Circumcision

Circumcision is the removal of some or all of the foreskin (prepuce) from the penis. The frenulum may also be removed at the same time, in a procedure called frenectomy. The word "circumcision" comes from Latin circum (meaning "around") and caedere (meaning "to cut"). Female circumcision is a term applied to a variety of procedures performed on the female genitalia. Except where specified, "circumcision" in this article should be regarded as "male circumcision".

Circumcision as a therapeutic medical procedure may be recommended to treat a variety of conditions, such as pathological phimosis, chronic inflammations of the penis and penile cancer. The frequent use of circumcision is often criticised since the indicators for circumcision are regularly misdiagnosed, e.g. confusing normal, congenital infant phimosis with pathological phimosis,[1] and circumcision is often used where less invasive treatments are available and effective. [2]

Routine, non-therapeutic infant circumcision is controversial. National medical associations in America, Canada, and Australia do not recommend routine infant circumcision, and several recommend that doctors discuss the benefits and risks with prospective parents.[3] [4] [5] The genital integrity movement condemns non-therapeutic infant circumcision as a human rights violation that they consider comparable to female genital cutting,[6] while circumcision advocates stress the medical benefits of the procedure.[7]

A circumcised penis in both flaccid and fully erect states, respectively (larger version).

File:UncirPenisFlaccid1.jpg

Penis, not circumcised, flaccid and erect. (larger version).

The procedures of circumcision

Circumcision is the removal of the foreskin from the penis. Clamps, such as the Gomco, Plastibell, and Mogen are commonly used for infant circumcision.[8] These are intended to protect the glans from harm, and crush the foreskin to achieve hemostasis. When the Gomco or Mogen clamp is used, a dorsal slit must be made before application of the clamp. In the case of the Mogen and Plastibell, the foreskin is then surgically removed, while when the Plastibell is used, the foreskin sloughs away along with the clamp in three to seven days.

According to a 1998 study, anaesthesia is used by 45% of physicians performing infant circumcision.[9] Dorsal penile nerve block is the most commonly used form. Obstetricians were notable in the study for a significantly lower rate of anaesthesia use (25%) than pediatricians or family practitioners. A study found that circumcision is a very painful procedure when conducted without adequate anesthesia, and reveals that even the use of an anesthetic is not completely effective. [10] Adult circumcisions are often performed without clamps, and require the following 4 to 6 weeks of abstinence from masturbation or intercourse to allow wound healing. [11]

Cultures and Religions

For information on circumcision in the Bible, see Circumcision in the Bible.

Some cultures circumcise their males, either shortly after birth, or around puberty as an initiation rite. The practice is most notable among Muslims and Jews, and is more prevalent in the United States than in other Western nations.

Aesthetics

Circumcision may be undertaken as a body modification of the genitals to change the looks of the penis to appeal more to certain aesthetics. Where infant or childhood circumcision is the norm, people may consider non-circumcised penises to be less preferable sexually, visually or otherwise. In a few cultures, circumcision may be one of other modifications of the penis, such as a split penis or a subincision.

The United States, the Philippines and South Korea are the only countries that circumcise a majority of young males for non-religious reasons. Routine circumcision practices in South Korea are largely the result of American cultural and military influence following the Korean War. The origin of the practice in the Philippines is uncertain according to one newspaper article [12]. However, Antonio de Morga's "History of the Philippine Islands" (1907) attributes circumcision to Islamic influence [13].

Coptic Christian

Circumcision is also customary in the Coptic Christian and Ethiopian Orthodox religious traditions. It is usually performed on the eighth day of life.

