Circumcision

From Wikipedia, the free encyclopedia

This article is about male circumcision. For female circumcision, see Female genital cutting.

Circumcision being performed in central Asia, (most likely Turkmenistan,) c. 1865-1872. Restoredalbumen 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 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, including some Oriental
Orthodox Churches.[8] According to the World Health Organization (WHO), global estimates suggest that 30%
of males are circumcised, of whom 68% are Muslim. [9] The prevalence of circumcision varies mostly with
religious affiliation, and sometimes culture. Most circumcisions are performed during adolescence for cultural or
religious reasons;[10] in some countries they are more commonly performed during infancy. [9]

There is controversy regarding circumcision. Arguments that have been raised in favour of circumcision include
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.[11] Those raised in opposition to circumcision include that it adversely affects penile
function and sexual pleasure, is justified only by medical myths, is extremely painful, and is a violation
of human rights.[12]

The American Medical Association report of 1999, which was "…confined to circumcisions that are not
performed for ritualistic or religious purposes," states that "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." [13]

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 partial protection and should not replace other interventions to prevent
transmission of HIV.[14][15]

Contents
 [hide]

1 History

o 1.1 Non-religious circumcision in the English-

speaking world

2 Cultures and religions

3 Prevalence

4 Modern circumcision procedures

5 Ethical, psychological, and legal considerations

o 5.1 Ethical issues

 5.1.1 Consent

 5.1.2 Acknowledgment of pain

o 5.2 Psychological and emotional consequences

o 5.3 Legal issues

6 Medical aspects

o 6.1 Pain and pain relief

o 6.2 Sexual effects

o 6.3 Complications

o 6.4 Sexually transmitted diseases

 6.4.1 Human immunodeficiency virus

 6.4.2 Human papilloma virus

 6.4.3 Other sexually transmitted

infections

o 6.5 Hygiene, and infectious and chronic conditions

 6.5.1 Urinary tract infections

o 6.6 Penile cancer

7 Policies of various national medical associations

o 7.1 Australasia

o 7.2 Canada

o 7.3 Netherlands
 o 7.4 United Kingdom

o 7.5 United States

8 See also

9 Further reading

10 Notes

11 External links

o 11.1 Circumcision opposition

o 11.2 Circumcision promotion

o 11.3 Circumcision techniques and videos

History

Main article:  History of male circumcision

The origination of male circumcision is not known with certainty. It has been variously proposed that it 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 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, or 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. [16][17][18] 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." [17] 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.[19]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. [20]

It is possible that circumcision arose independently in different cultures for different reasons.
Circumcision in Ancient Egypt.

The oldest documentary evidence for circumcision comes from ancient Egypt.[21] Circumcision was common,
although not universal, among ancient Semiticpeoples.[22] 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. [23]

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. [24]

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
practised universally.[25] In the view of many practitioners at the time, circumcision was a method of treating and
preventing masturbation.[25] Aggleton wrote that John Harvey Kellogg viewed male circumcision in this way, and
further "advocated an unashamedly punitive approach." [26] Circumcision was also said to protect
against syphilis,[27] phimosis, paraphimosis, balanitis, and "excessivevenery" (which was believed to
produce paralysis).[25] Gollaher states that physicians advocating circumcision in the late nineteenth century
expected public scepticism, and refined their arguments to overcome it. [25]

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. [28] 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. [28]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.
[29]
 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. [30] 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. [31] 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.[32] A report by the Agency for Healthcare Research and
Quality placed the 2005 national circumcision rate at 56%.[33]

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. [34] 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 2000-01 survey finding 32% of those aged 16–19 years circumcised, 50% for 20–29 years
and 64% for those aged 30–39 years.[35][36]

In Canada, Ontario health services delisted circumcision in 1994. [37]

Cultures and religions

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.
Jewish ritual circumcision

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

See also Brit milah, Circumcision controversies, Religious male circumcision, Khitan (circumcision)

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. [38] It is usually performed by amohel on the
eighth day after birth in a ceremony called a Brit milah (or Bris milah, colloquially simply bris), which
means "Covenant of circumcision" inHebrew. It is considered of such importance that in some Orthodox
communities the body of an uncircumcised Jewish male will sometimes be circumcised before burial.
[39]
 Although 19th century Reform leaders described it as "barbaric", the practice of circumcision
"remained a central rite"[40] and the Union for Reform Judaism has, since 1984, trained and certified over
300 practicing mohels under its "Berit Mila Program".[41] Humanistic Judaism argues that "circumcision is
not required for Jewish identity." [42]
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.
[43]
 Some have quoted the hadith to argue that the requirement of circumcision is based on
the covenantwith Abraham.[44] While endorsing circumcision for males, Islamic scholars note that it is not
a requirement for converting to Islam.[45]

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.[46] The Church presently
maintains a neutral stance on circumcision as a medical practice. [47]

