Circumcision

Male circumcision is the removal of some or all of the foreskin (prepuce) from the penis.^[1] The word "circumcision" comes from Latin circum (meaning "around") and cædere (meaning "to cut").

Early depictions of circumcision are found in cave drawings and Ancient Egyptian tombs, though some pictures may be open to interpretation.^[2]^[3]^[4] Male circumcision is a commandment from God in Judaism.^[5] In Islam, though not discussed in the Qur'an, circumcision is widely practiced and most often considered to be a sunnah.^[6] It is also customary in some Christian churches in Africa, including some Oriental Orthodox Churches.^[7] According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, of whom 68% are Muslim.^[8] The prevalence of circumcision varies widely between cultures. For example, estimates of the rate of circumcision among boys include nearly all in the Middle East^[9], 2% in Scandinavia and less than 5% in Britain.^[10] Recent estimates of the infant circumcision rate include 56% in the United States,^[11] less than 14% in Canada,^[12] and less than 15% in Australia.^[13] Neonatal circumcision is thought to have become common in English-speaking countries in the mid-nineteenth century;^[14] more recently, the rate is reported to have declined in Australia and Canada.^[15] In the United States, reports variously state that it is falling,^[16] stable,^[17] or increasing.^[18]

There is scientific evidence supporting both sides of the circumcision controversy. Opponents of circumcision claim that it violates the individual's bodily rights, is medically unnecessary, adversely affects sexual pleasure and performance, and is a practice defended by myths.^[19] Advocates for circumcision claim that it provides important health advantages which outweigh the risks, that it has no substantial effects on sexual function, has a complication rate of less than 0.5% when carried out by an experienced physician, and is best performed during the neonatal period.^[20]

The American Medical Association stated in 1999: "Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice."^[21]

The World Health Organization (WHO; 2007), the Joint United Nations Programme on HIV/AIDS (UNAIDS; 2007), and the Centers for Disease Control and Prevention (CDC; 2008) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides partial protection and should not replace other interventions to prevent transmission of HIV.^[22]^[23]

Modern circumcision procedures

All devices follow the same basic procedure. First the amount of foreskin to be removed is estimated. Then the foreskin is opened via the preputial orifice to reveal the glans 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) and remains there until bleeding has stopped. Finally, the foreskin is amputated.^[25]

Adult circumcisions are often performed without clamps and require 4 to 6 weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.^[30] In poor African countries, male circumcision is often performed by non-medical personnel under unsterile conditions.^[31] After circumcision, the disposition of the foreskin varies. After hospital circumcision, the foreskin may be used in biomedical research,^[32] consumer skin-care products.^[33], skin grafts^[34]^[35]^[36], for β-interferon-based drugs,^[37]. In parts of Africa, the foreskin may be dipped in brandy and eaten by the patient, eaten by the circumciser, or fed to animals.^[38] According to Jewish law, after a Brit milah, the foreskin should be buried.^[39]

Cultures and religions

Jewish law states that circumcision is a 'mitzva aseh ("positive commandment" to perform an act) and is obligatory for Jewish-born males and some Jewish male converts. It is only postponed or abrogated in the case of threat to the life or health of the child.^[40] It is usually performed by a mohel on the eighth day after birth in a ceremony called a Brit milah (or Bris milah, colloquially simply bris), which means "Covenant of circumcision" in Hebrew. It is considered of such religious importance that the body of an uncircumcised Jewish male will sometimes be circumcised before burial.^[41]

In Islam, circumcision is mentioned in some hadith, but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended (Sunnah); others that it is obligatory.^[42] Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham.^[43] While endorsing circumcision for males, scholars note that it is not a requirement for converting to Islam.^[44]

Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches.^[7] Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya,^[7]^[45] require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ.^[46]^[47] 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. In West Africa infant circumcision may have had tribal significance as a rite of passage or otherwise in the past; today in some non-Muslim Nigerian societies it is medicalised and is simply a cultural norm.^[48]

Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land,^[50] where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.^[51] Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature: subincision is practised amongst some aboriginal peoples in the Western Desert.^[52] In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu;^[53] participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.^[54]

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

Among some West African animist groups, such as the Dogon and Dowayo, circumcision is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males.^[55] Among the Urhobo of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te Oshare ("the boy is now man"), constitutes a rite of passage from one age set to another.^[56] For Nilotic peoples, such as the Kalenjin and Maasai, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set.^[57]

