Circumcision

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Circumcision
Circumcision surgery with hemostats and scissors
ICD-10-PCSZ41.2
ICD-9-CMV50.2
MeSHD002944
OPS-301 code5–640.2
MedlinePlus002998
eMedicine1015820

Circumcision is a procedure that removes the foreskin from the human penis. In the most common form of the operation, the foreskin is extended with forceps, then a circumcision device may be placed, after which the foreskin is excised. Topical or locally injected anesthesia is generally used to reduce pain and physiologic stress.[1] Circumcision is generally electively performed, most commonly done as a form of preventive healthcare, as a religious obligation, or as a cultural practice.[2] It is also an option for cases of phimosis, other pathologies that do not resolve with other treatments, and chronic urinary tract infections (UTIs).[3][4] The procedure is contraindicated in cases of certain genital structure abnormalities or poor general health.[4][5]

The procedure is associated with reduced rates of sexually transmitted infections[6] and urinary tract infections.[1][7][8] This includes reducing the incidence of cancer-causing forms of human papillomavirus (HPV) and significantly reducing HIV transmission among heterosexual men in high-risk populations;[9] its prophylactic efficacy against HIV transmission in the developed world or among men who have sex with men is debated.[10][11][12] Neonatal circumcision decreases the risk of penile cancer.[13] Complication rates increase significantly with age.[14] Bleeding, infection, and the removal of either too much or too little foreskin are the most common acute complications, while meatal stenosis is the most common long-term.[15] Major medical organizations hold variant views on the strength of circumcision's prophylactic efficacy in developed countries. Some medical organizations take the position that it carries prophylactic health benefits which outweigh the risks, while other medical organizations generally hold the belief that in these situations its medical benefits are not counterbalanced by risk.[16][17][18][19]

Circumcision is one of the world's most common and oldest medical procedures.[2] Prophylactic usage originated in England during the 1850s and subsequently widely spread, becoming predominately established as a way to prevent sexually transmitted infections.[20][21] Beyond use as a prophylactic or treatment option in healthcare, circumcision plays a major role in many of the world's cultures and religions, most prominently Judaism and Islam. Circumcision is among the most important commandments in Judaism.[22][23] It is widespread in Australia, Canada, the United States, South Korea, most of Africa, and parts of Asia.[2] It is relatively rare for non-religious reasons in parts of Southern Africa, Latin America, Europe, and parts of Asia.[2] The origin of circumcision is not known with certainty; the oldest documentation comes from ancient Egypt.[2][24][25]

The ethics of the procedure has seen debate within bioethics and theological circles, with legal positions on the procedure varying across the globe.

Uses

Elective

Around half of all circumcisions worldwide are performed for reasons of prophylactic healthcare.[4]

Prophylactic usage in high-risk populations

Actor Melusi Yeni became the 1 millionth VMMC against HIV/AIDS transmission in the province of KwaZulu-Natal, South Africa.[26]

There is a consensus among the world's major medical organizations and in the academic literature that circumcision is an efficacious intervention for HIV prevention in high-risk populations if carried out by medical professionals under safe conditions.[27][11][9]

In 2007, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that they recommended adolescent and adult circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV, as long as the program includes "informed consent, confidentiality, and absence of coercion" — known as voluntary medical male circumcision, or VMMC.[27] In 2010, this was expanded to routine neonatal circumcision, as long as those undergoing the procedure received assent from their parents.[17] In 2020, the World Health Organization again concluded that male circumcision is an efficacious intervention for HIV prevention and that the promotion of male circumcision is an essential strategy, in addition to other preventive measures, for the prevention of heterosexually acquired HIV infection in men. Eastern and southern Africa had a particularly low prevalence of circumcised males. This region has a disproportionately high HIV infection rate, with a significant number of those infections stemming from heterosexual transmission. As a result, the promotion of prophylactic circumcision has been a priority intervention in that region since the WHO's 2007 recommendations.[27][17]

The International Antiviral Society–USA also suggests circumcision be discussed with men who have insertive anal sex with men, especially in regions where HIV is common.[28] There is evidence that circumcision is associated with a reduced risk of HIV infection for such men, particularly in low-income countries.[6]

The finding that circumcision significantly reduces female-to-male HIV transmission has prompted medical organizations serving communities affected by endemic HIV/AIDS to promote circumcision as an additional method of controlling the spread of HIV.[18]

Prophylactic usage in developed countries

Major medical organizations hold varying positions on the prophylactic efficacy of the elective circumcision of minors in the context of developed countries.[18] Literature on the matter is polarized, with the cost-benefit analysis being highly dependent on the kinds and frequencies of health problems in the population under discussion and how circumcision affects them.[19][29][30]

The World Health Organization (WHO), UNAIDS, and American medical organizations take the position that it carries prophylactic health benefits which outweigh the risks, while European medical organizations generally hold the belief that in these situations its medical benefits are not counterbalanced by risk.[16][17][18][19] Advocates of circumcision consider it to have a net health benefit, and therefore feel that increasing the circumcision rate is "imperative".[31] They recommend performing it during the neonatal period when it is less expensive and has a lower risk of complications.[29] The American Academy of Pediatrics and Centers for Disease Control and Prevention stated that the potential benefits of circumcision outweigh the risks.[1][32]

Pathologies

Circumcision is also used to treat various pathologies. These include pathological phimosis, refractory balanoposthitis and chronic or recurrent urinary tract infections (UTIs).[3][4]

Contraindications

Circumcision is contraindicated in certain cases.[5][4][33]

These include infants with certain genital structure abnormalities, such as a misplaced urethral opening (as in hypospadias and epispadias), curvature of the head of the penis (chordee), or ambiguous genitalia, because the foreskin may be needed for reconstructive surgery. Circumcision is contraindicated in premature infants and those who are not clinically stable and in good health.[5][4][33] If an individual is known to have or has a family history of serious bleeding disorders such as hemophilia, it is recommended that the blood be checked for normal coagulation properties before the procedure is attempted.[4][33]

Technique

Before (left) and after (right) an adult circumcision that was undertaken to treat phimosis. After the operation, the glans is exposed even when the penis is flaccid.

