The widespread practice of removing all or part of the foreskin of the penis. The age of circumcision varies; male Jewish babies, for example, are circumcised eight days after birth, while other groups circumcise just before or at puberty as part of an initiation ceremony which marks the changing status from childhood to adulthood. In female circumcision, some or all external genitalia are removed. Circumcision may also be carried out for health reasons.
This article is about male circumcision. For the practice sometimes referred to as "female circumcision", see Female genital cutting.Circumcision is the removal of some or all of the foreskin (prepuce) from the penis. The word "circumcision" comes from Latin circum (meaning "around") and caedere (meaning "to cut"). The practice of circumcision predates recorded human history, with depictions found in stone-age cave drawings and Egyptian tombs. Theories include that circumcision is a form of ritual sacrifice or offering, 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. Circumcision of males is a religious requirement of the Muslim and Jewish faiths.
Elective infant circumcision has come under increasing discussion in recent decades. In a report confined to discussing circumcisions that are not performed for ritualistic or religious purposes, the American Medical Association states that medical associations in the US, Australia, and Canada do not recommend routine “non-therapeutic” circumcision, which it defines as non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. According to the AMA's 1999 literature review, in the US when non-ritualistic elective circumcision is chosen, it is largely because of social or cultural expectations, rather than medical concerns. The genital integrity movement condemns infant circumcision as a form of male genital mutilation that they consider comparable to female circumcision, and does not differentiate between religio-ritualistic versus purely elective circumcision of minors. When discussing non-religio-ritualistic neonatal circumcision, some explain their views in terms of the perceived medical benefits of the procedure (i.e. Circumcision is recommended by some physicians to treat medical conditions in males, such as phimosis, chronic inflammation of the penis, and penile cancer while other physicians believe there are less invasive treatments for phimosis that can be tried first.
The procedures of circumcision
Circumcision removes the foreskin from the penis. For infant circumcision, clamps, such as the Gomco clamp, Plastibell, and Mogen are often used.
With a Mogen clamp, used by many physicians and all mohels (Jewish ritual circumcisers), the foreskin is dissected away from the glans with a blunt probe and/or curved hemostat (as with the first part of the Gomco procedure).
According to a 1998 study, anaesthesia is used by 45% of physicians performing infant circumcisions.
Judaism
See also: Circumcision in the BibleCircumcision is fundamental to Judaism. It is usually performed in a ceremony called a Brit milah (or Bris milah, colloquially simply bris) (Hebrew for "Covenant of circumcision"). The expressly ritual element of circumcision in Judaism, as distinguished from its non-ritual requirement in Islam, is shown by the requirement that a child who either is born aposthetic (without a foreskin) or who has been circumcised without the ritual must nevertheless undergo a Brit Milah in which a drop of blood (hatafat-dam, הטפת דם) is drawn from the penis at the point where the foreskin would have been or was attached.
Christianity
Catholic, Protestant, Eastern and Oriental Orthodox Christianity do not prescribe circumcision. The first Church Council in Jerusalem decided that circumcision was not a requirement (Acts 15), and St. Paul warned gentile Christians against adopting the practice (Galatians 6:12-16, Philippians 3:2-3). For example, circumcision is customary among members of the Coptic Orthodox, Ethiopian Orthodox, and Eritrean Orthodox churches in their home countries. On 1 January, the Catholic Church used to celebrate the Circumcision of Christ. This change in the liturgy has led to some discussion by Christians
Islam
The origin of the requirement of circumcision in Islam is a matter of religious and scholarly debate. Fiqh scholars have different opinions about circumcision in Shariah, depending on which Hadith are accepted and how they are interpreted. Moreover, there are some who interpret verses in the Qur'an to imply that the requirement of circumcision is based on the covenant with Abraham.