Ethical, psychological and legal considerations

Ethical issues

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,^[25]^[61]^[62] but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue.^[63]^[64] 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.^[64] 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."^[65]

Some argue that the medical problems that have their risk reduced by circumcision are already rare, can be avoided, and, if they occur, can usually be treated in less invasive ways than circumcision. Somerville states that the removal of healthy genital tissue from a minor should not be subject to parental discretion and that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient.^[58] Denniston contends that circumcision is harmful and asserts that in the absence of the individual's consent, non-therapeutic child circumcision violates several ethical principles that govern medicine.^[66]

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.^[67] 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."^[68]

Acknowledgment of pain

Williams (2003) argued that human attitudes toward the pain that animals (including humans) experience may not be based on speciesism; developing an analogy between attitudes toward the pain pigs endure while having their tails "docked", and "our culture's indifference to the pain that male human infants experience while being circumcised."^[69]

Psychological and emotional consequences

The British Medical Association (2006) state that "it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks."^[64] Goldman (1999) discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure.^[70] Milos and Macris (1992) argue that circumcision encodes the perinatal brain with violence and negatively affects infant-maternal bonding and trust.^[19] Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, and cite a longitudinal study which did not find a difference in developmental and behavioural indices.^[71] In the United States, the Centers for Disease Control and Prevention stated: "In a study of adolescents¸ only 69% of circumcised and 65% of uncircumcised young men correctly identified their circumcision status as verified by physical exam."^[72]

Legality

In 2001, Sweden allowed only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anaesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the law,^[73] and in 2001, the World Jewish Congress stated that it was “the first legal restriction on Jewish religious practice in Europe since the Nazi era.”^[74] 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 mohels had been certified under the law and 3000 Muslim and 40–50 Jewish boys were circumcised each year.^[75]

In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised was illegal. The prosecutor argued that, "part of healthy genitalia is removed without medical foundation, or competent consent". No punishment was assigned by the court.^[76] In 2008, the Finnish government was reported to be considering a new law to legalize ritual circumcision if the practitioner is a doctor and if the child or parents consents.^[77]

Medical analysis

Medical cost-benefit analyses of circumcision have varied. Some found a small net benefit of circumcision,^[78]^[79]^{verification needed} some found a small net decrement,^[80]^[81] 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."^[82]

Pain and pain relief during circumcision

According to the American Academy of Pediatrics' 1999 Circumcision Policy Statement, “There is considerable evidence that newborns who are circumcised without analgesia experience pain and psychologic stress.”^[25] It therefore recommended using pain relief for circumcision.^[25] One of the supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response during vaccination months later. While acknowledging that there may be "other factors" besides circumcision to account for different levels of pain response, they stated that they did not find evidence of such. They concluded "pretreatment and postoperative management of neonatal circumcision pain is recommended based on these results."^[83] Other medical associations also cite evidence that circumcision without anesthetic is painful.^[84]^[85]

Stang, 1998, found 45% of physicians used anaesthesia – most commonly a dorsal penile nerve block – for infant circumcisions. Obstetricians used anaesthesia significantly less often (25%) than family practitioners (56%) or pediatricians (71%).^[86] 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."^[87] 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%.^[88] 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.^[88]

J.M. Glass, 1999, stated that Jewish ritual circumcision is so quick that "most mohelim do not routinely use any anaesthesia as they feel there is probably no need in the neonate. However, there is no Talmudic objection and should the parents wish for local anaesthetic cream to be applied there is no reason why this cannot be done."^[40] Tannenbaum and Shechet, 2000, stated that an “authentic, traditional bris performed by a mohel does not use clamps, so there is no pain associated with crushing tissue.”^[89] They also asserted that due to the speed of the procedure and rarity of complication, it is “more humane not to subject the infant to a local anesthetic.”^[89]

Lander et al. demonstrated that babies circumcised without anesthesia showed behavioral and physiological signs of pain and distress.^[90] Comparisons of the dorsal penile nerve block and EMLA (lidocaine/prilocaine) topical cream methods of pain control have revealed that while both are safe,^[91]^[92] the dorsal nerve block controls pain more effectively than topical treatments,^[93] but neither method eliminates pain completely.^[91] 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.^[94] Ng et al. found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.^[95]

