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Family circumcision set and trunk, ca. eighteenth century Wooden box covered in cow hide with silver implements: silver trays, clip, pointer, silver flask, spice vessel.

Circumcision is 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").

The earliest depictions of circumcision are from cave drawings of Ancient Egyptian tombs, though some pictures may be open to interpretation.[2][3][4] Male circumcision is a religious commandment in Judaism and is recommended or obligatory in Islam.[5][6] It is also customary in some Christian churches in Africa including some Oriental Orthodox Churches.[7]

According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, mostly in the Middle East and Africa.[8]

Neonatal circumcision advocates claim circumcision provides important health advantages which outweigh the risks, has no substantial effects on sexual function, has a complication rate of less than 0.5% when carried out by an experienced physician, and is best performed on newborns.[9] Opponents of neonatal circumcision claim it violates the individual's bodily rights, is medically unnecessary, adversely affects sexual pleasure and performance, and is largely supported by myths.[10]

The American Medical Association stated in 1999: "Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice."[11]

The World Health Organisation (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 that 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.[12][13]

However, this is in complete contrast to the studies conducted by the University of Chicago that concluded that circumcision has no significant effect on the prevention of HIV/AIDS.[14]

Circumcision procedures

For infant circumcision, clamps, such as the Gomco clamp, Plastibell, and Mogen are often used.[15] Clamps cut the blood supply to the foreskin, limit any bleeding and protect the glans. Before using a clamp, the foreskin and the glans are separated with a blunt probe and/or curved hemostat.

  • With the Plastibell, the adhesions between glans and foreskin are first cut with a probe. The foreskin is cut longitudinally, the Plastibell is placed over the glans and the foreskin is covered over the Plastibell. A ligature is then tied firmly around the foreskin. This crushes the skin against the groove in the Plastibell. The skin protruding beyond the ring is then cut away. The remaining foreskin and the clamp come off in three to seven days.[16]
  • With a Gomco clamp, a section of skin is first crushed with a hemostat then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is then tightened, "crushing the foreskin between the bell and the base plate." The crushing limits bleeding (provides hemostasis). While the flared bottom of the bell fits tightly against the hole of the base plate, the foreskin is then cut away with a scalpel from above the base plate. The bell prevents the glans being reached by the scalpel.[17]
  • With a Mogen clamp, the foreskin is grabbed dorsally with a straight hemostat, and lifted up. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result," than with Gomco or Plastibell circumcisions. The clamp is locked shut, and a scalpel is used to cut the foreskin from the flat (upper) side of the clamp.[18][19]

Cultures and religions <span id="Cultures and religions"/>

See also: Circumcision in cultures and religions
See also: Brit milah

Circumcising cultures may circumcise their males either shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is most prevalent in the Muslim world, Israel, the United States, the Philippines, South Korea and Africa. It is less common in Europe, Latin America, China and India. It is commonly practiced in the Jewish and Islamic faiths.

Under Jewish law circumcision is a mitzva aseh ("positive commandment" to perform an act) and is obligatory for Jewish males. It is only postponed or abrogated in the case of threat to the life or health of the child.[20] It is usually performed by a mohel on the eighth day after birth in a ceremony called a Brit milah (or Bris milah, colloquially simply bris), which means "Covenant of circumcision" in Hebrew. It is considered of such religious importance that the body of an uncircumcised Jewish male is circumcised before burial: the only modification to bodily remains performed under halakha (Jewish religious law), which demands that corpses be treated with absolute respect and dignity.[21]

Circumcision of Jesus. Illumination from a missal, ca 1460. Municipal Library of Clermont-Ferrand, France

Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches.[7] Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya,[7][22] require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ.[23][24]

In Islam, circumcision is mentioned in some hadith, but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended (Sunnah); others that it is obligatory.[25] Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham.[26] While endorsing circumcision for males, scholars note that it is not a requirement for converting to Islam.[27]

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.[28]

Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land,[29] where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.[30] Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature: subincision is practised amongst some aboriginal peoples in the Western Desert.[31] In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu;[32] participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.[33]

Circumcision is also commonly practiced in the Polynesian islands of Samoa, Tonga, Niue, and Tikopia. In Samoa it is accompanied by a celebration.

Among some West African animist groups, such as the Dogon and Dowayo, circumcision is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males.[34] 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.[35] 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.[36]

Ethical, emotional and legal considerations

Ethical issues

The American Medical Association defines “non-therapeutic” circumcision as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. It states that medical associations in the US, Australia, and Canada do not recommend the routine non-therapeutic circumcision of newborns.[37]

Circumcision advocates argue that circumcision prevents infections and slows down the spread of AIDS.[38] Opponents of circumcision question the ethical validity of removing healthy, functioning genital tissue from a minor, arguing that infant circumcision infringes upon individual autonomy and represents a human rights violation.[39][40]

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,[41][37][42] but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue.[43][44] 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.[44]

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.[39] Denniston contends 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.[45]

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.[46] 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."[47]

Emotional consequences

Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, and cite a longitudinal study finding no difference in developmental and behavioural indices.[48] 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.[49] Milos asserts the existence of "excruciating pain, perinatal encoding of the brain with violence, interruption of maternal-infant bonding, betrayal of infant trust..." among other consequences, and points to support groups providing information to Jewish parents "who are grappling with this difficult issue" as well as men "who perceive themselves as victims of a sexual assault."[10]

Legality

Main article: Circumcision and law

In 2001, Sweden allowed only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anaesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the law,[50] 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.”[51] In 2005, the Swedish National Board of Health and Welfare reviewed the law and recommended that it be maintained. In 2006, the United States 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.[52]

In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised were illegal. The prosecutor claimed that, "part of healthy genitalia is removed without medical foundation, or competent consent". No punishment was assigned by the court.[53]

Pain and pain relief during circumcision

According to the American Academy of Pediatrics' 1999 Circumcision Policy Statement, “There is considerable evidence that newborns who are circumcised without analgesia experience pain and psychologic stress.”[41] It therefore recommended using pain relief for circumcision.[41] One of the supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response during vaccination months later. 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."[54] Other medical associations also cite evidence that circumcision without anesthetic is painful.[55][56]

Stang, 1998, found 45% of physicians used anaesthesia – most commonly a dorsal penile nerve block – for infant circumcisions. Obstetricians used anaesthesia significantly less often (25%) than family practitioners (56%) or pediatricians (71%).[57]