Islam

Islam stresses form of natural hygiene. Although circumcision is not mentioned in the Qur'an, it is mentioned in some parts of the Hadith. Fiqh scholars have different opinions about circumcision in Shariah, depending on which Hadith are accepted and how they are interpreted. According to Imam Abu Hanifa, Imam Malik and a majority of others it is a recommended practice (Sunnah), but others, including Imam Shafi, consider it obligatory. The timing of Muslim circumcision varies. Some Muslim communities perform circumcision on the eighth day of life, as with Jews, while others perform the rite later. Turkish, Balkan, rural Egyptians and Central Asian Muslims typically circumcise boys between the ages of six and eleven and the event is viewed communally as a joyous occasion and is celebrated with sweets and feasting. In contrast, Iranian Muslims are typically circumcised in the hospital at birth without much ado. Urban Egyptians, as with many industrialized countries such as the USA, perform the procedure at a hospital. Kamyar et al describe it as an 'obligatory custom', and note that it is not necessary for the circumciser to be a Muslim. Recently, world opinion, including Islamic opinion [14], has become increasingly critical of the practice of female circumcision, which is also widespread in Islamic cultures. [15]

Judaism

Main article: Brit milah

Circumcision is a religious practice traditionally required by Judaism, usually performed in a ceremony called a Brit (or Bris) milah (Hebrew for "Covenant of circumcision"). A mohel performs the ceremony on the eighth day after birth unless health reasons force a delay. According to the Torah (Genesis, chapter 17 verses 9-14), God commanded Abraham to circumcise himself, his offspring and his slaves as part of an everlasting covenant. According to Jewish law, failure to follow the commandment carries the penalty of karet, or being cut off from the community by God. Brit milah is so important that should the eighth day fall on Shabbat, actions that would normally be forbidden because of the sanctity of the day are permitted in order to fulfill the requirement to circumcise. See also Circumcision in the Bible.

Tribal traditions

Circumcision is part of the initiation rite in a number of African and Australian Aboriginal tribal traditions. Among some West African animist groups, such as the Dogon and Dowayo, it is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males. Among Nilotic peoples, such as the Nandi, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set. Aboriginal circumcision ceremonies, which also constitute a rite of passage, are noted for their painful nature, including subincision for some tribes.

Ethical Issues

Main article: Bioethics of neonatal circumcision

Circumcising infants as a public health measure is controversial. In cultures such as the United States, lay people may regard infant circumcision as a routine medical practice but medical organizations in Australia, Canada, and America do not recommend routine infant circumcision [16]. While the risks of circumcision-related complications are very low [17], the possible catastrophic complications of a poorly carried out circumcision, or of post-operative bleeding or infection, are not to be taken lightly. The American Academy of Pediatrics recommend that parents should be informed about the benefits and risks of the procedure.[18] Circumcision advocates argue that circumcision is a significant public health measure, preventing infections, and possibly slowing down the spread of AIDS, while the genital integrity movement asserts that infant circumcision is a human rights violation and a sexual assault, and that the practice of circumcising infants or children should be discouraged or banned.

Consent

Debate often focuses on what limits, if any, should be placed on a caregiver's ability to make a decision for a boy about a procedure with disputed immediate medical value and that may be unwanted and mostly irreversible later in life. Some question the apparent inconsistency of allowing male circumcision but prohibiting female genital cutting [19]. It has been suggested that circumcision may cause emotional scarring later in life, and claim that the procedure should be left until a man is mature enough to make the choice for himself. Those in favour claim the procedure is less traumatic when performed in infancy as well as point out it may disturb the traditional and religious rights of parents to make decisions on behalf of their child.

Emotional consequences

Much attention has been given to the emotional impact of female genital cutting. For no clear reasoning the emotional impact of male circumcision has traditionally been ignored. Issues about the rights of the child are often overlooked, as is the possibility that circumcision may cause emotional and physical harm to males.

In the USA, most neonatal circumcisions are performed without anaesthesia.[20] Several studies suggest that circumcised infants do not forget the pain during circumcision easily, as a correlation between circumcision with ineffective anaesthesia and intensity of pain response during vaccination months later could be established.[21]

Legality

Main article: Circumcision and law

The mainstream medical organizations do not consider circumcision to be a legal issue as long as the decision for circumcision was made by the legal guardians, and that they have given their informed consent.

