circumcision

Circumcision being performed in central Asia, (most likely Turkestan,) c. 1865-1872. Restored albumen print.

Male circumcision is the removal of some or all of the foreskin (prepuce) from the penis.^[1] The word "circumcision" comes from Latin circum (meaning "around") and cædere (meaning "to cut"). Early depictions of circumcision are found in cave drawings and Ancient Egyptian tombs, though some pictures are open to interpretation.^[2][3][4] Religious male circumcision is considered a commandment from God in Judaism.^[5] In Islam, though not discussed in the Qur'an, circumcision is widely practiced and most often considered to be a sunnah.^[6] It is also customary in some Christian churches in Africa, including some Oriental Orthodox Churches.^[7] According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, of whom 68% are Muslim.^[8] The prevalence of circumcision varies mostly with religious affiliation, and sometimes culture. Most circumcisions are performed during adolescence for cultural or religious reasons;^[9] in some countries they are more commonly performed during infancy.^[8]

There is controversy regarding circumcision. Advocates of circumcision argue, for example, that it provides important health advantages which outweigh the risks, has no substantial effects on sexual function, has a low complication rate when carried out by an experienced physician, and is best performed during the neonatal period.^[10] Opponents of circumcision argue, for example, that it adversely affects normal sexual pleasure and performance, is performed due to excuses and myths believed or conjured by parents and health providers, is extremely painful, and is comparable to female genital cutting.^[11]

The American Medical Association stated in 1999: "Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice."^[12]

The World Health Organization (WHO; 2007), the Joint United Nations Programme on HIV/AIDS (UNAIDS; 2007), and the Centers for Disease Control and Prevention (CDC; 2008) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides minimal protection and should not replace other interventions to prevent transmission of HIV.^[13][14]

History

Origins

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 BC.

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 sexual pleasure or to increase a man's attractiveness to women, or as an aid to hygiene where regular bathing was impractical, among other possibilities. Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practicing circumcision, leading to its spread regardless of whether the people understood this.^[15] It is possible that circumcision arose independently in different cultures for different reasons.

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.

The oldest documentary evidence for circumcision comes from ancient Egypt.^[16] Circumcision was common, although not universal, among ancient Semitic peoples.^[17] In the aftermath of the conquests of Alexander the Great, however, Greek dislike of circumcision (they regarded a man as truly "naked" only if his prepuce was retracted) led to a decline in its incidence among many peoples that had previously practiced it.^[18]

Circumcision has ancient roots among several ethnic groups in sub-equatorial Africa, and is still performed on adolescent boys to symbolize their transition to warrior status or adulthood.^[19]

Non-religious circumcision in the English-speaking world

Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada, South Africa, New Zealand and to a lesser extent in the United Kingdom. There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The germ theory of disease elicited an image of the human body as a conveyance for many dangerous germs, making the public "germ phobic" and suspicious of dirt and bodily secretions. The penis became "dirty" by association with its function, and from this premise circumcision was seen as preventative medicine to be practiced universally.^[20] In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation.^[20] Aggleton wrote that John Harvey Kellogg viewed male circumcision in this way, and further "advocated an unashamedly punitive approach."^[21] Circumcision was also said to protect against syphilis,^[22] phimosis, paraphimosis, balanitis, and "excessive venery" (which was believed to produce paralysis).^[20] Gollaher states that physicians advocating circumcision in the late nineteenth century expected public scepticism, and refined their arguments to overcome it.^[20]

Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 32% of newborn American boys were being circumcised in 1933.^[23] Laumann et al. reported that the prevalence of circumcision among US-born males was approximately 70%, 80%, 85%, and 77% for those born in 1945, 1955, 1965, and 1971 respectively.^[23] Xu et al. reported that the prevalence of circumcision among US-born males was 91% for males born in the 1970s and 84% for those born in the 1980s.^[24] Between 1981 and 1999, National Hospital Discharge Survey data from the National Center for Health Statistics demonstrated that the infant circumcision rate remained relatively stable within the 60% range, with a minimum of 60.7% in 1988 and a maximum of 67.8% in 1995.^[25] A 1987 study found that the most prominent reasons US parents choose circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns.^[26] However, a later study speculated that an increased recognition of the potential benefits of neonatal circumcision may have been responsible for the observed increase in the US rate between 1988 and 2000.^[27] A report by the Agency for Healthcare Research and Quality placed the 2005 national circumcision rate at 56%.^[28]