J.M. Glass, 1999, stated that Jewish ritual circumcision is so quick that "most mohelim do not routinely use any anaesthesia as they feel there is probably no need in the neonate. However, there is no Talmudic objection and should the parents wish for local anaesthetic cream to be applied there is no reason why this cannot be done."[20] Tannenbaum and Shechet, 2000, stated that an “authentic, traditional bris performed by a mohel does not use clamps, so there is no pain associated with crushing tissue.”[58] They also asserted that due to the speed of the procedure and rarity of complication, it is “more humane not to subject the infant to a local anesthetic.”[58]

Lander et al., found that babies circumcised without pain relief "exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the circumcision and following. Two newborns ... became ill following circumcision (choking and apnea)."[4] A 2004 Cochrane review, which compared the dorsal penile nerve block and EMLA (topical anaesthesia) found both anaesthetics appear safe, but neither of them completely eliminated pain.[59] 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.[60] Ng et al. found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.[61]

Sexual effects

The American Academy of Pediatrics (1999) stated "a survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men. There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males. Masters and Johnson noted no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men."[41] 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."[55]

Boyle et al. (2002) 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."[62] They concluded, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well."

Medical aspects

The British Medical Association, states “there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.”[44] Cost-benefit analyses have varied. Some found a small net benefit of circumcision,[63][64] some found a small net decrement,[65][66] 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."[67]

Risks of circumcision

While the risk in a competently performed medical circumcision is very low,[68] complications from bleeding, infection and poorly carried out circumcisions can be catastrophic.[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.[37] Kaplan identified other complications, including urinary fistulas, meatal stenosis, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias, impotence and removal of too much tissue, sometimes causing secondary phimosis. He stated “Virtually all of these complications are preventable with only a modicum of care" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.”[70]

Complication rates ranging from 0.06% to 55% have been cited.[71] Infant circumcision may result in skin bridges,[72] and meatal stenosis may be a common longer-term complication from circumcision.[73][74] The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.[75]

Deaths have been reported.[70][76] 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.[55] Gairdner's 1949 study reported that an average of 16 children per year out of about 90,000 died following circumcision in the UK. He found that most deaths had occurred suddenly under anaesthesia and could not be explained further, but hemorrhage and infection had also proven fatal. Deaths attributed to phimosis and circumcision were grouped together, but Gairdner argued that such deaths were probably due to the circumcision operation.[77]

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.[citation needed]

HIV and other sexually transmitted diseases

In March 2007, WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an effective intervention for HIV prevention, but also noted that male circumcision only provides partial protection and should not replace other interventions to prevent the heterosexual transmission of HIV.[12] The Centers for Disease Control and Prevention (CDC) state that several types of research have documented that male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex. Both the WHO and CDC indicate that it 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 either a female or male partner, as either the insertive or receptive partner.[12][13]

The World Health Organization (WHO) stated that studies of three trials provide compelling evidence that male circumcision provides a 50–60% reduction in HIV transmission from female to male.[78] All three trials were stopped early by their monitoring boards, because it was judged that the significant reductions in HIV incidence made it unethical to continue following control group participants without offering circumcision.[79] In 2007, WHO and UNAIDS recommended that male circumcision should now be recognized as an efficacious intervention for HIV prevention,[12] but emphasised that it does not provide complete protection against HIV infection.[80] They have stated that scientific findings regarding the role of male circumcision in preventing heterosexual HIV infection are particularly relevant in regions where the incidence of heterosexually acquired HIV infection is high, such as Sub-Saharan Africa, and stressed that the procedure must be carried out safely and under conditions of informed consent.[80][81] Before there were any results from randomized controlled trials, reviews of observational data differed as to whether there was sufficient evidence for an intervention effect of circumcision against HIV.[82][83]

McCoombe et al. stated that a layer of keratin could provide protection from viral entry, and found that the keratin is thinner on the foreskin than the glans penis, and thinnest on the inner surface of the foreskin.[84]

A meta-analysis found that circumcision is associated with lower rates of syphilis, chancroid and possibly genital herpes.[85]

Hygiene, and infectious and chronic conditions

Studies have found that boys with foreskins tend to have higher rates of various infections and inflammations of the penis than those who are circumcised.[86][87][88] The foreskin may harbor bacteria and become infected if it is not cleaned properly,[89] but may become inflamed if it is cleaned too often with soap.[90] Also, the forcible retraction of the foreskin in boys can lead to infections.[71]

Circumcision is one treatment for balanitis. The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams.[91]

Several studies have shown that uncircumcised men are at greater risk of human papilloma virus (HPV) infection.[92][93][94] One study found no statistically significant difference in the incidence of HPV infection between circumcised and uncircumcised men, but did note a higher prevalence of urethritis in the uncircumcised.[95] Results of the 1999 to 2004 United States National Health and Nutrition Examination Survey demonstrated that more circumcised men reported having been diagnosed with genital warts compared with uncircumcised men (4.5% and 2.4%, respectively).[96]

Twelve studies have indicated that neonatal circumcision reduces the rate of Urinary tract infections (UTI's) in male infants by a factor of about 10.[97] 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.[41] 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.[37]

Penile cancer

Penile cancer affects from 0.82 per 100,000 in Denmark to 10.5 per 100,000 men per year in parts of India (0.9 to 1 per 100,000 in the United States).[41] Studies have reported a rate of penile cancer from 3 to 22 times higher in uncircumcised than circumcised men.[98][99]

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.[41]

The American Cancer Society (2006) stated, "The current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer."[100]

Policies of various national medical associations

United States

The American Academy of Family Physicians (2007) recommends that physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering circumcision for newborn boys.[101]

The American Academy of Pediatrics (1999) do not recommend that all infant boys be circumcised, and state that parents should choose what is best for their child by looking at the benefits and risks.[102] The AAP also recommended using analgesia as a safe and effective method for reducing pain associated with circumcision, and that circumcision only be performed on newborns who are stable and healthy.[103]

The American Medical Association supports the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics.[37]

The American Urological Association (2007) believes that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. In the context of HIV studies carried out in Africa, the AUA states that while "the results of studies in African nations may not necessarily be extrapolated to men in the United States at risk for HIV infection," the AUA "recommends that circumcision should be presented as an option for health benefits."[104]

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Circumcision: Information for Parents" in November 2004,[56] and "Neonatal circumcision revisited" in 1996. The 1996 position statement says that "circumcision of newborns should not be routinely performed," (a statement with which the Royal Australasian College of Physicians concurs,) and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many pediatricians no longer perform circumcisions."[42]

United Kingdom

The British Medical Association's position (June 2006) was that male circumcision for medical purposes should only be used where less invasive procedures are either unavailable or not as effective. The BMA specifically refrained from issuing a policy regarding “non-therapeutic circumcision,” stating that as a general rule, it “believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.”[105]

Australasia

The Royal Australasian College of Physicians states "there is no medical indication for routine neonatal circumcision". It states, "If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment"[43]

History of circumcision

It has been variously proposed that circumcision began as a religious sacrifice, as a rite of passage marking a boy's entrance into adulthood, as a form of sympathetic magic to ensure virility, as a means of suppressing (or enhancing) sexual pleasure or to increase a man's attractiveness to women, or as an aid to hygiene where regular bathing was impractical, among other possibilities. Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practicing circumcision, leading to its spread regardless of whether the people understood this.[106] It is possible that circumcision arose independently in different cultures for different reasons.

