Information about Male Circumcision
This article is about male circumcision. For the practice sometimes referred to as "female circumcision", see Female genital cutting.
Circumcision is the surgical or other cutting of some or all of the foreskin (prepuce) from the penis.[1] The word "circumcision" comes from Latin circum (meaning "around") and caedere (meaning "to cut").
Circumcision predates recorded human history, with pictures in stone-age cave drawings and Ancient Egyptian tombs, though some pictures may be open to interpretation.[2][3] Theories include that circumcision is a form of ritual sacrifice or offering, a health precaution, a sign of submission to a deity, a rite of passage to adulthood, a mark of defeat or slavery, or an attempt to alter esthetics or sexuality.[4] Male circumcision is a religious commandment in Judaism as well as in Islam,[5][6] and customary in some Oriental Orthodox and other Christian churches in Africa.[7] Circumcision is most common in the Middle East, the USA and parts of Africa and Asia. According to WHO, 30% of men worldwide have had the procedure, mostly in countries where it is common for religious or cultural reasons.[8] Genital integrity supporters condemn infant circumcision as a human rights abuse and a genital mutilation like female genital cutting[9], while advocates of circumcision regard it as a worthwhile public health measure,[10] particularly in the control of HIV.[11][12][13] In March 2007 the World Health Organization and UNAIDS recognized male circumcision as an effective intervention for HIV prevention, but warned that male circumcision only provides partial protection and should not replace other interventions to prevent the heterosexual transmission of HIV.[14] Circumcision may also be used to treat inflammation of the glans and penile cancer.[15][16] Using circumcision to treat phimosis (see section below) is debated in medical literature.[17][18]
Circumcision procedures
For infant circumcision, clamps, such as the Gomco clamp, Plastibell, and Mogen are often used.[19] 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.[20]
- 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.[21][22]
The frenulum is cut if frenular chordee is evident.[23]<ref name = "Shechet" />
In pacific islands circumcisions do not remove the foreskin REF (mp3)Cultures and religions
- See also:
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 Muslim countries, Israel, the United States, the Philippines and South Korea and is commonly practised in the Jewish and Muslim 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.[24] 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").
While in most countries, Christians do not circumcise,[25] it 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[26][7], require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ. [27][28]
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.[29] Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham.[30]
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.[31]
Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land,[32] where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.[33] Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature, including subincision for some aboriginal peoples in the Western Desert.[34] In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu;[35] participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.[36]
Circumcision is also commonly practised 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.[37] 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.[38] 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.[39]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.[40]
Circumcision advocates argue that circumcision is a significant public health measure, preventing infections, and slowing down the spread of AIDS.[41] 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.[42][43]Consent
Views differ on whether limits should be placed on caregivers having a child circumcised.
Some medical associations accept that the parents should determine what is in the best interest of the infant or child,[44]<ref name = "CSA:I-99" />[44][44] but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue.[45][46] The BMA insists that a circumcision must not go ahead without the consent of both parents and the competent child.<ref name = "BMAGuide" />
Some argue that the nature of the medical benefits associated with infant circumcision are such that the potential medical problems can be avoided or, if they occur, can usually be treated in far 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.<ref name = "Somerville" /> Denniston contends that circumcision is inherently harmful and asserts that in the absence of the individual's consent, non-therapeutic child circumcision violates several ethical principles that govern medicine.[47]
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 there is no convincing evidence of sexual or emotional harm; and that if circumcision should become necessary, there are greater monetary and psychological costs in circumcising later rather than in infancy.[48] 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.[49]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.[50] 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.[51] Some organizations have been formed as support groups for men who are resentful about being circumcised.[9]Legality
Traditionally, circumcision has been presumed to be legal when performed by a trained operator.
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. [52].
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,[53] 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.”[54] 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 National Board of Health and Welfare reviewed the law in 2005 and recommended that it be maintained.[55]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.”[44] It therefore recommended using pain relief for circumcision.[44] 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 "[p]retreatment and postoperative management of neonatal circumcision pain is recommended based on these results." [56] Other medical associations also cite evidence that circumcision without anesthetic is painful. [57] [57]
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%).[58]
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."[24] 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.”[59] 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.”<ref name = "Shechet" />
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)."[1] 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.[60] 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.[61] Ng et al found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.[62]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."<ref name = "AAP1999" /> 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."<ref name = "AAFP" />
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."[63] 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.”<ref name = "BMAGuide" /> Cost-benefit analyses have varied. Some found a small net benefit of circumcision,[64][65] some found a small net decrement,[66][67] 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."[68]Risks of circumcision
A circumcised penis with a skin bridge.