The timing of Muslim circumcision varies. But circumcision may be performed at all ages from newborn period to adulthood the medical profession has encouraged the medicalising of circumcision and its performance within the first week after birth as a means of reducing complications, though "circumcision is performed by barbers, medical technicians, quacks and doctors including paediatric surgeon[s] [and as] yet there is no consensus for the best age and method."
Baha'i
"Bahá'ís are not advised on a particular course of action in respect to circumcision of males; circumcision of females is considered mutilation."
Hinduism
There is no specific reference to male circumcision in the Hindu holy books, and Hindus in India generally do not practice circumcision.
Sikhism
"Circumcision holds no relevance to a Sikh."
Secular tradition
Routine circumcision practices in South Korea are largely the result of American cultural and military influence following the Korean War. This is supported by the seventeenth century text of Antonio de Morga's History of the Philippine Islands, which equally speculatively attributes circumcision to Islamic influence. In West Africa infant circumcision may have had tribal significance as a rite of passage or otherwise in the past;
Non-Western initiatory traditions
Circumcision can be part of an initiation rite in some African, Pacific Islander, and certain isolated Australian aboriginal traditions, such as in Arnhem Land, where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago. Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature, including subincision for some aboriginal peoples in the Western Desert. In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu; Circumcision is also commonly practised in the Polynesian islands of Samoa, Tonga, Niue, and Tikopia. Although in many West African traditional societies circumcision has become medicalised and is simply performed in infancy without ado or any particular conscious cultural significance, among the Urhobo people of southern Nigeria it is symbolic of a boy entering into manhood. For Nilotic peoples, such as the Nandi, 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. Circumcision advocates assert that circumcision is a significant public health measure, preventing infections, and slowing down the spread of AIDS. The genital integrity movement, however, asserts that infant circumcision is a human rights violation and a sexual assault, and that the practice of circumcising infants or children should be discouraged or banned. Some believe that male circumcision is ethically identical to female genital cutting and question the perceived inconsistency of not prohibiting the former in the same manner as the latter. Some assert that circumcision causes sexual harm and emotional scarring later in life, or urge that the procedure should be left until the boy is mature enough to make the choice for himself. Others assert that circumcision is less traumatic when performed in infancy and that there is no evidence of sexual or emotional harm. They point out that restrictions on circumcision would be highly intrusive on the religious or cultural rites and practices of various communities and would interfere with the traditional right of parents to make this decision on behalf of their child.
Emotional consequences
An article discussed the extent to which circumcision may cause emotional harm to males. Several studies suggest that circumcised infants do not forget the pain during circumcision easily, as a correlation between circumcision with ineffective anaesthesia and intensity of pain response during vaccination months later has been noted.
Legality
The mainstream medical organizations do not consider circumcision to be a legal issue as long as the decision for circumcision was made by the legal guardians, and that they have given their informed consent. Muslims and Jews in Sweden objected to the law, and the World Jewish Congress stated that it was “the first legal restriction on Jewish religious practice in Europe since the Nazi era.”
Medical aspects
The direct medical benefits of neonatal circumcision are still under debate, with various studies reaching different opinions. The complication morbidity is compared to the potential gain in expected longevity, and the medical costs of circumcision are compared to the expected reduction in lifetime health costs. In the words of the BMA, “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.” Biases notwithstanding, some studies decided that circumcision has a net benefit, some decided that it has a net decrement, and others decided that the benefits and risks balance each other out and that other factors must be taken into consideration.
The American Medical Association, American Academy of Pediatrics, and the Royal Australasian College of Physicians all suggest that anasthesia be used if performing circumcision.
Risks of circumcision
Circumcision is a surgical procedure. While the risks of circumcision-related complications are very low, the complications resulting from a poorly carried out circumcision, post-operative bleeding, or infection can be catastrophic. Unfortunately, most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.” Infant circumcision may cause problems such as skin bridges, when the cut skin does not heal neatly but attaches to the glans penis instead. Meatal stenosis may be a common longer-term complication from circumcision. Gairdner's 1949 study reported that during the 1940's an average of 16 children per year, out of an estimated 90,000, died following circumcision in the UK. Deaths attributed to phimosis and circumcision were grouped together, but Gairdner guessed that such deaths were more likely due to the circumcision operation.
