Circumcision
Overview
Male circumcision is the surgical removal of some or all of the foreskin
Foreskin
In male human anatomy, the foreskin is a generally retractable double-layered fold of skin and mucous membrane that covers the glans penis and protects the urinary meatus when the penis is not erect...

 (prepuce) from the penis
Penis
The penis is a biological feature of male animals including both vertebrates and invertebrates...

. The word "circumcision" comes from Latin
Latin
Latin is an Italic language originally spoken in Latium and Ancient Rome. It, along with most European languages, is a descendant of the ancient Proto-Indo-European language. Although it is considered a dead language, a number of scholars and members of the Christian clergy speak it fluently, and...

  (meaning "around") and (meaning "to cut").
Early depictions of circumcision are found in cave painting
Cave painting
Cave paintings are paintings on cave walls and ceilings, and the term is used especially for those dating to prehistoric times. The earliest European cave paintings date to the Aurignacian, some 32,000 years ago. The purpose of the paleolithic cave paintings is not known...

s and Ancient Egypt
Ancient Egypt
Ancient Egypt was an ancient civilization of Northeastern Africa, concentrated along the lower reaches of the Nile River in what is now the modern country of Egypt. Egyptian civilization coalesced around 3150 BC with the political unification of Upper and Lower Egypt under the first pharaoh...

ian tomb
Tomb
A tomb is a repository for the remains of the dead. It is generally any structurally enclosed interment space or burial chamber, of varying sizes...

s, though some pictures are open to interpretation. Religious male circumcision is considered a commandment from God
Mitzvah
The primary meaning of the Hebrew word refers to precepts and commandments as commanded by God...

 in Judaism
Judaism
Judaism ) is the "religion, philosophy, and way of life" of the Jewish people...

. In Islam
Islam
Islam . The most common are and .   : Arabic pronunciation varies regionally. The first vowel ranges from ~~. The second vowel ranges from ~~~...

, though not discussed in the Qur'an
Qur'an
The Quran , also transliterated Qur'an, Koran, Alcoran, Qur’ān, Coran, Kuran, and al-Qur’ān, is the central religious text of Islam, which Muslims consider the verbatim word of God . It is regarded widely as the finest piece of literature in the Arabic language...

, male circumcision is widely practised and most often considered to be a sunnah
Sunnah
The word literally means a clear, well trodden, busy and plain surfaced road. In the discussion of the sources of religion, Sunnah denotes the practice of Prophet Muhammad that he taught and practically instituted as a teacher of the sharī‘ah and the best exemplar...

.
Quotations

"Circumcising a baby boy to protect against STDs is like selling your car to make sure he's never injured in a crash." ~ Dr Schwanz, Men's Health, July/August 2002

"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." - Dr Auvert, et al, PLoS Medicine, November 2005

"To cut off the uppermost skin of the secret parts is directly against the honesty of nature, and an injurious insufferable trick put upon her." ~ Dr John Bulwer Anthropometamorphosis, man transform'd, or the artificial changeling (London 1650), p. 213

"Despite overwhelming evidence from urological surgeons that neoplasm of the penis is a lethal disease that can be prevented by removal of the foreskin, some physicians continue to argue against routine circumcision in a highly emotional and aggressive fashion." - Dr Dagher, Journal of Urology, 1973

"Why is the operation of circumcision practiced? One might as well attempt to explain the rites of voodoo!" ~ William Keith C. Morgan, MD The Rape of the Phallus, 1967

"In an apparent effort to bolster the weak anticircumcision argument, 2 anecdotal beliefs are added to the listed reasons not to choose circumcision: the "protective benefit" of the foreskin on the tip of the penis and the belief that circumcision causes decreased sexual pleasure later in life. Neither of these anecdotal beliefs meets the stated criterion of being evidence-based." - Dr Schoen, et al, Pediatrics, 2000

"Circumcision is a solution looking for a problem. The medical profession bears responsibility for the introduction of prophylactic circumcision without scientific basis in the past and for its continued use and rationalization without scientific basis in the present. ~ Edward Wallerstein, Circumcision: An American Health Fallacy, 1980

"The multiple benefits of newborn circumcision are additive over a lifetime and include prevention of cancer of the penis, of balanoposthitis, and protection against the effects of phimosis and poor hygiene as well as prevention of UTI and STD, particularly of HIV." - Dr Schoen, et al, Archives of Diseases in Childhood, 1997

"Circumcised males do not benefit from their circumcision but instead only suffer pain and permanent disfigurement of their genitalia." ~ Thomas Bartman, MD, PHD Division of Neonatology University of California, San Francisco Pediatrics, Evanston, Jan 2001, Vol. 107:1, p 210

Encyclopedia
Male circumcision is the surgical removal of some or all of the foreskin
Foreskin
In male human anatomy, the foreskin is a generally retractable double-layered fold of skin and mucous membrane that covers the glans penis and protects the urinary meatus when the penis is not erect...

 (prepuce) from the penis
Penis
The penis is a biological feature of male animals including both vertebrates and invertebrates...

. The word "circumcision" comes from Latin
Latin
Latin is an Italic language originally spoken in Latium and Ancient Rome. It, along with most European languages, is a descendant of the ancient Proto-Indo-European language. Although it is considered a dead language, a number of scholars and members of the Christian clergy speak it fluently, and...

  (meaning "around") and (meaning "to cut").
Early depictions of circumcision are found in cave painting
Cave painting
Cave paintings are paintings on cave walls and ceilings, and the term is used especially for those dating to prehistoric times. The earliest European cave paintings date to the Aurignacian, some 32,000 years ago. The purpose of the paleolithic cave paintings is not known...

s and Ancient Egypt
Ancient Egypt
Ancient Egypt was an ancient civilization of Northeastern Africa, concentrated along the lower reaches of the Nile River in what is now the modern country of Egypt. Egyptian civilization coalesced around 3150 BC with the political unification of Upper and Lower Egypt under the first pharaoh...

ian tomb
Tomb
A tomb is a repository for the remains of the dead. It is generally any structurally enclosed interment space or burial chamber, of varying sizes...

s, though some pictures are open to interpretation. Religious male circumcision is considered a commandment from God
Mitzvah
The primary meaning of the Hebrew word refers to precepts and commandments as commanded by God...

 in Judaism
Judaism
Judaism ) is the "religion, philosophy, and way of life" of the Jewish people...

. In Islam
Islam
Islam . The most common are and .   : Arabic pronunciation varies regionally. The first vowel ranges from ~~. The second vowel ranges from ~~~...

, though not discussed in the Qur'an
Qur'an
The Quran , also transliterated Qur'an, Koran, Alcoran, Qur’ān, Coran, Kuran, and al-Qur’ān, is the central religious text of Islam, which Muslims consider the verbatim word of God . It is regarded widely as the finest piece of literature in the Arabic language...

, male circumcision is widely practised and most often considered to be a sunnah
Sunnah
The word literally means a clear, well trodden, busy and plain surfaced road. In the discussion of the sources of religion, Sunnah denotes the practice of Prophet Muhammad that he taught and practically instituted as a teacher of the sharī‘ah and the best exemplar...

. It is also customary in some Christian churches in Africa.

Global estimates by the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

 (WHO) suggest that 30 percent of males are circumcised, of whom 68 percent are Muslim. The prevalence of circumcision varies mostly with religious affiliation, and sometimes culture. Most circumcisions are performed during adolescence for cultural or religious reasons; in some countries they are more commonly performed during infancy. Circumcision is also used therapeutically, as one of the treatment options for balanitis xerotica obliterans
Balanitis xerotica obliterans
Balanitis xerotica obliterans is a dermatological condition affecting the male genitalia. It was first described by Stuhmer in 1928, though earlier reports describe what may have been the same condition....

, paraphimosis
Paraphimosis
Paraphimosis is an uncommon medical condition where the foreskin becomes trapped behind the glans penis, and cannot be reduced...

, balanitis
Balanitis
Balanitis is inflammation of the glans penis . When the foreskin is also affected, it is termed balanoposthitis....

, posthitis
Posthitis
Posthitis is inflammation of the foreskin of the human penis .The term "posthitis" comes from the Greek "posthe" meaning foreskin + "-itis" meaning inflammation = inflammation of the foreskin.-Signs and Symptoms:...

, balanoposthitis
Balanoposthitis
-Background:Balenoposthitis is defined as the inflammation of the foreskin and glans in uncircumcised males. Balanoposthitis occurs over a wide age range and may have any of multiple bacterial or fungal origins or be caused by contact dermatitis...

 and urinary tract infections.

Circumcision reduces the risk of HIV
HIV
Human immunodeficiency virus is a lentivirus that causes acquired immunodeficiency syndrome , a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive...

 infection in heterosexual populations that are at high risk. Evidence among heterosexual men in sub-Saharan Africa
Sub-Saharan Africa
Sub-Saharan Africa as a geographical term refers to the area of the African continent which lies south of the Sahara. A political definition of Sub-Saharan Africa, instead, covers all African countries which are fully or partially located south of the Sahara...

 shows a decreased risk of between 38 percent and 66 percent over two years and in this population it appears cost effective. Evidence of benefit for women is controversial and evidence of benefit in developed countries and among men who have sex with men
Men who have sex with men
Men who have sex with men are male persons who engage in sexual activity with members of the same sex, regardless of how they identify themselves; many men choose not to accept sexual identities of homosexual or bisexual...

 is yet to be determined. The WHO currently recommends circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV. Ethical concerns remain regarding the implementation of campaigns to promote circumcision. According to the Royal Dutch Medical Association
Royal Dutch Medical Association
The Royal Dutch Medical Association is the professional organisation for medical practitioners in the Netherlands....

 (2010), no professional association of physicians currently recommends routine circumcision. Some bodies have discussed under what circumstances neonatal circumcision is ethical.

There is controversy regarding circumcision
Circumcision controversies
Male circumcision has often been, and remains, the subject of controversy on a number of grounds—including religious, ethical, sexual, and health....

. Arguments that have been raised in opposition to circumcision include that it adversely affects penile function and sexual pleasure, is justified only by medical myths, is extremely painful, and is a violation of human rights
Human rights
Human rights are "commonly understood as inalienable fundamental rights to which a person is inherently entitled simply because she or he is a human being." Human rights are thus conceived as universal and egalitarian . These rights may exist as natural rights or as legal rights, in both national...

