History of circumcision

It has been variously proposed that male 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 has been suggested that the custom of circumcision gave advantages to tribes that practiced it and thus led to its spread regardless of whether the people understood this. It is possible that circumcision arose independently in different cultures for different reasons.

File:Egypt circ.jpg

Circumcision in Ancient Egypt.

Circumcision in the Ancient world

Ancient Egyptian caved scene of circumcision, from the inner northern wall of the Temple of Khonspekhrod at the Precinct of Mut, Luxor, Egypt. Eighteenth dynasty, Amenhotep III, c. 1360 BC.

The oldest documentary evidence for circumcision comes from Egypt. Tomb artwork from the Sixth Dynasty (2345 - 2181 BC) 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 BC, lists the Egyptians, Jews, Edomites, Ammonites, and Moabites as circumcising cultures. Herodotus, writing in the fifth century BC, would add the Colchians, Ethiopians, Phoenicians, and Syrians to that list.

Except in the portrayal of satyrs, lechers, and barbarians, ancient Greece artwork portrayed penises covered by foreskins. In the aftermath of Alexander the Great's conquests, Greek dislike of circumcision led to a decline in its incidence among many peoples that had previously practiced it. The writer of 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.

Cultural pressures to circumcise operated throughout the Hellenistic world: when the Judean king John Hyrcanus conquered the Idumeans, he forced them to become circumcised and convert to Judaism, but their ancestors the Edomites had practiced circumcision in pre-Hellenistic times.

Male circumcision in the Greco-Roman world

According to Hodges, ancient Greek aesthetics of the human form considered circumcision a mutilation of a previously perfectly shaped organ. Greek artwork of the period portrayed penises as covered by the foreskin (sometimes in exquisite detail), except in the portrayal of satyrs, lechers, and barbarians.[1]

The 1st century Jewish author Philo Judaeus[2] defended Jewish circumcision on several grounds, including health, cleanliness, fertility and as a symbol of "the excision of all superfluous and excessive pleasure" [3] Maimonides argued that circumcision was instituted for moral reasons, 'for perfecting what is defective morally' [4] See also "Circumcision: A Jewish Inquiry," Midstream 38 (January 1992) pages 20-23 [5]. (history)

This dislike of the appearance of the circumcised penis led to a decline in the incidence of circumcision among many peoples that had previously practiced it throughout Hellenistic times. In Egypt, only the priestly caste retained circumcision, and by the second century, the only circumcising groups in the Roman Empire were Jews and Proselytes and some Christians, Egyptian priests, and the Nabatean Arabs. Circumcision was sufficiently rare among non-Jews that being circumcised was considered conclusive evidence of Judaism (or Early Christianity and others derogatively called Judaizers) in Roman courts—Suetonius in Domitian 12.2 [6] described a court proceeding in which a ninety-year-old man was stripped naked before the court to determine whether he was evading the head tax placed on Jews and Judaizers. The first-century Alexandrian Apion denounced circumcision as a barbaric custom in his diatribe against the Jews, notwithstanding that it was still practised among the Egyptian priestly caste.

Roman satirists including Horace and Juvenal equated the exposure of the glans that results from circumcision to its exposure during erection, and they caricatured Jewish men as being lustful or lecherous, sometimes in an incestuous or homosexual sense, often implying that Jewish men had unusually large penises and were of great sexual potency.

Techniques for restoring the appearance of an uncircumcised penis were known by the 2nd century B.C. In one such technique, a copper weight (called the Judeum pondum) was hung from the remnants of the circumcised foreskin until, in time, they became sufficiently stretched to cover the glans. The first-century writer Celsus described two surgical techniques for foreskin restoration in his medical treatise De Medicina. [7] In one of these, the skin of the penile shaft was loosened by cutting in around the base of the glans. The skin was then stretched over the glans and allowed to heal, giving the appearance of an uncircumcised penis. Jewish religious writers denounced such practices as abrogating the covenant of Abraham in 1 Maccabees and the Talmud [8]. Because of these attempts, and for other reasons, the Pharisees, ca. 100, added two more steps to the Biblical rite of circumcision:

• Brit Peri'ah, which went beyond the relatively simple and Biblical trimming of excess foreskin, and stripped the mucosal lining of the foreskin back to the coronal sulcus.
• Brit Mezizah, by which the trained rabbi ("mohel") sucks the wound made by the circumcision.