HIV
The most recent data indicate that circumcision is correlated with reduced risks of HIV transfer, although the topic remains the subject of ongoing research and debate in the medical community. There are also fears that some may mistakenly believe they will be protected against HIV through circumcision and see circumcision as a safe alternative to other forms of protection, such as condoms.
Research by the World Health Organization published in the US Public Library of Science Medicine journal in July, 2006, showed that men who had been circumcised had a significantly lower risk of infection with the AIDS virus, and calculated that if all men were circumcised over the next 10 years, some two million new infections could be avoided.
The results of the first randomised controlled trials were published in November 2005, reporting that male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa, affording a 60% reduction in the rate of new HIV infection (from 2.1 per 100 to 0.85 per 100 in the intervention group). Results of two further randomised trials to investigate the possible protective effect of circumcision against HIV infections will become available in 2007.
An earlier study in the March 2005 Cochrane review of the medical evidence concluded that, “Although the positive results of these observational studies suggest that circumcision is an intervention worth evaluating in randomised controlled trials, the current quality of evidence is insufficient to consider implementation of circumcision as a public-health intervention.” Initial population based studies suggesting that circumcision might play a protective role were criticised because confounding factors such as religion may have skewed the results;
If circumcision does protect against HIV transmission, the mechanism by which it does so is unclear.
Hygiene
The American Academy of Pediatrics observes “Circumcision has been suggested as an effective method of maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene.” It states that the "relationship among hygiene, phimosis, and penile cancer is uncertain" and further remarks that "genital hygiene needs to be emphasized as a preventive health topic throughout a patient's lifetime."
Circumcision reduces the amount of smegma produced by the male.
It has been suggested that circumcision arose in peoples living in arid and sandy regions as a public health measure intended to prevent recurring irritation and infection caused by sand accumulating under the foreskin. Darby, after checking the official war histories of Britain, Australia and New Zealand and other records, and finding no mention of ‘balanitis’ or ‘foreskin’ or ‘circumcision’ dismissed this idea as a “medical urban myth,” concluding that “‘sand under the foreskin,’ balanitis, and circumcision were not significant problems during either of the World Wars.”
Infectious and chronic conditions
Non-circumcised boys and men tend to have higher rates of various infections and inflammations of the foreskin than circumcised men.
There are less invasive treatments than circumcision for posthitis. There are less invasive treatments than circumcision that have been shown effective in treating most mild cases of balanitis. Birley, et al, also agrees that for many mild forms of balanitis there are less invasive procedures, but does state that there are times when circumcision “might be of benefit in a patient whose balanitis relapses despite these measures, and remains the principal treatment for specific conditions such as lichen sclerosus and plasma cell balanitis.” Also, less invasive procedures are not as successful in treating balanitis xerotica obliterans, or BXO, which is harder to treat. Circumcision is believed to reliably reduce the threat of BXO. However, they close their predictions section with the following “Since the uncircumcised male is uniquely susceptible, virtually all of these cancers are preventable by neo-natal circumcision. The number of lifetime incident cancers that could be prevented annually by circumcision can be estimated with birth statistics available for 1971. If none had been neonatally circumcised, our analysis predicts that one in 600, or more than 3,000 would have penile cancer in their lifetimes.”
However, a small risk is associated with non-classic vigorous circumcisions that leave scarring.
In 2005, the American Cancer Society said that while studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer, it is important to concentrate on the main risk factors: poor hygiene, having unprotected sex with multiple partners, and cigarette smoking. They further state that the current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer.
The American Academy of Pediatrics states 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.