Ancient Egyptian carved scene of circumcision, from the inner northern wall of the Temple of Khonspekhrod at the Precinct of Mut, Luxor, Egypt. Eighteenth dynasty, Amenhotep III, c. 1360 BC.

The oldest documentary evidence for circumcision comes from ancient Egypt.[107] Circumcision was common, although not universal, among ancient Semitic peoples.[108] 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 practised it.[109]

Medical circumcision in the 19th century and early 20th century

There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The 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. Because of its function, the penis became "dirty" by association, and from this premise circumcision was seen as preventative medicine to be practiced universally.[110] In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation.[110] It was also said to protect against syphilis,[111] phimosis, paraphimosis, balanitis, and "excessive venery" (which was believed to produce paralysis).[110] Gollaher states that physicians advocating circumcision in the late nineteenth century expected public skepticism, and refined their arguments to overcome it.[110]

Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada, South Africa and to a lesser extent in the United Kingdom and New Zealand. Although it is difficult to determine historical circumcision rates, one estimate[5] of infant circumcision rates in the United States holds that 30% of newborn American boys were being circumcised in 1900, 55% in 1925, and 72% in 1950.

Circumcision since 1945

In 1949, the United Kingdom's newly-formed National Health Service removed infant circumcision from its list of covered services. Since then, circumcision has been an out-of-pocket cost to parents, and the proportion of newborns circumcised in England and Wales has fallen to less than one percent. In Canada, individual provincial health services began delisting circumcision in the 1980s.

In South Korea, circumcision grew in popularity following the establishment of the United States trusteeship in 1945 and the spread of American influence. More than 90% of South Korean high school boys are now circumcised, but the average age of circumcision is 12 years.[112]

In some South African ethnic groups, circumcision has roots in several belief systems, and is mostly performed on teenage boys.

A study in 1987 found that the prominent reasons for parents choosing circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns.[6] A 2005 study speculated that increased recognition of the potential benefits may be responsible for an observed increase in the rate of neonatal circumcision in the USA between 1988 and 2000.[7]

Prevalence of circumcision

Estimates of the proportion of males that are circumcised worldwide vary from one-sixth[113] to a third.[114] WHO has estimated that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), with almost 70% of these being Muslim.[80] Prevalence is near universal in the Middle East and Central Asia.[80] WHO states that "there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines".[80] WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe,[80] and Klavs et al. report findings that "support the notion that the prevalence is low in Europe".[115] In Latin America, prevalence is universally low.[116] Estimates for individual countries include Spain[117], Columbia[117] and Denmark[118] less than 2%, Finland[119] and Brazil[117] 7%, Taiwan[120] 9% and Thailand[117] 13%.

WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively.[80] Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.[116] 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.[121][122] Prevalence in the UK is also age-graded, with 12% of those aged 16-19 years circumcised and 20% of those aged 40-44 years.[123]