. Those raised in favour of circumcision include that it provides important health advantages which outweigh the risks, has no substantial effects on sexual function, has a low complication rate when carried out by an experienced physician, and is best performed during the neonatal
Infant
A newborn or baby is the very young offspring of a human or other mammal. A newborn is an infant who is within hours, days, or up to a few weeks from birth. In medical contexts, newborn or neonate refers to an infant in the first 28 days after birth...

 period.

Modern procedure

If anesthesia is to be used there are several options: local anesthetic
Local anesthetic
A local anesthetic is a drug that causes reversible local anesthesia, generally for the aim of having local analgesic effect, that is, inducing absence of pain sensation, although other local senses are often affected as well...

 cream (EMLA cream) can be applied to the end of the penis 60–90 minutes prior to the procedure; local anesthetic can be injected at the base of the penis to block the dorsal penile nerve; local anesthetic can be injected in a ring around the middle of the penis in what is called a subcutaneous ring block. It is also possible to use general anesthetics in the case of adult surgery, though not the standard practice.

For infant circumcision, devices such as the Gomco clamp
Gomco clamp
A Gomco clamp, otherwise known as a Yellen clamp, is a specialized clamp for performing circumcisions. It was invented by Hiram S. Yellen and Aaron Goldstein in 1934-1935. Gomco stands for the GOldstein Medical COmpany, the original manufacturer of the clamp...

, Plastibell
Plastibell
The Plastibell Circumcision Device is a clear plastic ring with a deep groove running circumferentially designed for circumcising infant males. The Plastibell is placed onto the head of the penis during a 10 minute surgical procedure, and the device will fall off within 3 to 7 days...

, and Mogen clamp
Mogen clamp
The Mogen clamp, one of the three most common circumcision devices, was invented by Rabbi Harry Bronstein in 1954. It has two flat blades that open approx. 3 mm...

 are commonly used, together with a restraining device.

With all these devices the same basic procedure is followed. First, the amount of foreskin to be removed is estimated. The foreskin is then opened via the preputial orifice to reveal the glans
Glans penis
The glans penis is the sensitive bulbous structure at the distal end of the penis. The glans penis is anatomically homologous to the clitoral glans of the female...

 underneath and ensure it is normal. The inner lining of the foreskin (preputial epithelium) is then bluntly separated from its attachment to the glans. The device is then placed (this sometimes requires a dorsal slit
Dorsal slit
A dorsal slit is a single incision along the upper length of the foreskin from the tip to the corona, exposing the glans without removing any tissue....

) and remains there until blood flow has stopped. Finally, the foreskin is amputated. Sometimes, the frenulum
Frenulum of prepuce of penis
The word frenulum on its own is often used for the frenulum of prepuce of penis, which is an elastic band of tissue under the glans penis that connects to the prepuce, or foreskin to the vernal mucosa, and helps contract the prepuce over the glans. This is sometimes colloquially known as the "banjo...

 band may need to be broken or crushed and cut from the corona near the urethra to ensure that the glans can be freely and completely exposed.
  • With the Plastibell
    Plastibell
    The Plastibell Circumcision Device is a clear plastic ring with a deep groove running circumferentially designed for circumcising infant males. The Plastibell is placed onto the head of the penis during a 10 minute surgical procedure, and the device will fall off within 3 to 7 days...

    , once the glans is freed the Plastibell is placed over the glans, and the foreskin is placed over the Plastibell. A ligature
    Ligature (medicine)
    In surgery or medical procedure, a ligature consists of a piece of thread tied around an anatomical structure, usually a blood vessel or another hollow structure to shut it off. With a blood vessel the surgeon will clamp the vessel perpendicular to the axis of the artery or vein with a hemostat,...

     is then tied firmly around the foreskin and tightened into a groove in the Plastibell to achieve hemostasis
    Hemostasis
    Hemostasis or haemostasis is a process which causes bleeding to stop, meaning to keep blood within a damaged blood vessel . Most of the time this includes blood changing from a liquid to a solid state. Intact blood vessels are central to moderating blood's tendency to clot...

    . Foreskin distal to the ligature is excised and the handle is snapped off the Plastibell device. The Plastibell falls from the penis after the wound has healed, typically in four to six days.
  • With a Gomco clamp, a section of skin is dorsally crushed with a hemostat
    Hemostat
    A hemostat , is a vital surgical tool used in almost any surgical procedure, usually to control bleeding. Therefore, it is not uncommon to see the initial incision lined with hemostats closing blood vessels awaiting ligation during the initial phases of surgery...

     and then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is tightened, "crushing the foreskin between the bell and the base plate." The crushed blood vessels provide hemostasis. The flared bottom of the bell fits tightly against the hole of the base plate, so the foreskin may be cut away with a scalpel from above the base plate.
  • With a Mogen clamp, the foreskin is pulled dorsally with a straight hemostat, and lifted. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result" to Gomco or Plastibell circumcisions. The clamp is locked, and a scalpel is used to cut the skin from the flat (upper) side of the clamp.


Adult circumcisions are often performed without clamps and require four to six weeks of abstinence from masturbation
Masturbation
Masturbation refers to sexual stimulation of a person's own genitals, usually to the point of orgasm. The stimulation can be performed manually, by use of objects or tools, or by some combination of these methods. Masturbation is a common form of autoeroticism...

 or intercourse after the operation to allow the wound to heal. In some African countries, male circumcision is often performed by non-medical personnel under unsterile conditions. After hospital circumcision, the foreskin may be used in biomedical research, consumer skin-care products, skin grafts, or β-interferon
Interferon
Interferons are proteins made and released by host cells in response to the presence of pathogens—such as viruses, bacteria, or parasites—or tumor cells. They allow communication between cells to trigger the protective defenses of the immune system that eradicate pathogens or tumors.IFNs belong to...

-based drugs. In parts of Africa, the foreskin may be dipped in brandy and eaten by the patient, eaten by the circumciser, or fed to animals. According to Jewish law
Halakha
Halakha — also transliterated Halocho , or Halacha — is the collective body of Jewish law, including biblical law and later talmudic and rabbinic law, as well as customs and traditions.Judaism classically draws no distinction in its laws between religious and ostensibly non-religious life; Jewish...

, after a Brit milah
Brit milah
The brit milah is a Jewish religious circumcision ceremony performed on 8-day old male infants by a mohel. The brit milah is followed by a celebratory meal .-Biblical references:...

, the foreskin should be buried.

Ethical, psychological, and legal considerations


Ethical issues

Ethical questions have been raised over removing healthy, functioning genital tissue from a minor. Opponents of circumcision state that infant circumcision infringes upon individual autonomy and represents a human rights violation
Human rights
Human rights are "commonly understood as inalienable fundamental rights to which a person is inherently entitled simply because she or he is a human being." Human rights are thus conceived as universal and egalitarian . These rights may exist as natural rights or as legal rights, in both national...

. Rennie et al. note that using circumcision as a way of preventing HIV in high prevalence, low-income countries in sub-Saharan Africa
Sub-Saharan Africa
Sub-Saharan Africa as a geographical term refers to the area of the African continent which lies south of the Sahara. A political definition of Sub-Saharan Africa, instead, covers all African countries which are fully or partially located south of the Sahara...

, is controversial, but argue that "it would be unethical to not seriously consider one of the most promising [. . .] new approaches to HIV-prevention in the 25-year history of the epidemic".

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, but the Royal Australasian College of Physicians
Royal Australasian College of Physicians
The Royal Australasian College of Physicians, or RACP, is the organisation responsible for training, educating, and representing over 9,000 physicians and paediatricians in Australia and New Zealand. It was founded in 1938....

 (RACP) and the British Medical Association
British Medical Association
The British Medical Association is the professional association and registered trade union for doctors in the United Kingdom. The association does not regulate or certify doctors, a responsibility which lies with the General Medical Council. The association’s headquarters are located in BMA House,...

 (BMA) observe that controversy exists on this issue.
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. UNAIDS states that "[m]ale circumcision is a voluntary surgical procedure and health
care providers must ensure that men and young boys are given all the necessary information to
enable them to make free and informed choices either for or against getting circumcised."

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
Margaret Somerville
Margaret Anne Ganley Somerville, AM, FRSC is a conservative Australian/Canadian ethicist and academic. She is the Samuel Gale Professor of Law, Professor in the Faculty of Medicine and the Founding Director of the Faculty of Law's Centre for Medicine, Ethics and Law at McGill...

 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 states that circumcision is harmful and asserts that in the absence of the individual's consent, non-therapeutic child circumcision violates several ethical principles that govern medicine.

Others believe neonatal circumcision is permissible, if parents should so choose. Viens argues that, in a cultural or religious context, circumcision is of significant enough importance that parental consent is sufficient and that there is "an absence of sufficient evidence or persuasive argumentation" to support changing the present policy. 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."

Acknowledgment of pain

Williams (2003) argued that human attitudes toward the pain that animals (including humans) experience may not be based on speciesism
Speciesism
Speciesism is the assigning of different values or rights to beings on the basis of their species membership. The term was created by British psychologist Richard D...

, developing an analogy between attitudes toward the pain pigs endure while having their tails docked
Docking (animal)
Docking is a term for the intentional removal of part of an animal's tail or ears. The term cropping is also used, though more commonly in reference to the cropping of ears, while docking more commonly—but not exclusively—refers to the tail. The term tailing is also commonly used...

, and "our culture's indifference to the pain that male human infants experience while being circumcised."

Psychological issues

The British Medical Association (BMA) states that "it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks." Milos
Marilyn Milos
Marilyn Fayre Milos is the founder and director of the National Organization of Circumcision Information Resource Centers , a genital integrity organization which opposes the genital modification of children.-Early life:...

 and Macris (1992) argue that circumcision encodes the perinatal brain with violence and negatively affects infant-maternal bonding and trust. Goldman 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. Furthermore, Schultheiss (1998) reports males attempting to undo the effects of circumcision through the practice of foreskin restoration
Foreskin restoration
Foreskin restoration is the process of expanding the residual skin on the penis, via surgical or non-surgical methods. It can be performed for several reasons, among them being a desire to create the appearance of a natural foreskin covering the glans penis, or to increase sexual sensitivity of...