Circumcision was an important issue for first century Jews and Christians. Flavius Josephus in Jewish Antiquities book 20 [9], chapter 2 recorded the story of King Izates who decided to follow the Law of Moses at the advice of a Jewish merchant named Ananias. He was going to get circumcised, but his mother, Helen, who herself embraced the Jewish customs, advised against it on the grounds that the subjects wouldn't stand to be ruled by someone who followed such "strange and foreign rites". Ananias likewise advised against it, on the grounds that worship of God was superior to circumcision (Robert Eisenman in James the Brother of Jesus claims that Ananias is Paul of Tarsus who held similar views) and that God would forgive him for fear of his subjects. So Izates decided against it. However, later, "a certain other Jew that came out of Galilee, whose name was Eleazar", who was well versed in the Law, convinced him that he should, on the grounds that it was one thing to read the Law and another thing to practice it, and so he did. Once Helen and Ananias found out, they were struck by great fear of the possible consequences, but as Josephus put it, God looked after Izates. As his reign was peaceful and blessed, Helen visited the Jerusalem Temple to thank God, and since there was a terrible famine at the time, she brought lots of food and aid to the people of Jerusalem.

There was also division in Pharisaic Judaism between Hillel the Elder and Shammai on the issue of circumcision of proselytes. See also Circumcision in the Bible#In rabbinic literature

The Council of Jerusalem in Acts of the Apostles 15 addressed the issue of whether circumcision was required of new converts to Christianity. Both Simon Peter and James the Just spoke against requiring circumcision in Gentile converts and the Council ruled that circumcision was not necessary. However, Acts 16 and many references in the Letters of Paul show that the practice was not immediately eliminated. Paul of Tarsus, who was said to be directly responsible for one man's circumcision in Acts 16:1-3 and who appeared to praise Jewish circumcision in Romans 3:2, said that circumcision didn't matter in 1 Corinthians 7:19 and then increasingly turned against the practice, accusing those who promoted circumcision of wanting to make a good showing in the flesh and boasting or glorying in the flesh in Galatians 6:11-13. In a later letter, Philippians 3:2, he is repored as warning Christians to beware the "mutilation" (Strong's G2699). Circumcision was so closely associated with Jewish men that Jewish Christians were referred to as "those of the circumcision" (e.g. Colossians 3:20) [10] or conversely Christians who were circumcised were referred to as Jewish Christians or Judaizers. These terms (circumcised/uncircumcised) are generally interpreted to mean Jews and Greeks, who were predominate, however it is an oversimplification as 1st century Iudaea Province also had some Jews who no longer circumcised, and some Greeks (called Proselytes or Judaizers) and others such as Egyptians, Ethiopians, and Arabs who did. According to the Gospel of Thomas saying 53, Jesus says:

"His disciples said to him, "is circumcision useful or not?" He said to them, "If it were useful, their father would produce children already circumcised from their mother. Rather, the true circumcision in spirit has become profitable in every respect."" SV [11]

Parallels to Thomas 53 are found in Paul's Romans 2:29, Philippians 3:3, 1 Corinthians 7:19, Galatians 6:15, Colossians 2:11-12.

In John's Gospel 7:23 Jesus is reported as giving this response to those who criticized him for healing on the Sabbath:

Now if a man can be circumcised on the sabbath so that the Law of Moses is not broken, why are you angry with me for making a man whole and complete on a sabbath? ( Jerusalem Bible)

This passage has been seen as a comment on the Rabbinic belief that circumcision heals the penis (Jerusalem Bible, note to John 7:23) or as a criticism of circumcision [12].

Male circumcision in the Renaissance

Europeans, with the exception of the Jews, did not practice male circumcision.

The Church issued a papal bull in 1442 that prohibited the practice of circumcision for all Christians [13].

Male circumcision in East Africa

Male circumcision in East Africa is a rite of passage from childhood to adulthood, but is only practiced in some nations (tribes). Some peoples in East Africa do not practice male circumscision (for example the Luo of western Kenya). There is no incidence of child circumcision in indigenous tribes of this part of the world.

Amongst the Gikuyu (Kikuyu) people of Kenya and the Maasai people of Kenya and Tanzania, male circumcision has historically been the graduation element of an educational program which tought tribal beliefs, practices, culture, religion and history to youth who were on the verge of becoming full fledged members of society. The circumcision ceremony was very public, and required a display of courage under the knife in order to maintain the honor and prestige of the young man and his family. The only form of anesthetia was a bath in the cold morning waters of a river, which tended to numb the senses to a minor degree. The youths being circumcised were required to maintain a stoic expression and not to flinch from the pain.