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][48] require circumcision for
membership. Some Christian churches celebrate the Circumcision of Christ.[49][50] 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.[51] Circumcision is part of initiation rites in some African, Pacific Islander, and Australian
aboriginal traditions in areas such as Arnhem Land,[52] where the practice was introduced by Makassan
traders from Sulawesi in the Indonesian Archipelago.[53] Circumcision ceremonies among certain
Australian aboriginal societies are noted for their painful nature: subincision is practised amongst some
aboriginal peoples in the Western Desert. [54]

In the Pacific, circumcision or superincision is nearly universal among the Melanesians

of Fiji and Vanuatu,[55] while participation in the traditional land diving on Pentecost Island is reserved for
those who have been circumcised.[56] 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. [57] Among the Urhobo
of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te
Oshare ("the boy is now man"), constitutes a rite of passage from one age set to another.
[58]
 For Nilotic peoples, such as the Kalenjin and Maasai, circumcision is a rite of passage observed
collectively by a number of boys every few years, and boys circumcised at the same time are taken to be
members of a single age set.[59]
Prevalence

Main article:  Prevalence of circumcision

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 [60] to a third.
[61]
 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 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. [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".[62] In Latin America, prevalence is universally low.[63] Estimates for individual countries include
Spain,[64] Colombia[64] and Denmark[65] less than 2%, Finland 0.006%[66] and
7%[67], Brazil[64] 7%, Taiwan[68] 9%,Thailand[64] 13% and Australia[36] 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.[63]

Modern circumcision procedures

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. [69]

For infant circumcision, devices such as the Gomco clamp, Plastibell, and Mogen clamp are commonly
used,[70] together with a restraining device.[71]
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. [69] 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.[72]

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.[73]

 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.
[74]

 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.[75][76]

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. [77] In some African
countries, male circumcision is often performed by non-medical personnel under unsterile conditions.
[78]
 After hospital circumcision, the foreskin may be used in biomedical research, [79] consumer skin-care
products,[80] skin grafts,[81][82][83] or β-interferon-based drugs.[84] In parts of Africa, the foreskin may be
dipped in brandy and eaten by the patient, eaten by the circumciser, or fed to animals. [85] According
to Jewish law, after a Brit milah, the foreskin should be buried.[86]

Ethical, psychological, and legal considerations

Main article:  Circumcision controversies

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.[87][88][89] 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".[90]

Consent

A protest against routine infant circumcision.

Main article:  Ethics of 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,[13][69][91] but the Royal Australasian College of Physicians (RACP) and the British
Medical Association (BMA) observe that controversy exists on this issue.[18][92] 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. [92] 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."[93]

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.[87] 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.[94]

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.[95] 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."[96]

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."[97]

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." [92] Milos and Macris (1992) argue that
circumcision encodes the perinatal brain with violence and negatively affects infant-maternal bonding and
trust.[12] 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. [98]Furthermore, there are reports of
males attempting to undo the effects of circumcision through the practice of foreskin restoration.
[99]
 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.[100] A literature review by Gerharz and Haarmann (2000) reached a similar
conclusion.[101] 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.[102] Hirji et al. (2005) state that "Reports of [...] psychological trauma
are not borne out in studies but remain as an anecdotal cause for concern." [103]

Legal issues
Main article:  Circumcision and law

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, [104] 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."[105] 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.[106]

In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised was illegal.
[107]
 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. [108] 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. [109]

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. [110]

Medical aspects

Main article:  Medical analysis of circumcision

Medical cost-benefit analyses of circumcision have varied. Some found a small net benefit of
circumcision,[111][112] some found a small net decrement,[113][114] 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."[115]

Pain and pain relief

 Injection of 1% 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."[69] It therefore recommended using pain relief for circumcision.[69] One of the
supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response
during vaccination months later.[116] 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."[116] Other medical associations also cite evidence that
circumcision without anesthetic is painful.[117][118]

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%). [119] 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".[120] 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%.[121] 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. [121]

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.[38] In 2001 the Swedish government passed a law requiring all boys undergoing a bris to be given
anaesthetic administered by a medical professional.[122]
Lander et al. demonstrated that babies circumcised without anesthesia showed behavioral and
physiological signs of pain and distress.[123] Comparisons of the dorsal penile nerve block
and EMLA(lidocaine/prilocaine) topical cream methods of pain control have revealed that while both are
safe,[124][125] the dorsal nerve block controls pain more effectively than topical treatments, [126] but neither
method eliminates pain completely.[124] 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.
[127]
 Ng et al. found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain
induced by needle puncture.[128]

Sexual effects
Main article:  Sexual effects of circumcision

The sexual effects of circumcision are the subject of much debate. 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.[69] 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, "intercourse is less satisfying for both partners when the man is circumcised". [129] 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." [117] Payne et al. reported that direct
measurement of penile sensation in the shaft and glans during sexual arousal failed to support the
hypothesised sensory differences associated with circumcision status. [130] 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." [131] In a 2008 study,
Krieger et al. found that 'compared to before they were circumcised, 64.0% of circumcised men reported
their penis was “much more sensitive,” and 54.5% rated their ease of reaching orgasm as “much more” at
month 24'.[132]