See also

Notes

Some referenced articles are available on-line only in the Circumcision Information and Resource Page’s (CIRP) library or in The Circumcision Reference Library (CIRCS). CIRP articles are chosen from an anti-circumcision point of view, and text in support of this position is often highlighted on-screen using HTML. CIRCS articles are chosen from a pro-circumcision point of view. If documents are not freely available on-line elsewhere, links to articles in one or other of these two websites may be provided.
  1. Dictionary definitions of circumcision:
    • "The act of cutting off the prepuce or foreskin of males, or the internal labia of females." Webster's Revised Unabridged Dictionary (1913) [1]
    • "to remove the foreskin of (males) sometimes as a religious rite." The Macquarie Dicitionary (2nd Edition, 1991)
    • "Cut off foreskin of (as Jewish or Mohammedan rite, or surgically), Concise Oxford Dictionary, 5th Edition, 1964
    Circumcision defined in a medical context:
  2. Hodges, F.M. (Fall 2001). "The ideal prepuce in ancient Greece and Rome: male genital aesthetics and their relation to lipodermos, circumcision, foreskin restoration, and the kynodesme.". The Bulletin of the History of Medicine 75 (3): 375-405. PMID 11568485.
  3. Wrana, P. (1939). "Historical review: Circumcision". Archives of Pediatrics 56: 385–392. as quoted in: Zoske, Joseph (Winter 1998). "Male Circumcision: A Gender Perspective". The Journal of Men's Studies 6 (2): 189–208. Retrieved on 2006-06-14.
  4. Gollaher, David L. (February 2000). Circumcision: a history of the world’s most controversial surgery. New York, NY: Basic Books, 53–72. ISBN 978-0-465-04397-2 LCCN 99-40015. 
  5. Circumcision. American-Israeli Cooperative Enterprise. Retrieved on 2006-10-03.
  6. Beidelman, T. (1987). "CIRCUMCISION". The Encyclopedia of religion Volume 3. Ed. Mircea Eliade. New York, NY: Macmillan Publishers. 511–514. LCCN 86-5432 ISBN 978-0-02-909480-8. Retrieved on 2006-10-03. 
  7. 7.0 7.1 7.2 Customary in some Coptic and other churches:
    • "The Coptic Christians in Egypt and the Ethiopian Orthodox Christians— two of the oldest surviving forms of Christianity— retain many of the features of early Christianity, including male circumcision. Circumcision is not prescribed in other forms of Christianity... Some Christian churches in South Africa oppose the practice, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership and participants in focus group discussions in Zambia and Malawi mentioned similar beliefs that Christians should practice circumcision since Jesus was circumcised and the Bible teaches the practice." Male Circumcision: context, criteria and culture (Part 1), Joint United Nations Programme on HIV/AIDS, February 26, 2007.
    • "The decision that Christians need not practice circumcision is recorded in Acts 15; there was never, however, a prohibition of circumcision, and it is practiced by Coptic Christians." "circumcision", The Columbia Encyclopedia, Sixth Edition, 2001-05.
  8. Insert 2. Information Package on Male Circumcision and HIV Prevention. World Health Organization (2007). Retrieved on 2007-08-15.
  9. Schoen, Edgar J (2007). "Should newborns be circumcised? Yes". Can Fam Physician 53 (12): 2096–8, 2100–2. PMID 18077736. Retrieved on 2008-05-02.
  10. 10.0 10.1 Milos, Marilyn Fayre; Donna Macris (March–April 1992). "Circumcision: A medical or a human rights issue?". Journal of Nurse-Midwifery 37 (2 S1): S87–S96. doi:10.1016/0091-2182(92)90012-R. PMID 1573462. Retrieved on 2007-04-06.
  11. Neonatal Circumcision. Retrieved on 2008-04-20.
  12. 12.0 12.1 12.2 12.3 (March 28, 2007). "New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications" (PDF). World Health Organization. Retrieved on 2007-08-13.
  13. 13.0 13.1 Male Circumcision and Risk for HIV Transmission and Other Health Conditions: Implications for the United States. Centers for Disease Control and Prevention (2008).
  14. http://chronicle.uchicago.edu/970403/circumcision.shtml
  15. Holman, John R.; Evelyn L. Lewis, Robert L. Ringler (August 1995). "Neonatal circumcision techniques – includes patient information sheet". American Family Physician 52 (2): 511–520. ISSN 0002-838X PMID 7625325. Retrieved on 2006-06-29.
  16. Herbert, Barrie; et al (1965). "The Plastibell Technique for Circumcison". Br Med J 2 (5456): 273–275.
  17. Peleg, David; Ann Steiner (September 15, 1998). "The Gomco Circumcision: Common Problems and Solutions". American Family Physician 58 (4): 891–898. ISSN 0002-838X PMID 9767725. Retrieved on 2006-06-29.
  18. Pfenninger, John L.; Grant C. Fowler [1994] (July 21, 2003). Procedures for primary care, 2nd, Mosby. ISBN 978-0-323-00506-7 LCCN 2003-56227. 
  19. Reynolds, RD (July 1996). "Use of the Mogen clamp for neonatal circumcision" (Abstract). American Family Physician 54 (1): 177–182. PMID 8677833. Retrieved on 2006-07-18.
  20. 20.0 20.1 Glass, J.M. (January 1999). "Religious circumcision: a Jewish view" (PDF). BJU International 83 (Supplement 1): 17–21. doi:doi:10.1046/j.1464-410x.1999.0830s1017.x. PMID 10766529. Retrieved on 2006-10-18.
  21. Lamm, Maurice [1969]. The Jewish Way in Death and Mourning. New York: Jonathan David, 239–240. 
  22. Mattson, C.L.; R.C. Bailey, R. Muga, R. Poulussen, T. Onyango (February 2005). "Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya". AIDS Care 17 (2): 182–194. PMID 15763713.
  23. Greek Orthodox Archdiocese calendar of Holy Days.
  24. Russian Orthodox Church, Patriarchate of Moscow.
  25. Al-Munajjid, Muhammed Salih. Question #9412: Circumcision: how it is done and the rulings on it. Islam Q&A. Retrieved on 2006-07-01.
  26. Al-Munajjid, Muhammed Salih. Question #7073: The health and religious benefits of circumcision. Islam Q&A. Retrieved on 2006-07-01.
  27. al-Sabbagh, Muhammad Lutfi (1996). Islamic ruling on male and female circumcision. Alexandria: World Health Organization, 16. 
  28. Ajuwon et al., "Indigenous surgical practices in rural southwestern Nigeria: Implications for disease," Health Educ. Res..1995; 10: 379–384 Health Educ. Res..1995; 10: 379–384 Retrieved 3 October 2006
  29. Aaron David Samuel Corn (2001). "Ngukurr Crying: Male Youth in a Remote Indigenous Community" (PDF). Working Paper Series No. 2. University of Wollongong. Retrieved on 2006-10-18.
  30. Migration and Trade. Green Turtle Dreaming. Retrieved on 2006-10-18. “In exchange for turtles and trepang the Makassans introduced tobacco, the practice of circumcision and knowledge to build sea-going canoes.”
  31. Jones, IH (June 1969). "Subincision among Australian western desert Aborigines". British Journal of Medical Psychology 42 (2): 183–190. ISSN 0007-1129 PMID 5783777.
  32. RECENT GUEST SPEAKER. Australian AIDS Fund Incorporated (2006). Retrieved on 2006-07-01.
  33. Weird & Wonderful. United Travel. Retrieved on 2006-07-01.
  34. Circumcision amongst the Dogon. The Non-European Components of European Patrimony (NECEP) Database (2006). Retrieved on 2006-09-03.
  35. Agberia, John Tokpabere (2006). "Aesthetics and Rituals of the Opha Ceremony among the Urhobo People" (PDF). Journal of Asian and African Studies 41 (3): 249–260. doi:10.1177/0021909606063880. Retrieved on 2006-10-18.
  36. Masai of Kenya. Retrieved on 2007-04-06. “Authority derives from the age-group and the age-set. Prior to circumcision a natural leader or olaiguenani is selected; he leads his age-group through a series of rituals until old age, sharing responsibility with a select few, of whom the ritual expert (oloiboni) is the ultimate authority. Masai youths are not circumcised until they are mature, and a new age-set is initiated together at regular intervals of twelve to fifteen years. The young warriors (ilmurran) remain initiates for some time, using blunt arrows to hunt small birds which are stuffed and tied to a frame to form a head-dress.