The American Medical Association states similarly that although neonatal circumcision seems to lower the risk of contracting penile cancer, because it is rare and occurs later in life, the use of circumcision as a preventive practice is not justified.
Urinary tract infections
Twelve studies have indicated that neonatal circumcision reduces the occurrence rate of Urinary tract infections in male infants by a factor of about 10. The AMA cites evidence that the incidence of UTI’s is “small (0.4%-1%)” in uncircumcised infants, and “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI…One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition.”
The Canadian Paediatric Society poses the question of whether increased UTI and balanitis rates in non-circumcised male infants may be caused by forced premature retraction. According to the Lerman and Liao, aside from its effects on UTI infection rates, "Most of the other medical benefits of circumcision probably can be realized without circumcision as long as access to clean water and proper penile hygiene are achieved."
Policies of various national medical associations
The medical associations noted below find the current data insufficient to recommend neonatal circumcision.
United States
The American Academy of Pediatrics recommends the following:
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. 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.
—Circumcision Policy Statement, American Academy of Pediatrics
The American Medical Association supports the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics.
Canada
The Fetus and Newborn Committee of the Canadian Paediatric Society posted Circumcision: Information for Parents in November of 2004, and Neonatal circumcision revisited statements in 1996, undergoing revision as of 2004:
Circumcision is a “non-therapeutic” procedure, which means it is not medically necessary. To help make the decision about circumcision, parents should have information about risks and benefits. After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys.
—Circumcision: Information for Parents, Canadian Paediatric Society
We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. 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%. 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. 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. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms.
—Neonatal circumcision revisited, Canadian Paediatric Society
United Kingdom
As of June of 2006, the British Medical Association's position was as follows:
Circumcision for medical purposes
Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. Male circumcision in cases where there is a clear clinical
need is not normally controversial. 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 law and ethics of male circumcision - guidance for doctors, British Medical Association
Australasia
The Royal Australasian College of Physicians position is as follows:
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. (emphasis as in the original document)
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.
—ROUTINE CIRCUMCISION OF MALE INFANTS AND BOYS - SUMMARY STATEMENT, Royal Australasian College of Physicians
Sexual
The American Academy of Pediatrics states "a survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men. The American Academy of Family Physicians (AAFP) states "The effect of circumcision on penile sensation or sexual satisfaction is unknown.
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, as an aid to hygiene where regular bathing was impractical, as a means of marking those of lower (or higher) social status, as a means of differentiating a circumcising group from their non-circumcising neighbors, as a means of discouraging masturbation or other socially proscribed sexual behaviors, to remove "excess" pleasure, to increase a man's attractiveness to women, as a symbolic castration, as a demonstration of one's ability to endure pain, or as a male counterpart to menstruation or the breaking of the hymen. It is possible that circumcision arose independently in different cultures for different reasons.
Circumcision in the ancient world
The oldest documentary evidence for circumcision comes from ancient Egypt.
Circumcision was common, although not universal, among ancient Semitic peoples.
In the aftermath of the conquests of Alexander the Great, Greek dislike of circumcision led to a decline in its incidence among many peoples that had previously practised it. 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.
Medical circumcision in the 19th century and early 20th century
Several hypotheses have been raised in explaining the American public's acceptance of infant circumcision as preventive medicine. Accordingly, the smegma that collects under the foreskin was viewed as unhealthy, and circumcision readily accepted as good penile hygiene. In this climate, circumcision could be employed as a means of discouraging masturbation. All About the Baby, a popular parenting book of the 1890s, recommended infant circumcision for precisely this purpose. It has been suggested that once a critical mass of infants were being circumcised in the hospital, circumcision became a class marker of those wealthy enough to afford a hospital birth.
By the 1920s, advances in the understanding of disease had undermined much of the original medical basis for preventive circumcision.