The foreskin is the double-layered fold of tissue at the distal end of the human penis that covers the glans and the urinary meatus.[2] For adult medical circumcision, superficial wound healing takes up to a week, and complete healing 4 to 6 months. For infants, healing is usually complete within one week.[33]

Removal of the foreskin

For infant circumcision, devices such as the Gomco clamp, Plastibell and Mogen clamp are commonly used in the USA.[1] These follow the same basic procedure. First, the amount of foreskin to be removed is estimated. The practitioner opens the foreskin via the preputial orifice to reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin (preputial epithelium) from its attachment to the glans. The practitioner then places the circumcision device (this sometimes requires a dorsal slit), which remains until blood flow has stopped. Finally, the foreskin is amputated.[1] For older babies and adults, circumcision is often performed surgically without specialized instruments,[33] and alternatives such as Unicirc or the Shang ring are available.[34]

Pain management

The circumcision procedure causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes,[35] so the use of analgesia is advocated.[1][36] Ordinary procedural pain may be managed in pharmacological and non-pharmacological ways. Pharmacological methods, such as localized or regional pain-blocking injections and topical analgesic creams, are safe and effective.[1][37][38] The ring block and dorsal penile nerve block (DPNB) are the most effective at reducing pain, and the ring block may be more effective than the DPNB. They are more effective than EMLA (eutectic mixture of local anesthetics) cream, which is more effective than a placebo.[37][38] Topical creams have been found to irritate the skin of low birth weight infants, so penile nerve block techniques are recommended in this group.[1]

For infants, non-pharmacological methods such as the use of a comfortable, padded chair and a sucrose or non-sucrose pacifier are more effective at reducing pain than a placebo,[38] but the American Academy of Pediatrics (AAP) states that such methods are insufficient alone and should be used to supplement more effective techniques.[1] A quicker procedure reduces duration of pain; use of the Mogen clamp was found to result in a shorter procedure time and less pain-induced stress than the use of the Gomco clamp or the Plastibell.[38] The available evidence does not indicate that post-procedure pain management is needed.[1] For adults, topical anesthesia, ring block, dorsal penile nerve block (DPNB) and general anesthesia are all options,[39] and the procedure requires four to six weeks of abstinence from masturbation or intercourse to allow the wound to heal.[33]

Effects

Sexually transmitted infections

Human immunodeficiency virus

Male circumcision reduces the risk of human immunodeficiency virus (HIV) transmission from HIV positive women to men in high risk populations.[40][41]

In 2020, the World Health Organization (WHO) reiterated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions.[42]

Circumcision reduces the risk that a man will acquire HIV and other sexually transmitted infections (STIs) from an infected female partner through vaginal sex.[43] The evidence regarding whether circumcision helps prevent HIV is not as clear among men who have sex with men (MSM).[42] The effectiveness of using circumcision to prevent HIV in the developed world is not determined.[42][44]

Human papillomavirus

Human papillomavirus (HPV) is the most commonly transmitted sexually transmitted infection, affecting both men and women. While most infections are asymptomatic and are cleared by the immune system, some types of the virus cause genital warts, and other types, if untreated, cause various forms of cancer, including cervical cancer, and penile cancer. Genital warts and cervical cancer are the two most common problems resulting from HPV.[45]

Circumcision is associated with a reduced prevalence of oncogenic types of HPV infection, meaning that a randomly selected circumcised man is less likely to be found infected with cancer-causing types of HPV than an uncircumcised man.[46][47] It also decreases the likelihood of multiple infections.[7] As of 2012 there was no strong evidence that it reduces the rate of new HPV infection,[8][7][48] but the procedure is associated with increased clearance of the virus by the body,[8][7] which can account for the finding of reduced prevalence.[7]

Although genital warts are caused by a type of HPV, there is no statistically significant relationship between being circumcised and the presence of genital warts.[8][47][48]

Other infections

Studies evaluating the effect of circumcision on the rates of other sexually transmitted infections have, generally, found it to be protective. A 2006 meta-analysis found that circumcision was associated with lower rates of syphilis, chancroid, and possibly genital herpes.[49] A 2010 review found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%.[50] The researchers found mixed results for protection against trichomonas vaginalis and chlamydia trachomatis, and no evidence of protection against gonorrhea or syphilis.[50] It may also possibly protect against syphilis in MSM.[51]

Phimosis, balanitis and balanoposthitis

Phimosis is the inability to retract the foreskin over the glans penis.[52] At birth, the foreskin cannot be retracted due to adhesions between the foreskin and glans, and this is considered normal (physiological phimosis).[52] Over time the foreskin naturally separates from the glans, and a majority of boys are able to retract the foreskin by age three.[52] Less than one percent are still having problems at age 18.[52] If the inability to do so becomes problematic (pathological phimosis) circumcision is a treatment option.[3][53] This pathological phimosis may be due to scarring from the skin disease balanitis xerotica obliterans (BXO), repeated episodes of balanoposthitis or forced retraction of the foreskin.[54] Steroid creams are also a reasonable option and may prevent the need for surgery including in those with mild BXO.[54][55] The procedure may also be used to prevent the development of phimosis.[4] Phimosis is also a complication that can result from circumcision.[56]