Religious circumcision of minors

Main article: Religious circumcision

In some parts and cultures of the world, it is customary or obligatory for minors of both sexes to be circumcised for religious reasons. Many believe that this practice is protected by the principle of freedom of religion. Others disagree, arguing that no right has precedence over the rights of bodily integrity of a child. Still others contend that freedom of religion only applies to belief, not action involving others. Female circumcision is prohibited in most western countries, and Sweden has restricted religious male infant circumcision. [22]

Medical Aspects

Main article: Medical analysis of circumcision

Recently there has been increasing cost-benefit analysis of the medical aspects of neonatal circumcision. Largely these have compared the average cost of neonatal circumcision, to the expected reduction in lifetime health costs, both financial and longevity, associated with reduced incidence of disease.

These studies have been conflicting but have formed the basis of public health policies. The American Academy of Pediatrics (1999) said the medical benfits of circumcision are not sufficient to recommend routine neonatal circumcision, but that it should be the decision of informed parents.[23]

Risks of circumcision

Circumcision is a surgical procedure, and there is a risk of complications. The AAP, AMA, and AAFP state that the rate is between 0.2% and 0.6%, based upon large series. The CPS acknowledge these series, but additionally cite a review which suggested that a rate of 2% to 10% would be more realistic. The Royal Australasian College of Physicians states the rate of complications of infant circumcision as "between 0.2% and 0.6% to 2%-10%" in one section, and "1% to 5%" in another. They suggest that the variation in reported rates depends upon the situation in which circumcision is performed and the definition of complication used.

The Royal Australasian College of Physicians and the American Medical Association criticise neonatal circumcision without anaesthetics because of the pain involved in the procedure [24] [25]. The American Academy of Pediatrics explicitly recommends that if the procedure is to be performed, anaesthetics are to be used [26]. Bleeding and infection are the most common complications, according to the AMA. Other complications are known, including infections, urinary fistulas, meatal stenosis, ulceration of the glans, removal of too much tissue, and secondary phimosis. Infant circumcision may cause problems such as skin bridges, when the foreskin does not just heal back together but instead attaches to the glans penis [27]. Loss of the penis itself has been documented. The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.

Gairdner's 1949 study [28] reported that 16 children per year died in the UK during the 1940s, a rate of 1.8 in 10,000 [29]. At that time, deaths attributed to phimosis and circumcision were grouped together, but Gairdner stated that the deaths were probably due to circumcision. Gairdner stated that most deaths had occurred suddenly under anaesthesia, and couldn't be explained further, but haemorrhage and infection had also proven fatal.

The American Academy of Family Physicians states that death is rare, and cites an estimated death rate with circumcisions of infants of 1 in 500,000 [30].

HIV

The possible role of circumcision in reducing HIV transmission remains the subject of ongoing research and debate in the medical community. he March 2005 Cochrane review of the medical evidence concluded that, while individual studies are of variable quality, there are clear indicators that circumcision can significantly reduce the rate of female-to-male HIV infection in an African population.[31] Initial population based studies suggesting that circumcision might play a protective role were crticised on the grounds that confounding factors such as religion may have influenced results; the reviewers therefore commented that the results of randomised controlled trials now underway will be critical. The results of the first of these trials were published in November 2005, reporting a 60% reduction in the rate of new HIV infection in the circumcised group.[32]. Results of two further randomised trials to investigate the protective effect of circumcision against HIV infections will become available in 2007. The World Health Organization stresses that the protective effect offered by male circumcision in Africa has to be confirmed by further studies, and is not reliable enough to replace sex education and safer sex practice as a means to combat AIDS.