Sexual effects of circumcision

The sexual effects of circumcision are the subject of much debate. The American Academy of Pediatrics (1999) stated "There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males", however they also stated that "[a] survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men." They continued, "Masters and Johnson noted no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men."^[25] 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."^[84] Payne et al. reported that direct measurement of penile sensation during sexual arousal failed to support the hypothesised sensory differences associated with circumcision status.^[96] In a 2008 study, Krieger et al. stated that "Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm."^[97]

Conversely 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, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well."^[98] 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."^[99]

Reports detailing the effect of circumcision on erectile dysfunction have been mixed. Studies have shown that circumcision can result in a statistically significant increase,^[100]^[101] or decrease,^[102]^[103] in erectile dysfunction among circumcised men, while other studies have shown little to no effect.^[104]^[105]^[106]

Complications from circumcision

Complication rates ranging from 0.06% to 55% have been cited,^[107] though a 1993 survey of circumcision complications by Williams and Kapilla put the rate at 2-10%.^[108] Another major survey of circumcision complications was conducted by G.W Kaplan in 1983.^[109]

According to the American Medical Association (AMA), blood loss and infection are the most common complications, but most bleeding is minor and can be stopped by applying pressure.^[61] In studies reviewed by Kaplan, the rate of bleeding complications was between 0.1% and 35%.^[109] A 1999 study of 48 boys who had complications from traditional male circumcision in Nigeria found that haemorrhage occurred in 52% of boys, infection in 21% and one child had his penis amputated.^[110]

Meatal stenosis (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, ammonia formed from urine in wet diapers irritates and inflames the exposed urethral opening. Meatal stenosis can lead to discomfort with urination, incontinence, bleeding after urination and urinary tract infections.^[111]^[112]

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 study warned though that this was a conservative estimate because it did not capture the very rare but serious delayed complications associated with circumcisions (eg, necrotizing fasciitis, cellulitis) and the less serious but more common complications such as the circumcision scar or a less than ideal cosmetic result. It also warned that the risks of circumcision "do not seem to be mitigated by the hands of more experienced physicians".^[113]

Circumcisions may remove too much or too little skin.^[108] If insufficient skin is removed, true phimosis can result.^[108] Cathcart et al. report that 0.5% of boys required a procedure to revise the circumcision.^[114]

Other complications include concealed penis^[115]^[116], urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias and impotence.^[109] 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.”^[109]

Infant circumcision may result in skin bridges, whereby the end of the severed part of the foreskin fuses to other parts of the penis (normally the glans) on repair.^[117]

Although deaths have been reported^[109]^[118], the American Academy of Family Physicians states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision.^[84] Gairdner's 1949 study^[119] 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. The penis is thought to be lost in 1 in 1,000,000 circumcisions.^[120]

Sexually transmitted diseases

Human immunodeficiency virus

The origin of the theory that circumcision can lower the risk of a man contracting HIV is disputed.^[121]^[122]^[123] Since the idea was first mooted, over 40 epidemiological studies have been conducted to investigate the relationship between circumcision and HIV infection.^[124] Reviews of these studies have reached differing conclusions about whether circumcision could be used as a prevention method against HIV.^[125]^[126]^[127]^[128]

Because experimental evidence was needed to establish a causal relationship between lack of circumcision and HIV,^[60] 3 randomized controlled trials were commissioned as a means to reduce the effect of any confounding factors.^[127] Trials took place in South Africa,^[60] Kenya^[129] and Uganda.^[130] 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.^[129] 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 reported that 72 circumcisions would need to be performed to prevent one HIV infection. The authors concluded 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.^[131]

As a result of these findings, the WHO 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.^[22]^[132]^[133] Both the WHO and CDC indicate that circumcision may not reduce HIV transmission from men to women, and that data is lacking for the transmission rate of men who engage in anal sex with either a female or male partner, as either the insertive or receptive partner.^[22]^[23] The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should never replace known methods of HIV prevention.^[132]

Some earlier reports had expressed the position that circumcision has little to no effect on HIV transmission.^[134]^[135]^[136] Furthermore, 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.^[137]^[138]