An inflammation of the glans penis and foreskin is called balanoposthitis, and the condition affecting the glans alone is called balanitis.[57][58] Most cases of these conditions occur in uncircumcised males,[59] affecting 4–11% of that group.[52] The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor. Yeasts, especially Candida albicans, are the most common penile infection and are rarely identified in samples taken from circumcised males.[59] Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams.[57][58] Circumcision is a treatment option for refractory or recurrent balanoposthitis, but in the twenty-first century the availability of the other treatments has made it less necessary.[57][58]

Urinary tract infections

A UTI affects parts of the urinary system including the urethra, bladder, and kidneys. There is about a one percent risk of UTIs in boys under two years of age, and the majority of incidents occur in the first year of life. There is good but not ideal evidence that circumcision of babies reduces the incidence of UTIs in boys under two years of age, and there is fair evidence that the reduction in incidence is by a factor of 3–10 times (100 circumcisions prevents one UTI).[1][60][conflicted source][61] Circumcision is most likely to benefit boys who have a high risk of UTIs due to anatomical defects,[1] and may be used to treat recurrent UTIs.[3]

There is a plausible biological explanation for the reduction in UTI risk after circumcision. The orifice through which urine passes at the tip of the penis (the urinary meatus) hosts more urinary system disease-causing bacteria in uncircumcised boys than in circumcised boys, especially in those under six months of age. As these bacteria are a risk factor for UTIs, circumcision may reduce the risk of UTIs through a decrease in the bacterial population.[1][61]

Cancers

Not being circumcised is the primary risk factor for penile cancer.[62][63] Pre-adolescent circumcision has a strong protective effect against penile cancer in later life.[13] Penile cancer is a rare disease in the developed world but much more prevalent in the developing world.[13] The penile tissue removed during circumcision is a potential origin for penile cancer.[64] Risk-benefit considerations around the use of circumcision as a cancer-preventative measure are a source of debate.[62]

Penile cancer development can be detected in the carcinoma in situ (CIS) cancerous precursor stage and at the more advanced invasive squamous cell carcinoma stage.[1] There is an association between adult circumcision and an increased risk of invasive penile cancer; this is believed to be from men being circumcised as a treatment for penile cancer or a condition that is a precursor to cancer rather than a consequence of circumcision itself.[65] Penile cancer has been observed to be nearly eliminated in populations of males circumcised neonatally.[52]

Important risk factors for penile cancer include phimosis and HPV infection, both of which are mitigated by circumcision.[65] The mitigating effect circumcision has on the risk factor introduced by the possibility of phimosis is secondary, in that the removal of the foreskin eliminates the possibility of phimosis. This can be inferred from study results that show uncircumcised men with no history of phimosis are equally likely to have penile cancer as circumcised men.[1][65] Circumcision is also associated with a reduced prevalence of cancer-causing types of HPV in men[7] and a reduced risk of cervical cancer (which is caused by a type of HPV) in female partners of men.[4]

There is some evidence that circumcision is associated with reduced risk of prostate cancer.[66]

Women's health

A 2017 systematic review found consistent evidence that male circumcision prior to heterosexual contact was associated with a decreased risk of cervical cancer, cervical dysplasia, HSV-2, chlamydia, and syphilis among women. The evidence was less consistent in regards to the potential association of circumcision with women's risk of HPV and HIV.[67]

Sexual effects

The accumulated data show circumcision does not have an adverse physiological effect on sexual pleasure, function, desire, or fertility.[68][69] There is some evidence that circumcision has no effect on pain with intercourse, premature ejaculation, time until ejaculation, erectile dysfunction or difficulties with orgasm.[70]

According to a 2014 review, the effect of circumcision on sexual partners' experiences is unclear as this has not been well studied.[71] According to a policy statement from the Canadian Paediatric Society that was reaffirmed in 2021,[72] "medical studies do not support circumcision as having an impact on sexual function or satisfaction for partners of circumcised individuals".[69]

There are popular misconceptions that circumcision benefits or adversely impacts the sexual pleasure of the circumcised person.[69]

Adverse effects

Neonatal circumcision is generally a safe, low-risk procedure when done by an experienced practitioner.[73][74][75]

The most common acute complications are bleeding, infection and the removal of either too much or too little foreskin.[1][76] These complications occur in approximately 0.13% of procedures, with bleeding being the most common acute complication in the United States.[76] Minor complications are reported to occur in three percent of procedures.[74] Severe complications are rare.[56] A specific complication rate is difficult to determine due to scant data on complications and inconsistencies in their classification.[1] Complication rates are greater when the procedure is performed by an inexperienced operator, in unsterile conditions, or when the child is at an older age.[14] Significant acute complications happen rarely,[1][14] occurring in about 1 in 500 newborn procedures in the United States.[1] Severe to catastrophic complications, including death, are so rare that they are reported only as individual case reports.[1][75] Where a Plastibell device is used, the most common complication is the retention of the device occurring in around 3.5% of procedures.[15] Other possible complications include buried penis, chordee, phimosis, skin bridges, urethral fistulas, and meatal stenosis.[75] These complications may be partly avoided with proper technique, and are often treatable without requiring surgical revision.[75] The most common long-term complication is meatal stenosis, this is almost exclusively seen in circumcised children, it is thought to be caused by ammonia producing bacteria coming into contact with the meatus in circumcised infants.[15] It can be treated by meatotomy.[15]