In 1949, the United Kingdom's newly-formed National Health Service removed infant circumcision from its list of covered services, and circumcision has since been an out-of-pocket cost to parents. As a result, prevalence in the UK is age-graded, with 12% of those aged 16–19 years circumcised and 20% of those aged 40–44 years,^[29] and the proportion of newborns circumcised in England and Wales has fallen to less than one percent.

The circumcision rate has declined sharply in Australia since the 1970s, leading to an age-graded fall in prevalence, with a 2000-01 survey finding 32% of those aged 16–19 years circumcised, 50% for 20–29 years and 64% for those aged 30–39 years.^[30][31]

In Canada, Ontario health services delisted circumcision in 1994.^[32]

Cultures and religions

Jewish ritual circumcision.

See also Circumcision in cultures and religions, Brit milah ("covenant of circumcision" is ritual circumcision in Judaism) and Khitan (circumcision) (circumcision as carried out in Islam), and Circumcision controversy in early Christianity.

In some cultures, males must be circumcised shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is commonly practised in the Jewish and Islamic faiths.

Jewish law states that circumcision is a 'mitzva aseh ("positive commandment" to perform an act) and is obligatory for Jewish-born males and for non-circumcised Jewish male converts. It is only postponed or abrogated in the case of threat to the life or health of the child.^[33] It is usually performed by a mohel on the eighth day after birth in a ceremony called a Brit milah (or Bris milah, colloquially simply bris), which means "Covenant of circumcision" in Hebrew. It is considered of such religious importance that the body of an uncircumcised Jewish male will sometimes be circumcised before burial.^[34]

In Islam, circumcision is mentioned in some hadith(it is referred as Khitan), but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended (Sunnah); others that it is obligatory.^[35] Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham.^[36] While endorsing circumcision for males, Islamic scholars note that it is not a requirement for converting to Islam.^[37]

Illustrated account of the circumcision ceremony of Sultan Ahmed III's three sons.

The Catholic Church condemned the observance of circumcision as a mortal sin and ordered against its practice in the Ecumenical Council of Basel-Florence in 1442.^[38]

Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches.^[7] Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya,^[7][39] require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ.^[40][41] The vast majority of Christians do not practise circumcision as a religious requirement.

Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War. 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.^[42] Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land,^[43] where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.^[44] Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature: subincision is practised amongst some aboriginal peoples in the Western Desert.^[45] In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu;^[46] participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.^[47]

Circumcision is also commonly practiced in the Polynesian islands of Samoa, Tonga, Niue, and Tikopia, where the custom is recorded as a pre-Christian/colonial practice. In Samoa it is accompanied by a celebration.

Among some West African groups, such as the Dogon and Dowayo, circumcision is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males.^[48] 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.^[49] 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.^[50]

Prevalence

Map published by the United Nations (WHO/UNAIDS) showing percentage of males who have been circumcised, at a country level. Data was provided by MEASURE DHS [2] and other sources. [3]

Estimates of the proportion of males that are circumcised worldwide vary from one-sixth^[51] to a third.^[52] The WHO has estimated that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), with almost 70% of these being Muslim.^[8] Circumcision is most prevalent in the Muslim world, parts of South East Asia, Africa, the United States, The Philippines, Israel, and South Korea. It is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia and Oceania. Prevalence is near-universal in the Middle East and Central Asia.^[8] The WHO states that "there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines".^[8] The WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe,^[8] and Klavs et al report findings that "support the notion that the prevalence is low in Europe".^[53] In Latin America, prevalence is universally low.^[54] Estimates for individual countries include Spain^[55], Colombia^[55] and Denmark^[56] less than 2%, Finland^[57] and Brazil^[55] 7%, Taiwan^[58] 9%, Thailand^[55] 13% and Australia^[31] 58.7%.

The WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively.^[8] Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.^[54]

Modern circumcision procedures

For infant circumcision, modern devices such as the Gomco clamp, Plastibell, and Mogen clamp are available.^[59]

With all modern devices the same basic procedure is followed. First, the amount of foreskin to be removed is estimated. The foreskin is then opened via the preputial orifice to reveal the glans underneath and ensure it is normal. The inner lining of the foreskin (preputial epithelium) is then bluntly separated from its attachment to the glans. The device is then placed (this sometimes requires a dorsal slit) and remains there until blood flow has stopped. Finally, the foreskin is amputated.^[60]

• With the Plastibell, adhesions between the glans and inner preputial epithelium having been separated with a probe, the foreskin is cut longitudinally, the Plastibell is placed over the glans and the foreskin is placed over the Plastibell. A ligature is then tied firmly around the foreskin and tightened into a groove in the Plastibell to achieve hemostasis. Foreskin distal to the ligature is excised and the handle is snapped off the Plastibell device. The Plastibell falls from the penis after the wound has healed, typically in four to six days.^[61]
• With a Gomco clamp, a section of skin is dorsally crushed with a hemostat and then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is tightened, "crushing the foreskin between the bell and the base plate." The crushed blood vessels provide hemostasis. The flared bottom of the bell fits tightly against the hole of the base plate, so the foreskin may be cut away with a scalpel from above the base plate.^[62]
• With a Mogen clamp, the foreskin is pulled dorsally with a straight hemostat, and lifted. 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" to Gomco or Plastibell circumcisions. The clamp is locked, and a scalpel is used to cut the skin from the flat (upper) side of the clamp.^[63][64]

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.^[65] In some African countries, male circumcision is often performed by non-medical personnel under unsterile conditions.^[66] After hospital circumcision, the foreskin may be used in biomedical research,^[67] consumer skin-care products,^[68] skin grafts,^[69][70][71] or β-interferon-based drugs.^[72] In parts of Africa, the foreskin may be dipped in brandy and eaten by the patient, eaten by the circumciser, or fed to animals.^[73] According to Jewish law, after a Brit milah, the foreskin should be buried.^[74]

Ethical, psychological, and legal considerations

Ethical issues

Ethical questions have been raised over removing healthy, functioning genital tissue from a minor. Opponents of circumcision state that infant circumcision infringes upon individual autonomy and represents a human rights violation.^[75][76][77] Rennie et al. note that using circumcision as a way of preventing HIV in high prevalence, low-income countries in Sub-Saharan Africa, is controversial, but argue that "it would be unethical to not seriously consider one of the most promising [...] new approaches to HIV-prevention in the 25-year history of the epidemic".^[78]

Consent

A protest against routine infant circumcision.

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

Some medical associations take the position that the parents should determine what is in the best interest of the infant or child,^[12][60][79] but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue.^{[80][dead link][81]} The BMA state that in general, "the parents should determine how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices." They state that because the parents' interests and the child's interests sometimes differ, there are "limits on parents' rights to choose and parents are not entitled to demand medical procedures contrary to their child's best interests." They state that competent children may decide for themselves.^[81] UNAIDS states that "[m]ale circumcision is a voluntary surgical procedure and health care providers must ensure that men and young boys are given all the necessary information to enable them to make free and informed choices either for or against getting circumcised."^[82]

Some argue that the medical problems that have their risk reduced by circumcision are already rare, can be avoided, and, if they occur, can usually be treated in less invasive ways than circumcision. Somerville states that the removal of healthy genital tissue from a minor should not be subject to parental discretion and that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient.^[75] Denniston states that circumcision is harmful and asserts that in the absence of the individual's consent, non-therapeutic child circumcision violates several ethical principles that govern medicine.^[83]

Others believe neonatal circumcision is permissible, if parents should so choose. Viens argues that, in a cultural or religious context, circumcision is of significant enough importance that parental consent is sufficient and that there is "an absence of sufficient evidence or persuasive argumentation" to support changing the present policy.^[84] Benatar and Benatar argue that circumcision can be beneficial to a male before he would be able to otherwise provide consent, that "it is far from obvious that circumcision reduces sexual pleasure," and that "it is far from clear that non-circumcision leaves open a future person’s options in every regard."^[85]

