Circumcision

This article is about male circumcision. For female circumcision, see Female genital cutting. For Judaism\'s circumcision ritual, see Brit milah.

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.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:

• "Male circumcision is the surgical removal of all or part of the foreskin of the penis." Information Package on Male Circumcision and HIV Prevention:Insert 1, World Health Organization
• "Circumcision, surgical removal of all or part of the foreskin of the human male...", "Circumcision", Microsoft Encarta, 2007.
• "Male circumcision is an elective surgery to remove the foreskin..." Circumcision, British Columbia Health Guide, June 2, 2006. Retrieved July 18, 2007.
• "Circumcision is surgery..." Pain and Your Infant: Medical Procedures, Circumcision and Teething, University of Michigan Health System, February 2007. Retrieved July 18, 2007.
• " Circumcision is cutting away part of the foreskin... When this surgery is performed..." Newborn Care, Danbury Hospital website. Retrieved July 18, 2007.

The word "circumcision" comes from Latin circum (meaning "around") and cædere (meaning "to cut").

The earliest pictures are from cave drawings of Ancient Egyptian tombs, though some pictures may be open to interpretation.http://www.cirp.org/library/history/hodges2 See \'Egyptians\'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.  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.  Male circumcision is a religious commandment in Judaism as well as in Islam,Circumcision. American-Israeli Cooperative Enterprise. Retrieved on 2006-10-03. 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.  and customary in some Oriental Orthodox and other Christian churches in Africa.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.

Circumcision is most common in the Middle East, the USA and parts of Africa and Asia. According to the WHO, global estimates suggest that 30% of males have been circumcised.Insert 2. Information Package on Male Circumcision and HIV Prevention. World Health Organization (2007). Retrieved on 2007-08-15.

Opponents of circumcision condemn infant circumcision as being medically unjustified, an infringement upon individual bodily rights, and a cause of sexual impairment,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.  while advocates of circumcision regard it as a worthwhile public health measure,Schoen, Edgar J (1997). "Benefits of newborn circumcision: is Europe ignoring medical evidence?" ((free registration required)). Archives of Disease in Childhood 77 (3): 258-260. PMID 9370910. Retrieved on 2007-04-06.  particularly in the control of HIV in Sub-Saharan Africa.Newell, Marie-Lousie; Till Bärnighausen (February 24, 2007). "Male circumcision to cut HIV risk in the general population" (PDF). The Lancet 369 (9562): 617–619. doi:DOI:10.1016/S0140-6736(07)60288-8. PMID 17321292. Retrieved on 2007-04-01.  Bailey, Robert C; Stephen Moses, Corette B Parker, Kawango Agot, Ian Maclean, John N Krieger, Carolyn F M Williams, Richard T Campbell, Jeckoniah O Ndinya-Achola (February 24, 2007). "Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial" (PDF). The Lancet 369 (9562): 643–656. doi:DOI:10.1016/S0140-6736(07)60312-2. PMID 17321310. Retrieved on 2007-04-01.  Gray, Ronald H; Godfrey Kigozi, David Serwadda, Frederick Makumbi, Stephen Watya, Fred Nalugoda, Noah Kiwanuka, Lawrence H Moulton, Mohammad A Chaudhary, Michael Z Chen, Nelson K Sewankambo, Fred Wabwire-Mangen, Melanie C Bacon, Carolyn F M Williams, Pius Opendi, Steven J Reynolds, Oliver Laeyendecker, Thomas C Quinn, Maria J Wawer (February 24, 2007). "Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial" (PDF). The Lancet 369 (9562): 657–666. doi:DOI:10.1016/S0140-6736(07)60313-4. PMID 17321311. Retrieved on 2007-04-01. 

In March 2007 the World Health Organization and UNAIDS stated that male circumcision is an effective intervention for HIV prevention, but also stated that male circumcision only provides partial protection and should not replace other interventions to prevent the heterosexual transmission of HIV. (March 28, 2007). "New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications" (PDF). World Health Organization. Retrieved on 2007-08-13.