After circumcision, young men became members of the warrior class, and were free to date and marry. The graduants became a fraternity which served together, and continued to have mutual obligation to each other for life.

In the modern context in East Africa, the physical element of male circumcision remains (in the societies that have historically practiced it) but without most of the other accompanying rites, context and programs. For many, the operation is now performed in private on one individual, in a hospital or doctor's office. Anesthesia is often used in such settings. There are tribes however, that do not accept this modernized practice. They insist on circumcision in a group ceremony, and a test of courage at the banks of a river. This more traditional approach is common amongst the Meru and the Kisii tribes of Kenya.

Despite the loss of the rites and ceremonies that accompanied male circumcision in the past, the physical operation remains crucial to personal identity and pride, and acceptance in society. Uncircumcised men in these communities risk being "outed", and subjected to ridicule as "boys". There have been many cases of forced circumcision of men from such communities who are discovered to have escaped the ritual.

Male circumcision in the 18th century

Circumcision was not practiced amongst Christians in Europe in the 18th Century. It was regarded with repulsion.

Edward Gibbon had referred to it as a "singular mutilation" practised only by Jews and Turks and as "a painful and often dangerous rite" ... (R. Darby) [14]

In 1753 in London there was a proposal for Jewish emancipation. It was furiously opposed by the pamphleteers of the time, who spread the fear that Jewish emancipation meant universal circumcision. Men were urged to protect:

"the best of Your property" and guard their threatened foreskins. It was an extraordinary outpouring of popular beliefs about sex, fears about masculinity and misconceptions about Jews, but also a striking indication of how central to their sexual identity men considered their foreskins at that time. (R.Darby) [15]

Male circumcision in the 19th century and beyond

Until well into the Nineteenth Century, the same sentiments prevailed.

Richard Burton observed that "Christendom practically holds circumcision in horror". This attitude is reflected in the ninth edition of the Encyclopaedia Britannica (1876) which discusses the practice as a religious rite among Jews, Moslems, the ancient Egyptians and tribal peoples in various parts of the world. The author of the entry rejected sanitary explanations of the procedure in favour of a religious one: "like other body mutilations ... [it is] of the nature of a representative sacrifice". (R. Darby) [16]

Then, a change of attitude began, something that was reflected in successive editions of the Encyclopaedia Britannica:

By 1910 the entry had been turned on its head: "This surgical operation, which is commonly prescribed for purely medical reasons, is also an initiation or religious ceremony among Jews and Muslims": now it was primarily a medical procedure and only after that a religious ritual. The entry explained that "in recent years the medical profession has been responsible for its considerable extension among other than Jewish children ... for reasons of health" (11th edition, Vol. 6). By 1929 the entry is much reduced in size and consists merely of a brief description of the operation, which is "done as a preventive measure in the infant" and "performed chiefly for purposes of cleanliness". Ironically, readers are then referred to the entries for "Mutilation" and "Deformation" for a discussion of circumcision in its religious context (14th edition, 1929, Vol. 5). (R. Darby) [17]

Historically, routine neonatal circumcision was promoted during late Victorian times in the English-speaking parts of Canada, Australia, New Zealand, the United States and the United Kingdom and was widely practiced during the first part of the 20th century in these countries. However, the practice declined sharply in the United Kingdom after the Second World War, and somewhat later in Canada, Australia and New Zealand. It has been argued (e.g., Goldman 1997) that the practice did not spread to other European countries because others considered the arguments for it fallacious. In South Korea, circumcision was largely unknown before the establishment of the United States trusteeship in 1945. More than 90% of South Korean high school boys are now circumcised, but the average age of circumcision is 12 years, which makes South Korea a unique case.

Routine infant circumcision has been abandoned in New Zealand and Britain, and is now much less common in Australia and in Canada (see table 1). The decline in circumcision in the United Kingdom followed the decision by the National Health Service (NHS) in 1948 not to cover the procedure following an influential article by Douglas Gardiner which claimed that circumcision resulted in the deaths of about 16 children under 5 each year in the United Kingdom. [18]. In most of the rest of the world, circumcision is done either as a religious or cultural practice.