Human papilloma virus

In several studies, uncircumcised men were found to have a greater incidence of human papilloma virus (HPV) infection than circumcised men.^[139]^[140]^[141] One study did not find a statistically significant difference in the incidence of HPV infection between circumcised and uncircumcised men, but did note a higher prevalence of urethritis in the uncircumcised.^[142] A meta-analysis by Van Howe in 2006 found that there was no significant association between circumcision status and HPV infection and that "the medical literature does not support the claim that circumcision reduces the risk for genital HPV infection".^[143] However, Castellsagué et al. maintain that this meta-analysis was flawed, and further note that a re-analysis of the same data "... clearly shows, no matter how the studies are grouped, a moderate to strong protective effect of circumcision on penile HPV and related lesions."^[144]

Two studies have shown that circumcised men report, or were found to have, a higher prevalence of genital warts than uncircumcised men.^[145]^[146]

Other sexually transmitted infections

In a meta-analysis of data from twenty-six studies, circumcision was associated with lower rates of syphilis, chancroid and possibly genital herpes.^[147]

Other studies have failed to find a prophylactic benefit to circumcision. One study found circumcision offered no protective benefit against herpes simplex virus type 2, syphilis, or gonorrhea.^[148] 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 or trichomoniasis.^[149]

Laumann et al found that circumcised men were "slightly more likely to have had both a bacterial and a viral STD in their lifetime", noting that the difference in the case of chlamydia were quite large. However, these findings were not statistically significant. They stated: "[w]e find no significant differences between circumcised and uncircumcised men in their likelihood of contracting sexually transmitted diseases".^[102]

Hygiene, and infectious and chronic conditions

The American Academy of Pediatrics (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." ^[25] Some studies found that boys with foreskins had higher rates of various infections and inflammations of the penis than those who were circumcised.^[150]^[151]^[152]

One study looked at 75 circumcised and 150 non-circumcised men at a sexually transmitted infections (STI) clinic at Ealing Hospital, London. It found that circumcised men were more likely than non-circumcised men to wash the genital area more than once a day.^[153] However, a follow-up study of 480 men attending the same London clinic, found a very low incidence of the subpreputial penile wetness that is associated poor genital hygiene and an increased risk of HIV infection^[154]^[155].

The foreskin may harbor bacteria and become infected if it is not cleaned properly,^[153] but may become inflamed if it is cleaned too often with soap.^[156]

The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams, but circumcision is another option.^[158]

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 (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 or a history of recurrent UTIs, where the number needed to treat declined to 11 and 4, respectively).^[159]

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.^[25] 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.^[61]

Penile cancer

The American Cancer Society (2006) stated, "The current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer."^[160]

The American Academy of Pediatrics (1999) stated that studies suggest that neonatal circumcision confers some protection from penile cancer, but circumcision at a later age does not seem to confer the same level of protection. Further, because penile cancer is a rare disease, the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low.^[25]

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.^[25] Two studies have reported that the rate of penile cancer is 3 to 22 times higher in men who were not circumcised.^[161]^[162]

Policies of various national medical associations

Most guidelines make a distinction between therapeutic and non-therapeutic circumcision. Therapeutic circumcision (where there is a medical need to circumcise) is rarely controversial. Neonatal circumcision is not considered medically necessary and is therefore categorised as non-therapeutic.

United States

The American Medical Association defines “non-therapeutic” circumcision as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. It states that medical associations in the US, United Kingdom, Australia, and Canada do not recommend the routine non-therapeutic circumcision of newborns.^[61] The medical harms or benefits of non-threapeutic have not been unequivocally proven but there are clear risks of harm if the procedure is done inexpertly.^[163] Reasons for non-therapeutic circumcision include religious beliefs as well as cultural and family conformity.^[64]

The American Academy of Pediatrics (1999) does not recommend routine neonatal circumcision.^[25] If parents choose to circumcise, the AAP also recommends using analgesia to reduce pain associated with circumcision, and that circumcision only be performed on newborns who are stable and healthy.^[164] The American Medical Association echoes the 1999 Circumcision Policy Statement of the American Academy of Pediatrics.^[61]

The American Academy of Family Physicians (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 circumcision for newborn boys.^[165]

The American Urological Association (2007) believes that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks.^[166]

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Circumcision: Information for Parents" in November 2004,^[85] and "Neonatal circumcision revisited" in 1996. The 1996 position statement says that "circumcision of newborns should not be routinely performed," (a statement with which the Royal Australasian College of Physicians concurs,) and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many pediatricians no longer perform circumcisions."^[62]

United Kingdom

There is a spectrum of views within the British Medical Association's (BMA) membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. Moreover, the Association states that “there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.”^[64] As a general rule, the BMA believe that "parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices." They also state that "both parents...must give consent for non-therapeutic circumcision", and that parents and children should be provided with up-to-date written information about the risks involved.^[64]