  37. 37.0 37.1 37.2 37.3 37.4 Report 10 of the Council on Scientific Affairs (I-99):Neonatal Circumcision. 1999 AMA Interim Meeting: Summaries and Recommendations of Council on Scientific Affairs Reports 17. American Medical Association (December 1999). Retrieved on 2006-06-13.
  38. Auvert, Bertran; Dirk Taljaard, Emmanuel Lagarde, Joëlle Sobngwi-Tambekou, Rémi Sitta, Adrian Puren (November 2005). "Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial" (PDF). PLoS Medicine 2 (11): 1112–1122. doi:10.1371/journal.pmed.0020298. PMID 16231970. Retrieved on 2006-07-09.
  39. 39.0 39.1 Somerville, Margaret (November 2000). "Altering Baby Boys’ Bodies: The Ethics of Infant Male Circumcision", The ethical canary: science, society, and the human spirit. New York, NY: Viking Penguin Canada, 202–219. LCCN 2001-369341. ISBN 0670893021. 
  40. Van Howe, R.S.; J.S. Svoboda, J.G. Dwyer, and C.P. Price (January 1999). "Involuntary circumcision: the legal issues" (PDF). BJU International 83 (Supp1): 63–73. doi:10.1046/j.1464-410x.1999.0830s1063.x. PMID 10349416. Retrieved on 2007-02-12.
  41. 41.0 41.1 41.2 41.3 41.4 41.5 41.6 American Academy of Pediatrics Task Force on Circumcision (March 1, 1999). "Circumcision Policy Statement" (PDF). Pediatrics 103 (3): 686–693. doi:10.1542/peds.103.3.686. ISSN 0031-4005 PMID 10049981. Retrieved on 2006-07-01.
  42. 42.0 42.1 Fetus and Newborn Committee (March 1996). "Neonatal circumcision revisited". Canadian Medical Association Journal 154 (6): 769–780. Retrieved on 2006-07-02. “We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors.
  43. 43.0 43.1 Policy Statement On Circumcision (PDF). Royal Australasian College of Physicians (September 2004). Retrieved on 2007-02-28. “The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision. Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It remains an important ritual in some religious and cultural groups.…In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis.…The complication rate of neonatal circumcision is reported to be around 1% to 5% and includes local infection, bleeding and damage to the penis. Serious complications such as bleeding, septicaemia and meningitis may occasionally cause death. The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law. If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate.
  44. 44.0 44.1 44.2 Medical Ethics Committee (June 2006). The law and ethics of male circumcision – guidance for doctors. British Medical Association. Retrieved on 2006-07-01.
  45. Circumcision and the Code of Ethics, George C. Denniston, Humane Health Care Volume 12, Number 2.
  46. Viens AM (2004). "Value judgment, harm, and religious liberty". J Med Ethics 30: 241-7.
  47. Benatar, David; Benatar, Michael (2003). "How not to argue about circumcision". American Journal of Bioethics 3 (2): W1–W9.
  48. Moses, S; Bailey, RC; Ronald AR (1998). "Male circumcision: assessment of health benefits and risks". Sex Transm Infect 74: 368–73.
  49. Goldman, R. (January 1999). "The psychological impact of circumcision" (PDF). BJU International 83 (S1): 93–102. doi:10.1046/j.1464-410x.1999.0830s1093.x. Retrieved on 2006-07-02.
  50. Sweden restricts circumcisions. BBC Europe (October 1, 2001). Retrieved on 2006-10-18. “Swedish Jews and Muslims object to the new law, saying it violates their religious rights.”
  51. Reuters (June 7, 2001). Jews protest Swedish circumcision restriction. Canadian Children's Rights Council. Retrieved on 2006-10-18. “A WJC spokesman said, ‘This is the first legal restriction placed on a Jewish rite in Europe since the Nazi era. This new legislation is totally unacceptable to the Swedish Jewish community.’”
  52. Bureau of Democracy, Human Rights, and Labor (September 15, 2006). Sweden. International Religious Freedom Report 2006. US Department of State. Retrieved on 2007-07-04.
  53. Court rules circumcision of four-year-old boy illegal. HELSINGIN SANOMAT, INTERNATIONAL EDITION (2006-08-07). Retrieved on 2007-09-17.
  54. Taddio, Anna; Joel Katz, A Lane Ilersich, Gideon Koren (March 1997). "Effect of neonatal circumcision on pain response during subsequent routine vaccination" (PDF — free registration required). The Lancet 349 (9052): 599–603. doi:10.1016/S0140-6736(96)10316-0. Retrieved on 2007-08-08.
  55. 55.0 55.1 55.2 Circumcision: Position Paper on Neonatal Circumcision. American Academy of Family Physicians (2007). Retrieved on 2007-01-30.
  56. 56.0 56.1 Circumcision: Information for parents. Caring for kids. Canadian Paediatric Society (November 2004). Retrieved on 2006-10-24. “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. To help make the decision about circumcision, parents should have information about risks and benefits. It is helpful to speak with your baby’s doctor. 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.
  57. Stang, Howard J.; Leonard W. Snellman (June 1998). "Circumcision Practice Patterns in the United States" (PDF). Pediatrics 101 (6): e5–. doi:10.1542/peds.101.6.e5. ISSN 1098-4275. Retrieved on 2006-06-29.
  58. 58.0 58.1 Shechet, Jacob; Barton Tanenbaum (2000). "Circumcision—The Debates Goes On" (PDF). Pediatrics 105 (3): 682–683. doi:doi:10.1542/peds.105.3.681. PMID 10733391. Retrieved on 2007-04-06.
  59. Brady-Fryer, B; Wiebe N, Lander JA (July 2004). "Pain relief for neonatal circumcision". The Cochrane Database of Systematic Reviews (3): Art. No.: CD004217. doi:10.1002/14651858.CD004217.pub2. PMID 15495086. Retrieved on 2006-06-29.
  60. Razmus I, Dalton M, Wilson D. "Pain management for newborn circumcision". Pediatr Nurs 30 (5): 414–7, 427. PMID 15587537.
  61. Ng, WT; et al. (2001). "The use of topical lidocaine/prilocaine cream prior to childhood circumcision under local anesthesia". Ambul Surg 9 (1): 9–12. PMID 11179706.
  62. Boyle, Gregory J; Svoboda, J Steven; Goldman, Ronald; Fernandez, Ephrem (2002). Male circumcision: pain, trauma, and psychosexual sequelae. Bond University Faculty of Humanities and Social Sciences.
  63. Schoen, Edgar J.; Christopher J. Colby, Trinh T. To (March 2006). "Cost Analysis of Neonatal Circumcision in a Large Health Maintenance Organization" (Abstract). The Journal of Urology 175 (3): 1111–1115. doi:10.1016/S0022-5347(05)00399-X. PMID 16469634. Retrieved on 2006-07-01.
  64. Alanis, Mark C.; Richard S. Lucidi (May 2004). "Neonatal Circumcision: A Review of the World’s Oldest and Most Controversial Operation" (Abstract). Obstetrical & Gynecological Survey 59 (5): 379–395. PMID 15097799. Retrieved on 2006-09-27.
  65. Van Howe, Robert S. (November 2004). "A Cost-Utility Analysis of Neonatal Circumcision" (Abstract). Medical Decision Making 24 (6): 584–601. doi:10.1177/0272989X04271039. PMID 15534340. Retrieved on 2006-07-01.
  66. Ganiats, TG; Humphrey JB, Taras HL, Kaplan RM. (Oct–Dec 1991). "Routine neonatal circumcision: a cost-utility analysis". Medical Decision Making 11 (4): 282–293. PMID 1766331. Retrieved on 2006-07-01.
  67. Lawler, FH; Bisonni RS, Holtgrave DR. (Nov–Dec 1991). "Circumcision: a decision analysis of its medical value.". Family Medicine 23 (8): 587–593. PMID 1794670. Retrieved on 2006-07-01.
  68. Christakis, Dmitry A.; Eric Harvey, Danielle M. Zerr, Chris Feudtner, Jeffrey A. Wright, and Frederick A. Connell (January 2000). "A Trade-off Analysis of Routine Newborn Circumcision" (PDF). Pediatrics 105 (1): 246–249. doi:10.1542/peds.105.1.S2.246. PMID 10617731. Retrieved on 2006-07-01.
  69. Ahmed A,, A; Mbibi NH, Dawam D, Kalayi GD (March 1999). "Complications of traditional male circumcision". Annals of Tropical Paediatrics 19 (1): 113–117. PMID 10605531 ISSN 0272-4936. Retrieved on 2006-07-01.
