Circumcision
| Circumcision | |
|---|---|
| Intervention | |
A circumcision performed in central Asia, possibly Turkmenistan c. 1865–1872
| |
| ICD-10-PCS | 0VBT |
| ICD-9-CM | V50.2 |
| MeSH | D002944 |
| MedlinePlus | 002998 |
| eMedicine | 1015820 |
Male circumcision (from Latin circumcidere, meaning "to cut around") is the surgical removal of the foreskin
(prepuce) from the humanpenis. In a typical procedure, the foreskin is opened and then separated from the glans
after inspection. The circumcision device (if used) is placed, and then the foreskin is removed. Topical or locally
injected anesthesia may be used to reduce pain and physiologic stress.[For adults,general anesthesia is an option, and the procedure is often performed without a specialized circumcision device. The procedure is most often electedfor religious reasons or
personal preferences, but may be indicated for both therapeutic and prophylactic reasons. It is a treatment option for
pathological phimosis, refractory balanoposthitis and chronic urinary tract infections (UTIs); it is contraindicated in
cases of certain genital structure abnormalities or poor general health
The positions of the world's major medical organizations range from considering neonatal circumcision as having a modest health benefit that outweighs small risks to viewing it as having no benefit and significant risks. No major medical organization
recommends either universal circumcision for all infant males (aside from the recommendations of the World Health
Organization for parts of Africa), or banning the procedure.]Ethical and legal questions regarding informed consent
and autonomy have been raised over non-therapeutic neonatal circumcision.
A 2009 Cochrane meta-analysis of studies done on sexually active men in Africa found that circumcision reduces
the infection rate of HIV among heterosexual men by 38–66% over a period of 24 months. The WHO recommends
considering circumcision as part of a comprehensive HIV program in areas with high endemic rates of HIV, such as
sub-Saharan Africa where studies have concluded it is cost-effective against HIV.Circumcision reduces the incidence
of HSV-2 infections by 28%,and is associated with reduced oncogenic HPV prevalence and a reduced risk of both
UTIs and penile cancer, but routine circumcision is not justified for the prevention of those conditions. Studies of its
protective effects against other sexually transmitted infections have been inconclusive. A 2010 review of literature
worldwide
found circumcisions performed by medical providers to have a median complication rate of 1.5% for newborns and 6% for older children, with few severe complications.[16] Bleeding,infection and the removal of either too much or too little foreskin are the most common complications cited.
Circumcision does not appear to have a negative impact on sexual function.
About one-third of males worldwide are circumcised .The procedure is most prevalent in the Muslim world and
Israel (where it is near-universal), the United States and parts of Southeast Asia and Africa; it is relatively rare in
Europe, Latin America, parts of Southern Africa and most of Asia. The origin of circumcision is not known with
certainty; the oldest documentary evidence for it comes from ancient Egypt. Various theories have been proposed as
to its origin, including as a religious sacrifice and as a rite of passage marking a boy's entrance into adulthood.
It is part of religious law in Judaism and is an established practice in Islam, Coptic Christianity and the Ethiopian
Technique
Main article: Circumcision surgical procedure
The foreskin extends out from the base of the glans and covers the glans when the penis is flaccid. Proposed
theories for the purpose of the foreskin are that it serves to protect the penis as the fetus develops in the mother's
womb, that it helps to preserve moisture in the glans, or that it improves sexual pleasure. The foreskin may also be
a pathway of infection for certain diseases. Circumcision removes the foreskin at its attachment to the base of the
glans.
Removal of the foreskin
For infant circumcision, devices such as the Gomco clamp, Plastibell and Mogen clamp are commonly used in the
USA.[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. For adults, circumcision is often performed without
clamps, and non-surgical alternatives such as the elastic ring controlled radial compression device are available.
Pain management
The circumcision procedure causes pain, and for neonates this pain may interfere with mother-infant interaction
or cause other behavioral changes, so the use of analgesia is advocated. 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.
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. Topical creams have been found to irritate the skin of low birth
weight infants, so penile nerve block techniques are recommended in this group.
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, but the American Academy of
Pediatrics (AAP) states that such methods are insufficient alone and should be used to supplement more effective
techniques. 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. The available
evidence does not indicate that post-procedure pain management is needed. For adults, general anesthesia
is an option, and the procedure requires four to six weeks of abstinence from masturbation or intercourse to allow
the wound to heal.
