circumcision

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Circumcision
Intervention
Circumcision being performed in central Asia, possibly Turkmenistan c. 1865–1872. Restored albumen print.
ICD-10-PCS	Z41.2
ICD-9-CM	V50.2
MeSH	D002944
MedlinePlus	002998
eMedicine	1015820

Male circumcision is the surgical removal of some or all of the foreskin (prepuce) from the penis.^[1] Early depictions of circumcision are found in cave paintings 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][6] In Islam, though not discussed in the Qur'an, male circumcision is widely practised and most often considered to be a sunnah.^[7] It is also customary in some Christian churches in Africa.^[8]

Estimates by the World Health Organization (WHO) suggest that 30 percent of males worldwide are circumcised, of whom 68 percent are Muslim.^[9] The prevalence of circumcision varies mostly with religious affiliation, and sometimes culture. The timing of circumcision similarly varies, though it is commonly practised between birth and the early twenties.^[9]

Circumcision is used therapeutically, as one of the treatment options for balanitis xerotica obliterans, phimosis, balanitis, posthitis, balanoposthitis and urinary tract infections.^[10][11] Strong evidence indicates that circumcision reduces the risk of HIV infection in heterosexual men by 38-66% in populations that are at high risk,^[12] and studies have concluded it is cost effective in sub-Saharan Africa.^[13] The WHO currently recommends circumcision be recognised as an intervention as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV.^[14] Most medical associations recommend neither universal circumcision nor a prohibition against the practice.^[15] Some bodies have discussed under what circumstances circumcision is ethical.^[16][17]

There is controversy regarding circumcision.^[18] Specific controversies have included the health benefits and risks of the procedure,^[19][18] ethical and legal considerations,^[18] and the application of human rights principles to the practice.^[20]

Modern procedure

If anesthesia is to be used there are several options: local anesthetic cream (EMLA cream) can be applied to the end of the penis 60–90 minutes prior to the procedure; local anesthetic can be injected at the base of the penis to block the dorsal penile nerve; local anesthetic can be injected in a ring around the middle of the penis in what is called a subcutaneous ring block.^[21] It is also possible to use general anesthetics in the case of adult surgery, though not the standard practice.

For infant circumcision, devices such as the Gomco clamp, Plastibell, and Mogen clamp are commonly used,^[22] together with a restraining device.^[23]

With all these 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.^[21] Sometimes, the frenulum band may need to be broken or crushed and cut from the corona near the urethra to ensure that the glans can be freely and completely exposed.^[24]

Plastibell Circumcision day 4 post operation

• With the Plastibell, once the glans is freed 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.^[25]
• 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.^[26]
• 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.^[27][28]

Adult circumcisions are often performed without clamps and require four to six weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.^[29] In some African countries, male circumcision is often performed by non-medical personnel under unsterile conditions.^[30] After hospital circumcision, the foreskin may be used in biomedical research,^[31] consumer skin-care products,^[32] skin grafts,^[33][34][35] or β-interferon-based drugs.^[36] In parts of Africa, the foreskin may be dipped in brandy and eaten by the patient, eaten by the circumciser, or fed to animals.^[37] According to Jewish law, the foreskin should be buried after a brit milah.^[38]

Medical aspects

Studies comparing healthcare cost to benefits of circumcision have reached varying conclusions. Some found a small net benefit of circumcision,^[39][40] some found a small net decrement,^[41][42] 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."^[43]

Pain

Injection of lignocaine at 10 o'clock and 2 o'clock

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 physiologic stress."^[21] One of the supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response during vaccination months later.^[44] While acknowledging that there may be other factors than circumcision to account for different levels of pain response, they stated that they did not find evidence of such. It therefore recommended to use pain relief for circumcision.^[44] Other medical associations also cite evidence that circumcision without anesthetic is painful.^[45][46]

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%).^[47] 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".^[48] 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%.^[49] 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.^[49]

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.^[50] In 2001 the Swedish government passed a law requiring all boys undergoing a bris to be given anaesthetic administered by a medical professional.^[51]

Comparisons of the dorsal penile nerve block and EMLA (lidocaine/prilocaine) topical cream methods of pain control have revealed that while both are safe, the dorsal nerve block controls pain more effectively than topical treatments. Neither method eliminates pain completely.^[52] The ring block may provide more effective pain control than either of these treatments.^[53] The use of sucrose pacifiers and comfortable, padded chairs may also help.^[53]