Acknowledgment of pain

Williams (2003) argued that human attitudes toward the pain that animals (including humans) experience may not be based on speciesism, developing an analogy between attitudes toward the pain pigs endure while having their tails docked, and "our culture's indifference to the pain that male human infants experience while being circumcised."^[86]

Psychological and emotional consequences

The British Medical Association (2006) states that "it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks."^[81] Milos and Macris (1992) argue that circumcision encodes the perinatal brain with violence and negatively affects infant-maternal bonding and trust.^[11] Goldman (1999) discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure.^[87] Furthermore, there are reports of males attempting to undo the effects of circumcision through the practice of foreskin restoration.^[88] Moses et al.' (1998) state, however, that "scientific evidence is lacking" for psychological and emotional harm, citing a longitudinal study which did not find a difference in developmental and behavioural indices.^[89] A literature review by Gerharz and Haarmann (2000) reached a similar conclusion.^[90] Boyle et al. (2002) state that circumcision may result in psychological harm, including post-traumatic stress disorder (PTSD), citing a study reporting high rates of PTSD among Filipino boys after either ritual or medical circumcision.^[91] Hirji et al. (2005) state that "Reports of [...] psychological trauma are not borne out in studies but remain as an anecdotal cause for concern."^[92]

Legal issues

In 2001, Sweden passed a law allowing 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,^[93] 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."^[94] In 2005, the Swedish National Board of Health and Welfare reviewed the law and recommended that it be maintained. In 2006, the U.S. State Department's report on Sweden stated that most Jewish mohels had been certified under the law and 3000 Muslim and 40–50 Jewish boys were circumcised each year.^[95]

In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised was illegal.^[96] However, no punishment was assigned by the court, and in 2008 the Finnish Supreme Court ruled that the mother's actions did not constitute a criminal offense and that circumcision of a child for religious reasons, when performed properly, is not a crime.^[97] In 2008, the Finnish government was reported to be considering a new law to legalize ritual circumcision if the practitioner is a doctor, "according to the parents' wishes, and with the child's consent", as reported.^[98]

By 2007, the Australian states of Victoria, New South Wales, Western Australia and Tasmania had stopped the practice of non-therapeutic male circumcision in all public hospitals.^[99]

Medical aspects

Medical cost-benefit analyses of circumcision have varied. Some found a small net benefit of circumcision,^[100][101] some found a small net decrement,^[102][103] 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."^[104]

Pain and pain relief

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.”^[60] It therefore recommended using pain relief for circumcision.^[60] One of the supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response during vaccination months later.^[105] While acknowledging that there may be "other factors" besides circumcision to account for different levels of pain response, they stated that they did not find evidence of such. They concluded "pretreatment and postoperative management of neonatal circumcision pain is recommended based on these results."^[105] Other medical associations also cite evidence that circumcision without anesthetic is painful.^[106][107]

Stang, 1998, found 45% of physicians responding to a survey who circumcise used anaesthesia – most commonly a dorsal penile nerve block – for infant circumcisions. The obstetricians in the sample used anaesthesia less often (25%) than the family practitioners (56%) or pediatricians (71%).^[108] Howard et al. (1998) surveyed US medical doctor residency programs and directors, and found that 26% of the programs that taught the circumcision procedure "failed to provide instruction in anesthesia/analgesia for the procedure" and recommended that "residency training in neonatal circumcision should include instruction in pain relief techniques".^[109] A 2006 follow-up study revealed that the percentage of programs that taught circumcision and also taught administration of topical or local anesthetic had increased to 97%.^[110] However, the authors of the follow-up study also noted that only 84% of these programs used anesthetic "frequently or always" when the procedure was conducted.^[110]

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." Glass continued, "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." Glass also stated that for older children and adults, a penile block is used.^[33]

Lander et al. demonstrated that babies circumcised without anesthesia showed behavioral and physiological signs of pain and distress.^[111] Comparisons of the dorsal penile nerve block and EMLA (lidocaine/prilocaine) topical cream methods of pain control have revealed that while both are safe,^[112][113] the dorsal nerve block controls pain more effectively than topical treatments,^[114] but neither method eliminates pain completely.^[112] 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.^[115] Ng et al. found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.^[116]