Circumcision may also be used to treat inflammation of the glans.

Contents 1 Circumcision procedures 2 Cultures and religions 3 Ethical, emotional and legal considerations 3.1 Ethical issues 3.1.1 Consent 3.2 Emotional consequences 3.3 Legality 4 Pain and pain relief during circumcision 5 Sexual effects 6 Medical aspects 6.1 Risks of circumcision 6.2 HIV and other sexually transmitted diseases 6.3 Hygiene, and infectious and chronic conditions 6.4 Penile cancer 6.5 Policies of various national medical associations 6.5.1 United States 6.5.2 Canada 6.5.3 United Kingdom 6.5.4 Australasia 7 History of circumcision 7.1 Medical circumcision in the 19th century and early 20th century 7.2 Circumcision since 1950 8 Prevalence of circumcision 9 See also 10 Notes 11 External links 11.1 Circumcision opposition 11.2 Circumcision promotion 11.3 Circumcision techniques 12 Further reading

Circumcision procedures

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

• With the Plastibell, the foreskin and the clamp come away in three to seven days.
• With a Gomco clamp, a section of skin is first crushed with a hemostat then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp and the clamp is tightened, "crushing the foreskin between the bell and the base plate." The crushing limits bleeding (provides hemostasis). While the flared bottom of the bell fits tightly against the hole of the base plate, the foreskin is then cut away with a scalpel from above the base plate. The bell prevents the glans being reached by the scalpel.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. 

• 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.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. 

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. 

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, Africa, and is commonly practised in the Jewish and Islamic faiths. It is less common in Europe, Latin America, China and India.

Circumcision is a positive commandment obligatory under Jewish law for Jewish males, and is only postponed or abrogated in the case of threat to the life or health of the child.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.  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) (Hebrew for "Covenant of circumcision").

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

It is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches. Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya,Mattson CL, Bailey RC, Muga R, Poulussen R, Onyango T (2005) Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza province Kenya. AIDS Care 17:182–194. require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ.Greek Orthodox Archdiocese calendar of Holy Days.Russian Orthodox Church, Patriarchate of Moscow.

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.Al-Munajjid, Muhammed Salih. Question #9412: Circumcision: how it is done and the rulings on it. Islam Q&A. Retrieved on 2006-07-01. Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham.Al-Munajjid, Muhammed Salih. Question #7073: The health and religious benefits of circumcision. Islam Q&A. Retrieved on 2006-07-01. While endorsing circumcision for males, scholars note that it is not a requirement for converting to Islam.al-Sabbagh, Muhammad Lutfi (1996). Islamic ruling on male and female circumcision. Alexandria: World Health Organization, 16. 

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.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

Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land,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. where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.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.” Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature, including subincision for some aboriginal peoples in the Western Desert.Jones, IH (June 1969). "Subincision among Australian western desert Aborigines". British Journal of Medical Psychology 42 (2): 183–190. ISSN 0007-1129 PMID 5783777.  In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu;RECENT GUEST SPEAKER. Australian AIDS Fund Incorporated (2006). Retrieved on 2006-07-01. participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.Weird & Wonderful. United Travel. Retrieved on 2006-07-01.

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, it is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males.Circumcision amongst the Dogon. The Non-European Components of European Patrimony (NECEP) Database (2006). Retrieved on 2006-09-03. 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.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.  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.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.”

Ethical, emotional and legal considerations

Ethical issues

Main article: Bioethics of neonatal circumcision

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.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.

Circumcision advocates argue that circumcision is a significant public health measure, preventing infections, and slowing down the spread of AIDS.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.  Opponents of circumcision question the ethical validity of removing genital tissue from a minor, arguing that infant circumcision infringes upon individual autonomy and represents a human rights violation.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.  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. 

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,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.  but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue.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.”Medical Ethics Committee (June 2006). The law and ethics of male circumcision - guidance for doctors. British Medical Association. Retrieved on 2006-07-01. 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.

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. 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.Circumcision and the Code of Ethics, George C. Denniston, Humane Health Care Volume 12, Number 2.