  70. 70.0 70.1 Kaplan, G.W. (August 1983). "Complications of Circumcision" (HTML). Urologic Clinics of North America 10 (3): 543–549. PMID 6623741. Retrieved on 2006-09-29.
  71. 71.0 71.1 Fetus and Newborn Committee (March 1996). "Neonatal circumcision revisited". Canadian Medical Association Journal 154 (6): 769–780. Retrieved on 2006-07-02.
  72. Naimer, Sody A.; Roni Peleg, Yevgeni Meidvidovski, Alex Zvulunov, Arnon Dov Cohen, and Daniel Vardy (November 2002). "Office Management of Penile Skin Bridges with Electrocautery" (PDF). Journal of the American Board of Family Practice 15 (6): 485–488. PMID 10605531. Retrieved on 2006-07-01.
  73. Yegane, Rooh-Allah; Abdol-Reza Kheirollahi, Nour-Allah Salehi, Mohammad Bashashati, Jamal-Aldin Khoshdel, and Mina Ahmadi (May 2006). "Late complications of circumcision in Iran" (Abstract). Pediatric Surgery International 22 (5): 442–445. doi:10.1007/s00383-006-1672-1. PMID 16649052. Retrieved on 2006-07-02.
  74. Angel, Carlos A. (June 12, 2006). Meatal Stenosis. eMedicine. WebMD. Retrieved on 2006-07-02.
  75. Complications Of Circumcision. Paediatric Policy – Circumcision. The Royal Australasian College of Physicians (October 2004). Retrieved on 2006-07-11.
  76. Paediatric Death Review Committee: Office of the Chief Coroner of Ontario (April 2007). Coroner's Corner Circumcision: A minor procedure?. Paediatric Child Health Vol 12 No 4, April 2007 pages 311–312. Pulsus Group Inc.. Retrieved on 2007-06-17.
  77. Gairdner, Douglas (December 1949). "The Fate of the Foreskin". British Medical Journal 2 (4642): 1433–1437. PMID 15408299. Retrieved on 2006-07-01.
  78. WHO and UNAIDS Secretariat welcome corroborating findings of trials assessing impact of male circumcision on HIV risk. World Health Organization (February 23, 2007). Retrieved on 2007-02-23.
  79. Bailey, R.C.; S. Moses, C.B. Parker, K. Agot, I. Maclean, J.N. Krieger, C.F.M. Williams, R.T. Campbell, J.O. Ndinya-Achola (February 24, 2007). "Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial" (PDF). The Lancet 369 (9562): 643–656. doi:10.1016/S0140-6736(07)60312-2. PMID 17321310. Retrieved on 2007-04-01.
  80. 80.0 80.1 80.2 80.3 80.4 80.5 80.6 WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention. World Health Organisation (March 2007).
  81. Male circumcision: Global trends and determinants of prevalence, safety and acceptability. World Health Organisation/UNAIDS (February 2007).
  82. Weiss, HA; Quigley MA, Hayes RJ. (Oct 20 2000). "Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis.". AIDS. 2000 14 (15): 2361–70. Retrieved on 2007-12-27. “Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised.”
  83. Siegfried, N; M Muller, J Volmink, J Deeks, M Egger, N Low, H Weiss, S Walker, P Williamson. "Male circumcision for prevention of heterosexual acquisition of HIV in men". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD003362. CD003362. Retrieved on 2007-12-27. “We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV.”
  84. McCoombe SG, Cameron PU, Short RV (July 7, 2002). "The distribution of HIV-1 target cells and keratin in the human penis." (Abstract). International AIDS Society. Retrieved on 2006-07-09.
  85. Weiss, HA; Thomas, SL; Munabi SK; Hayes RJ (Apr 2006). "Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis". Sex Transm Infect 82 (2): 101–9. PMID 16581731.
  86. Fergusson, DM; JM Lawton and FT Shannon (April 1988). "Neonatal circumcision and penile problems: an 8-year longitudinal study". Pediatrics 81 (4): 537–541. PMID 3353186. Retrieved on 2007-07-18.
  87. Fakjian, N; S Hunter, GW Cole and J Miller (August 1990). "An argument for circumcision. Prevention of balanitis in the adult". Arch Dermatol 126 (8): 1046–7. PMID 2383029.
  88. Herzog, LW; SR Alvarez (March 1986). "The frequency of foreskin problems in uncircumcised children". Am J Dis Child 140 (3): 254–6. PMID 3946358.
  89. O’Farrel, Nigel; Maria Quigley and Paul Fox (August 2005). "Association between the intact foreskin and inferior standards of male genital hygiene behaviour: a cross-sectional study" (Abstract). International Journal of STD & AIDS 16 (8): 556–588(4). doi:10.1258/0956462054679151. PMID 16105191. Retrieved on 2006-08-20.
  90. Birley (October 1993). "Clinical Features and management of recurrent balanitis; association with atopy and genital washing". Genitourinary Medicine 69 (5): 400–403. doi:10.1136/jme.2002.001313. PMID 8244363. Retrieved on 2008-04-12.
  91. Osipov, Vladimir O.; Scott M. Acker (November 14, 2006). Balanoposthitis. Reactive and Inflammatory Dermatoses. EMedicine. Retrieved on 2006-11-20.
  92. Castellsagué, Xavier; et al. (April 11, 2002). "Male circumcision, penile human papillomavirus infection, and cervical cancer" (PDF — free registration required). The New England Journal of Medicine 346 (15): 1105–1112. doi:10.1056/NEJMoa011688. PMID 11948269. Retrieved on 2006-07-09.
  93. Lajous, Martín; Nancy Mueller, Aurelio Cruz-Valdéz, Luis Victor Aguilar, Silvia Franceschi, Mauricio Hernández-Ávila, and Eduardo Lazcano-Ponce (July 2005). "Determinants of Prevalence, Acquisition, and Persistence of Human Papillomavirus in Healthy Mexican Military Men" (PDF). Cancer Epidemiology Biomarkers and Prevention 14 (7): 1710–1716. doi:10.1158/1055-9965.EPI-04-0926. PMID 16030106. Retrieved on 2006-07-09.
  94. Hernandez, B.Y.; L.R. Wilkens, X. Zhu, K. McDuffie, P. Thompson, Y.B. Shvetsov, L. Ning and M.T. Goodman (2008 March). "Circumcision and Human Papillomavirus Infection in Men: A Site-Specific Comparison". The Journal of Infectious Diseases 197 (6): 787–794. doi:10.1086/528379. PMID 18284369.
  95. Aynaud, O.; D. Piron, G. Bijaoui, and JM Casanova (1999 July). "Developmental factors of urethral human papillomavirus lesions: correlation with circumcision" (PDF). BJU International 84 (1): 57–60. doi:10.1046/j.1464-410x.1999.00104.x. PMID 10444125. Retrieved on 2006-07-09.
  96. Dinh, T.H.; M. Sternberg, E.F. Dunne and L.E. Markowitz (April 2008). "Genital Warts Among 18- to 59-Year-Olds in the United States, National Health and Nutrition Examination Survey, 1999-2004". Sexually Transmitted Diseases 35 (4): 357-360. PMID 18360316. “The percentage of circumcised men reporting a diagnosis of genital warts was significantly higher than uncircumcised men, 4.5% (95% CI, 3.6%–5.6%) versus 2.4% (95% CI, 1.5%–4.0%)”
  97. Singh-Grewal, D.; J. Macdessi, and J. Craig (August 1, 2005). "Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies" (PDF). Archives of Disease in Childhood 90 (8): 853–858. doi:10.1136/adc.2004.049353. PMID 15890696. Retrieved on 2006-09-21.
  98. Maden, C; et al (Jan 1993). "History of circumcision, medical conditions, and sexual activity and risk of penile cancer". J Natl Cancer Inst 85 (1): 19–24. PMID 8380060.
  99. Schoen, EJ; Oehrli, M; Colby, C; Machin, G (Mar 2000). "The highly protective effect of newborn circumcision against invasive penile cancer". Pediatrics 105 (3): e36.
  100. Can Penile Cancer be Prevented?.
  101. Circumcision: Position Paper on Neonatal Circumcision. American Academy of Family Physicians (2007). Retrieved on 2007-01-30. “Considerable controversy surrounds neonatal circumcision. Putative indications for neonatal circumcision have included preventing UTIs and their sequelae, preventing the contraction of STDs including HIV, and preventing penile cancer as well as other reasons for adult circumcision. Circumcision is not without risks. Bleeding, infection, and failure to remove enough foreskin occur in less than 1% of circumcisions. Evidence-based complications from circumcision include pain, bruising, and meatitis. More serious complications have also occurred. Although numerous studies have been conducted to evaluate these postulates, only a few used the quality of methodology necessary to consider the results as high level evidence.