Sexual effects

The sexual effects of circumcision are the subject of much debate. 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." They continued, "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."^[60] Conversely a 2002 review by Boyle et al. stated that "the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings—many of which are lost to circumcision, with an inevitable reduction in sexual sensation experienced by circumcised males." They concluded, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well."^[117] 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. [...] No valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction."^[106] Payne et al. reported that direct measurement of penile sensation during sexual arousal failed to support the hypothesised sensory differences associated with circumcision status.^[118] In a 2007 study, Sorrells et al., using monofilament touch-test mapping, found that the foreskin contains the most sensitive parts of the penis, noting that these parts are lost to circumcision. They also found that "the glans of the circumcised penis is less sensitive to fine-touch than the glans of the uncircumcised penis."^[119] In a 2008 study, Krieger et al. stated that "Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm."^[120]

Reports detailing the effect of circumcision on erectile dysfunction have been mixed. Studies have shown that circumcision can result in a statistically significant increase,^[121][122] or decrease,^[23][123] in erectile dysfunction among circumcised men, while other studies have shown little to no effect.^{[124][125][126]}

Complications

Complication rates ranging from 0.06% to 55% have been cited,^[127] though a 1993 survey of circumcision complications by Williams and Kapilla put the rate at 2-10%.^[51]

According to the American Medical Association (AMA), blood loss and infection are the most common complications, but most bleeding is minor and can be stopped by applying pressure.^[12] A survey of circumcision complications by Kaplan in 1983 revealed that the rate of bleeding complications was between 0.1% and 35%.^[128] A 1999 study of 48 boys who had complications from traditional male circumcision in Nigeria found that haemorrhage occurred in 52% of the boys, infection in 21% and one child had his penis amputated.^[129]

A penis that has been circumcised.

A penis that has not been circumcised.

One study looking at 354,297 births in Washington State from 1987-1996 found that immediate post-birth complications occurred at a rate of 0.2% in the circumcised babies and at a rate of 0.01% in the uncircumcised babies. The authors judged that this was a conservative estimate because it did not capture the very rare but serious delayed complications associated with circumcisions (eg, necrotizing fasciitis, cellulitis) and the less serious but more common complications such as the circumcision scar or a less than ideal cosmetic result. They also stated that the risks of circumcision "do not seem to be mitigated by the hands of more experienced physicians".^[130]

Meatal stenosis (a narrowing of the urethral opening) may be a longer-term complication of circumcision. It is thought that because the foreskin no longer protects the meatus, ammonia formed from urine in wet diapers irritates and inflames the exposed urethral opening. Meatal stenosis can lead to discomfort with urination, incontinence, bleeding after urination and urinary tract infections.^{[131][132][133]}

Circumcisions may remove too much or too little skin.^[51][134] If insufficient skin is removed, the child may still develop phimosis in later life.^[51] Van Howe states that "when operating on the infantile penis, the surgeon cannot adequately judge the appropriate amount of tissue to remove because the penis will change considerably as the child ages, such that a small difference at the time of surgery may translate into a large difference in the adult circumcised penis. To date (1997), there have been no published studies showing the ability of a circumciser to predict the later appearance of the penis."^[135]

Cathcart et al. report that 0.5% of boys required a procedure to revise the circumcision.^[136]

Other complications include concealed penis^[137][138], urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias and impotence.^[128] Kaplan 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.”^[128]

Another complication of infant circumcision is skin bridge formation, whereby a remaining part of the foreskin fuses to other parts of the penis (often the glans) upon healing. This can result in pain during erections and minor bleeding can occur if the shaft skin is forcibly retracted.^[139] Van Howe advises that to prevent adhesions forming after circumcision, parents should be instructed to retract and clean any skin covering the glans.^[135]

Although deaths have been reported,^[128][140] 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.^[106] Gairdner's 1949 study^[141] 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. The penis is thought to be lost in 1 in 1,000,000 circumcisions.^[142]