Effective pain management should be used during the procedure.[1] Inadequate pain relief may carry the risks of heightened pain response for newborns.[35] Newborns that experience pain due to being circumcised have different responses to vaccines given afterwards, with higher pain scores observed.[77] For adult men who have been circumcised, there is a risk that the circumcision scar may be tender.[78][conflicted source]

It is unclear what the psychological outcomes of circumcision are. Studies have shown positive, neutral, or negative effects. There is debate in the literature over whether the pain of circumcision has lasting psychological impact, with only weak underlying data available.[78][conflicted source] There is no good evidence that circumcision affects cognitive abilities.[79]

Prevalence

Map of circumcision prevalence, based on a 2007 WHO report
  Widespread, near-universal: >80% prevalence
  Widespread, common: 20–80% prevalence
  Uncommon: <20% prevalence
  N/A

The prevalence of circumcision is the percentage of males in a given population who have been circumcised, with the procedure most commonly being performed as a part of preventive healthcare, a religious obligation, or cultural practice.

Since 2010, both the World Health Organization and Joint United Nations Programme on HIV/AIDS have been promoting a higher rate of circumcision prevalence as a prevention against HIV transmission and some STIs in areas with high HIV transmission and low circumcision rates.[80][81][82][83] According to Hay & Levin, 2012, around 50% of all circumcisions worldwide are performed for reasons of preventive healthcare, while the other 50% are predominately performed for religious or cultural reasons.[84]

History

Circumcision knife from the Congo; wood, iron; late 19th/early 20th century

Circumcision is the oldest known surgical procedure.[85] Depictions of circumcised penises are found in Paleolithic art,[86] predating the earliest signs of trepanation.[85][87]

The history of the migration and evolution of circumcision is known mainly from the cultures of two regions. In the lands south and east of the Mediterranean, starting with Sudan and Ethiopia, the procedure was practiced by the ancient Egyptians and the Semites, and then by the Jews and Muslims, with whom the practice travelled to and was adopted by the Bantu Africans. In Oceania, circumcision is practiced by the Australian Aboriginals and Polynesians.[88] There is also evidence that circumcision was practiced among the Aztec and Mayan civilizations in the Americas,[2] but little is known about that history.[24][25]

It has been speculated that circumcision originated as a substitute for castration of defeated enemies or as a religious sacrifice.[25] In many traditions, it acts as a rite of passage marking a boy's entrance into adulthood.[25]

Middle East, Africa and Europe

At Oued Djerat, in Algeria, engraved rock art with masked bowmen, which feature male circumcision and may be a scene involving ritual, have been dated to earlier than 6000 BP amid the Bubaline Period;[89] more specifically, while possibly dating much earlier than 10,000 BP, rock art walls from the Bubaline Period have been dated between 9200 BP and 5500 BP.[90] The cultural practice of circumcision may have spread from the Central Sahara, toward the south in Sub-Saharan Africa and toward the east in the region of the Nile.[89] Based on engraved evidence found on walls and evidence from mummies, circumcision has been dated to at least as early as 6000 BCE in ancient Egypt.[91] Some ancient Egyptian mummies, which have been dated as early as 4000 BCE, show evidence of circumcision.[92][93]

Evidence suggests that circumcision was practiced in the Middle East by the fourth millennium BCE, when the Sumerians and the Semites moved into the area that is modern-day Iraq from the North and West.[24] The earliest historical record of circumcision comes from Egypt, in the form of an image of the circumcision of an adult carved into the tomb of Ankh-Mahor at Saqqara, dating to about 2400–2300 BCE. Circumcision was possibly done by the Egyptians for hygienic reasons, but also was part of their obsession with purity and was associated with spiritual and intellectual development. No well-accepted theory explains the significance of circumcision to the Egyptians, but it appears to have been endowed with great honor and importance as a rite of passage, performed in a public ceremony emphasizing the continuation of family generations and fertility. It may have been a mark of distinction for the elite: the Egyptian Book of the Dead describes the sun god Ra as having circumcised himself.[25][88]

Detail of the Artemision Bronze; the Greeks abhorred circumcision, making life difficult for circumcised Jews living among the Greeks.

Circumcision is prominent in the Hebrew Bible.[94] In addition to proposing that circumcision was adopted by the Israelites purely as a religious mandate, scholars have suggested that Judaism's patriarchs and their followers adopted circumcision to make penile hygiene easier in hot, sandy climates; as a rite of passage into adulthood; or as a form of blood sacrifice.[24][88][95]

Historical campaigns of ethnic, cultural, and religious persecution frequently included bans on circumcision as a means of forceful assimilation, conversion, and ethnocide.[96] Alexander the Great conquered the Middle East in the fourth century BCE, and in the following centuries ancient Greek cultures and values came to the Middle East. The Greeks abhorred circumcision, making life for circumcised Jews living among the Greeks and later the Romans very difficult.[96] Restrictions on the Jewish practice by European governments have occurred several times in world history, including the Seleucid Empire under Antiochus IV and the Roman Empire under Hadrian, where it was used as a means of forceful assimilation and conversion.[96] Antiochus IV's restriction on Jewish circumcision was a major factor in the Maccabean Revolt.[96] Hadrian's prohibition has also been considered by some to have been a contributing cause of the Bar Kokhba revolt.[96] According to Silverman (2006), these restrictions were part of a "broad campaign" by the Romans to "civilize" the Jewish people, viewing the practice as replusive and analogous to castration.[96] His successor, Antoninus Pius, altered the edict to permit Brit Milah.[96] During this period in history, Jewish circumcision called for the removal of only a part of the prepuce, and Hellenized Jews often attempted to look uncircumcised by stretching the extant parts of their foreskins. This was considered by the Jewish leaders to be a serious problem, and during the second century CE they changed the requirements of Jewish circumcision to call for the complete removal of the foreskin,[97] emphasizing the Jewish view of circumcision as intended to be not just the fulfillment of a Biblical commandment but also an essential and permanent mark of membership in a people.[88][95]