Sexual effects

The effect of circumcision on sexual function is poorly determined with studies reporting mixed effects.^[54] The American Academy of Pediatrics points to a survey (self-report) finding circumcised adult men had less sexual dysfunction and more varied sexual practices, but also noted anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males.^[21] A 2002 review 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." The authors concluded, "intercourse is less satisfying for both partners when the man is circumcised".^[55]

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."^[45] A 2010 review reported that "despite conflicting results in some of the historical observational studies, most recent articles do not show evidence of adverse effects on sexual function."^[56] A review which analysed the data from eight clinical trials concluded that the "evidence suggests that adult circumcision does not affect sexual satisfaction and function."^[57]

Complications

Complication rates ranging from 0.06% to 55% have been cited;^[58] more specific estimates have included 2–10%^[59] and 0.2–0.6%.^[60][21] The authors of a systematic review found a median complication rate of 1.5% among neonates, with a range of 0 to 16%. In older boys, rates varied from 2-14%, with a median of 6%. The median risk of serious complications was 0% in both cases.^[61]

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.^[60] A survey of circumcision complications by Kaplan in 1983 revealed that the rate of bleeding complications was between 0.1% and 35%.^[62]

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.^{[63][verification needed]}

Circumcisions may remove too much or too little skin.^[59][64] If insufficient skin is removed, the child may still develop phimosis in later life.^[59] Other complications include concealed penis, urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias and impotence.^[62] 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."^[62] 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.^{[citation needed]}

Although deaths have been reported,^[62] 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.^[45] The penis is thought to be lost in 1 in 1,000,000 circumcisions.^[65]

Sexually transmitted diseases

There is strong evidence that circumcision reduces the risk of HIV infection in heterosexual men in populations that are at high risk.^[66][67] Evidence among heterosexual men in sub-Saharan Africa shows a decreased risk of between 38 percent and 66 percent over two years^[12] and in this population studies rate it cost effective.^[68] Whether it is of benefit for women is disputed^[69][70] and whether it is of benefit in developed countries and among men who have sex with men is undetermined.^[71][72][73]

Human immunodeficiency virus

Over forty observational studies have been conducted to investigate the relationship between circumcision and HIV infection.^[74] Reviews of these studies have reached differing conclusions about whether circumcision could be used as a prevention method against HIV.^{[75][76][77][78]}

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.^[78] Trials took place in South Africa, Kenya and Uganda.^[12] 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.^[12] The results showed that circumcision reduced vaginal-to-penile transmission of HIV by 60%, 53%, and 51%, respectively.^[12] 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.^[79]

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.^[9][80][14] Both the WHO and CDC indicate that circumcision may not reduce HIV transmission from men to women, and that data are lacking for the transmission rate of men who engage in anal sex with a female partner.^[80][81] The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should never replace known methods of HIV prevention. The Male Circumcision Clearinghouse website was formed by WHO, UNAIDS, FHI and AVAC to provide current evidence-based guidance, information and resources to support the delivery of safe male circumcision services in countries that choose to scale up male circumcision as one component of comprehensive HIV prevention services. ^[82][83]

Circumcision has been judged to be a cost-effective method to reduce the spread of HIV in a population,^[9][84] though not necessarily more cost-effective than condoms.^[9][85] 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.^[86][87]

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.^[88] 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."^[89]

Human papilloma virus

A 2007 meta-analysis of eight observational studies found no protective effect against human papillomavirus (HPV);^[90] critics reported that reanalysis of the same data showed a protective effect.^[91] A later analysis of 14 studies, by Bosch et al, found a protective effect.^[92] In 2011, a meta-analysis of 23 studies (including both randomised controlled trials and observational studies) found reduced risk of prevalent HPV and (though the evidence was less strong) some evidence of reduced risk of new HPV infections.^[93] In another analysis, in which 21 studies were included, there was a statistically significant reduction in prevalence of HPV, but no statistically significant association with new acquisitions was observed.^[94]

A 2009 meta-analysis of multiple studies found a significant association between genital warts and HPV and the presence of a foreskin, as well as HPV alone. While circumcision was associated with a lesser risk of genital warts alone, the association did not reach statistical significance.^[92] However, later analyses found no association between circumcision and penile warts.^[93][94]