Sexually transmitted diseases

Human immunodeficiency virus

Over forty observational studies have been conducted to investigate the relationship between circumcision and HIV infection.^[143] Reviews of these studies have reached differing conclusions about whether circumcision could be used as a prevention method against HIV.^{[144][145][146][147]}

Experimental evidence was needed to establish a causal relationship between lack of circumcision and HIV, so three randomized controlled trials were commissioned as a means to reduce the effect of any confounding factors.^[147] Trials took place in South Africa,^[148] Kenya^[149] and Uganda.^[150] All three trials were stopped early by their monitoring boards on ethical grounds, because those in the circumcised group had a lower rate of HIV contraction than the control group.^[149] The results showed that circumcision reduced vaginal-to-penile transmission of HIV by 60%, 53%, and 51%, respectively.^[151] A meta-analysis of the African randomised controlled trials found that the risk in circumcised males was 0.44 times that in uncircumcised males, and that 72 circumcisions would need to be performed to prevent one HIV infection. The authors also stated that using circumcision as a means to reduce HIV infection would, on a national level, require consistently safe sexual practices to maintain the protective benefit.^[152]

As a result of these findings, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an efficacious intervention for HIV prevention but should be carried out by well trained medical professionals and under conditions of informed consent.^[8][13][153] Both the WHO and CDC indicate that circumcision may not reduce HIV transmission from men to women, and that data is lacking for the transmission rate of men who engage in anal sex with a female partner.^[13][14] The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should never replace known methods of HIV prevention.^[153]

Circumcision has been judged to be a cost-effective method to reduce the spread of HIV in a population,^[8] though not necessarily more cost-effective than condoms.^[8][154] Some have challenged the validity of the African randomized controlled trials, prompting a number of researchers to question the effectiveness of circumcision as an HIV prevention strategy.^[155][156]

In addition to the studies which provided information about female-to-male transmission, some studies have addressed other transmission routes. A randomised controlled trial in Uganda found that male circumcision did not reduce male to female transmission of HIV. The authors could not rule out the possibility of higher risk of transmission from men who did not wait for the wound to fully heal before engaging in intercourse.^[157] A meta-analysis of data from fifteen observational studies of men who have sex with men found "insufficient evidence that male circumcision protects against HIV infection or other STIs."^[158]

Human papillomavirus

Meta-analyses by Van Howe ^[159] and Bosch et al.^[160] of observational studies reached differing conclusions as to whether circumcision reduces infection with human papillomavirus (HPV). A recent prospective trial in Uganda ^[161] randomized 3393 subjects to circumcision or a control group and found a significant reduction of HPV infection in the circumcision group. At 24 month follow-up, there was a 27.9% prevalence of high-risk HPV genotypes in the control group and only a 18.0% prevalence in the circumcision group (adjusted risk ratio, 0.65; 95% CI, 0.46 to 0.90; P=0.009). Another recent trial by Auvert et al. in Orange Farm, South Africa, randomized men to either a circumcision or control group. At the 21 month visit, the prevalence of high-risk HPV infection was lower in the circumcised men than the uncircumcised participants (14.8% and 22.3% respectively, a prevalence rate ratio of 0.66) in the absence of any difference in reported sexual behaviour or gonorrhea prevalence.^[162]

Two studies have shown that circumcised men report, or were found to have, a higher prevalence of genital warts than uncircumcised men;^[163][164] however, a 2009 meta-analysis of multiple studies found a non-significant association between genital warts and the presence of a foreskin.^[160]

Other sexually transmitted infections

Studies evaluating the effect of circumcision on the incidence of other sexually transmitted infections have reached conflicting conclusions. A meta-analysis of observational data from twenty-six studies found that circumcision was associated with lower rates of syphilis, chancroid and possibly genital herpes.^[165] A large randomized prospective trial in Uganda found a reduction in HSV-2 infection, but not syphilis infection, in the circumcision arm of the study.^[161] In contrast, some studies have failed to find a prophylactic benefit to circumcision. A prospective trial in India found that circumcision offered no protective benefit against herpes simplex virus type 2, syphilis, or gonorrhea.^[166] A clinical study of 5,925 women from Uganda, Zimbabwe and Thailand found that the circumcision status of their partner did not significantly affect the incidence of Chlamydia, gonorrhea or trichomoniasis.^[167] Laumann et al. examined observational data from the United States and found no significant differences between circumcised and uncircumcised men in their likelihood of contracting sexually transmitted diseases.^[23]