Routine infant circumcision was taken up in the English-speaking parts of Canada, the United States and Australia, and to a lesser extent in New Zealand and the United Kingdom. Although it is difficult to determine historical circumcision rates, one estimate 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, a lack of consensus in the medical community as to whether circumcision carried with it any notable health benefit motivated the United Kingdom's newly-formed National Health Service to remove routine infant circumcision from its list of covered services. One factor in this rejection of circumcision may have been Douglas Gairdner’s famous study, The fate of the foreskin, which revealed that for the years 1942–1947, about 16 children per year had died because of circumcision in England and Wales, a rate of about 1 per 6000 performed circumcisions. 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 (where public medical insurance is universal and there is no private insurance), individual provincial health services began delisting circumcision in the 1980s.
In South Korea, circumcision was largely unknown before 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 .
In some South African ethnic groups, circumcision has roots in several belief systems, and is performed most of the time on teenage boys:
"...The young men in the eastern Cape belong to the Xhosa ethnic group for whom circumcision is considered part of the passage into manhood...Prior to 1989, the American Academy of Pediatrics had a long-standing opinion that medical indications for routine circumcision were lacking. 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. A 1999 study reported that reasons for circumcision included "ease of hygiene (67 percent), ease of infant circumcision compared with adult circumcision (63 percent), medical benefit (41 percent), and father circumcised (37 percent)." A 2001 study reported that "The most important reason to circumcise or not circumcise the child was health reasons."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.
The major medical societies in Britain, Canada, Australia and New Zealand do not support routine non-therapeutic infant circumcision. Major medical organizations in the United States do not recommend routine circumcision, but instead state that parents should decide what is in their child's best interests. Neonatal circumcision remains the most common pediatric operation carried out in the U.S. today.
Table 1: International circumcision rates| Country | Year | Neonatal circumcisions (%) |
|---|---|---|
| United States | 2003 | 55.9%* |
| Canada | 2005 | 9.2% |
| Australia | 2004 | 10%-20% |
| New Zealand | 1995 | 10%-20% |
| United Kingdom | 1972 | 0.41% |
| *The percentage refers to infants born in non-Federal hospitals; | ||
| **Samoans, Tongans and Niueans in New Zealand continue to practice circumcision, but not in public hospitals, to which these data refer. | ||
Prevalence of circumcision
Estimates of the proportion of males that are circumcised worldwide vary from one sixth to one third.
Denmark
Denmark has a circumcision rate which has been stable for the last fifty years amongst male children at about 2%. For example, only 511 out of approximately 478000 Danish boys aged 0-14 years were circumcised in 1986, corresponding to a cumulative national circumcision rate of around 1.6% by the age of 15 years.
South Korea
It has been estimated on the basis of an academic medical survey that some 78% of South Korean men may be circumcised and it has been stated that "South Korea has possibly the largest absolute number of teenage or adult circumcisions anywhere in the world. Because circumcision started through contact with the American military during the Korean War, South Korea has an unusual history of circumcision."
United States
Statistics from different sources give different pictures of infant circumcision rates in the United States. Deferral of discussion until after birth, combined with the fact that many parents’ decisions about circumcision are preconceived, contribute to the high rate of elective circumcision.
Figures from the Nationwide Hospital Discharge Survey (for the 2003 survey based on a sample of 320,000 inpatient stays in 426 non-Federal short-stay hospitals), state that circumcision rates declined from 64.7% in 1980 to 59.0% in 1990, then rose to 64.1% in 1995, and fell again to 55.9% in 2003. the reported figures do not include males who are circumcised at a later date for religious, medical, or personal reasons or who received newborn circumcision that was not coded."
Some obstetricians have been accused of using circumcision as a quick and easy way of making money . Medicaid funding for infant circumcision used to be universal in the United States however sixteen states no longer pay for the procedure under Medicaid . One study in the Midwest of the US found that this had no effect on the newborn circumcision rate but it did affect the demand for circumcision at a later time.
Canada
The incidence of child circumcision in Canada has been declining steadily.
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