.
Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, citing a longitudinal study which did not find a difference in developmental and behavioural indices. A literature review by Gerharz and Haarmann (2000) reached a similar conclusion.
Boyle et al. (2002) state that circumcision may result in psychological harm, including post-traumatic stress disorder (PTSD), citing a study reporting high rates of PTSD among Filipino boys after either ritual or medical circumcision. Hirji et al. (2005) state that "Reports of [. . .] psychological trauma are not borne out in studies but remain as an anecdotal cause for concern."

Legal issues

In 2001, Sweden passed a law allowing only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anaesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the law, and in 2001, the World Jewish Congress
World Jewish Congress
The World Jewish Congress was founded in Geneva, Switzerland, in August 1936 as an international federation of Jewish communities and organizations...

 stated that it was "the first legal restriction on Jewish religious practice in Europe since the Nazi era." In 2005, the Swedish National Board of Health and Welfare reviewed the law and recommended that it be maintained. In 2006, the U.S. State Department's report on Sweden stated that most Jewish mohel
Mohel
A mohel is a Jewish person trained in the practice of brit milah "covenant of circumcision."-Etymology of the Hebrew and Aramaic term:...

s had been certified under the law and 3000 Muslim and 40–50 Jewish boys were circumcised each
year.

In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised was illegal. However, no punishment was assigned by the court, and in 2008 the Finnish Supreme Court ruled that the mother's actions did not constitute a criminal offense and that circumcision of a child for religious reasons, when performed properly, is not a crime. In 2008, the Finnish government was reported to be considering a new law to legalize ritual circumcision if the practitioner is a doctor, "according to the parents' wishes, and with the child's consent", as reported.

By 2007, the Australian states of Victoria, New South Wales, Western Australia and Tasmania had stopped the practice of non-therapeutic male circumcision in all public hospitals.

Medical aspects

Medical cost-benefit analyses of circumcision have varied. Some found a small net benefit of circumcision, some found a small net decrement, 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."

Pain and pain relief

According to the American Academy of Pediatrics
American Academy of Pediatrics
The American Academy of Pediatrics is the major professional association of pediatricians in the United States. The AAP was founded in 1930 by 35 pediatricians to address pediatric healthcare standards. It currently has 60,000 members in primary care and sub-specialist areas...

' 1999 Circumcision Policy Statement, "There is considerable evidence that newborns who are circumcised without analgesia experience pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...

 and physiologic stress." 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 than circumcision to account for different levels of pain response, they stated that they did not find evidence of such. It therefore recommended to use pain relief for circumcision. Other medical associations also cite evidence that circumcision without anesthetic is painful.

Stang, 1998, found 45% of physicians responding to a survey who circumcise used anaesthesia – most commonly a dorsal penile nerve block – for infant circumcisions. The obstetricians in the sample used anaesthesia less often (25%) than the family practitioners (56%) or pediatricians (71%). Howard et al. (1998) surveyed US medical doctor residency programs and directors, and found that 26% of the programs that taught the circumcision procedure "failed to provide instruction in anesthesia/analgesia for the procedure" and recommended that "residency training in neonatal circumcision should include instruction in pain relief techniques". A 2006 follow-up study revealed that the percentage of programs that taught circumcision and also taught administration of topical or local anesthetic had increased to 97%. However, the authors of the follow-up study also noted that only 84% of these programs used anesthetic "frequently or always" when the procedure was conducted.

Glass, 1999, stated that Jewish ritual circumcision is so quick that "most mohelim do not routinely use any anaesthesia as they feel there is probably no need in the neonate." Glass continued, "However, there is no Talmudic objection and should the parents wish for local anaesthetic cream to be applied there is no reason why this cannot be done." Glass also stated that for older children and adults, a penile block is used. In 2001 the Swedish government passed a law requiring all boys undergoing a bris to be given anaesthetic administered by a medical professional.

Lander et al. demonstrated that babies circumcised without anesthesia showed behavioral and physiological signs of pain and distress. Comparisons of the dorsal penile nerve block and EMLA (lidocaine/prilocaine) topical cream methods of pain control have revealed that while both are safe, the dorsal nerve block controls pain more effectively than topical treatments, but neither method eliminates pain completely. 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. Ng et al. found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.

Sexual effects

The sexual effects of circumcision are the subject of much debate. The American Academy of Pediatrics points to a survey (self-report) finding circumcised adult men had less sexual dysfunction and more varied sexual practices, but also noted anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males. A 2002 review by Boyle et al. stated that "the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings—many of which are lost to circumcision, with an inevitable reduction in sexual sensation experienced by circumcised males." They concluded, "intercourse is less satisfying for both partners when the man is circumcised". 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." Payne et al. reported that direct measurement of penile sensation in the shaft and glans during sexual arousal
Sexual arousal
Sexual arousal, or sexual excitement, is the arousal of sexual desire, during or in anticipation of sexual activity. Things that precipitate human sexual arousal are called erotic stimuli, or colloquially known as turn-ons. There are many potential stimuli, both physical or mental, which can cause...

 failed to support the hypothesised sensory differences associated with circumcision status.
In a 2007 study, Sorrells et al., using monofilament touch-test mapping, found that the foreskin contains the most sensitive parts of the penis, noting that these parts are lost to circumcision. They also found that "the glans of the circumcised penis is less sensitive to fine-touch than the glans of the uncircumcised penis." In a 2008 study, Krieger et al. found that 'compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," and 54.5% rated their ease of reaching orgasm as "much more" at month 24'. In contrast, they also found that '6–7% reported that their penis was “somewhat less” or “much less” sensitive' and 10.2% reported that it was "somewhat less" or "much less" easy to achieve orgasm.

Reports detailing the effect of circumcision on erectile dysfunction
Erectile dysfunction
Erectile dysfunction is sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual performance....

 have been mixed. Studies have shown that circumcision can result in a statistically significant increase, or decrease, in erectile dysfunction among circumcised men, while other studies have shown little to no effect.

Complications

Complication rates ranging from 0.06% to 55% have been cited; more specific estimates have included 2-10% and 0.2-0.6%.

According to the American Medical Association
American Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...

 (AMA), blood loss and infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...

 are the most common complications, but most bleeding is minor and can be stopped by applying pressure. A survey of circumcision complications by Kaplan in 1983 revealed that the rate of bleeding complications was between 0.1% and 35%. A 1999 study of 48 boys who had complications from traditional male circumcision in Nigeria
Nigeria
Nigeria , officially the Federal Republic of Nigeria, is a federal constitutional republic comprising 36 states and its Federal Capital Territory, Abuja. The country is located in West Africa and shares land borders with the Republic of Benin in the west, Chad and Cameroon in the east, and Niger in...

 found that haemorrhage occurred in 52% of the boys, infection in 21% and one child had his penis amputated.

One study looking at 354,297 births in Washington State from 1987-1996 found that immediate post-birth complications occurred at a rate of 0.2% in the circumcised babies and at a rate of 0.01% in the uncircumcised babies. The authors judged that this was a conservative estimate because it did not capture the very rare but serious delayed complications associated with circumcisions (e.g., necrotizing fasciitis
Necrotizing fasciitis
Necrotizing fasciitis , commonly known as flesh-eating disease or Flesh-eating bacteria syndrome, is a rare infection of the deeper layers of skin and subcutaneous tissues, easily spreading across the fascial plane within the subcutaneous tissue.Necrotizing fasciitis is a quickly progressing and...

, cellulitis
Cellulitis
Cellulitis is a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin. Cellulitis can be caused by normal skin flora or by exogenous bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters,...

) and the less serious but more common complications such as the circumcision scar
Circumcision scar
In males who have been circumcised, the circumcision scar refers to the scar after a circumcision has healed. In some cases, the scar can be darker-colored, and, in all cases, it will encircle the shaft of the penis.-Appearance:...

 or a less than ideal cosmetic result. They also stated that the risks of circumcision "do not seem to be mitigated by the hands of more experienced physicians".

Meatal stenosis
Meatal stenosis
Urethral meatal stenosis or urethral stricture is a narrowing of the opening of the urethra at the external meatus , thus constricting the opening through which urine leaves the body from the urinary bladder....

 (a narrowing of the urethral opening) may be a longer-term complication of circumcision. It is thought that because the foreskin no longer protects the meatus
Urinary meatus
The urinary meatus is an orifice of the urethra. It is the point at which urine and, in males, semen exits the urethra. The meatus features varying degrees of sensitivity to the touch among males and females....

, ammonia
Ammonia
Ammonia is a compound of nitrogen and hydrogen with the formula . It is a colourless gas with a characteristic pungent odour. Ammonia contributes significantly to the nutritional needs of terrestrial organisms by serving as a precursor to food and fertilizers. Ammonia, either directly or...

 formed from urine
Urine
Urine is a typically sterile liquid by-product of the body that is secreted by the kidneys through a process called urination and excreted through the urethra. Cellular metabolism generates numerous by-products, many rich in nitrogen, that require elimination from the bloodstream...

 in wet diapers irritates and inflames
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...

 the exposed urethral opening. Meatal stenosis can lead to discomfort with urination, incontinence
Urinary incontinence
Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...

, bleeding after urination and urinary tract infections.

Circumcisions may remove too much or too little skin. If insufficient skin is removed, the child may still develop phimosis
Phimosis
Phimosis , from the Greek phimos ), is a condition where, in men, the foreskin cannot be fully retracted over the glans penis...

 in later life. Van Howe states that "when operating on the infantile penis, the surgeon cannot adequately judge the appropriate amount of tissue to remove because the penis will change considerably as the child ages, such that a small difference at the time of surgery may translate into a large difference in the adult circumcised penis. To date (1997), there have been no published studies showing the ability of a circumciser to predict the later appearance of the penis."

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

Other complications include concealed penis, urinary fistulas, chordee
Chordee
Chordee is a condition in which the head of the penis curves downward or upward, at the junction of the head and shaft of the penis. The curvature is usually most obvious during erection, but resistance to straightening is often apparent in the flaccid state as well. In many cases but not all,...