The Circumcision of Jesus Christ, by Ludovico Mazzolino

A narrative in the Christian Gospel of Luke makes a brief mention of the circumcision of Jesus, but physical circumcision is not part of the received teachings of Jesus. Circumcision has played an important role in Christian history and theology. Paul the Apostle reinterpreted circumcision as a spiritual concept, arguing literal circumcision to be unnecessary for Gentile converts to Christianity. The teaching that circumcision was unnecessary for membership in a divine covenant was instrumental to the separation of Christianity from Judaism.[98][99] While the circumcision of Jesus is celebrated as a feast day in the liturgical calendar of many Christian denominations.[99]

Although it is not explicitly mentioned in the Quran (early seventh century CE), circumcision is considered essential to Islam, and it is nearly universally performed among Muslims. The practice of circumcision spread across the Middle East, North Africa, and Southern Europe with Islam.[100]

Genghis Khan and the following Yuan Emperors in China forbade Islamic practices such as halal butchering and circumcision.[101][102]

The practice of circumcision is thought to have been brought to the Bantu-speaking tribes of Africa by either the Jews after one of their many expulsions from European countries, or by Muslim Moors escaping after the 1492 reconquest of Spain. In the second half of the first millennium CE, inhabitants from the Northeast of Africa moved south and encountered groups from Arabia, the Middle East, and West Africa. These people moved south and formed what is known today as the Bantu. Bantu tribes were observed to be upholding what was described as Jewish law, including circumcision, in the 16th century. Circumcision and elements of Jewish dietary restrictions are still found among Bantu tribes.[24]

Indigenous peoples of the Americas and Oceania

Circumcision is practiced by some groups amongst Australian Aboriginal peoples, Polynesians, and Native Americans.[2][24]

For Aboriginal Australians and Polynesians, circumcision likely started as a blood sacrifice and a test of bravery and became an initiation rite with attendant instruction in manhood in more recent centuries. Often seashells were used to remove the foreskin, and the bleeding was stopped with eucalyptus smoke.[24][103]

Christopher Columbus reported circumcision being practiced by Native Americans.[25] It probably started among South American tribes as a blood sacrifice or ritual to test bravery and endurance, and later evolved into a rite of initiation.[24]

Prophylactic circumcision

Anglophonic adoption (1855–1918)

The first medical professional to recommend circumcision as a prophylaxis against disease was the British physician Jonathan Hutchinson in 1855. By the late 19th century, the belief that circumcision acted as an effective prophylactic against disease was held by a majority of the core Anglosphere's medical communities and doctors, such as the prominent Lewis Sayre, president of the American Medical Association, subsequently leading to its widespread adoption.[20]

Circumcision began to be advocated as a means of prophylaxis in 1855, primarily as a means of preventing the transmission of sexually transmitted infections. At this time, British physician Jonathan Hutchinson published his findings that, among his venereal disease patients, Jews had a lower prevalence of syphilis.[104][105] Hutchinson suggested that circumcision lowers the risk of contracting syphilis.[105] Pursuing a successful career as a general practitioner, Hutchinson went on to advocate circumcision for health reasons for the next fifty years,[104] eventually earned a knighthood for his contributions to medicine. His viewpoint that circumcision was prophylactic against disease was adopted by other medical professionals.[106]

In 1870, orthopedic surgeon Lewis Sayre, a founder of the American Medical Association, introduced circumcision in the United States as a purported cure for several cases of young boys presenting with paralysis and other significant gross motor problems. He thought the procedure ameliorated such problems based on the then prominent "reflex neurosis" theory of disease, thinking that a tight foreskin inflamed the nerves and caused systemic problems.[107] The use of circumcision to promote good health also fit the germ theory of disease, which saw validation during the same period: the foreskin was thought to harbor infection-causing smegma.[108] Sayre published works on the subject and promoted it in speeches.[107] Although later discredited, many contemporary physicians believed it could cure, reduce, or otherwise prevent a wide-ranging array of perceived medical problems and social ills, including that of epilepsy, hernia, headache, masturbation, clubfoot, alcoholism and gout. Its popularity spread with publications such as Peter Charles Remondino's History of Circumcision.[109][110][111] By the late 19th century, circumcision had become common throughout the Anglophonic world—Australia, Canada, the United States, and the United Kingdom—as well as the Union of South Africa. In the United Kingdom and United States, it was universally recommended.[20][109]

Historian David Gollaher proposes that "Americans found circumcision appealing not merely on medical grounds, but also for its connotations of science, health, and cleanliness—newly important class distinctions" in a country where 17 million immigrants arrived between 1890 and 1914.[108]

Interwar Period and World War II (1918–1945)

During the interwar period, medical organizations and doctors in mainland Europe experimented with the idea of routine circumcision for prophylactic reasons as well, alongside developments in the Anglophonic world. In France, the medical profession went so far as to recommend universal routine circumcision. However, prevalence in France and mainland Europe remained low.[18] There is a lack of consensus in the academic literature on why this occurred.[18]