Reports detailing the effect of circumcision on erectile dysfunction have been mixed. Studies have shown
that circumcision can result in a statistically significant increase, [133][134] or decrease,[28][135]in erectile
dysfunction among circumcised men, while other studies have shown little to no effect. [136][137][138]

Complications
Complication rates ranging from 0.06% to 55% have been cited; [139] more specific estimates have
included 2-10%[60] and 0.2-0.6%.[13][69]

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. [13] A survey of
circumcision complications by Kaplan in 1983 revealed that the rate of bleeding complications was
between 0.1% and 35%.[140] 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.[141]

Circumcised penis.

Uncircumcised penis.

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 (e.g., 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".[142]

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.[143][144][145]

Circumcisions may remove too much or too little skin.[60][146] If insufficient skin is removed, the child may
still develop phimosis in later life.[60] 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." [147]

Cathcart et al. report that 0.5% of boys required a procedure to revise the circumcision. [148]

Other complications include concealed penis, [149]

[150]
 urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the
penis, hypospadias, epispadias and impotence.[140] 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." [140]

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.[151] Van Howe advises that to
prevent adhesions forming after circumcision, parents should be instructed to retract and clean any skin
covering the glans.[147]

Although deaths have been reported,[140][152] 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. [117] In 2010, Bollinger
estimated a death rate of 9.01 per 100,000, or 117 per year in the United States. [153] Gairdner's 1949
study[154] 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. Wiswell and Geschke reported no deaths in the first month of life after 100,157
circumcisions (in contrast with two deaths among 35,929 uncircumcised boys); they also reported finding
no deaths in separate series of 300,000 US Army circumcisions, and 650,000 boys circumcised in Texas.
[155]
 King reported no deaths among 500,000 circumcisions.[156] The penis is thought to be lost in 1 in
1,000,000 circumcisions.[157]

Sexually transmitted diseases

Human immunodeficiency virus
Main article:  Circumcision and HIV

Over forty observational studies have been conducted to investigate the relationship between
circumcision and HIV infection.[158] Reviews of these studies have reached differing conclusions about
whether circumcision could be used as a prevention method against HIV.[159][160][161][162]

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.[162] Trials took place in South Africa,[163] Kenya[164] and Uganda.[165] 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. [164] The results showed that circumcision
reduced vaginal-to-penile transmission of HIV by 60%, 53%, and 51%, respectively. [166] 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. [167]

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][14][168] 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. [14][15] The joint
WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV
and should never replace known methods of HIV prevention. 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. [169][170]

Circumcision has been judged by the WHO to be a cost-effective method to reduce the spread of HIV in a
population,[9] though not necessarily more cost-effective than condoms.[9][171] 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. [172][173]

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.[174] 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."[175]

Human papilloma virus

Meta-analyses by Van Howe[176] and Bosch et al.[177] of observational studies reached differing

conclusions as to whether circumcision reduces infection with human papillomavirus (HPV). A
prospective trial in Uganda randomized 3393 subjects to circumcision or a control group and found a
significant reduction of HPV infection in the circumcision group.[178] 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). A later report on the same
study found that the risk in female partners was reduced; the percentages of women in the control and
circumcision groups testing positive for high-risk HPV were 38.7% and 27.8%, respectively. [179] 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. [180]

Two studies have shown that circumcised men report, or were found to have, a higher prevalence
of genital warts than uncircumcised men;[181][182] however, a 2009 meta-analysis of multiple studies found a
non-significant association between genital warts and the presence of a foreskin. [177]

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.[183] 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.[178] 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.[184] 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.[185] 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. [28]

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." [69]

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. [186][187] 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. [188]

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.[189] 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. [190] 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."[191] 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."[192] 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. [193]

The American Medical Association states that circumcision, properly performed, protects against the
development of phimosis.[13] 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.[194][195] Metcalfe et al. stated that "Gairdner[154] and Oster[196] 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." [197] 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. [198]

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).[199]

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. [69] 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. [13]

Penile cancer
The American Cancer Society (2009) stated, "Most experts agree that circumcision should not be
recommended solely as a way to prevent penile cancer."[200]

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.[69]

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. [69] 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 [201] and 22.[202]

Policies of various national medical associations

Australasia

The Royal Australasian College of Physicians (RACP; September 2010) state that "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."[203]
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. [204]

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", [91] 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.'[118]

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 good reasons for
legal prohibition of male circumcision as exists for female genital cutting. [205]

United Kingdom

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

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 BMA 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." [92]

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."[69] 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.[69]

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."[13]

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." [206]

The American Urological Association (2007) stated that neonatal circumcision has potential medical
benefits and advantages as well as disadvantages and risks. [207