    The evidence indicates that neonatal circumcision prevents UTIs in the first year of life with an absolute risk reduction of about 1% and prevents the development of penile cancer with an absolute risk reduction of less than 0.2%. The evidence suggests that circumcision reduces the rate of acquiring an STD, but careful sexual practices and hygiene may be as effective. Circumcision appears to decrease the transmission of HIV in underdeveloped areas where the virus is highly prevalent. No study has systematically evaluated the utility of routine neonatal circumcision for preventing all medically-indicated circumcisions in later life. Evidence regarding the association between cervical cancer and a woman’s partner being circumcised or uncircumcised, and evidence regarding the effect of circumcision on sexual functioning is inconclusive. If the decision is made to circumcise, anesthesia should be used.

    The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son.
  102. Circumcision Information for Parents. American Academy of Pediatrics (2001).
  103. Task Force on Circumcision (March 1, 1999). "Circumcision Policy Statement" (PDF). Pediatrics 103 (3): 686–693. doi:10.1542/peds.103.3.686. ISSN 0031-4005 PMID 10049981. Retrieved on 2006-07-01. “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. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. It is legitimate for parents to take into account cultural, religious, and ethnic traditions, in addition to the medical factors, when making this decision. Analgesia is safe and effective in reducing the procedural pain associated with circumcision; therefore, if a decision for circumcision is made, procedural analgesia should be provided. If circumcision is performed in the newborn period, it should only be done on infants who are stable and healthy.”
  104. American Urological Association. [[2] Circumcision]. Retrieved on 2007-08-26.
  105. Medical Ethics Committee (June 2006). The law and ethics of male circumcision – guidance for doctors. British Medical Association. Retrieved on 2006-07-01. “Circumcision for medical purposes Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. Male circumcision in cases where there is a clear clinical need is not normally controversial. Nevertheless, normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal. The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. Doctors should be aware of this and reassure parents accordingly.