, cyst
Cyst
A cyst is a closed sac, having a distinct membrane and division on the nearby tissue. It may contain air, fluids, or semi-solid material. A collection of pus is called an abscess, not a cyst. Once formed, a cyst could go away on its own or may have to be removed through surgery.- Locations :* Acne...

s, lymphedema
Lymphedema
Lymphedema , also known as lymphatic obstruction, is a condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system....

, ulceration of the glans, necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...

 of all or part of the penis, hypospadias
Hypospadias
Hypospadias is a birth defect of the urethra in the male that involves an abnormally placed urinary meatus...

, epispadias
Epispadias
An epispadias is a rare type of malformation of the penis in which the urethra ends in an opening on the upper aspect of the penis. It can also develop in females when the urethra develops too far anteriorly...

 and impotence. Kaplan stated "Virtually all of these complications are preventable with only a modicum of care" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons."

Another complication of infant circumcision is skin bridge
Skin bridge
A skin bridge is a penile skin adhesion. It most commonly occurs as a consequence of an improperly healed circumcision, being formed when the inner lining of the remaining foreskin attaches to another part of the penis as the cut heals. While less common, skin bridges can also occur in...

 formation, whereby a remaining part of the foreskin fuses to other parts of the penis (often the glans
Glans
The glans is a vascular structure located at the tip of the penis in men or a homologous genital structure of the clitoris in women.-Structure:...

) upon healing. This can result in pain during erections and minor bleeding can occur if the shaft skin is forcibly retracted
Forcible retraction of the foreskin
Forcible retraction of the foreskin, sometimes called premature retraction, in infants or young children can damage the glans and mucous inner tissue of the foreskin. Doctors or parents who may be unfamiliar with the foreskin can often forcibly retract it, unaware that it can be damaging.At birth,...

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

Although deaths have been reported, the American Academy of Family Physicians
American Academy of Family Physicians
The American Academy of Family Physicians was founded in 1947 to promote the science and art of family medicine. It is one of the largest medical organizations in the United States, with over 100,000 members...

 states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision. In 2010, Bollinger estimated a death rate of 9.01 per 100,000, or 117 per year in the United States. 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. Wiswell and Geschke reported no deaths in the first month of life after 100,157 circumcisions (in contrast with two deaths among 35,929 uncircumcised boys); they also reported finding no deaths in separate series of 300,000 US Army circumcisions, and 650,000 boys circumcised in Texas. King reported no deaths among 500,000 circumcisions. The penis is thought to be lost in 1 in 1,000,000 circumcisions.

Human immunodeficiency virus

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

Experimental evidence was needed to establish a causal relationship between lack of circumcision and HIV, so three randomized controlled trials were commissioned as a means to reduce the effect of any confounding factors
Confounding
In statistics, a confounding variable is an extraneous variable in a statistical model that correlates with both the dependent variable and the independent variable...

. Trials took place in South Africa, Kenya
Kenya
Kenya , officially known as the Republic of Kenya, is a country in East Africa that lies on the equator, with the Indian Ocean to its south-east...

 and Uganda
Uganda
Uganda , officially the Republic of Uganda, is a landlocked country in East Africa. Uganda is also known as the "Pearl of Africa". It is bordered on the east by Kenya, on the north by South Sudan, on the west by the Democratic Republic of the Congo, on the southwest by Rwanda, and on the south by...

. All three trials were stopped early by their monitoring boards on ethical grounds, because those in the circumcised group had a lower rate of HIV contraction than the control group. The results showed that circumcision reduced vaginal-to-penile transmission of HIV by 60%, 53%, and 51%, respectively. A meta-analysis of the African randomised controlled trials found that the risk in circumcised males was 0.44 times that in uncircumcised males, and that 72 circumcisions would need to be performed to prevent one HIV infection. The authors also stated that using circumcision as a means to reduce HIV infection would, on a national level, require consistently safe sexual practices to maintain the protective benefit.

As a result of these findings, the WHO
Who
Who may refer to:* Who , an English-language pronoun* who , a Unix command* Who?, one of the Five Ws in journalism- Art and entertainment :* Who? , a 1958 novel by Algis Budrys...

 and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an efficacious intervention for HIV prevention but should be carried out by well trained medical professionals and under conditions of informed consent. Both the WHO and CDC
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention are a United States federal agency under the Department of Health and Human Services headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta...

 indicate that circumcision may not reduce HIV transmission from men to women, and that data are lacking for the transmission rate of men who engage in anal sex with a female partner. The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should never replace known methods of HIV prevention. Male Circumcision Clearinghouse website was formed by WHO, UNAIDS, FHI and AVAC to provide current evidence-based guidance, information and resources to support the delivery of safe male circumcision services in countries that choose to scale up male circumcision as one component of comprehensive HIV prevention services.
Circumcision has been judged to be a cost-effective method to reduce the spread of HIV in a population, though not necessarily more cost-effective than condoms. Some have challenged the validity of the African randomized controlled trials, prompting a number of researchers to question the effectiveness of circumcision as an HIV prevention strategy.

In addition to the studies which provided information about female-to-male transmission, some studies have addressed other transmission routes. A randomised controlled trial in Uganda found that male circumcision did not reduce male to female transmission of HIV. The authors could not rule out the possibility of higher risk of transmission from men who did not wait for the wound to fully heal before engaging in intercourse. A meta-analysis of data from fifteen observational studies of men who have sex with men
Men who have sex with men
Men who have sex with men are male persons who engage in sexual activity with members of the same sex, regardless of how they identify themselves; many men choose not to accept sexual identities of homosexual or bisexual...

 found "insufficient evidence that male circumcision protects against HIV infection or other STIs."

Human papilloma virus

Meta-analyses by Van Howe and Bosch et al. of observational studies reached differing conclusions as to the extent of the effect of circumcision on infection with human papillomavirus
Human papillomavirus
Human papillomavirus is a member of the papillomavirus family of viruses that is capable of infecting humans. Like all papillomaviruses, HPVs establish productive infections only in keratinocytes of the skin or mucous membranes...

 (HPV). A later meta-analysis of 23 studies (including both randomised controlled trials and observational studies) found reduced risk of prevalent HPV and (though the evidence was less strong) some evidence of reduced risk of incident HPV.

A 2009 meta-analysis of multiple studies found a significant association between genital warts and HPV and the presence of a foreskin, as well as HPV alone. While circumcision was associated with a lesser risk of genital warts alone, the association did not reach statistical significance. However, a later analysis found no association between circumcision and penile warts.

Other sexually transmitted infections

Studies evaluating the effect of circumcision on the incidence of other sexually transmitted infections have reached conflicting conclusions. A meta-analysis
Meta-analysis
In statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses. In its simplest form, this is normally by identification of a common measure of effect size, for which a weighted average might be the output of a meta-analyses. Here the...

 of observational data from twenty-six studies found that circumcision was associated with lower rates of syphilis, chancroid
Chancroid
Chancroid is a sexually transmitted infection characterized by painful sores on the genitalia...

 and possibly genital herpes. A large randomized prospective trial in Uganda found a reduction in HSV-2 infection, but not syphilis infection, in the circumcision arm of the study. In contrast, some studies have failed to find a prophylactic benefit to circumcision. A prospective trial in India found that circumcision offered no protective benefit against herpes simplex virus type 2, syphilis, or gonorrhea
Gonorrhea
Gonorrhea is a common sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. The usual symptoms in men are burning with urination and penile discharge. Women, on the other hand, are asymptomatic half the time or have vaginal discharge and pelvic pain...

. A clinical study of 5,925 women from Uganda, Zimbabwe and Thailand found that the circumcision status of their partner did not significantly affect the incidence of Chlamydia, gonorrhea
Gonorrhea
Gonorrhea is a common sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. The usual symptoms in men are burning with urination and penile discharge. Women, on the other hand, are asymptomatic half the time or have vaginal discharge and pelvic pain...

 or trichomoniasis
Trichomoniasis
Trichomoniasis, sometimes referred to as "trich", is a common cause of vaginitis. It is a sexually transmitted disease, and is caused by the single-celled protozoan parasite Trichomonas vaginalis producing mechanical stress on host cells and then ingesting cell fragments after cell death...

. Laumann et al. examined observational data from the United States and found no significant differences between circumcised and uncircumcised men in their likelihood of contracting sexually transmitted diseases.

Hygiene, and infectious and chronic conditions

The American Academy of Pediatrics
American Academy of Pediatrics
The American Academy of Pediatrics is the major professional association of pediatricians in the United States. The AAP was founded in 1930 by 35 pediatricians to address pediatric healthcare standards. It currently has 60,000 members in primary care and sub-specialist areas...

 (1999) stated: "Circumcision has been suggested as an effective method of maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene."

An inflammation of the glans penis and foreskin is called balanoposthitis
Balanoposthitis
-Background:Balenoposthitis is defined as the inflammation of the foreskin and glans in uncircumcised males. Balanoposthitis occurs over a wide age range and may have any of multiple bacterial or fungal origins or be caused by contact dermatitis...

; that affecting the glans alone is called balanitis
Balanitis
Balanitis is inflammation of the glans penis . When the foreskin is also affected, it is termed balanoposthitis....

. Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. Although not as necessary as in the past, circumcision may be considered for recurrent or resistant cases. Escala and Rickwood recommend against a policy of routine infant circumcision to avoid balanitis saying that the condition affects no more than 4% of boys, does not cause pathological phimosis, and in most cases is not serious.

Fergusson studied 500 boys and found that by 8 years, the circumcised children had a rate of 11.1 problems per 100 children, and the uncircumcised children had a rate of 18.8 per 100. During infancy, circumcised children were found to have a significantly higher risk of problems than uncircumcised children, but after infancy the rate of penile problems was significantly higher among the uncircumcised. Fergusson et al. said that the great majority of penile problems were relatively minor (penile inflammation including balanitis, meatitis, and inflammation of the prepuce) and most (64%) were resolved after a single medical consultation. Herzog and Alverez found the overall frequency of complications (including balanitis, irritation, adhesions, phimosis, and paraphimosis) to be higher among the uncircumcised children; again, most of the problems were minor. In a study of 398 randomly selected dermatology students, Fakjian et al. reported: "Balanitis was diagnosed in 2.3% of circumcised men and in 12.5% of uncircumcised men." In a study of 225 men, O'Farrell et al. reported: "Overall, circumcised men were less likely to be diagnosed with a STI/balanitis (51% and 35%, P = 0.021) than those non-circumcised." Van Howe found that circumcised penises required more care in the first 3 months of life, and that circumcised boys are more likely to develop balanitis.