Others believe neonatal circumcision is permissible, if parents should so choose. 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."Benatar, David; Benatar, Michael (2003). "How not to argue about circumcision". American Journal of Bioethics 3 (2): W1-W9.  In a cultural or religious context, Levenson argues that circumcision is of significant enough importance that parental consent is sufficient and that any possible misgivings surrounding the issue of consent are not significant enough to limit the exercise of infant/childhood circumcision.The New Enemies of Circumcision, Jon D. Levenson, Commentary Magazine.

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.Moses, S; Bailey, RC; Ronald AR (1998). "Male circumcision: assessment of health benefits and risks". Sex Transm Infect 74: 368-73.  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.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.  Some organizations have been formed as support groups for men who are resentful about being circumcised.

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,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.” 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.”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.’” However, in 2006, the United States State Department stated, in a report on Sweden, that most Jewish mohels had been certified under the law and 3000 Muslim and 40-50 Jewish boys were circumcised each year. The Swedish National Board of Health and Welfare reviewed the law in 2005 and recommended that it be maintained.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.

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.Court rules circumcision of four-year-old boy illegal. HELSINGIN SANOMAT, INTERNATIONAL EDITION (2006-08-07). Retrieved on 2007-09-17.

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.” It therefore recommended using pain relief for circumcision. 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."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.  Other medical associations also cite evidence that circumcision without anesthetic is painful.Circumcision: Position Paper on Neonatal Circumcision. American Academy of Family Physicians (2007). Retrieved on 2007-01-30.

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%).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. 

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." 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.”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.  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.”

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)."[2] 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.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.  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.Razmus I, Dalton M, Wilson D. "Pain management for newborn circumcision". Pediatr Nurs 30 (5): 414-7, 427. PMID 15587537.  Ng et al. found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.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. 

Sexual effects

Main article: Sexual effects of circumcision

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." 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."

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."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. 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

Main article: Medical analysis of circumcision

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.” Cost-benefit analyses have varied. Some found a small net benefit of circumcision,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.  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.  ^{[verification needed]} some found a small net decrement,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.  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.  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."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. 

Risks of circumcision

Main article: Medical analysis of circumcision

While the risk in a competently performed medical circumcision is very low,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.  complications from bleeding, infection and poorly carried out circumcisions can be catastrophic.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.  According to the American Medical Association (AMA), blood loss and infection are the most common complications, and most bleeding is minor and can be stopped by applying pressure. 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.”Kaplan, George W., M.D. (August 1983). "Complications of Circumcision" (HTML). UROLOGIC CLINICS OF NORTH AMERICA 10 (3): 543–549. Retrieved on 2006-09-29. 

A circumcised penis with a skin bridge.

Complication rates ranging from 0.06% to 55% have been cited.Fetus and Newborn Committee (March 1996). "Neonatal circumcision revisited". Canadian Medical Association Journal 154 (6): 769–780. Retrieved on 2006-07-02.  Infant circumcision may result in skin bridges,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.  and meatal stenosis may be a common longer-term complication from circumcision.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.  Angel, Carlos A. (June 12, 2006). http://www.emedicine.com/PED/topic2356.htm. eMedicine. WebMD. Retrieved on 2006-07-02. The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.Complications Of Circumcision. Paediatric Policy - Circumcision. The Royal Australasian College of Physicians (October 2004). Retrieved on 2006-07-11.

Deaths have been reported.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. 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. 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.Gairdner, Douglas (December 1949). "The Fate of the Foreskin". British Medical Journal 2 (4642): 1433–1437. PMID 15408299. Retrieved on 2006-07-01. 

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

The World Health Organization (WHO) stated that studies of three trials, one of which was completed, provide compelling evidence that male circumcision provides a 50-60% reduction in HIV transmission from female to male.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. In 2007, the WHO and UNAIDS recommended that male circumcision should now be recognized as an efficacious intervention for HIV prevention, but emphasised that it does not provide complete protection against HIV infection.WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention. World Health Organisation (March 2007). 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 pr