Hygiene, and infectious and chronic conditions

The American Academy of Pediatrics (1999) stated: "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."^[60]

An inflammation of the glans penis and foreskin is called balanoposthitis; that affecting the glans alone is called balanitis. Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. Although not as necessary as in the past, circumcision may be considered for recurrent or resistant cases.^[168][169] Escala and Rickwood recommend against a policy of routine infant circumcision to avoid balanitis saying that the condition affects no more than 4% of boys, does not cause pathological phimosis, and in most cases is not serious.^[170]

Fergusson studied 500 boys and found that by 8 years, the circumcised children had a rate of 11.1 problems per 100 children, and the uncircumcised children had a rate of 18.8 per 100. During infancy, circumcised children were found to have a significantly higher risk of problems than uncircumcised children, but after infancy the rate of penile problems was significantly higher among the uncircumcised. Fergusson et al. said that the great majority of penile problems were relatively minor (penile inflammation including balanitis, meatitis, and inflammation of the prepuce) and most (64%) were resolved after a single medical consultation.^[171] Herzog and Alverez found the overall frequency of complications (including balanitis, irritation, adhesions, phimosis, and paraphimosis) to be higher among the uncircumcised children; again, most of the problems were minor.^[172] In a study of 398 randomly selected dermatology students, Fakjian et al. reported: "Balanitis was diagnosed in 2.3% of circumcised men and in 12.5% of uncircumcised men."^[173] In a study of 225 men, O'Farrell et al. reported: "Overall, circumcised men were less likely to be diagnosed with a STI/balanitis (51% and 35%, P = 0.021) than those non-circumcised."^[174] Van Howe found that circumcised penises required more care in the first 3 months of life, and that circumcised boys are more likely to develop balanitis.^[175]

The American Medical Association states that circumcision, properly performed, protects against the development of phimosis.^[12] Rickwood and other authors have argued that many infant circumcisions are performed unnecessarily for developmental non-retractability of the prepuce rather than for pathological phimosis.^[176][177] Metcalfe et al. stated that "Gairdner^[141] and Oster^[178] made a strong case for leaving boys uncircumcised, allowing the natural separation of the foreskin from the glans to take place gradually, and instructing boys in proper hygiene. This obviates the need for 'preventive' circumcision."^[179] In a study to determine the most cost-effective treatment for phimosis, Van Howe concluded that using cream was 75% more cost-effective than circumcision at treating pathological phimosis.^[180]

Urinary tract infections

A meta-analysis of 12 studies (one randomised controlled trial, four cohort studies and seven case-control studies) representing 402,908 children determined that circumcision was associated with a significantly reduced risk of urinary tract infection (UTI). However, the authors noted that only 1% of boys with normal urinary tract function experience a UTI, and the number-needed-to treat (number of circumcisions necessary) to prevent one urinary tract infection was calculated to be 111. Because haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%, assuming equal utility of benefits and harms, the authors concluded that the net clinical benefit of circumcision is only likely in boys at high risk of urinary tract infection (such as those with high grade vesicoureteral reflux or a history of recurrent UTIs, where the number needed to treat declined to 11 and 4, respectively).^[181]

Some UTI studies have been criticized for not taking into account a high rate of UTI's among premature infants, who are usually not circumcised because of their fragile health status.^[60] The AMA stated that “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI," and noted one decision analysis model that concluded that circumcision was not justified as a preventative measure against UTI.^[12]

Penile cancer

The American Cancer Society (2006) stated, "The current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer."^[182]

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, because penile cancer is a rare disease, the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low.^[60]