The American Medical Association states that circumcision, properly performed, protects against the development of phimosis. Rickwood and other authors have argued that many infant circumcisions are performed unnecessarily for developmental non-retractability of the prepuce rather than for pathological phimosis. Metcalfe et al. stated that "Gairdner and Oster made a strong case for leaving boys uncircumcised, allowing the natural separation of the foreskin from the glans to take place gradually, and instructing boys in proper hygiene. This obviates the need for 'preventive' circumcision." In a study to determine the most cost-effective treatment for phimosis, Van Howe concluded that using cream was 75% more cost-effective than circumcision at treating pathological phimosis.

Urinary tract infections

A meta-analysis of 12 studies (one randomised controlled trial, four cohort studies and seven case-control studies) representing 402,908 children determined that circumcision was associated with a significantly reduced risk of urinary tract infection
Urinary tract infection
A urinary tract infection is a bacterial infection that affects any part of the urinary tract. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. The main causal agent is Escherichia coli...

 (UTI). However, the authors noted that only 1% of boys with normal urinary tract function experience a UTI, and the number-needed-to treat (number of circumcisions necessary) to prevent one urinary tract infection was calculated to be 111. Because haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%, assuming equal utility of benefits and harms, the authors concluded that the net clinical benefit of circumcision is only likely in boys at high risk of urinary tract infection (such as those with high grade vesicoureteral reflux
Vesicoureteral reflux
Vesicoureteral reflux is an abnormal movement of urine from the bladder into ureters or kidneys. Urine normally travels from the kidneys via the ureters to the bladder...

 or a history of recurrent UTIs, where the number needed to treat declined to 11 and 4, respectively).

Some UTI studies have been criticized for not taking into account a high rate of UTI's among premature infants, who are usually not circumcised because of their fragile health status. The AMA stated that "depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI," and noted one decision analysis model that concluded that circumcision was not justified as a preventative measure against UTI.

Penile cancer

The American Academy of Pediatrics
American Academy of Pediatrics
The American Academy of Pediatrics is the major professional association of pediatricians in the United States. The AAP was founded in 1930 by 35 pediatricians to address pediatric healthcare standards. It currently has 60,000 members in primary care and sub-specialist areas...

 (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.

Micali et al describe penile cancer as an "emerging problem", noting that "public health measures, such as prophylactic use of circumcision, have proven successful". A 2011 meta-analysis found that childhood or adolescent circumcision substantially reduces the risk. It has been suggested that this may be due, in part, to reduced risk of phimosis, a predisposing factor for penile cancers.

The age-adjusted annual incidence of penile cancer is 0.82 per 100,000 in Denmark, 2.9–6.8 per 100,000 in Brazil, 0.9 to 1 per 100,000 in the USA, and 2.0–10.5 per 100,000 in India. Researchers have reported that the risk of penile cancer is greater in never-circumcised men than in men who had been circumcised at birth; estimates of the relative risk include 3 and 22.

The American Cancer Society
American Cancer Society
The American Cancer Society is the "nationwide community-based voluntary health organization" dedicated, in their own words, "to eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and...

 (2009) stated, "Most experts agree that circumcision should not be recommended solely as a way to prevent penile cancer
Carcinoma of the penis
Penile cancer is a malignant growth found on the skin or in the tissues of the penis. A Squamous cell carcinoma usually originating in the glans or foreskin is by far the most common type, occurring in 9 out of 10 cases. Penis cancer tends to develop in men over the age of sixty. Penile cancer is...

."

Prevalence

Estimates of the proportion of males that are circumcised worldwide vary from one-sixth to a third. The WHO has estimated that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), with almost 70% of these being Muslim. Circumcision is most prevalent in the Muslim world
Muslim world
The term Muslim world has several meanings. In a religious sense, it refers to those who adhere to the teachings of Islam, referred to as Muslims. In a cultural sense, it refers to Islamic civilization, inclusive of non-Muslims living in that civilization...

, parts of Southeast Asia
Southeast Asia
Southeast Asia, South-East Asia, South East Asia or Southeastern Asia is a subregion of Asia, consisting of the countries that are geographically south of China, east of India, west of New Guinea and north of Australia. The region lies on the intersection of geological plates, with heavy seismic...

, Africa, the United States, the Philippines, Israel
Israel
The State of Israel is a parliamentary republic located in the Middle East, along the eastern shore of the Mediterranean Sea...

, and South Korea
South Korea
The Republic of Korea , , is a sovereign state in East Asia, located on the southern portion of the Korean Peninsula. It is neighbored by the People's Republic of China to the west, Japan to the east, North Korea to the north, and the East China Sea and Republic of China to the south...

. It is relatively rare in Europe, Latin America
Latin America
Latin America is a region of the Americas where Romance languages  – particularly Spanish and Portuguese, and variably French – are primarily spoken. Latin America has an area of approximately 21,069,500 km² , almost 3.9% of the Earth's surface or 14.1% of its land surface area...

, parts of Southern Africa
Southern Africa
Southern Africa is the southernmost region of the African continent, variably defined by geography or geopolitics. Within the region are numerous territories, including the Republic of South Africa ; nowadays, the simpler term South Africa is generally reserved for the country in English.-UN...

, and most of Asia and Oceania
Oceania
Oceania is a region centered on the islands of the tropical Pacific Ocean. Conceptions of what constitutes Oceania range from the coral atolls and volcanic islands of the South Pacific to the entire insular region between Asia and the Americas, including Australasia and the Malay Archipelago...

. Prevalence is near-universal in the Middle East and Central Asia. The WHO states that "there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines". The WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe, and Klavs et al. report findings that "support the notion that the prevalence is low in Europe". In Latin America, prevalence is universally low. Estimates for individual countries include Spain, Colombia
Colombia
Colombia, officially the Republic of Colombia , is a unitary constitutional republic comprising thirty-two departments. The country is located in northwestern South America, bordered to the east by Venezuela and Brazil; to the south by Ecuador and Peru; to the north by the Caribbean Sea; to the...

 and Denmarkless than 2%, Finland 0.006% and 7%, Brazil
Brazil
Brazil , officially the Federative Republic of Brazil , is the largest country in South America. It is the world's fifth largest country, both by geographical area and by population with over 192 million people...

 7%, Taiwan
Taiwan
Taiwan , also known, especially in the past, as Formosa , is the largest island of the same-named island group of East Asia in the western Pacific Ocean and located off the southeastern coast of mainland China. The island forms over 99% of the current territory of the Republic of China following...

 9%, Thailand
Thailand
Thailand , officially the Kingdom of Thailand , formerly known as Siam , is a country located at the centre of the Indochina peninsula and Southeast Asia. It is bordered to the north by Burma and Laos, to the east by Laos and Cambodia, to the south by the Gulf of Thailand and Malaysia, and to the...

 13% and Australia 58.7%.

The WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively. Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.

History

The origination of male circumcision is not known with certainty. It has been variously proposed that it began as a religious sacrifice, as a rite of passage
Rite of passage
A rite of passage is a ritual event that marks a person's progress from one status to another. It is a universal phenomenon which can show anthropologists what social hierarchies, values and beliefs are important in specific cultures....

 marking a boy's entrance into adulthood, as a form of sympathetic magic
Magical thinking
Magical thinking is causal reasoning that looks for correlation between acts or utterances and certain events. In religion, folk religion, and superstition, the correlation posited is between religious ritual, such as prayer, sacrifice, or the observance of a taboo, and an expected benefit or...

 to ensure virility or fertility, as a means of enhancing sexual pleasure, as an aid to hygiene where regular bathing was impractical, as a means of marking those of higher social status, as a means of humiliating enemies and slaves by symbolic castration
Castration
Castration is any action, surgical, chemical, or otherwise, by which a male loses the functions of the testicles or a female loses the functions of the ovaries.-Humans:...

, as a means of differentiating a circumcising group from their non-circumcising neighbors, as a means of discouraging masturbation
Masturbation
Masturbation refers to sexual stimulation of a person's own genitals, usually to the point of orgasm. The stimulation can be performed manually, by use of objects or tools, or by some combination of these methods. Masturbation is a common form of autoeroticism...

 or other socially proscribed sexual behaviors, as a means of removing "excess" pleasure, as a means of increasing a man's attractiveness to women, as a demonstration of one's ability to endure pain, or as a male counterpart to menstruation
Menstruation
Menstruation is the shedding of the uterine lining . It occurs on a regular basis in sexually reproductive-age females of certain mammal species. This article focuses on human menstruation.-Overview:...

 or the breaking of the hymen
Hymen
The hymen is a membrane that surrounds or partially covers the external vaginal opening. It forms part of the vulva, or external genitalia. The size of the hymenal opening increases with age. Although an often practiced method, it is not possible to confirm with certainty that a girl or woman is a...

, or to copy the rare natural occurrence of a missing foreskin
Aposthia
Aposthia is a rare congenital condition in humans, in which the foreskin of the penis is missing.Toward the end of the nineteenth century, E. S. Talbot claimed in Medicine that aposthia among Jews was evidence for the now-discredited Lamarckian theory of evolution...

 of an important leader, and as a display of disgust of the smegma
Smegma
Smegma is a combination of exfoliated epithelial cells, transudated skin oils, and moisture. It occurs in both female and male mammalian genitalia.-Human smegma:Both females and males produce smegma...

 produced by the foreskin
Foreskin
In male human anatomy, the foreskin is a generally retractable double-layered fold of skin and mucous membrane that covers the glans penis and protects the urinary meatus when the penis is not erect...

. It has been suggested that the custom of circumcision gave advantages to tribes that practiced it and thus led to its spread. Darby describes these theories as "conflicting", and states that "the only point of agreement among proponents of the various theories is that promoting good health had nothing to do with it." Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practising circumcision, leading to its spread.Wilson suggests that circumcision reduces insemination efficiency, reducing a man's capacity for extra-pair fertilizations by impairing sperm competition. Thus, men who display this signal of sexual obedience, may gain social benefits, if married men are selected to offer social trust and
investment preferentially to peers who are less threatening to their paternity.
It is possible that circumcision arose independently in different cultures for different reasons.