The mechanism by which circumcision might protect against HIV transmission remains unclear. Langerhans cells, a part of the human immune system, can be infected by the HIV virus.[33]. Two studies, Szabo and Short (2000) and Patterson et al. (2002) [34] have suggested that Langerhan's cells in the foreskin may provide an entry posint for viral infection. Conversely, some authors are of the opinion that the prepuce has an important immunological function, and that its removal increases the chances of infections. Their hypothesis has been criticised on technical grounds.[35] [36]

HPV

Several studies have shown that non-circumcised men are at greater risk of human papilloma virus (HPV) infection.[37] [38] [39] While most genital HPV strains are considered harmless, some can, but not necessarily do, cause genital warts or even cancer. One study found no statistically significant difference between men with foreskins for HPV infection than those who are circumcised, but did note a significantly higher incidence of HPV lesions and urethritis [40].

Hygiene

Circumcision reduces the amount of smegma produced by the body. Smegma, a transliteration of the Greek word σμήγμα for soap, is a combination of exfoliated (shed) , epithelial cells, transudated skin oils and moisture that can accumulate under the foreskin of males and within the female vulva area, with a characteristic strong odor and taste. Smegma is common to all mammals, male and female. While smegma is generally not believed to be harmful to health, the strong odour may be considered to be a nuisance giving the impression of lacking hygiene. In rare cases, accumulating smegma may play into causing balanitis.

The Royal Australasian College of Physicians and the Canadian Pediatric Society emphasize that a non-circumcised infants penis should be left alone and requires no special care. Attempts to forcibly retract the foreskin, e.g. to clean it, are painful, often injure the foreskin, and can lead to scarring, infections and pathologic phimosis. It is recommended that, while there is no special age where the foreskin should be retractible, once the foreskin becomes retractible, the child should gently wash it with soap and water. It has been suggested, however, that excessive washing of the foreskin and the glans will make infections such as balanitis more likely.

Infectious and chronic conditions

Non-circumcised children and men tend to have higher rates of various infections and inflammations of the penis, and of the foreskin, than circumcised men.[41] The reasons are unclear, but several hypotheses have been suggested:

• The foreskin may harbor bacteria and infect if it is not cleaned enough.[42]
• The foreskin may become inflamed if it is cleaned too often with soap.[43]
• The forcible retraction in boys can lead to infections.[44]

There are less invasive treatments than circumcision for posthitis (an inflamed foreskin) [45] and balanitis (inflammation of the glans) [46][47][48]. However, these are not as successful in treating balanitis xerotica obliterans (BXO) [49] [50] [51], which is harder to treat [52] [53].

Lichen sclerosus et atrophicus (LSA) produces a whitish-yellowish patch on the skin, and is not believed to be always harmful or painful, and may sometimes disappear without intervention. Some consider balanitis xerotica obliterans to be a form of LSA that happens to be on the foreskin, where it may cause pathological phimosis. Circumcision is believed to reliably reduce the threat of BXO. [54]

Penile cancer

Penile cancer is cancer of the penis, i.e. on the glans or the foreskin. The lifetime risk is estimated to be 0.17% for a non-circumcised male, [55] and 80% of the cases are men over the age of 70. [56] Penile cancer is a very rare type of cancer, even rarer than breast cancer in men, and there has been data that shows that circumcised males have about the same chance of getting penile cancer than those who are uncircumcised. In addition, several developed countries which do not routinely circumcise, have a slightly lower rate than that of the United States. [57][58] There are many other factors which affect the rate of penile cancer, such as smoking. [59]

In 1998, the American Cancer Society labelled some claims about a relationship of circumcision with penile cancer misleading. It said:

However, the penile cancer risk is low in some non-circumcised populations, and the practice of circumcision is strongly associated with socio-ethnic factors, which in turn are associated with lessened risk. The consensus among studies that have taken these other factors into account is circumcision is not of value in preventing cancer of the penis. (1998, [60])

However, in 2005, the society said:

Recent studies have found that circumcised men are less likely to be infected with HPV, even after this risk is adjusted for differences in sexual behavior. Other studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer. However, it is important that the issue of circumcision not distract the public's attention from avoiding known penile cancer risk factors – poor hygiene, having unprotected sex with multiple partners (increasing the likelihood of human papillomavirus infection), and cigarette smoking. (2005, [61])

While in another 2005 statement, they state:

In the past, circumcision has been suggested as a way to prevent penile cancer. This suggestion was based on studies that reported much lower penile cancer rates among circumcised men than among non-circumcised men. However, most researchers now believe those studies were flawed because they failed to consider other factors that are now known to affect penile cancer risk. (2005, [62])

Phimosis and paraphimosis

Pathological phimosis is a condition of a very tight foreskin that makes retraction over the glans painful or impossible. Rickwood suggested that the term 'phimosis' should be restricted to cases in which the prepuce loses suppleness and becomes scarred.[63] Paraphimosis is an acute condition where the tight foreskin is stuck behind the glans and cannot be moved back, curbs the blood flow from the glans, and in children, is sometimes caused by a caregiver trying to forcibly retract the infant foreskin.[64]

The AAP state that the true frequency of such problems is unknown.[65] Fergusson et al found phimosis in 16% of non-circumcised boys,[66] while Herzog and Alvarez found it in 2.6%.[67] Rickwood and Walker raised concern that phimosis is frequently misdiagnosed by physicians confusing it with the developmentally non-retractible foreskin.[68]

Several studies have identified phimosis as a risk factor for penile cancer, leading Willcourt to state that it would be irresponsible to expose a patient to risk for longer than necessary.[69]

Urinary tract infections

Several studies and statistics have indicated that neonatal circumcision reduces the occurrence rate of UTI in male infants by a factor of about 10.[70] Some of these studies have been criticised in not taking other factors (especially for non-circumcision) into account.[71] A Swedish study found that the cumulative incidence of UTIs in boys under 2 years of age was 2.2%.[72]

The Canadian Pediatric Society poses the question of whether increased UTI and balanitis rates in non-circumcised male infants may be caused by forced premature retraction. [73]

Sexual

Main article: Sexual effects of circumcision

The sexual effects of circumcision are controversial.

There are few studies on partner preference for circumcised or non-circumcised penises, with inconclusive results; they are discussed more fully in the full article.

The American Academy of Pediatrics states "a survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men. There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males."[74] The American Academy of Family Physicians states "no valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction."[75]

History of circumcision

Main article: History of male circumcision

It has been variously proposed that circumcision began as a religious sacrifice, as a rite of passage marking a boy's entrance into adulthood, as a form of sympathetic magic to ensure virility, as a means of suppressing (or enhancing) sexual pleasure, as an aid to hygiene where regular bathing was impractical, as a means of marking those of lower (or higher) social status, as a means of differentiating a circumcising group from their non-circumcising neighbors, as a means of discouraging masturbation or other socially proscribed sexual behaviors, to remove "excess" pleasure, to increase a man's attractiveness to women, as a symbolic castration, as a demonstration of one's ability to endure pain, or as a male counterpart to menstruation or the breaking of the hymen. It is possible that circumcision arose independently in different cultures for different reasons.

Köçeks at a fair
Köçek troupe dancing at Sultan Ahmed III's 14-day celebration of his sons' circumcision in 1720. Miniature from the Surname-i Vehbi, Topkapi Palace, Istanbul.

Circumcision in the ancient world

The oldest documentary evidence for circumcision comes from ancient Egypt. Tomb artwork from the Sixth Dynasty (2345-2181 BCE) shows men with circumcised penises, and one relief from this period shows the rite being performed on a standing adult male. The Egyptian hieroglyph for "penis" depicts either a circumcised or an erect organ. The examination of Egyptian mummies has found some with foreskins and others who were circumcised.