Other sexually transmitted infections

Studies evaluating the effect of circumcision on the incidence of other sexually transmitted infections have reached conflicting conclusions. A 2006 meta-analysis of observational data from twenty-six studies found that circumcision was associated with lower rates of syphilis, chancroid and possibly genital herpes.^[95] More recently, a 2010 review of clinical trial data found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%. The researchers found mixed results for protection against Trichomonas vaginalis and Chlamydia trachomatis, and no evidence of protection against gonorrhoea or syphilis.^[96] Among men who have sex with men, reviews have found insufficient evidence of an effect against sexually transmitted infections other than HIV,^[97][98] with the possible exception of syphilis.^[98]

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."^[21]

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.^[99][100] Most cases of these conditions occur in uncircumcised males,^[101][102] and affect 4 to 11% of uncircumcised boys.^[103] The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor. Yeasts, especially Candida albicans, are the most common penile infection, and are rarely identified in samples taken from circumcised males.^[102] 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;^[104] in contrast, Morris regards circumcision as "mandated", citing reduced risk of balanitis among other benefits.^[105]

Phimosis is the inability to retract the foreskin over the glans penis; authors frequently distinguish between "physiologic" phimosis (or developmental non-retractility) and "pathological" phimosis.^[103] The latter is most commonly caused by balanitis xerotica obliterans, for which circumcision is the preferred treatment.^[106] The American Medical Association states that circumcision, properly performed, protects against the development of phimosis.^[60] 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.^[107][108] Metcalfe et al. stated that "Gairdner and Oster 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."^[109] 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.^[110]

Urinary tract infections

Circumcision is associated with a reduced risk of urinary tract infections (UTIs) however the magnitude of this benefit is likely to outweigh the risk only in those at high risk of UTIs.^[111]

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.^[21] 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.^[60]

Penile cancer

A 2011 meta-analysis concluded that childhood or adolescent circumcision substantially reduces the risk of invasive penile cancer. It was suggested that this may be due, in part, to reduced risk of phimosis, a predisposing factor for penile cancers.^[112] While the same study found "some evidence" of an association between adult circumcision and an increased risk of invasive penile cancer, the authors suggested this may have been due to adult circumcisions being used as a treatment for penile cancer or a condition that is itself a precursor to cancer, rather than a direct result of the procedure itself. With respect to the quality of the studies included in the meta-analysis, the overall risk of bias was evaluated as "high", leading to a possibility that the protective effect of circumcision was underestimated.^[112]

Micali et al describe penile cancer as an "emerging problem", noting that "public health measures, such as prophylactic use of circumcision, have proven successful".^[113] 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.^[21] The American Cancer Society (2009) stated, "Most experts agree that circumcision should not be recommended solely as a way to prevent penile cancer."^[114]

Prevalence

Prevalence of circumcision by country

Estimates of the proportion of males that are circumcised worldwide vary from one-sixth^[59] to a third.^[115] 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.^[9] Circumcision is most prevalent in the Muslim world, parts of Southeast 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.^[9] The WHO states that "there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines".^[9] The WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe,^[9] and Klavs et al. report findings that "support the notion that the prevalence is low in Europe".^[116] In Latin America, prevalence is universally low.^[117] Estimates for individual countries include Spain,^[118] Colombia^[118] and Denmark^[119]less than 2%, Finland 0.006%^[120] and 7%,^[121] Brazil^[118] 7%, Taiwan^[122] 9%, Thailand^[118] 13% and Australia^[123] 58.7%.

The WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively.^[9] Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.^[117]

History

Circumcision in Ancient Egypt

The origination of male circumcision is not known with certainty. There have been various theories proposed of how it being, including:

• 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 or fertility
• As a means of enhancing sexual pleasure
• As an aid to hygiene where regular bathing was impractical
• As a means of marking those of higher social status
• As a means of humiliating enemies and slaves by symbolic castration
• 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
• As a means of removing "excess" pleasure
• As a means of increasing a man's attractiveness to women
• As a demonstration of one's ability to endure pain
• As a male counterpart to menstruation or the breaking of the hymen, or
• To copy the rare natural occurrence of a missing foreskin of an important leader, and as a display of disgust of the smegma produced by the foreskin.