According to the BMA, circumcision for medical purposes should only be used where less invasive procedures are either unavailable or not as effective. They state that "to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate." Furthermore, the BMA believe that children who are capable of expressing a view should be involved in the decision making process with regard to their own circumcision, and their views should be taken into account. The BMA state that they "cannot envisage a situation in which it is ethically acceptable to circumcise a competent, informed young person who consistently refuses the procedure."^[64]

The BMA state that parents should be informed about the lack of consensus within the medical profession with regard to the potential health benefits of non-therapeutic circumcision, adding that they consider the evidence for such benefits to be insufficient as the sole reason for carrying out a circumcision.^[64]

Australasia

The Royal Australasian College of Physicians (RACP) state that "after extensive review of the literature" they "reaffirm that there is no medical indication for routine neonatal circumcision". They also state that "if the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment." Additionally, the RACP state that there is an obligation to provide parents who request a circumcision for their child with accurate, up-to-date and unbiased information about the risks and benefits of circumcision, adding that "there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate."^[63]

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.^[167]

History of circumcision

It has been variously proposed that circumcision began as a religious sacrifice, as a rite of passage marking a boy's entrance into adulthood, as a form of sympathetic magic to ensure virility, as a means of suppressing sexual pleasure or to increase a man's attractiveness to women, or as an aid to hygiene where regular bathing was impractical, among other possibilities. Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practicing circumcision, leading to its spread regardless of whether the people understood this.^[168] It is possible that circumcision arose independently in different cultures for different reasons.

The oldest documentary evidence for circumcision comes from ancient Egypt.^[169] Circumcision was common, although not universal, among ancient Semitic peoples.^[170] 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.^[171]

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.^[172]

Circumcision in the English-speaking world

Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada, South Africa and to a lesser extent in the United Kingdom and New Zealand. There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The germ theory of disease elicited an image of the human body as a conveyance for many dangerous germs, making the public "germ phobic" and suspicious of dirt and bodily secretions. Because of its function, the penis became "dirty" by association, and from this premise circumcision was seen as preventative medicine to be practiced universally.^[173] In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation.^[173] It was also said to protect against syphilis,^[174] phimosis, paraphimosis, balanitis, and "excessive venery" (which was believed to produce paralysis).^[173] Gollaher states that physicians advocating circumcision in the late nineteenth century expected public skepticism, and refined their arguments to overcome it.^[173]

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.^[102] 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.^[102] 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.^[175] Between 1981 and 1999, National Hospital Discharge Survey data from the National Center for Health Statistics 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.^[176] 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.^[177] 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.^[178] A report by the Agency for Healthcare Research and Quality placed the 2005 national circumcision rate at 56%.^[179]

Circumcision grew in popularity in South Korea following the establishment of the United States trusteeship in 1945 and the spread of American influence. More than 90% of South Korean high school boys are now circumcised, and the average age of circumcision is 12 years.^[180]

In 1949, the United Kingdom's newly-formed National Health Service removed infant circumcision from its list of covered services, and circumcision has since been an out-of-pocket cost to parents. As a result, prevalence in the UK is age-graded, with 12% of those aged 16-19 years circumcised and 20% of those aged 40-44 years,^[181] and 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 2000-01 survey finding 32% of those aged 16-19 years circumcised, 50% for 20-29 years and 64% for those aged 30-39 years.^[182]^[13]

In Canada, individual provincial health services began delisting circumcision in the 1980s.^{citation needed}

Prevalence of circumcision

Estimates of the proportion of males that are circumcised worldwide vary from one-sixth^[108] to a third.^[183] WHO has estimated that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), with almost 70% of these being Muslim.^[132] Prevalence is near universal in the Middle East and Central Asia.^[132] WHO states that "there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines".^[132] WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe,^[132] and Klavs et al. report findings that "support the notion that the prevalence is low in Europe".^[184] In Latin America, prevalence is universally low.^[185] Estimates for individual countries include Spain^[186], Colombia^[186] and Denmark^[187] less than 2%, Finland^[188] and Brazil^[186] 7%, Taiwan^[189] 9%, Thailand^[186] 13%, New Zealand^[9] less than 20% and Australia^[13] 58.7%.

WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively.^[132] Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.^[185]

Contents