Circumcision was common, although not universal, among ancient Semitic peoples. The Book of Jeremiah, written in the sixth century BCE, lists the Egyptians, Jews, Edomites, Ammonites, and Moabites as circumcising cultures. Herodotus, writing in the fifth century BCE, would add the Colchians, Ethiopians, Phoenicians, and Syrians to that list.

In the aftermath of the conquests of Alexander the Great, Greek dislike of circumcision led to a decline in its incidence among many peoples that had previously practiced it. The writer of the 1 Maccabees wrote that under the Seleucids, many Jewish men attempted to hide or reverse their circumcision so they could exercise in Greek gymnasia, where nudity was the norm. First Maccabees also relates that the Seleucids forbade the practice of brit milah (Jewish circumcision), and punished those who performed it–as well as the infants who underwent it–with death.

Medical circumcision in the 19th century and early 20th century

Several hypotheses have been raised in explaining the American public's acceptance of infant circumcision as preventive medicine. The success of the germ theory of disease had not only enabled physicians to combat many of the postoperative complications of surgery, but had made the wider public deeply suspicious of dirt and bodily secretions. Accordingly, the smegma that collects under the foreskin was viewed as unhealthy, and circumcision readily accepted as good penile hygiene.[76] Secondly, moral sentiment of the day regarded masturbation as not only sinful, but also physically and mentally unhealthy, stimulating the foreskin to produce the host of maladies of which it was suspected. In this climate, circumcision could be employed as a means of discouraging masturbation.[77] All About the Baby, a popular parenting book of the 1890s, recommended infant circumcision for precisely this purpose. Interestingly, a 1410-man survey in the United States in 1992, Laumann found that circumcised men were more likely to report masturbating at least once a month.

With the proliferation of hospitals in urban areas, childbirth, at least among the upper and middle classes, was increasingly undertaken in the care of a physician in a hospital rather than that of a midwife in the home. It has been suggested that once a critical mass of infants were being circumcised in the hospital, circumcision became a class marker of those wealthy enough to afford a hospital birth.[78]

By the 1920s, advances in the understanding of disease had undermined much of the original medical basis for preventive circumcision. Doctors continued to promote it, however, as good penile hygiene and as a preventive for a handful of conditions local to the penis: balanitis, phimosis, and penile cancer.

Routine infant circumcision was taken up in the English-speaking parts of Canada, the United States and Australia, and to a lesser extent in New Zealand and the United Kingdom. Although it is difficult to determine historical circumcision rates, one estimate[79] of infant circumcision rates in the United States holds that 30% of newborn American boys were being circumcised in 1900, 55% in 1925, and 72% in 1950.

Circumcision since 1950

In 1949, a lack of consensus in the medical community as to whether circumcision carried with it any notable health benefit motivated the United Kingdom's newly-formed National Health Service to remove routine infant circumcision from its list of covered services. One factor in this rejection of circumcision may have been Douglas Gardiner's famous paper, The fate of the foreskin, which revealed, that for the years 1942–1947, about 16 children per year had died because of circumcision in England and Wales, a rate of about 1 per 6'000 performed circumcisions. [80] Since then, circumcision has been an out-of-pocket cost to parents, and the proportion of newborns circumcised in England and Wales has fallen to less than one percent.

In Canada, individual provincial health services began delisting circumcision in the 1980s. At present, only Manitoba pays for the procedure. The infant circumcision rate in Canada has fallen from roughly 50% in the 1970s to 13.9% in 2003. However, the figures varied from 29.5% on Prince Edward Island to zero in Labrador and Newfoundland. [81]

In South Korea, circumcision was largely unknown before the establishment of the United States trusteeship in 1945 and the spread of American influence. More than 90% of South Korean high school boys are now circumcised, but the average age of circumcision is 12 years [82].