It has been suggested that the custom of circumcision gave advantages to tribes that practiced it and thus led to its spread.^[124][125] Darby describes these theories as "conflicting", and states that "the only point of agreement among proponents of the various theories is that promoting good health had nothing to do with it."^[125] Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practising circumcision, leading to its spread.^[126] Wilson suggests that circumcision reduces insemination efficiency, reducing a man's capacity for extra-pair fertilizations by impairing sperm competition. Thus, men who display this signal of sexual obedience, may gain social benefits, if married men are selected to offer social trust and investment preferentially to peers who are less threatening to their paternity.^[127] It is possible that circumcision arose independently in different cultures for different reasons.

The oldest documentary evidence for circumcision comes from ancient Egypt^[128] and Greek historian Herodotus states that "the Egyptians and those who have learned it from them are the only people who practise circumcision".^[129] Circumcision was common, although not universal, among ancient Semitic peoples.^[130] 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.^[131]

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.^[132]

Non-religious circumcision

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 practised universally.^[133] In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation.^[133] Aggleton wrote that John Harvey Kellogg viewed male circumcision in this way, and further "advocated an unashamedly punitive approach."^[134] Circumcision was also said to protect against syphilis,^[135] phimosis, paraphimosis, balanitis, and "excessive venery" (which was believed to produceparalysis).^[133] Gollaher states that physicians advocating circumcision in the late nineteenth century expected public scepticism, and refined their arguments to overcome it.^[133]

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.^[136] 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.^[136] 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.^[137] 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.^[138] 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.^[139] 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.^[140] A report by the Agency for Healthcare Research and Quality placed the 2005 national circumcision rate at 56%.^[141]

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. Among men (aged 15 years or older) who are neither Jews nor Muslims, the overall prevalence of circumcision in the UK is 6% according to the WHO's estimates.^[9] When "data from targeted oversampling of black Caribbean, black African, Indian, and Pakistani groups (the Natsal ethnic minority boost) were combined with the main [Natsal II] survey data", it was found that the prevalence of circumcision in the UK is age-graded, with 11.7% of those aged 16–19 years circumcised and 19.6% of those aged 40–44 years.^[142] There is a clear ethnic division: "With the exception of black Caribbeans, men from all ethnic minority backgrounds were significantly [(3.02 times)] more likely to report being circumcised compared to men who described their ethnicity as white". These particular findings "confirm that the prevalence of male circumcision among British men appears to be declining. This is despite an increase in the proportion of the British population describing their ethnicity as nonwhite"; indeed, 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 2000–1 survey finding 32% of those aged 16–19 years circumcised, 50% for 20–29 years and 64% for those aged 30–39 years.^[143][123]

In Canada, Ontario health services delisted circumcision in 1994.^[144]

Etymology

The word "circumcision" comes from Latin circumcisione from circum (meaning "around") andcædere (meaning "to cut").

Society and culture

A protest against infant circumcision.

Circumcision has been described as the most controversial surgical procedure of all times.^[18][145]

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.^{[146][147][148]} 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".^[149]

Consent

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,^{[60][21][150]} but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue.^[151][152] 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.^[152] 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."^[153]

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.^[146] 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.^[154]

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.^[155] 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."^[156]

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."^[157]

Psychological issues

The British Medical Association (BMA) states that "it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks."^[152] Milos and Macris (1992) argue that circumcision encodes the perinatal brain with violence and negatively affects infant-maternal bonding and trust.^[158] Goldman 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.^[159] Furthermore, Schultheiss (1998) reports males attempting to undo the effects of circumcision through the practice of foreskin restoration.^[160] Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, citing a longitudinal study which did not find a difference "in relation to a number of developmental and behavioural indices."^[161] A literature review by Gerharz and Haarmann (2000) reached a similar conclusion.^[162] 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.^[163] Hirji et al. (2005) state that "Reports of [. . .] psychological trauma are not borne out in studies but remain as an anecdotal cause for concern."^[164]

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,^[165] 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."^[166] 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.^[167]

In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised was illegal.^[168] 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.^[169] 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.^[170]

In 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, but did not forbid the procedure from being peformed in private hospitals.^[171]

Cultures and religions

Jewish ritual circumcision

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.