Yosha & Bolnick & Koyle (2012) have suggested that a factor in its Anglophonic adoption and dismissal in mainland Europe relates to attitudes towards Judaism and Jewish practices. While many of these Anglophonic polities would not be considered tolerant by modern standards: the United Kingdom had Benjamin Disraeli—a Jew—as Prime Minister; Jews in the United States were prominent and generally well-respected; while in Australia "the racial issues of the time involved primarily Aborigines and Chinese immigration, and Jews were essentially below the radar". They argue that once "a substantial proportion of the male population [was] circumcised, the idea that it [was] a Jewish practice [became] no longer relevant. In Britain this was aided by the fact that circumcision was well known to be as much a practice of the nobility as a Jewish religious rite, so that the racial-religious nexus was broken." These factors were absent in continental Europe.[18]

Rates in the Anglophonic world began to sharply diverge after 1945.[25]

Pediatrician and political activist Benjamin Spock recommended circumcision in his influential work The Common Sense Book of Baby and Child Care, one of the best-selling books of the twentieth century.[112]

Mid-20th century (1945–1985)

After the end of World War II, Britain implemented a National Health Service. Douglas Gairdner's 1949 article "The Fate of the Foreskin" argued that the evidence showed that the risks outweighed the benefits, leading to a significant reduction in circumcision incidence within the United Kingdom.[113]

In contrast to Gairdner, American pediatrician Benjamin Spock argued in favor of circumcision in his popular The Common Sense Book of Baby and Child Care which led to rates in the United States significantly rising. In the 1970s, national medical associations in Australia and Canada issued recommendations against routine infant circumcision, leading to drops in the rates of both of those countries. The United States made similar statements in the 1970s but stopped short of recommending against it.[25]

Modernity (since 1985)

An association between circumcision and reduced heterosexual HIV infection rates was first suggested in 1986.[25]

Experimental evidence was needed to establish a causal relationship, so three randomized controlled trials were commissioned to exclude other confounding factors.[11] Trials took place in South Africa, Kenya and Uganda.[11] All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV contraction than the control group, so it was considered unethical to withhold the procedure, in light of strong evidence of prophylactic efficacy.[11][114] WHO assessed these as "gold standard" studies and found "strong and consistent" evidence from later studies that confirmed the results of the studies.[27] A scientific consensus subsequently developed that circumcision reduces heterosexual HIV infection rates in high-risk populations;[12][9][115] the WHO, along with other major medical organizations, have since promoted circumcision of high-risk populations as part of the program to reduce the spread of HIV.[27] The Male Circumcision Clearinghouse website was created in 2009 by WHO, UNAIDS, FHI and AVAC to provide evidence-based guidance, information, and resources to support the delivery of safe male circumcision services in countries that choose to scale up the procedure as one component of comprehensive HIV prevention services.[116][117]

Society and culture

A circumcision being performed in Central Asia, c. 1865–1872

The word circumcision is from Latin circumcidere, meaning "to cut around".[2]

Cultures and religions

Many societies hold cultural, ethical, or social views on the practice, with perspectives ranging widely. In some cultures, males are generally required to be circumcised shortly after birth, during childhood or around puberty as part of a rite of passage. Circumcision is commonly practiced in the Jewish and Islamic and Druze faiths and in Coptic Christianity and the Ethiopian Orthodox Church and the Eritrean Orthodox Tewahedo Church.[18][118][119][120][121][122][123] In contrast, some religions, such as Mandaeism and Hinduism and Sikhism, strongly prohibit the practice of routine circumcision.[124][125][126]

Judaism

Circumcision is near-universal among Jews.[127] The mitzvah of circumcision on the eighth day of life is considered among the most important commandments in Judaism. Barring extraordinary circumstances, failure to undergo the rite is seen by followers of Judaism as leading to a state of Kareth: the extinction of the soul and denial of a share in the world to come.[22][23][96]

Preparing for a Jewish ritual circumcision

The basis for its observance is found in the Torah of the Hebrew Bible, in Genesis chapter 17, in which a covenant of circumcision is made with Abraham and his descendants. Jewish circumcision is part of the brit milah ritual, to be performed by a specialist ritual circumciser, a mohel, on the eighth day of a newborn son's life, with certain exceptions for poor health. Jewish law requires that the circumcision leaves the glans bare when the penis is flaccid. Converts to Conservative and Orthodox Judaism must also be circumcised; those who are already circumcised undergo a symbolic circumcision ritual. Circumcision is not required by Judaism for one to be considered Jewish, but mainstream Judaism foresees serious negative spiritual consequences if it is neglected.[118][128] Circumcision is not considered a universal moral law within Judaism. Rather, the commandment to circumcise is seen as only applying to Jewish people. Those who are Gentiles are believed to have a portion in the "World to Come" as long as they follow the tenets of the Seven Laws of Noah.[129] There are also certain exceptions for Jews with poor health.[130]

According to traditional Jewish law, in the absence of an adult free Jewish male expert, a woman, a slave, or a child who has the required skills is also authorized to perform the circumcision, provided that they are Jewish.[131] However, most streams of non-Orthodox Judaism allow female mohels, called mohalot (Hebrew: מוֹהֲלוֹת, the plural of מוֹהֶלֶת mohelet, feminine of mohel), without restriction. In 1984 Deborah Cohen became the first certified Reform mohelet; she was certified by the Berit Mila program of Reform Judaism.[132] An increasing number of Jews in the United States have chosen not to circumcise their sons.[133]