The oldest documentary evidence for circumcision comes from ancient Egypt
Ancient Egypt
Ancient Egypt was an ancient civilization of Northeastern Africa, concentrated along the lower reaches of the Nile River in what is now the modern country of Egypt. Egyptian civilization coalesced around 3150 BC with the political unification of Upper and Lower Egypt under the first pharaoh...

. Circumcision was common, although not universal, among ancient Semitic
Semitic
In linguistics and ethnology, Semitic was first used to refer to a language family of largely Middle Eastern origin, now called the Semitic languages...

 peoples. In the aftermath of the conquests of Alexander the Great, however, Greek dislike of circumcision (they regarded a man as truly "naked" only if his prepuce was retracted) led to a decline in its incidence among many peoples that had previously practiced it.

Circumcision has ancient roots among several ethnic groups in sub-equatorial Africa, and is still performed on adolescent boys to symbolize their transition to warrior status or adulthood.

Non-religious circumcision

Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

, South Africa
South Africa
The Republic of South Africa is a country in southern Africa. Located at the southern tip of Africa, it is divided into nine provinces, with of coastline on the Atlantic and Indian oceans...

, New Zealand
New Zealand
New Zealand is an island country in the south-western Pacific Ocean comprising two main landmasses and numerous smaller islands. The country is situated some east of Australia across the Tasman Sea, and roughly south of the Pacific island nations of New Caledonia, Fiji, and Tonga...

 and to a lesser extent in the United Kingdom
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...

.
There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The germ theory of disease
Germ theory of disease
The germ theory of disease, also called the pathogenic theory of medicine, is a theory that proposes that microorganisms are the cause of many diseases...

 elicited an image of the human body as a conveyance for many dangerous germs, making the public "germ phobic" and suspicious of dirt and bodily secretions. The penis became "dirty" by association with its function, and from this premise circumcision was seen as preventative medicine to be practised universally. In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation. Aggleton wrote that John Harvey Kellogg
John Harvey Kellogg
John Harvey Kellogg was an American medical doctor in Battle Creek, Michigan, who ran a sanitarium using holistic methods, with a particular focus on nutrition, enemas and exercise. Kellogg was an advocate of vegetarianism and is best known for the invention of the corn flakes breakfast cereal...

 viewed male circumcision in this way, and further "advocated an unashamedly punitive approach." Circumcision was also said to protect against syphilis
Syphilis
Syphilis is a sexually transmitted infection caused by the spirochete bacterium Treponema pallidum subspecies pallidum. The primary route of transmission is through sexual contact; however, it may also be transmitted from mother to fetus during pregnancy or at birth, resulting in congenital syphilis...

, phimosis, paraphimosis, balanitis, and "excessive venery
Venery
Venery can refer to the following:*The practice or sport of hunting game animals, or the wild animals so hunted.*The practice or pursuit of sexual pleasure, or the indulgence of sexual desire.-See also:...

" (which was believed to produce paralysis
Paralysis
Paralysis is loss of muscle function for one or more muscles. Paralysis can be accompanied by a loss of feeling in the affected area if there is sensory damage as well as motor. A study conducted by the Christopher & Dana Reeve Foundation, suggests that about 1 in 50 people have been diagnosed...

). Gollaher states that physicians advocating circumcision in the late nineteenth century expected public scepticism, and refined their arguments to overcome it.

Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 32% of newborn American boys were being circumcised in 1933. Laumann et al. reported that the prevalence of circumcision among US-born males was approximately 70%, 80%, 85%, and 77% for those born in 1945, 1955, 1965, and 1971 respectively. Xu et al. reported that the prevalence of circumcision among US-born males was 91% for males born in the 1970s and 84% for those born in the 1980s. Between 1981 and 1999, National Hospital Discharge Survey data from the National Center for Health Statistics
National Center for Health Statistics
National Center for Health Statistics is a division of the United States federal agency the Centers for Disease Control and Prevention . As such, NCHS is under the United States Department of Health and Human Services...

 demonstrated that the infant circumcision rate remained relatively stable within the 60% range, with a minimum of 60.7% in 1988 and a maximum of 67.8% in 1995. A 1987 study found that the most prominent reasons US parents choose circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns. However, a later study speculated that an increased recognition of the potential benefits of neonatal circumcision may have been responsible for the observed increase in the US rate between 1988 and 2000. A report by the Agency for Healthcare Research and Quality
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality is a part of the United States Department of Health and Human Services, which supports research designed to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, and broaden access to effective...

 placed the 2005 national circumcision rate at 56%.

In 1949, the United Kingdom's newly formed National Health Service
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...

 removed infant circumcision from its list of covered services, and circumcision has since been an out-of-pocket cost
Out-of-pocket expenses
Out-of-pocket expenses are direct outlays of cash which may or may not be later reimbursed.In operating a vehicle, gasoline, parking fees and tolls are considered out-of-pocket expenses for the trip...

 to parents. Among men (aged 15 years or older) who are neither Jews nor Muslims, the overall prevalence of circumcision in the UK is 6% according to the WHO's estimates. When "data from
targeted oversampling of black Caribbean, black African, Indian, and Pakistani groups (the Natsal ethnic minority boost) were combined with the main [Natsal II
National Survey of Sexual Attitudes and Lifestyles
The National Survey of Sexual Attitudes and Lifestyles is the name given to a series of face-to-face surveys of people in the United Kingdom regarding their sexual behaviour and patterns. The two rounds of interviews completed to date are NATSAL I and NATSAL II . A third round of interviews is...

] survey data", it was found that the prevalence of circumcision in the UK is age-graded, with 11.7% of those aged 16–19 years circumcised and 19.6% of those aged 40–44 years. There is a clear ethnic division: "With the exception of black Caribbeans, men from all ethnic minority backgrounds were significantly [(3.02 times)] more likely to report being circumcised compared to men who described their ethnicity as white". These particular findings "confirm that the prevalence of male circumcision among British men appears to be declining. This is despite an increase in the proportion of the British population describing their ethnicity as nonwhite"; indeed, the proportion of newborns circumcised in England and Wales has fallen to less than one percent.

The circumcision rate has declined sharply in Australia since the 1970s, leading to an age-graded fall in prevalence, with a 2000–1 survey finding 32% of those aged 16–19 years circumcised, 50% for 20–29 years and 64% for those aged 30–39 years.

In Canada, Ontario health services delisted circumcision in 1994.

Cultures and religions

See also Brit milah
Brit milah
The brit milah is a Jewish religious circumcision ceremony performed on 8-day old male infants by a mohel. The brit milah is followed by a celebratory meal .-Biblical references:...

, Circumcision controversies
Circumcision controversies
Male circumcision has often been, and remains, the subject of controversy on a number of grounds—including religious, ethical, sexual, and health....

, Religious male circumcision, Khitan (circumcision)
Khitan (circumcision)
Khitān or Khatna is the term for male circumcision carried out as an Islamic rite, to introduce males into Islam and as a sign of belonging to the wider Islamic community. It is also referred to by the term Taharah, 'purity'....



In some cultures, males must be circumcised shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is commonly practised in the Jewish and Islamic faiths.

Jewish law
Halakha
Halakha — also transliterated Halocho , or Halacha — is the collective body of Jewish law, including biblical law and later talmudic and rabbinic law, as well as customs and traditions.Judaism classically draws no distinction in its laws between religious and ostensibly non-religious life; Jewish...

 states that circumcision is a mitzva aseh
613 mitzvot
The 613 commandments is a numbering of the statements and principles of law, ethics, and spiritual practice contained in the Torah or Five Books of Moses...

 ("positive commandment" to perform an act) and is obligatory for Jewish-born males and for non-circumcised Jewish male converts. It is only postponed or abrogated in the case of threat to the life or health of the child. It is usually performed by a mohel
Mohel
A mohel is a Jewish person trained in the practice of brit milah "covenant of circumcision."-Etymology of the Hebrew and Aramaic term:...

 on the eighth day after birth in a ceremony called a Brit milah
Brit milah
The brit milah is a Jewish religious circumcision ceremony performed on 8-day old male infants by a mohel. The brit milah is followed by a celebratory meal .-Biblical references:...

 (or Bris milah, colloquially simply bris), which means "Covenant of circumcision" in Hebrew
Hebrew language
Hebrew is a Semitic language of the Afroasiatic language family. Culturally, is it considered by Jews and other religious groups as the language of the Jewish people, though other Jewish languages had originated among diaspora Jews, and the Hebrew language is also used by non-Jewish groups, such...

. It is considered of such importance that in some Orthodox communities the body of an uncircumcised Jewish male will sometimes be circumcised before burial. Although 19th century Reform
Reform Judaism
Reform Judaism refers to various beliefs, practices and organizations associated with the Reform Jewish movement in North America, the United Kingdom and elsewhere. In general, it maintains that Judaism and Jewish traditions should be modernized and should be compatible with participation in the...

 leaders described it as "barbaric", the practice of circumcision "remained a central rite" and the Union for Reform Judaism
Union for Reform Judaism
The Union for Reform Judaism , formerly known as the Union of American Hebrew Congregations , is an organization which supports Reform Jewish congregations in North America. The current President is Rabbi Eric H...

 has, since 1984, trained and certified over 300 practicing mohels under its "Berit Mila Program".Humanistic Judaism
Humanistic Judaism
Humanistic Judaism is a movement in Judaism that offers a nontheistic alternative in contemporary Jewish life. It defines Judaism as the cultural and historical experience of the Jewish people and encourages humanistic and secular Jews to celebrate their Jewish identity by participating in Jewish...

 argues that "circumcision is not required for Jewish identity."

In Islam
Islam
Islam . The most common are and .   : Arabic pronunciation varies regionally. The first vowel ranges from ~~. The second vowel ranges from ~~~...

, circumcision is mentioned in some hadith
Hadith
The term Hadīth is used to denote a saying or an act or tacit approval or criticism ascribed either validly or invalidly to the Islamic prophet Muhammad....