Routine infant circumcision in the United States grew out of a widespread fear that masturbation caused various diseases, a view now universally rejected by the medical community. Circumcision was thought to reduce masturbation and other sexual behavior considered undesirable. Circumcision, depending on how it is practiced, can have a significant impact on masturbation; see masturbation for a detailed discussion.

Male circumcision to prevent masturbation

Non-religious circumcision in English-speaking countries arose in a climate of negative attitudes towards sex, especially concerning masturbation. In her 1978 article The Ritual of Circumcision,[19] Karen Erickson Paige writes: "In the United States, the current medical rationale for circumcision developed after the operation was in wide practice. The original reason for the surgical removal of the foreskin, or prepuce, was to control 'masturbatory insanity' - the range of mental disorders that people believed were caused by the 'polluting' practice of 'self-abuse.'"

"Self-abuse" was a term commonly used to describe masturbation in the 19th century. According to Paige, "treatments ranged from diet, moral exhortations, hydrotherapy, and marriage, to such drastic measures as surgery, physical restraints, frights, and punishment. Some doctors recommended covering the penis with plaster of Paris, leather, or rubber; cauterization; making boys wear chastity belts or spiked rings; and in extreme cases, castration." Paige details how circumcision became popular as a masturbation remedy:

"In the 1890s, it became a popular technique to prevent, or cure, masturbatory insanity. In 1891 the president of the Royal College of Surgeons of England published On Circumcision as Preventive of Masturbation, and two years later another British doctor wrote Circumcision: Its Advantages and How to Perform It, which listed the reasons for removing the 'vestigial' prepuce. Evidently the foreskin could cause 'nocturnal incontinence,' hysteria, epilepsy, and irritation that might 'give rise to erotic stimulation and, consequently, masturbation.' Another physician, P.C. Remondino, added that 'circumcision is like a substantial and well-secured life annuity...it insures better health, greater capacity for labor, longer life, less nervousness, sickness, loss of time, and less doctor bills.' No wonder it became a popular remedy." [20]

At the same time circumcisions were advocated on men, clitoridectomies (removal of the clitoris) were also performed for the same reason (to treat female masturbators). The US "Orificial Surgery Society" for female "circumcision" operated until 1925, and clitoridectomies and infibulations would continue to be advocated by some through the 1930s.

One of the leading advocates of circumcision was John Harvey Kellogg, who is well known for his pseudoscientific views on human sexuality. He advocated the consumption of Kellogg's corn flakes to prevent masturbation, and he believed that circumcision would be an effective way to eliminate masturbation in males.

"Covering the organs with a cage has been practiced with entire success. A remedy which is almost always successful in small boys is circumcision, especially when there is any degree of phimosis. The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. The soreness which continues for several weeks interrupts the practice, and if it had not previously become too firmly fixed, it may be forgotten and not resumed. If any attempt is made to watch the child, he should be so carefully surrounded by vigilance that he cannot possibly transgress without detection. If he is only partially watched, he soon learns to elude observation, and thus the effect is only to make him cunning in his vice."

Robert Darby, writing in the Australian Medical Journal, noted that some 19th Century circumcision advocates—and their opponents—believed that the foreskin was sexually sensitive:

In the 19th century the role of the foreskin in erotic sensation was well understood by physicians who wanted to cut it off precisely because they considered it the major factor leading boys to masturbation. The Victorian physician and venereologist William Acton (1814–1875) damned it as "a source of serious mischief", and most of his contemporaries concurred. Both opponents and supporters of circumcision agreed that the significant role the foreskin played in sexual response was the main reason why it should be either left in place or removed. William Hammond, a Professor of Mind in New York in the late 19th century, commented that "circumcision, when performed in early life, generally lessens the voluptuous sensations of sexual intercourse", and both he and Acton considered the foreskin necessary for optimal sexual function, especially in old age. Jonathan Hutchinson, English surgeon and pathologist (1828–1913), and many others, thought this was the main reason why it should be excised. [21]

Medical circumcision from 1870 to 1950 in English-speaking countries

Until 1870, medical circumcisions were performed to treat conditions local to the penis: phimosis, balanitis, and penile cancer. In that year, Lewis Sayre, a prominent New York orthopedic surgeon and vice president of the newly-formed American Medical Association, examined a five-year-old boy who was unable to straighten his legs, and whose condition had so far defied treatment. Upon noting that the boy's genitals were inflamed, Sayre hypothesized that chronic irritation of the boy's foreskin had paralyzed his knees via reflex neurosis. Sayre circumcised the boy, and within a few weeks, he recovered from his paralysis. After several additional incidents in which circumcision also appeared effective in treating paralyzed joints, Sayre began to promote circumcision as a powerful orthopedic remedy.

