Policy Statement On Circumcision (PDF). Royal Australasian College of Physicians (September 2004). Retrieved 2007-02-28.
  70. ↑ 70.0 70.1 70.2 Medical Ethics Committee (June 2006). The law and ethics of male circumcision - guidance for doctors. British Medical Association. Retrieved 2006-07-01.
  71. ↑ Goldman, R. (January 1999). The psychological impact of circumcision. BJU International 83 (S1): 93–102.
  72. ↑ National Organization of Restoring Men (2006). Retrieved 2006-07-01.
  73. ↑ Sweden restricts circumcisions. BBC Europe (October 1, 2001). Retrieved 2006-10-18.
  74. ↑ Reuters (June 7, 2001). Jews protest Swedish circumcision restriction. Canadian Children's Rights Council. Retrieved 2006-10-18.
  75. ↑ Bureau of Democracy, Human Rights, and Labor (September 15, 2006). Sweden. International Religious Freedom Report 2006. US Department of State. Retrieved 2007-07-04.
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  77. ↑ Boyle, Gregory J; Svoboda, J Steven; Goldman, Ronald; Fernandez, Ephrem (2002). Male circumcision: pain, trauma, and psychosexual sequelae. Bond University Faculty of Humanities and Social Sciences.
  78. ↑ Schoen, Edgar J. and Christopher J. Colby, Trinh T. To (March 2006). Cost Analysis of Neonatal Circumcision in a Large Health Maintenance Organization. The Journal of Urology 175 (3): 1111–1115. PMID 16469634.
  79. ↑ Alanis, Mark C. and Richard S. Lucidi (May 2004). Neonatal Circumcision: A Review of the World’s Oldest and Most Controversial Operation. Obstetrical & Gynecological Survey 59 (5): 379-395. PMID 15097799.
  80. ↑ Van Howe, Robert S. (November 2004). A Cost-Utility Analysis of Neonatal Circumcision. Medical Decision Making 24 (6): 584–601. PMID 15534340.
  81. ↑ Ganiats, TG and Humphrey JB, Taras HL, Kaplan RM. (Oct–Dec 1991). Routine neonatal circumcision: a cost-utility analysis. Medical Decision Making 11 (4): 282–293. PMID 1766331.
  82. ↑ Lawler, FH and Bisonni RS, Holtgrave DR. (Nov–Dec 1991). Circumcision: a decision analysis of its medical value.. Family Medicine 23 (8): 587–593. PMID 1794670.
  83. ↑ Christakis, Dmitry A. and Eric Harvey, Danielle M. Zerr, Chris Feudtner, Jeffrey A. Wright, and Frederick A. Connell (January 2000). A Trade-off Analysis of Routine Newborn Circumcision. Pediatrics 105 (1): 246–249. PMID 10617731.
  84. ↑ Ahmed A,, A and Mbibi NH, Dawam D, Kalayi GD (March 1999). Complications of traditional male circumcision. Annals of Tropical Paediatrics 19 (1): 113–117. PMID 10605531 ISSN 0272-4936.
  85. ↑ Kaplan, George W., M.D. (August 1983). Complications of Circumcision. UROLOGIC CLINICS OF NORTH AMERICA 10 (3): 543–549.
  86. ↑ www.ncbi.nlm.nih.gov/
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  88. ↑ Although the Academy's 1975 statement asserted that "A program of education leading to continuing good personal hygiene would offer all the advantages of circumcision without the attendant surgical risk," the 1999 statement cites a study which found that "appropriate hygiene decreased significantly the incidence of phimosis, adhesions, and inflammation, but did not eliminate all problems."
  89. ↑ Care Of The Foreskin. Paediatric Policy - Circumcision. The Royal Australasian College of Physicians (October 2004). Retrieved 2006-07-13.
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  93. ↑ Darby, Robert (July 2005). The riddle of the sands: circumcision, history, and myth. The New Zealand Medical Journal 118 (1218): 76–82. ISSN 11758716 PMID 16027753.
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  96. ↑ Herzog, LW and SR Alvarez (March 1986). The frequency of foreskin problems in uncircumcised children. Am J Dis Child 140 (3): 254–6. PMID 3946358.
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  100. ↑ Ronald Immerman and Wade Mackey (1997). A Biocultural Analysis of Circumcision. Social Biology 44: 265-275.
  101. ↑ (1855). On the influence of circumcision in preventing syphilis. Medical Times and Gazette NS Vol II: 542–3.
  102. ↑ Epstein E (1874). Have the Jews any Immunity from Certain Diseases?. Medical and Surgical Reporter (Philadelphia) XXX: 40–41.
  103. ↑ Weiss, HA and Thomas, SL; Munabi SK; Hayes RJ (Apr 2006). Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect 82 (2): 101-9. PMID 16581731.
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References
ISBN links support NWE through referral fees

External links

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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