 (it is referred as Khitan
Khitan
The history of the Khitans dates back to the 4th century AD. The Khitan people dominated much of Mongolia and modern Manchuria by the 10th century, under the Liao Dynasty, and eventually collapsed by 1125 ....

), but not in the Qur'an
Qur'an
The Quran , also transliterated Qur'an, Koran, Alcoran, Qur’ān, Coran, Kuran, and al-Qur’ān, is the central religious text of Islam, which Muslims consider the verbatim word of God . It is regarded widely as the finest piece of literature in the Arabic language...

. Some Fiqh
Fiqh
Fiqh is Islamic jurisprudence. Fiqh is an expansion of the code of conduct expounded in the Quran, often supplemented by tradition and implemented by the rulings and interpretations of Islamic jurists....

 scholars state that circumcision is recommended (Sunnah
Sunnah
The word literally means a clear, well trodden, busy and plain surfaced road. In the discussion of the sources of religion, Sunnah denotes the practice of Prophet Muhammad that he taught and practically instituted as a teacher of the sharī‘ah and the best exemplar...

); others that it is obligatory. Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant
Covenant (biblical)
A biblical covenant is an agreement found in the Bible between God and His people in which God makes specific promises and demands. It is the customary word used to translate the Hebrew word berith. It it is used in the Tanakh 286 times . All Abrahamic religions consider the Biblical covenant...

 with Abraham
Abraham
Abraham , whose birth name was Abram, is the eponym of the Abrahamic religions, among which are Judaism, Christianity and Islam...

. While endorsing circumcision for males, Islamic scholars note that it is not a requirement for converting to Islam.

The Roman Catholic Church formally condemned the ritual observance of circumcision and ordered against its practice in the Ecumenical Council of Basel-Florence
Council of Florence
The Council of Florence was an Ecumenical Council of the Roman Catholic Church. It began in 1431 in Basel, Switzerland, and became known as the Council of Ferrara after its transfer to Ferrara was decreed by Pope Eugene IV, to convene in 1438...

 in 1442. The Church presently maintains a neutral stance on circumcision as a medical practice.

Circumcision 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, require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ
Circumcision of Christ
The Feast of the Circumcision of Christ is a Christian celebration of the circumcision of Jesus in accordance with Jewish tradition, eight days after his birth, the occasion on which the child was formally given his name.The circumcision of Jesus has traditionally been seen, as explained in the...

. The vast majority of Christians do not practise circumcision as a religious requirement.

Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War
Korean War
The Korean War was a conventional war between South Korea, supported by the United Nations, and North Korea, supported by the People's Republic of China , with military material aid from the Soviet Union...

. 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 Nigeria
Nigeria
Nigeria , officially the Federal Republic of Nigeria, is a federal constitutional republic comprising 36 states and its Federal Capital Territory, Abuja. The country is located in West Africa and shares land borders with the Republic of Benin in the west, Chad and Cameroon in the east, and Niger in...

n societies it is medicalised and is simply a cultural norm.
Circumcision is part of initiation rites
Rite of passage
A rite of passage is a ritual event that marks a person's progress from one status to another. It is a universal phenomenon which can show anthropologists what social hierarchies, values and beliefs are important in specific cultures....

 in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land
Arnhem Land
The Arnhem Land Region is one of the five regions of the Northern Territory of Australia. It is located in the north-eastern corner of the territory and is around 500 km from the territory capital Darwin. The region has an area of 97,000 km² which also covers the area of Kakadu National...

, where the practice was introduced by Makassan traders from Sulawesi
Sulawesi
Sulawesi is one of the four larger Sunda Islands of Indonesia and is situated between Borneo and the Maluku Islands. In Indonesia, only Sumatra, Borneo, and Papua are larger in territory, and only Java and Sumatra have larger Indonesian populations.- Etymology :The Portuguese were the first to...

 in the Indonesia
Indonesia
Indonesia , officially the Republic of Indonesia , is a country in Southeast Asia and Oceania. Indonesia is an archipelago comprising approximately 13,000 islands. It has 33 provinces with over 238 million people, and is the world's fourth most populous country. Indonesia is a republic, with an...

n Archipelago. Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature: subincision
Subincision
Penile subincision is a form of body modification consisting of a urethrotomy, in which the underside of the penis is incised and the urethra slit open lengthwise, from the urethral opening toward the base...

 is practised amongst some aboriginal peoples in the Western Desert.

In the Pacific, circumcision or superincision is nearly universal among the Melanesians of Fiji
Fiji
Fiji , officially the Republic of Fiji , is an island nation in Melanesia in the South Pacific Ocean about northeast of New Zealand's North Island...

 and Vanuatu
Vanuatu
Vanuatu , officially the Republic of Vanuatu , is an island nation located in the South Pacific Ocean. The archipelago, which is of volcanic origin, is some east of northern Australia, northeast of New Caledonia, west of Fiji, and southeast of the Solomon Islands, near New Guinea.Vanuatu was...

, while participation in the traditional land diving on Pentecost Island
Pentecost Island
Pentecost Island is one of the 83 islands that make up the South Pacific nation of Vanuatu. It lies due north of capital Port Vila. Pentecost Island is known as Pentecôte in French and Pentikos in Bislama. The island was known in its native languages by names such as Vanu Aroaroa, although these...

 is reserved for those who have been circumcised. Circumcision or superincision is also commonly practiced in the Polynesian islands of Samoa
Samoa
Samoa , officially the Independent State of Samoa, formerly known as Western Samoa is a country encompassing the western part of the Samoan Islands in the South Pacific Ocean. It became independent from New Zealand in 1962. The two main islands of Samoa are Upolu and one of the biggest islands in...

, Tonga
Tonga
Tonga, officially the Kingdom of Tonga , is a state and an archipelago in the South Pacific Ocean, comprising 176 islands scattered over of ocean in the South Pacific...

, Niue
Niue
Niue , is an island country in the South Pacific Ocean. It is commonly known as the "Rock of Polynesia", and inhabitants of the island call it "the Rock" for short. Niue is northeast of New Zealand in a triangle between Tonga to the southwest, the Samoas to the northwest, and the Cook Islands to...

, and Tikopia
Tikopia
Tikopia is a small and high island in the southwestern Pacific Ocean. Covering an area of 5 km² , the island is the remnant of an extinct volcano. Its highest point, Mt. Reani, reaches an elevation of 380 m above sea level. Lake Te Roto covers an old volcanic crater which is 80 m...

, where the custom is recorded as a pre-Christian/colonial practice. In Samoa it is accompanied by a celebration.

Among some West African groups, such as the Dogon
Dogon people
The Dogon are an ethnic group living in the central plateau region of Mali, south of the Niger bend near the city of Bandiagara in the Mopti region. The population numbers between 400,000 and 800,000 The Dogon are best known for their religious traditions, their mask dances, wooden sculpture and...

 and Dowayo, circumcision is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males. 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
Age set
In anthropology, an age set is a social category or corporate social group, consisting of people of similar age, who have a common identity, maintain close ties over a prolonged period, and together pass through a series of age-related statuses...

 to another. For Nilotic
Nilotic
Nilotic people or Nilotes, in its contemporary usage, refers to some ethnic groups mainly in South Sudan, Uganda, Kenya, and northern Tanzania, who speak Nilotic languages, a large sub-group of the Nilo-Saharan languages...

 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.

Positions of medical associations

The World Health Organization (WHO; 2007), the Joint United Nations Programme on HIV/AIDS
Joint United Nations Programme on HIV/AIDS
The Joint United Nations Programme on HIV and AIDS, or UNAIDS, is the main advocate for accelerated, comprehensive and coordinated global action on the HIV epidemic....

 (UNAIDS; 2007), and the US Centers for Disease Control and Prevention (CDC; 2008) state that evidence indicates male circumcision significantly
Statistical significance
In statistics, a result is called statistically significant if it is unlikely to have occurred by chance. The phrase test of significance was coined by Ronald Fisher....

 reduces the risk of HIV
HIV
Human immunodeficiency virus is a lentivirus that causes acquired immunodeficiency syndrome , a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive...

 acquisition by men during penile-vaginal sex, but also state that circumcision only provides partial protection and should be considered only in conjunction with other proven prevention measures. (The CDC have not yet made any final recommendations regarding circumcision.)

Australasia

The Royal Australasian College of Physicians
Royal Australasian College of Physicians
The Royal Australasian College of Physicians, or RACP, is the organisation responsible for training, educating, and representing over 9,000 physicians and paediatricians in Australia and New Zealand. It was founded in 1938....

 (RACP; September 2010) state that "After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. However it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons."

The Tasmanian President of the Australian Medical Association (AMA), Haydn Walters, has stated that the AMA would support a call to ban circumcision for non-medical, non-religious reasons.

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society
Canadian Paediatric Society
The Canadian Paediatric Society is a national association of paediatricians, committed to working together to advance the health of children and youth by nurturing excellence in health care, advocacy, education, research and support of its membership....

 posted "Neonatal circumcision revisited" in 1996 and "Circumcision: Information for Parents" in November 2004. The 1996 position statement says that "circumcision of newborns should not be routinely performed", and the 2004 information to parents says: 'Circumcision is a "non-therapeutic" procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social, or cultural reasons. [. . .] After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.'

Netherlands

In the Netherlands
Netherlands
The Netherlands is a constituent country of the Kingdom of the Netherlands, located mainly in North-West Europe and with several islands in the Caribbean. Mainland Netherlands borders the North Sea to the north and west, Belgium to the south, and Germany to the east, and shares maritime borders...

, the Royal Dutch Medical Association
Royal Dutch Medical Association
The Royal Dutch Medical Association is the professional organisation for medical practitioners in the Netherlands....

 (KNMG) stated in 2010 that non-therapeutic male circumcision "conflicts with the child's right to autonomy and physical integrity." They called on doctors to inform caregivers seeking the intervention of the (in their assessment) medical and psychological risks and lack of convincing medical benefits. They stated that there are as good reasons for legal prohibition of male circumcision as exist for female genital mutilation (FGM).

United Kingdom

"Male circumcision that is performed for any reason other than physical clinical need is termed non-therapeutic (or sometimes "ritual") circumcision. Some people ask for non-therapeutic circumcision for religious reasons, some to incorporate a child into a community, and some want their sons to be like their fathers. Circumcision is a defining feature of some faiths".