All major rabbinical organizations make the recommendation that male infants should be circumcised. The issue of converts remains controversial in Reform and Reconstructionist Judaism;[134][135] circumcision of converts is not mandatory in either.[136]

Islam

Children in Turkey wearing traditional circumcision costumes
Boys in white clothing with bonnets at Tireli market, just after circumcision, Mali, 1990

Despite its common practice in Muslim-majority nations, circumcision is considered to be sunnah (tradition) and not required for a life directed by Allah.[137] According to historians of religion and scholars of Religious studies, the Islamic tradition of circumcision was derived from the Pagan practices and rituals of pre-Islamic Arabia.[138] Although there is some debate within Islam over whether it is a religious requirement or mere recommendation, circumcision (called khitan) is practiced nearly universally by Muslim males. Islam bases its practice of circumcision on the Genesis 17 narrative, the same Biblical chapter referred to by Jews. The procedure is not explicitly mentioned in the Quran, however, it is a tradition established by Islam's prophet Muhammad directly (following Abraham), and so its practice is considered a sunnah (prophet's tradition) and is very important in Islam. For Muslims, circumcision is also a matter of cleanliness, purification and control over one's baser self (nafs).[120][121][139]

There is no agreement across the many Islamic communities about the age at which circumcision should be performed. It may be done from soon after birth up to about age 15; most often it is performed at around six to seven years of age. The timing can correspond with the boy's completion of his recitation of the whole Quran, with a coming-of-age event such as taking on the responsibility of daily prayer or betrothal. Circumcision may be celebrated with an associated family or community event. Circumcision is recommended for, but is not required of, converts to Islam.[120][121][139]

Christianity

Traditionally, circumcision has not been practiced by Christians for religious reasons, with the practice being viewed as succeeded by Baptism, with the New Testament chapter Acts 15 recording that Christianity did not require circumcision from new converts.[140] Christian denominations generally hold a neutral position on circumcision for prophylactic, cultural, and social reasons, while strongly opposing it for religious reasons. This includes the Catholic Church, which explicitly banned the practice of religious circumcision in the Council of Florence,[141] and maintains a neutral position on the practice of circumcision for other reasons.[142] A majority of other Christian denominations take a similar position on circumcision, prohibiting it for religious observance, but neither explicitly supporting or forbidding it for other reasons.[142]

Coptic Children wearing traditional circumcision costumes

Thus, circumcision rates of Christians are predominately determined by the surrounding cultures in which they live in. In some African and Eastern Christian denominations circumcision is an established practice,[143][144] and generally men undergo circumcision shortly after birth as part of a rite of passage.[143] Circumcision is near-universal among Coptic Christians,[145] and they practice circumcision as a rite of passage.[2][119][123][146] The Ethiopian Orthodox Church calls for circumcision, with near-universal prevalence among Orthodox men in Ethiopia.[2] Eritrean Orthodox practice circumcision as a rite of passage, and they circumcise their sons "anywhere from the first week of life to the first few year".[147] Some Christian churches in South Africa disapprove of the practice, while others require it of their members.[2]

Circumcision is practiced in some predominantly Christian countries and Christian communities.[148][149][150] Christian communities in Africa,[151][152] some Anglosphere countries, the Philippines, the Middle East,[153][154] South Korea and Oceania have high circumcision rates,[155][156] while Christian communities in Europe and South America have low circumcision rates, although none of these are performed out of perceived religious obligation.[143][157] Scholar Heather L. Armstrong writes that, as of 2021, about half of Christian males worldwide are circumcised, with most of them being located in Africa, Anglosphere countries, and the Philippines.[158]

Druze faith

Preparing for a ritual circumcision to a Druze child

Circumcision is widely practiced by the Druze;[159] Druze practice Druzism, an Abrahamic,[160][161] monotheistic, syncretic, and ethnic religion. The procedure is practiced as a cultural tradition, and has no religious significance in the Druze faith.[162][163] There is no special date for this act in the Druze faith: male Druze infants are usually circumcised shortly after birth,[164] however some remain uncircumcised until the age of ten or older.[164]

Some Druses do not circumcise their male children and refuse to observe this "common Muslim practice".[165]

Samaritanism

Like Judaism, the religion of Samaritanism requires ritual circumcision on the eighth day of life.[166]

Mandaeism

Circumcision is forbidden in Mandaeism,[124][167] and the sign of the Jews given to Abraham by God, circumcision, is considered abhorrent by the Mandaeans.[168] According to the Mandaean doctrine a circumcised man cannot serve as a Mandaean priest.[169]

Yazidism

Circumcision is not required in Yazidism, but is practised by some Yazidis due to regional customs.[170] The ritual is usually performed soon after birth, it takes place on the knees of the kerîf (approximately "godfather"), with whom the child will have a life-long formal relationship.[171]

Sikhism

Sikhism does not require the elective circumcision of its followers and strongly criticizes the practice.[126][172]

For example, Bhagat Kabir criticizes the practise of circumcision in the hymn of Guru Granth Sahib.