The age-adjusted annual incidence of penile cancer is 0.82 per 100,000 in Denmark, 2.9-6.8 per 100,000 in Brazil, 0.9 to 1 per 100,000 in the USA, and 2.0-10.5 per 100,000 in India.^[60] Researchers have reported that the risk of penile cancer is greater in never-circumcised men than in men who had been circumcised at birth; estimates of the relative risk include 3^[183] and 22.^[184]

Policies of various national medical associations

Australasia

The Royal Australasian College of Physicians (RACP; 2009) state that "after extensive review of the literature [they do] not recommend that routine circumcision in infancy be performed, but [accept] that parents should be able to make this decision with their doctors. One reasonable option is for routine circumcision to be delayed until males are old enough to make an informed choice. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. In the absence of evidence of substantial harm, parental choice should be respected."^[185]

The Tasmanian President of the Australian Medical Association (AMA), Haydn Walters, has stated that the AMA would support a call to ban circumcision for non-medical, non-religious reasons.^[186]

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Neonatal circumcision revisited" in 1996 and "Circumcision: Information for Parents" in November 2004. The 1996 position statement says that "circumcision of newborns should not be routinely performed",^[79] and the 2004 information to parents says: 'Circumcision is a "non-therapeutic" procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social, or cultural reasons. [...] After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.'^[107]

United Kingdom

“Male circumcision that is performed for any reason other than physical clinical need is termed non-therapeutic (or sometimes “ritual”) circumcision. Some people ask for non-therapeutic circumcision for religious reasons, some to incorporate a child into a community, and some want their sons to be like their fathers. Circumcision is a defining feature of some faiths.” “The Association has no policy on these issues.”

The BMA provides that “male circumcision is generally assumed to be lawful provided that it is performed competently; it is believed to be in the child’s best interests; and there is valid consent” from both parents and the child, if possible."

The BMS stipulates that “competent children may decide for themselves; the wishes that children express must be taken into account; if parents disagree, non-therapeutic circumcision must not be carried out without the leave of a court; consent should be confirmed in writing."

"In the past, circumcision of boys has been considered to be either medically or socially beneficial or, at least, neutral. The general perception has been that no significant harm was caused to the child and therefore with appropriate consent it could be carried out. The medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks. It is essential that doctors perform male circumcision only where this is demonstrably in the best interests of the child. The responsibility to demonstrate that non-therapeutic circumcision is in a particular child’s best interests falls to his parents. The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it."^[81]

United States

The American Academy of Pediatrics (1999) stated: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child."^[60] The AAP recommends that if parents choose to circumcise, analgesia should be used to reduce pain associated with circumcision. It states that circumcision should only be performed on newborns who are stable and healthy.^[60]

The American Medical Association supports the AAP's 1999 circumcision policy statement with regard to non-therapeutic circumcision, which they define as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. They state that "policy statements issued by professional societies representing Australian, Canadian, and American pediatricians do not recommend routine circumcision of male newborns."^[12]

The American Academy of Family Physicians (2007) recognizes the controversy surrounding circumcision and recommends that physicians "discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son."^[187]

The American Urological Association (2007) stated that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks.^[188]

See also

• Frenectomy
• Genital modification and mutilation
• Holy Prepuce
• Preputioplasty, alternative to circumcision in the treatment for phimosis
• Penis
• Khitan(Islamic)

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 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)
• Peter Charles Remondino. History of Circumcision from the Earliest Times to the Present. Philadelphia and London; F. A. Davis; 1891.
• Holm Putzke, Ph.D. Die strafrechtliche Relevanz der Beschneidung von Knaben. Zugleich ein Beitrag über die Grenzen der Einwilligung in Fällen der Personensorge, in: H. Putzke u.a. (Hrsg.), Strafrecht zwischen System und Telos, Festschrift für Rolf Dietrich Herzberg zum siebzigsten Geburtstag am 14. Februar 2008 , Mohr Siebeck: Tübingen 2008, p. 669–709 (ISBN 978-3161495700)
• Holm Putzke, Ph.D., Maximilian Stehr, Ph.D., and Hans-Georg Dietz, Ph.D. Liability to penalty for circumcision in boys. Medico-legal aspects of a controversial medical intervention, in: Monatsschrift Kinderheilkunde 8/2008, p. 783–788
• 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.

Notes and references