In South Africa circumcision has roots in several belief systems, and is performed most of the time on teenage boys:

"...The young men in the eastern Cape belong to the Xhosa ethnic group for whom circumcision is considered part of the passage into manhood... A law was recently introduced requiring initiation schools to be licensed and only allowing circumcisions to be performed on youths aged 18 and older. But Eastern Cape provincial Health Department spokesman Sizwe Kupelo told Reuters news agency that boys as young as 11 had died. Each year thousands of young men go into the bush alone, without water, to attend initiation schools. Many do not survive the ordeal..." [83].

The major medical societies in Britain, Canada, Australia and New Zealand do not support routine non-therapeutic infant circumcision. Major medical organizations in the United States state that parents should decide what is in their child's best interests, explicitly not recommending the procedure for medical reasons. Neonatal circumcision remains the most common pediatric operation carried out in the U.S. today.

Table 1: International circumcision rates

Country	Year	Neonatal circumcisions (%)
United States	2002	60.1% [84]
Canada	2003	11.5% [85]
Australia	2004	12.7% [86]
New Zealand	1995	0.35%* [87]
United Kingdom	1972	0.41% [88]
*Samoans, Tongans and Niueans in New Zealand continue to practice circumcision, but not in public hospitals, to which these data refer.

Prevalence of circumcision worldwide

Estimates of the proportion of males that are circumcised worldwide vary from one sixth[89] to one third[90].

Except for Muslims and Jews, most males are not circumcised in:

Europe, Latin America, China, India, Australia and South-East Asia.

The majority of males are circumcised in the following countries, in most of which the predominant religion is Islam, which endorses circumcision:

Afghanistan, Albania, Algeria, Azerbaijan, Bahrain, Bangladesh, Benin, Bosnia and Herzegovina, Cameroon, Chad, Comoros, Djibouti, Egypt, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Indonesia, Iran, Iraq, Jordan, Kazakhstan, Kenya, Kuwait, Lebanon, Libya, Madagascar, Malaysia, Maldives, Mali, Mauritania, Morocco, Niger, Nigeria, Oman, Pakistan, "Palestine", Qatar, Republic of the Congo, Saudi Arabia, Sierra Leone, Somalia, "Somaliland", Sudan, Syria, Tajikistan, Tunisia, Turkey, "Turkish Republic of Northern Cyprus", Turkmenistan, United Arab Emirates, Uzbekistan, "Western Sahara", and Yemen.

In other countries where circumcision predominates it is endorsed by religion and/or by local customs and traditions:

Israel, Philippines, Samoa, South Africa, South Korea, Togo, Tonga, the United States, and Vanuatu

United States

Statistics from different sources give a somewhat different picture of the prevalence of circumcision in the United States.

The National Center for Health Statistics stated that the overall rate of neonatal circumcision was 64.3% in 1979 and 65.3% in 1999. However, the rate for white infants was 0.3% lower in 1999 than 1979 and the circumcision rate for black infants increased by 6.5% over this time [91]. Also, strong regional differences developed. In the West, circumcision declined from 63.9% to 36.7%, but this was counterbalanced by rises in the Midwest and South. [92] The decline in the West has been partly attributed to increasing births among Latin Americans, who usually do not circumcise [93]. Furthermore, the decline in the West may also be attributed to articles in newspapers and television appearances by Dr Dean Edel, a practicing surgeon in the San Francisco Bay Area, who argued against routine infant circumcision.

A recent study, which used data from the Nationwide Inpatient Sample (a sample of 5-7 million of the nation's total inpatient stays, and representing a 20% sample taken from 8 states in 1988 and 28 in 2000), stated that circumcisions rose from 48.3% in 1988 to 61.1% in 1997.[94]

Figures from the Nationwide Hospital Discharge Survey (a sample of 270,000 inpatient stays), state that circumcision rates declined from 64.7% in 1980 to 59.0% in 1990, then rose to 64.1% in 1995, and fell again to 60.1% in 2002. Overall, the West saw the most significant change, declining from 61.8% in 1980 to 32.6% in 2002 (see Table 44, page 51 of the National Hospital Discharge Survey, 2002) [95].