    Non-therapeutic 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. There is a spectrum of views within the BMA’s 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. The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly. The Association has no policy on these issues. Indeed, it would be difficult to formulate a policy in the absence of unambiguously clear and consistent medical data on the implications of the intervention. As a general rule, however, the BMA believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.
  106. Immerman, R.S.; W.C. Mackey (Fall-Winter 1997). "A biocultural analysis of circumcision". Social Biology 44 (3-4): 265-275. PMID 9446966.}}
  107. Tomb artwork from the Sixth Dynasty (2345–2181 BCE) shows men with circumcised penises, and one relief from this period shows the rite being performed on a standing adult male. The Egyptian hieroglyph for "penis" depicts either a circumcised or an erect organ. The examination of Egyptian mummies has found some with foreskins and others who were circumcised.
  108. The Book of Jeremiah, written in the sixth century BCE, lists the Egyptians, Jews, Edomites, Ammonites, and Moabites as circumcising cultures. Herodotus, writing in the fifth century BCE, would add the Colchians, Ethiopians, Phoenicians, and Syrians to that list.
  109. The writer of the 1 Maccabees wrote that under the Seleucids, many Jewish men attempted to hide or reverse their circumcision so they could exercise in Greek gymnasia, where nudity was the norm. First Maccabees also relates that the Seleucids forbade the practice of brit milah (Jewish circumcision), and punished those who performed it–as well as the infants who underwent it–with death.
  110. 110.0 110.1 110.2 110.3 Gollaher, David (Fall 1994). "From ritual to science: the medical transformation of circumcision in America". Journal of Social History 28 (1): 5–36. Retrieved on 2007-12-06.
  111. (1855) "On the influence of circumcision in preventing syphilis". Medical Times and Gazette NS Vol II: 542–3.
  112. Pang, MG; Kim DS (2002). "Extraordinarily high rates of male circumcision in South Korea: history and underlying causes". BJU Int 89 (1): 48–54.
  113. Williams, N; L. Kapila (October 1993). "Complications of circumcision". British Journal of Surgery 80 (10): 1231–1236. doi:10.1002/bjs.1800801005. Retrieved on 2006-07-11.
  114. Crawford DA. Circumcision: a consideration of some of the controversy. J Child Health Care. 2002 December;6(4):259–70. PMID 12503896
  115. Klavs I, Hamers FF (February 2008). "Male circumcision in Slovenia: results from a national probability sample survey". Sex Transm Infect 84 (1): 49–50. doi:10.1136/sti.2007.027524. PMID 17881413.
  116. 116.0 116.1 Drain, PK; et al (November 2006). "Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries". BMC Infect Dis 30 (6): 172. doi:10.1186/1471-2334-6-172. PMID 17137513. Retrieved on 2008-04-25.
  117. 117.0 117.1 117.2 117.3 Castellsagué, X; et al (2002). "Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners". N Engl J Med 346 (15): 1105-12. PMID 11948269.
  118. Frisch, M; et al (1995). "Falling incidence of penis cancer in an uncircumcised population (Denmark 1943-90)". BMJ 311: 1471.
  119. Schoen, E J; Colby, C J; Trinh, T To. "Cost analysis of neonatal circumcision in a large health maintenance organization". J Urol 175: 1111-1115.
  120. Ko, MC; et al (April 2007). "Age-specific prevalence rates of phimosis and circumcision in Taiwanese boys". J Formos Med Assoc 106 (4): 302–7. PMID 17475607. “… the prevalence of circumcision slightly increased with age from 7.2% (95% CI, 5.3-10.8%) for boys aged 7 years to 8.7% (95% CI, 6.5-13.3%) for boys aged 13 years.”
  121. "In Australia and New Zealand, the circumcision rate has fallen considerably in recent years and it is estimated that currently only 10%-20% of male infants are routinely circumcised." (RACP: 2004)
  122. Richters, J; et al. (2006). "Circumcision in Australia: prevalence and effects on sexual health". Int J STD AIDS 17: 547-554. PMID 16925903. “Neonatal circumcision was routine in Australia until the 1970s … In the last generation, Australia has changed from a country where most newborn boys are circumcised to one where circumcision is the minority experience.”
  123. Dave, SS; et al (2003). "Male circumcision in Britain: findings from a national probability sample survey". Sex Transm Infect 79: 499-500.

External links

Circumcision opposition

Circumcision promotion

Circumcision techniques

Further reading

  • Billy Ray Boyd. Circumcision Exposed: Rethinking a Medical and Cultural Tradition. Freedom, CA: The Crossing Press, 1998. (ISBN 978-0-89594-939-4)
  • Anne Briggs. Circumcision: What Every Parent Should Know. Charlottesville, VA: Birth & Parenting Publications, 1985. (ISBN 978-0-9615484-0-7)
  • Robert Darby. A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain. Chicago: University of Chicago Press, 2005. (ISBN 978-0-226-13645-5)
  • Aaron J. Fink, M.D. Circumcision: A Parent's Decision for Life. Kavanah Publishing Company, Inc., 1988. (ISBN 978-0-9621347-0-8)
  • Paul M. Fleiss, M.D. and Frederick Hodges, D. Phil. What Your Doctor May Not Tell You About Circumcision. New York: Warner Books, 2002. (ISBN 978-0-446-67880-3)
  • Leonard B. Glick. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. New York: Oxford University Press, 2005. (ISBN 978-0-19-517674-2)
  • David Gollaher. Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000. (ISBN 0465026532)
  • Ronald Goldman, Ph.D. Circumcision: The Hidden Trauma. Boston: Vanguard, 1996. (ISBN 978-0-9644895-3-0)
  • Paysach J. Krohn, Rabbi. Bris Milah. Circumcision—The Covenant Of Abraham/A Compendium of Laws, Rituals, And Customs From Birth To Bris, Anthologized From Talmudic, And Traditional Sources. New York: Mesorah Publications, 1985, 2005.
  • Brian J. Morris, Ph.D., D.Sc. In Favour of Circumcision. Sydney: UNSW Press, 1999. (ISBN 978-0-86840-537-7)
  • Peter Charles Remondino. History of Circumcision from the Earliest Times to the Present. Philadelphia and London; F. A. Davis; 1891.
  • Rosemary Romberg. Circumcision: The Painful Dilemma. South Hadley, MA Bergan & Garvey, 1985. (ISBN 978-0-89789-073-1)
  • Edgar J Schoen, M.D. Ed Schoen, MD on Circumcision. Berkeley, CA: RDR Books, 2005. (ISBN 978-1-57143-123-3)
  • Edward Wallerstein. Circumcision: An American Health Fallacy. New York: Springer, 1980 (ISBN 978-0-8261-3240-6)
  • Gerald N. Weiss M.D. and Andrea W Harter. Circumcision: Frankly Speaking. Wiser Publications, 1998. (ISBN 978-0-9667219-0-4)
  • Yosef David Weisberg, Rabbi. Otzar Habris. Encyclopedia of the laws and customs of Bris Milah and Pidyon Haben. Jerusalem: Hamoer, 2002.
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