Sayre's prominence within the medical profession allowed him to reach a wide audience. He lectured widely in the United States and the United Kingdom, and his ideas influenced physicians throughout the English-speaking world. As more practitioners tried circumcision as a treatment for otherwise intractable medical conditions, sometimes achieving positive results, the list of ailments reputed to be treatable through circumcision grew. By the 1890s, hernia, bladder infections, kidney stones, insomnia, chronic indigestion, rheumatism, epilepsy, asthma, bedwetting, Bright's disease, erectile dysfunction, syphilis, insanity, and skin cancer had all been linked to the foreskin, and many physicians advocated universal circumcision as a preventive health measure. In 1855, the Quaker surgeon, Jonathan Hutchinson, observed that circumcision appeared to protect against syphilis. Although this observation was challenged (the protection that Jews appear to have are more likely due to cultural factors), a 2006 systematic review concluded that the evidence "strongly indicates that circumcised men are at lower risk ... syphilis."

Specific medical arguments aside, several hypotheses have been raised in explaining the 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.[22] 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.[23] All About the Baby, a popular parenting book of the 1890s, recommended infant circumcision for precisely this purpose. (However, a survey of 1410 men in the United States in 1992, Laumann found that circumcised men were more likely to report masturbating at least once a month.) As hospitals proliferated in urban areas, childbirth, at least among the upper and middle classes, was increasingly under the care of physicians in hospitals rather than with midwives 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.

During the same time period, circumcision was becoming easier to perform. William Halstead's 1885 discovery of hypodermic cocaine as a local anaesthetic made it easier for doctors without expertise in the use of chloroform and other general anaesthetics to perform minor surgeries. Also, several mechanically-aided circumcision techniques, forerunners of modern clamp-based circumcision methods, were first published in the medical literature of the 1890s, allowing surgeons to perform circumcisions more safely and successfully.

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.

Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada and to a lesser extent in the United Kingdom and New Zealand. The British Royal Family had a long tradition requiring that all male children be circumcised” (Alfred J. Kolatach’s The Jewish Book of Why, Middle Village, New York; Jonathan David, 1981). Although it is difficult to determine historical circumcision rates, one estimate[24] 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 reason may have been Douglas Gairdner’s famous study, The fate of the foreskin, which revealed that for the years 1942–1947, about 16 children per year in England and Wales had died because of circumcision, a rate of about 1 per 6000 circumcisions. Since then, circumcision has been an out-of-pocket cost to parents, and the proportion of newborns circumcised in the hospital has fallen to less than one percent.

Similar trends have operated in Canada, (where public medical insurance is universal, and where private insurance does not replicate services already paid from the public purse) Individual provincial heath insurance plans began delisting non-therapeutic circumcision in the 1980s. Manitoba was the final province to delist non-therapeutic circumcision which occurred in 2006. The infant circumcision rate in Canada has fallen from roughly half in the 1970s to its present value of 11%, albeit with strong regional variations. St. Boniface Hospital, a major hospital in Winnipeg, no longer permits the performance of male newborn circumcision.[25]

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, which makes South Korea a unique case [26].

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

"...The young men in the eastern Cape belong to the Xhosa ethnic group for whom circumcision is considered part of the passage into manhood... 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..." [27].

Prior to 1989, the American Academy of Pediatrics had a long-standing opinion that medical indications for routine circumcision were lacking. This stance, according to the AMA, was reversed in 1989, following new evidence of reduction in risk of urinary tract infection. A study in 1987 found that the prominent reasons for parents choosing circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns.[28] A 1999 study reported that reasons for circumcision included "ease of hygiene (67 percent), ease of infant circumcision compared with adult circumcision (63 percent), medical benefit (41 percent), and father circumcised (37 percent)." The authors commented that "Medical benefits were cited more frequently in this study than in past studies, although medical issues remain secondary to hygience and convenience."[29] A 2001 study reported that "The most important reason to circumcise or not circumcise the child was health reasons." A 2005 study speculated that increased recognition of the potential benefits may be responsible for an observed increase in the rate of neonatal circumcision in the USA between 1988 and 2000.[30] In a 2001 survey, 86.6% of parents felt respected by their medical provider, and parents who did not circumcise "felt less respected by their medical provider".