African cultures

Circumcision in Africa, and the rites of initiation in Africa, as well as "the frequent resemblance between details of ceremonial procedure in areas thousands of kilometres apart, indicate that the circumcision ritual has an old tradition behind it and in its present form is the result of a long process of development."[173]

Australian cultures

Some Australian Aborigines use circumcision as a test of bravery and self-control as a part of a rite of passage into manhood, which results in full societal and ceremonial membership. It may be accompanied by body scarification and the removal of teeth, and may be followed later by penile subincision. Circumcision is one of many trials and ceremonies required before a youth is considered to have become knowledgeable enough to maintain and pass on the cultural traditions. During these trials, the maturing youth bonds in solidarity with the men. Circumcision is also strongly associated with a man's family, and it is part of the process required to prepare a man to take a wife and produce his own family.[122]

Filipino culture

In the Philippines, circumcision is known as "tuli" and is generally viewed as a rite of passage.[174] An overwhelming majority of Filipino men are circumcised.[174][a] Often this occurs, in April and May, when Filipino boys are taken by their parents. The practice dates back to the arrival of Islam in 1450. Pressure to be circumcised is even in the language: one Tagalog profanity for 'uncircumcised' is supot, meaning 'coward' literally. A circumcised eight or ten year-old is no longer considered a boy and is given more adult roles in the family and society.[176]

Ethical and legal issues

Ethics

There is substantial disagreement amongst bioethicists and theologians over the practice of circumcision, with many believing that the routine circumcision of neonates for health purposes is a cost-ineffective and ethically-problematic intervention in developed countries, while circumcision on a consenting adult is generally viewed as a morally permissible action. Positions taken on the issue are heavily influenced by prevalence in the given area, religion, and culture.[177] Some medical associations take the position that circumcision is an infringement of the child's autonomy and should be deferred until he is capable of making the decision himself. Others state that parents should be allowed to determine what is in his best interest.[178][179][180]

Legal

Worldwide, the large majority of polities do not have specific laws concerning the circumcision of males,[2] with religious infant circumcision being legal in every country.[127][181] A few countries have passed legislation on the procedure: Germany allows routine circumcision,[182] while non-religious routine circumcision is illegal in South Africa and Sweden.[2][181] No major medical organization recommends circumcising all males, and no major medical organization recommends banning the procedure.[18][183][127]

In the academic literature, there is general agreement among both supporters and opponents of the practice that an outright ban would be predominately ineffective and "harmful".[18][127][184][183] A consensus to keep the procedure within the purview of medical professionals is found across all major medical organizations, who advise medical professionals to yield to some degree to parental preferences in their decision to agree to circumcise.[18][127] The Royal Dutch Medical Association, which expresses some of the strongest opposition to routine neonatal circumcision, argues that while there are valid reasons for banning it, doing so could lead parents who insist on the procedure to turn to poorly trained practitioners instead of medical professionals.[18][181]

During the 2010s, several right-wing nationalist parties prominently called for the banning of circumcision.[185] Gressgård argued that politicians that supported Norway's proposed circumcision ban debated circumcision in a manner which constituted "ethnocentrism".[186]

Economic considerations

The cost-effectiveness of circumcision has been studied to determine whether a policy of circumcising all newborns or a policy of promoting and providing inexpensive or free access to circumcision for all adult men who choose it would result in lower overall societal healthcare costs. As HIV/AIDS is an incurable disease that is expensive to manage, significant effort has been spent studying the cost-effectiveness of circumcision to reduce its spread in parts of Africa that have a relatively high infection rate and low circumcision prevalence.[187] Several analyses have concluded that circumcision programs for adult men in Africa are cost-effective and in some cases are cost-saving.[188][189] In Rwanda, circumcision has been found to be cost-effective across a wide range of age groups from newborn to adult,[48][190] with the greatest savings achieved when the procedure is performed in the newborn period due to the lower cost per procedure and greater timeframe for HIV infection protection.[191][190] Circumcision for the prevention of HIV transmission in adults has also been found to be cost-effective in South Africa, Kenya, and Uganda, with cost savings estimated in the billions of US dollars over 20 years.[187] Hankins et al. (2011) estimated that a $1.5 billion investment in circumcision for adults in 13 high-priority African countries would yield $16.5 billion in savings.[192]

The overall cost-effectiveness of neonatal circumcision has also been studied in the United States, which has a different cost setting from Africa in areas such as public health infrastructure, availability of medications, and medical technology and the willingness to use it.[193] A study by the CDC suggests that newborn circumcision would be societally cost-effective in the United States based on circumcision's efficacy against the transmission of HIV alone during coitus, without considering any other cost benefits.[1] The American Academy of Pediatrics (2012) recommends that neonatal circumcision in the United States be covered by third-party payers such as Medicaid and insurance.[1] A 2014 review that considered reported benefits of circumcision such as reduced risks from HIV, HPV, and HSV-2 stated that circumcision is cost-effective in both the United States and Africa and may result in health care savings.[194] A 2014 literature review found that there are significant gaps in the current literature on male and female sexual health that need to be addressed for the literature to be applicable to North American populations.[71]

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    • Rosner, Fred (2003). Encyclopedia of Jewish Medical Ethics. Feldheim Publishers. p. 196. ISBN 9781583305928. Several eras in subsequent Jewish history were associated with forced conversions and with prohibitions against ritual circumcision... Jews endangered their lives during such times and exerted strenuous efforts to nullify such edicts. When they succeeded, they celebrated by declaring a holiday. Throughout most of history, Jews never doubted their obligation to observe circumcision... [those who attempted to reverse it or failed to perform the ritual were called] voiders of the covenant of Abraham our father, and they have no portion in the World to Come.
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Notes

  1. ^ The most commonly-done procedure is in actuality not a circumcision but a dorsal slit, where no foreskin is actually removed. When the foreskin is removed, it is commonly known locally as a "German cut" in reference to the introduction of the modern surgical technique by the founder of plastic and reconstructive surgery, Johann Friedrich Dieffenbach.[175]

General and cited references

External links