The BMA provides that "male circumcision is generally assumed to be lawful provided that it is performed competently; it is believed to be in the child's best interests; and there is valid consent" from both parents and the child, if possible".

The BMA stipulates that "competent children may decide for themselves; the wishes that children express must be taken into account; if parents disagree, non-therapeutic circumcision must not be carried out without the leave of a court; consent should be confirmed in writing".

"In the past, circumcision of boys has been considered to be either medically or socially beneficial or, at least, neutral. The general perception has been that no significant harm was caused to the child and therefore with appropriate consent it could be carried out. The medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks. It is essential that doctors perform male circumcision only where this is demonstrably in the best interests of the child. The responsibility to demonstrate that non-therapeutic circumcision is in a particular child's best interests falls to his parents. The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it."

United States

The American Academy of Pediatrics
American Academy of Pediatrics
The American Academy of Pediatrics is the major professional association of pediatricians in the United States. The AAP was founded in 1930 by 35 pediatricians to address pediatric healthcare standards. It currently has 60,000 members in primary care and sub-specialist areas...

 (1999) stated: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child." The AAP recommends that if parents choose to circumcise, analgesia should be used to reduce pain associated with circumcision. It states that circumcision should only be performed on newborns who are stable and healthy.

The American Medical Association
American Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...

 supports the AAP's 1999 circumcision policy statement with regard to non-therapeutic circumcision, which they define as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. They state that "policy statements issued by professional societies representing Australian, Canadian, and American pediatricians do not recommend routine circumcision of male newborns."

The American Academy of Family Physicians
American Academy of Family Physicians
The American Academy of Family Physicians was founded in 1947 to promote the science and art of family medicine. It is one of the largest medical organizations in the United States, with over 100,000 members...

 (2007) recognizes the controversy surrounding circumcision and recommends that physicians "discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son."
The evidence indicates that neonatal circumcision prevents UTIs in the first year of life with an absolute risk reduction of about 1% and prevents the development of penile cancer with an absolute risk reduction of less than 0.2%. The evidence suggests that circumcision reduces the rate of acquiring an STD, but careful sexual practices and hygiene may be as effective. Circumcision appears to decrease the transmission of HIV in underdeveloped areas where the virus is highly prevalent. No study has systematically evaluated the utility of routine neonatal circumcision for preventing all medically-indicated circumcisions in later life. Evidence regarding the association between cervical cancer and a woman's partner being circumcised or uncircumcised, and evidence regarding the effect of circumcision on sexual functioning is inconclusive. If the decision is made to circumcise, anesthesia should be used.

The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son.
|archiveurl = http://web.archive.org/web/20060925120138/http://www.aafp.org/online/en/home/clinical/clinicalrecs/circumcision.html |archivedate = 2006-09-25}}

The American Urological Association
American Urological Association
The American Urological Association is a professional association in the United States for urology professionals.-Awards:*Hugh Hampton Young Award. Presented annually to an individual for outstanding contributions to the study of genitourinary tract disease. This award is sponsored by Karl Storz...

 (2007) stated that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks.

See also

  • Circumcision scar
    Circumcision scar
    In males who have been circumcised, the circumcision scar refers to the scar after a circumcision has healed. In some cases, the scar can be darker-colored, and, in all cases, it will encircle the shaft of the penis.-Appearance:...

  • Foreskin restoration
    Foreskin restoration
    Foreskin restoration is the process of expanding the residual skin on the penis, via surgical or non-surgical methods. It can be performed for several reasons, among them being a desire to create the appearance of a natural foreskin covering the glans penis, or to increase sexual sensitivity of...

  • Frenectomy
    Frenectomy
    A lingual frenectomy is a form of frenectomy associated with the tongue.The removal of the lingual frenulum under the tongue can be accomplished with either frenectomy or frenuloplasty. This is used to treat a tongue tied patient. It is rumored that, immediately after this minor oral surgery, the...

  • Genital modification and mutilation
    Genital modification and mutilation
    The terms genital modification and genital mutilation can refer to permanent or temporary changes to human sex organs. Some forms of genital alteration are performed at the behest of an adult, with their informed consent. Others are performed on infants or children...

  • Holy Prepuce
    Holy Prepuce
    The Holy Prepuce, or Holy Foreskin is one of several relics attributed to Jesus, a product of the circumcision of Jesus....

  • Preputioplasty
    Preputioplasty
    Preputioplasty or prepuce plasty, also known as "limited dorsal slit with transverse closure", is a plastic surgical operation on the prepuce or foreskin of the penis, to widen a narrow non-retractile foreskin which cannot comfortably be drawn back off the head of the penis in erection because of a...


Further reading

  • Billy Ray Boyd. Circumcision Exposed: Rethinking a Medical and Cultural Tradition. Freedom, CA: The Crossing Press, 1998. (ISBN 978-0-89594-939-4)
  • Anne Briggs. Circumcision: What Every Parent Should Know. Charlottesville, VA: Birth & Parenting Publications, 1985. (ISBN 978-0-9615484-0-7)
  • Robert Darby. A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain. Chicago: University of Chicago Press, 2005. (ISBN 978-0-226-13645-5)
  • Aaron J. Fink, M.D. Circumcision: A Parent's Decision for Life. Kavanah Publishing Company, Inc., 1988. (ISBN 978-0-9621347-0-8)
  • Paul M. Fleiss, M.D. and Frederick Hodges, D. Phil. What Your Doctor May Not Tell You About Circumcision. New York: Warner Books, 2002. (ISBN 978-0-446-67880-3)
  • Leonard B. Glick. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. New York: Oxford University Press, 2005. (ISBN 978-0-19-517674-2)
  • Ronald Goldman, Ph.D. Circumcision: The Hidden Trauma. Boston: Vanguard, 1996. (ISBN 978-0-9644895-3-0)
  • Paysach J. Krohn
    Paysach Krohn
    Paysach J. Krohn is an Orthodox Jewish rabbi and a noted author, mohel, and lecturer on topics related to ethics and spiritual growth.-Biography:...

    , Rabbi. Bris Milah. Circumcision—The Covenant Of Abraham/A Compendium of Laws, Rituals, And Customs From Birth To Bris, Anthologized From Talmudic, And Traditional Sources. New York: Mesorah Publications, 1985, 2005.
  • Brian J. Morris, Ph.D., D.Sc. In Favour of Circumcision. Sydney: UNSW Press, 1999. (ISBN 978-0-86840-537-7)
  • Peter Charles Remondino
    Peter Charles Remondino
    Peter Charles Remondino was a physician, author, first president of the San Diego Board of Health, and co-founder of San Diego’s first private hospital. In the course of a medical career spanning 55 years, he served with the Union forces during the American Civil War as surgeon...

    . History of Circumcision from the Earliest Times to the Present. Philadelphia and London; F. A. Davis; 1891.
  • Holm Putzke, Ph.D. Die strafrechtliche Relevanz der Beschneidung von Knaben. Zugleich ein Beitrag über die Grenzen der Einwilligung in Fällen der Personensorge, in: H. Putzke u.a. (Hrsg.), Strafrecht zwischen System und Telos, Festschrift für Rolf Dietrich Herzberg zum siebzigsten Geburtstag am 14. Februar 2008 , Mohr Siebeck: Tübingen 2008, p. 669–709 (ISBN 978-3161495700)
  • Holm Putzke, Ph.D., Maximilian Stehr, Ph.D., and Hans-Georg Dietz, Ph.D. Liability to penalty for circumcision in boys. Medico-legal aspects of a controversial medical intervention, in: Monatsschrift Kinderheilkunde 8/2008, p. 783–788
  • Rosemary Romberg. Circumcision: The Painful Dilemma. South Hadley, MA Bergan & Garvey, 1985. (ISBN 978-0-89789-073-1)
  • Edgar J Schoen, M.D. Ed Schoen, MD on Circumcision. Berkeley, CA: RDR Books, 2005. (ISBN 978-1-57143-123-3)
  • Edward Wallerstein. Circumcision: An American Health Fallacy. New York: Springer, 1980 (ISBN 978-0-8261-3240-6)
  • Gerald N. Weiss M.D. and Andrea W Harter. Circumcision: Frankly Speaking. Wiser Publications, 1998. (ISBN 978-0-9667219-0-4)
  • Yosef David Weisberg, Rabbi. Otzar Habris. Encyclopedia of the laws and customs of Bris Milah and Pidyon Haben. Jerusalem: Hamoer, 2002.

External links

Opposition

Promotion
  • Malecircumcision.org – Clearinghouse on Male Circumcision for HIV Prevention by WHO
    World Health Organization
    The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

    , the Joint United Nations Programme on HIV/AIDS (UNAIDS)
    Joint United Nations Programme on HIV/AIDS
    The Joint United Nations Programme on HIV and AIDS, or UNAIDS, is the main advocate for accelerated, comprehensive and coordinated global action on the HIV epidemic....

    , the AIDS Vaccine Advocacy Coalition (AVAC)
    AIDS Vaccine Advocacy Coalition
    AVAC is a New York City-based international non-profit community- and consumer-based organization working to accelerate ethical development and delivery of AIDS vaccines and other HIV prevention options to populations throughout the world...

    , and Family Health International (FHI)
    Family Health International
    Family Health International is a public health and development organization dedicated to improving living standards of the world's most vulnerable people. Family Health International has 2,500 staff conducting research and implementing programs in fifty-five countries...

  • Circinfo.net – Male Circumcision Guide for Doctors, Parents, Adults, & Teens by Professor Brian Morris
    Brian Morris
    Brian Morris is a professor of molecular medical sciences at the University of Sydney, Australia. He is a molecular biologist, and has published about 250 research papers...

  • Medicirc.org – Circumcision: a lifetime of medical benefits by Edgar Schoen
    Edgar Schoen
    Dr. Edgar J. Schoen is an American physician, who works as a Clinical Professor in Pediatrics at the University of California, San Francisco, and held the position of Chair of the 1989 American Academy of Pediatrics Task Force on Circumcision.- Experience in hospitals :Dr...

    , BSc., M.D.
  • Circs.org maintained by Jake Waskett.


Techniques and videos
The source of this article is wikipedia, the free encyclopedia.  The text of this article is licensed under the GFDL.
 
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