In the United States, statistics collected by the National Center for Health Statistics show that the overall rate of neonatal circumcision has remained near 65% since data collection began in 1979 [31]. However, strong regional differences in the circumcision rates have developed during this time. While more than 80% of newborn boys are circumcised in the Midwest and South, circumcision rates have declined to about 37% in the West in 1999. [32]. This has been attributed in part to increasing births among Latin Americans, who usually do not circumcise [33].

Circumcision in the 21st century

The major medical societies in America[34], Britain[35], Canada[36], Australia and New Zealand[37] do not recommend routine non-therapeutic infant circumcision. Major medical organizations in the United States and Canada now say that parents should decide what is in their child's best interests, declining to make a recommendation one way or another.

In recent years, some have voiced ethical concerns about the procedure. See Bioethics of neonatal circumcision for more information.

As of August 2005, sixteen US states no longer pay for the procedure under Medicaid; the other 34 still do (see map). All thirteen Canadian provincial and territorial health insurance plans no longer pay for non-therapeutic circumcision.

Neonatal circumcision nonetheless still remains the most common pediatric operation carried out in the U.S. today.

The South African Children's Act (No. 38 of 2005) has made the circumcision of male children unlawful except for medical or religious reasons [38].

For current circumcision rates, please see this table.

The largest hospital in Winnipeg has stopped non-therapeutic circumcision of boys.[39]

A Finnish court has ruled that male non-therapeutic circumcision is unlawful in Finland.[40]

In 2005, a study suggested that male circumcision can reduce the chance of H.I.V. infection in men. The study was conducted on more than 3,000 HIV-negative South African men, ages 18 to 24. Half of the men were randomly selected to be circumcised while the other half remained uncircumcised.After following the men for a year, the researchers found that for every 10 uncircumcised men in the study who became infected with HIV, the virus that causes AIDS, only an estimated three circumcised men contracted the virus. [41]

The AMA remarked that, in one study, physicians in "nearly half" of neonatal circumcisions "did not discuss the potential medical risks and benefits of elective circumcision prior to delivery of the infant son. Deferral of discussion until after birth, combined with the fact that many parents' decisions about circumcision are preconceived, contribute to the high rate of elective circumcision."

Table 1: International circumcision rates

Country	Year	Neonatal circumcisions (%)
United States	2003	55.9%* [42]
Canada	2003	< 14% [43]
Australia	2004	10%-20% [44]
New Zealand	1995	0-5%[45]
*The percentage refers to infants born in non-Federal hospitals; see p 52, Table 44 of the reference.
**Samoans, Tongans and Niueans in New Zealand continue to practice circumcision, but not in public hospitals, to which these data refer.

In 2007, Victoria become the fourth Australian state to cease providing male neonatal circumcision in public hospitals.[46] Western Australia, New South Wales, and Tasmania had already deleted this service.

External links

• Doyle, D: Ritual Male Circumcision: A Brief History (PDF), in: Journal of the Royal College of Physicians, Edinburgh 2005; Vol.35, 279–285
• Hodges FM. The Ideal Prepuce in Ancient Greece and Rome: Male Genital Aesthetics and Their Relation to Lipodermos, Circumcision, Foreskin Restoration, and the Kynodesme., in: Bull. Hist. Med., 2001 Fall; 75(3): 375-405
• John M. Ephron: In Praise of German Ritual: Modern Medicine and the Defense of Ancient Traditions, in: Medicine and the German Jews, New Haven: Yale University Press, 2001: 222-233, ISBN 0-300-08377-7
• Dunsmuir WD, Gordon EM.: The history of circumcision., in: BJU Int, 1999;83 Suppl. 1:1-12
• Gollaher DL.: From ritual to science: the medical transformation of circumcision in America., in: Journal of Social History, 1994;28(1):5-36.
• Jewish Encyclopedia: Circumcision
• The History of Circumcision website

Bibliography

• David L. Gollaher, Circumcision: A history of the world's most controversial surgery, New York, Basic Books, 2000, ISBN 0-465-04397-6, hardback
• Paul M. Fleiss, M.D. and Frederick Hodges, D. Phil. What Your Doctor May Not Tell You About Circumcision. New York: Warner Books, 2002: pp. 118-146, paperback (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)
• Robert J. L. 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)