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

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.^[50] 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 importance that in Orthodox communities, the body of an uncircumcised Jewish male will sometimes be circumcised before burial.^[172] Although 19th centuryReform leaders described it as "barbaric", the practice of circumcision "remained a central rite"^[173] and the Union for Reform Judaism has, since 1984, trained and certified over 300 practicing mohels under its "Berit Mila Program".^[174]Humanistic Judaism argues that "circumcision is not required for Jewish identity."^[175]

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.^[176] Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant withAbraham.^[177] While endorsing circumcision for males, Islamic scholars note that it is not a requirement for converting to Islam.^[178]

The Roman Catholic Church formally condemned the ritual observance of circumcision and ordered against its practice in the Ecumenical Council of Basel-Florence in 1442.^[179] The Church presently maintains a neutral stance on circumcision as a medical practice.^[180]

Circumcision 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,^[8][181] require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ.^[182][183] 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.^[184] Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land,^[185] where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.^[186] Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature: subincision is practised amongst some aboriginal peoples in the Western Desert.^[187]

In the Pacific, circumcision or superincision is nearly universal among the Melanesians of Fiji and Vanuatu,^[188] while participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.^[189] Circumcision or superincision 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.^[190] 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.^[191] 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.^[192]

Positions of medical associations

Australasia

As of 2010^[update], the Royal Australasian College of Physicians state: "After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. However it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons."^[151]

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",^[150] 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.'^[46]

International

The World Health Organization and UNAIDS currently recommend circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV.^[14]

Netherlands

In the Netherlands, the Royal Dutch Medical Association (KNMG) stated in 2010 that non-therapeutic male circumcision "conflicts with the child's right to autonomy and physical integrity." They called on doctors to inform caregivers seeking the intervention of the (in their assessment) medical and psychological risks and lack of convincing medical benefits. They stated that there are as good reasons for legal prohibition of male circumcision as exist for female genital mutilation (FGM).^[193]

United Kingdom

There is a spectrum of views within the British Medical Association's (BMA) membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. Moreover, the Association states that “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.”^[152] As a general rule, the BMA believe that "parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices." They also state that "both parents [...] must give consent for non-therapeutic circumcision", and that parents and children should be provided with up-to-date written information about the risks involved.^[152]

The BMA state that parents should be informed about the lack of consensus within the medical profession with regard to the potential health benefits of non-therapeutic circumcision, adding that they consider the evidence for such benefits to be insufficient as the sole reason for carrying out a circumcision.^[152]

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."^[21] 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.^[21]

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."^[60]

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."^[194]

The American Urological Association (2007) stated that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks, recommending that "circumcision should be presented as an option for health benefits".^[195]

See also

• Circumcision scar
• Frenectomy
• Genital modification and mutilation
• Holy Prepuce
• Preputioplasty

Notes

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)
• 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.
• George C. Denniston; Frederick M. Hodges; Marilyn Fayre Milos (2009). Circumcision and Human Rights. Springer. ISBN 9781402091667. 

External links

Wikimedia Commons has media related to: Circumcision

Opposition

• Intact America: Say No to Circumcision by Georganne Chapin.
• National Organization of Circumcision Information Resource Centers by Marilyn Milos, RN.
• The Circumcision Information and Resource Pages by Geoffrey T. Falk.
• Doctors Opposing Circumcision Presided by George C. Denniston, MD, MPH.

Promotion

• Malecircumcision.org – Clearinghouse on Male Circumcision for HIV Prevention by WHO, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the AIDS Vaccine Advocacy Coalition (AVAC), and Family Health International (FHI)
• Circinfo.net – Male Circumcision Guide for Doctors, Parents, Adults, & Teens by Professor Brian Morris
• Medicirc.org – Circumcision: a lifetime of medical benefits by Edgar Schoen, BSc., M.D.
• Circs.org maintained by Jake Waskett.

Techniques and videos

• Description of an adult circumcision from the American Academy of Family Physicians.
• Videos of infant circumcision: using a Plastibell, a Gomco clamp and a Mogen clamp (all from Stanford Medical School.)
• Video of the circumcision procedure from the US Medical Videos Journal
• A video of dorsal penile and ring block and the Plastibell Circumcision