Complication rates ranging from 0.06% to 55% have been cited. [72] Infant circumcision may result in skin bridges, [73] and meatal stenosis may be a common longer-term complication from circumcision. [74] [75] The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.[76]
Deaths have been reported.[71][77] 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.<ref name = "AAFP" /> 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.[78]
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.<ref name="aafpadult" />HIV and other sexually transmitted diseases
Three randomised control trials published since 2005 confirm that adult male circumcision results in a 50-60% reduction in risk of HIV transmission from female to male.[79] In 2007, the World Health Organisation and UNAIDS recommended that male circumcision should now be recognized as an efficacious intervention for HIV prevention,<ref name="WHO-C&R" /> but emphasised that it does not provide complete protection against HIV infection.[80]
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.[81]
A meta-analysis found that circumcision is associated with lower rates of syphilis, chancroid and possibly genital herpes. [82]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.[83][84][85] Several hypotheses have been suggested:- The foreskin may harbor bacteria and become infected if it is not cleaned properly.[86]
- The foreskin may become inflamed if it is cleaned too often with soap.[87]
- The forcible retraction of the foreskin in boys can lead to infections.<ref name ="CMAJ" />
There are less invasive treatments than circumcision that have been shown to be effective in treating most mild cases of balanitis.[89] The less invasive procedures are not as successful in treating balanitis xerotica obliterans, or BXO,[90][91][92] which is much less common but harder to treat.[93] Circumcision is believed to reliably reduce the threat of BXO.[94]
Several studies have shown that uncircumcised men are at greater risk of human papilloma virus (HPV) infection.[95][96] One study found no statistically significant difference in HPV infection between circumcised and uncircumcised men, but did note a significantly higher incidence of urethritis in the uncircumcised.[97]
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.[98] Some UTI studies have been criticized for not taking into account a high rate of UTI's among premature infants, [2] who are usually not circumcised because of their fragile health status.<ref name = "AAP1999" /> The AMA states that “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI."<ref name = "CSA:I-99" />Penile cancer
Penile cancer affects from 0.82 per 100,000 in Demnark to 10.5 per 100,000 men per year in parts of India (0.9 to 1 per 100,000 in the United States). <ref name = "AAP1999" /> Studies have reported a rate of penile cancer from 3 to 22 times higher in uncircumcised than circumcised men. [99][100]
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. <ref name = "AAP1999" />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) found both potential benefits and risks in infant circumcision. It felt that there was insufficient data to recommend routine neonatal circumcision, and recommended that parental decisions on circumcision should be made with as much accurate and unbiased information as possible, taking medical, cultural, ethnic, traditional, and religious factors into account. 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.[102]
The American Medical Association supports the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics.<ref name = "CSA:I-99" />
The American Urological Association (2007) recommends "that circumcision should be presented as an option for health benefits."[103]Canada
The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Circumcision: Information for Parents" in November 2004,[57] 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 paediatricians no longer perform circumcisions."[44]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.”[44]Australasia
The Royal Australasian College of Physicians states there is no medical indication for routine neonatal circumcision (emphasis as in the original). 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"<ref name = "RACPSumm" />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. It has been suggested that the custom of circumcision gave advantages to tribes that practiced it and thus led to its spread regardless of whether the people understood this.[107] It is possible that circumcision arose independently in different cultures for different reasons.
Köçeks at a fair
Köçek troupe dancing at Sultan Ahmed III's 14-day celebration of his sons' circumcision in 1720. Miniature from the Surname-i Vehbi, Topkapı Palace, Istanbul.
The oldest documentary evidence for circumcision comes from ancient Egypt.[108] Circumcision was common, although not universal, among ancient Semitic peoples. [109] In the aftermath of the conquests of Alexander the Great, however, Greek dislike of circumcision led to a decline in its incidence among many peoples that had previously practised it. [110]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 success of the germ theory of disease made surgery safer, and made the public suspicious of dirt and bodily secretions, so circumcision was seen as good penile hygiene.[3] Some of the other possible reasons include because it was thought to be a way to discourage masturbation, [111] and to protect against syphilis.[112]
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[4] 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 1950
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.[113]
In some South African ethnic groups, circumcision has roots in several belief systems, and is performed most of the time 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.[5] 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.[6]Prevalence of circumcision
It has been estimated on the basis of an academic medical survey that some 78% of South Korean men may be circumcised, possibly the largest absolute number of teenage or adult circumcisions anywhere in the world. [118] For the United States, statistics from different sources give widely varying estimates of circumcision rates, from 55.9%[119] to 91%[120]
Rickwood et al reported that the proportion of English boys circumcised for medical reasons had fallen from 35% in the early 1930s to 6.5% by the mid-1980s. An estimated 3.8% of male children in the UK in 2000 were being circumcised by the age of 15 [7].
According to the Sydney Morning Herald, the infant circumcision rate in Australia was 12.9% in 2003.[121] In 1986, only 511 out of approximately 478,000 Danish boys aged 0-14 years were circumcised. This corresponds to a cumulative national circumcision rate of around 1.6% by the age of 15 years. [8].See also
- Brit milah
- Circumcision scar
- Foreskin restoration
- Genital integrity
- Holy Prepuce
- Preputioplasty, alternative to circumcision in the treatment for phimosis
- Zeved habat
Notes
- The foreskin may become inflamed if it is cleaned too often with soap.[87]
- 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.[21][22]
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