Sixteen states no longer pay for the procedure under Medicaid [96]. One study in the Midwest of the US found that this had no effect on the newborn circumcision rate but it did affect the demand for circumcision at a later time.[97]

See also

• Bioethics of neonatal circumcision
• Brit milah
• Brit shalom
• Circumcision advocacy
• Circumcision and law
• Circumcision in the Bible
• Circumcision scar
• Female genital cutting
• Foreskin restoration
• Foreskin
• Forcible retraction of the foreskin
• Frenectomy
• Genital integrity
• Genital modification and mutilation
• History of male circumcision
• Holy Prepuce
• Medical analysis of circumcision
• Sexual effects of circumcision
• Zeved habat

External links

General information

• American Academy of Family Physicians position paper
• American Academy of Pediatrics circumcision statement
• American Medical Association Circumcision Report
• Australasian Association of Pediatric Surgeons circumcision statement
• British Medical Association guideline
• Canadian Pediatric Society circumcision assessment
• Queensland Law Reform Commission research paper
• Royal Australasian College of Physicians summary statement

Circumcision techniques

• Description of an adult circumcision from the AAFP.
• Description of an infant Gomco circumcision from the AAFP.
• Description of a Plastibell circumcision from the Medical College of Georgia.
• Description of an infant Mogen circumcision from Euroband.
• Video footage of mass adult circumcision in Uganda
• Video footage of a single circumcision lead by a doctor while teaching the procedure

Circumcision opposition

• National Organization of Circumcision Information and Resource Center
• National Organization to Halt the Abuse and Routine Mutilation of Men
• CIRP.org, Circumcision Information and Resource Pages
• Circumcision resource center
• History of Circumcision pages

Circumcision promotion

• Benefits of circumcision: medical, health and sexual a literature review by Professor Brian Morris
• Circumcision: a lifetime of medical benefits by Dr Edgar Schoen
• Circuncisión en Español Circumcision discussion (in Spanish and English)
• International Circumcision Information Reference Centre
• Circumcision Independent Reference and Commentary Service

References

• Billy Ray Boyd. Circumcision Exposed: Rethinking a Medical and Cultural Tradition. Freedom, CA: The Crossing Press, 1998. (ISBN 0-89594-939-3)
• Anne Briggs. Circumcision: What Every Parent Should Know. Charlottesville, VA: Birth & Parenting Publications, 1985. (ISBN 0-9615484-0-1)
• Robert Darby. A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain. Chicago: University of Chicago Press, 2005. (ISBN 0-226-13645-0)
• Aaron J. Fink, M.D. Circumcision: A Parent's Decision for Life. Kavanah Publishing Company, Inc., 1988. (ISBN 0-962-13470-8)
• 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 0-446-67880-5)
• Leonard B. Glick. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. New York: Oxford University Press, 2005. (ISBN 0-19-517674-X)
• David L. Gollaher. Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000. (ISBN 0-456-04397-6)
• Ronald Goldman, Ph.D. Circumcision: The Hidden Trauma. Boston: Vanguard, 1996. (ISBN 0-964-44895-3-8)
• Brian J. Morris, Ph.D., D.Sc. In Favour of Circumcision. Sydney: UNSW Press, 1999. (ISBN 0-86840-537-X)
• Rosemary Romberg. Circumcision: The Painful Dilemma. South Hadley, MA Bergan & Garvey, 1985. (ISBN 0-897-89073-6)
• Edgar J Schoen, M.D. Ed Schoen, MD on Circumcision. Berkeley, CA: RDR Books, 2005. (ISBN 1-57143-123-3)
• Edward Wallerstein. Circumcision: An American Heath Fallacy. New York: Springer, 1980 (ISBN 0-826-13240-5)
• Gerald N. Weiss M.D. and Andrea W Harter. Circumcision: Frankly Speaking. Wiser Publications, 1998. (ISBN 0-966-72190-X)