Indications and contraindications
Routine or elective
Neonatal circumcision is often elected for non-medical reasons, such as for religious beliefs or for personal
preferences possibly driven by societal norms. Outside the parts of Africa with high prevalence of HIV/AIDS,
the positions of the world's major medical organizations on non-therapeutic neonatal circumcision range from
considering it as having a modest net health benefit that outweighs small risks to viewing it as having no benefit
with significant risks for harm. No major medical organization recommends non-therapeutic neonatal circumcision,
and no major medical organization calls for banning it either. The Royal Dutch Medical Association, which
expresses the strongest opposition to routine neonatal circumcision, does not call for the practice to be made
illegal out of their concern that parents who insist on the procedure would turn to poorly trained practitioners
instead of medical professionals. This argument to keep the procedure within the purview of medical professionals
is found across all major medical organizations. In addition, the organizations advise medical professionals
to yield to some degree to parents' preferences, commonly based in cultural or religious views, in the decision
to agree to circumcise.
Owing to the HIV/AIDS epidemic there, sub-Saharan Africa is a special case. The finding that circumcision
significantly reduces female-to-male HIV transmission has prompted medical organizations serving the affected
communities to promote circumcision as an additional method of controlling the spread of HIV. The World Health
Organization (WHO) and UNAIDS (2007) recommend circumcision as part of a comprehensive program for
prevention of HIV transmission in areas with high endemic rates of HIV.
Medical indications
Circumcision may be medically indicated in children for pathological phimosis, refractory balanoposthitis and
chronic, recurrent urinary tract infections (UTIs) in males who are chronically susceptible to them. The World
Health Organization promotes circumcision as a preventive measure for sexually active men in populations at
high risk for HIV.
Contraindications
Circumcision is contraindicated in 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. If an individual, child or adult, is
known to have or has a family history of serious bleeding disorders (hemophilia), it is recommended that the blood
be checked for normal coagulation properties before the procedure is attempted.
Effects
Sexually transmitted diseases
Human immunodeficiency virus
Main article: Circumcision and HIV
There is strong evidence that circumcision reduces the risk of HIV infection in heterosexual men in high-risk
populations. Evidence among heterosexual men in sub-Saharan Africa shows a decreased risk of between
38 percent and 66 percent over two years,[and in this population studies rate it cost effective. Whether it is of
benefit in developed countries is undetermined.
There are plausible explanations based on human biology for how circumcision can decrease the likelihood
of female-to-male HIV transmission. The superficial skin layers of the penis containLangerhans cells, which are
targeted by HIV; removing the foreskin reduces the number of these cells. When an uncircumcised penis is erect
during intercourse, any small tears on the inner surface of the foreskin come into direct contact with the vaginal
walls, providing a pathway for transmission. When an uncircumcised penis is flaccid, the pocket between the
inside of the foreskin and the head of the penis provides an environment conducive to pathogen survival;
circumcision eliminates this pocket. Some experimental evidence has been provided to support these theories.
The WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) state that male circumcision is an
efficacious intervention for HIV prevention, but should be carried out by well trained medical professionals and
under conditions of informed consent.The WHO has judged circumcision to be a cost-effective public
health intervention against the spread of HIV in Africa, although not necessarily more cost-effective than condoms.
The Centers for Disease Control and Prevention (CDC) has calculated that newborn circumcision is cost-effectiv E
against HIV in the US. The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial
protection from HIV and should not replace known methods of HIV prevention
The available evidence does not indicate that circumcision provides HIV protection for heterosexual women.
Data is lacking regarding the effect circumcision may have on the transmission rate of men who engage in anal s
x with a female partner. It is undetermined whether circumcision benefits men who have sex with men.
Human papillomavirus
Human papillomavirus (HPV) is the most commonly transmitted sexually transmitted disease, 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
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. It also decreases the likelihood of multiple infections. No strong evidence indicates that it
reduces the rate of new HPV infection,but the procedure is associated with increased clearance of the virus by
the body, which can account for the finding of reduced prevalence.
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.
Other infections
Studies evaluating the effect of circumcision on the incidence of other sexually transmitted infections have reached
conflicting conclusions. A 2006 meta-analysis found that circumcision was associated with lower rates of syphilis
, chancroid and possibly genital herpes. A 2010 review of clinical trial data found that circumcision reduced the
incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%. The researchers found mixed results for
protection against trichomonas vaginalis and chlamydia trachomatis and no evidence of protection against
gonorrhea or syphilis. Among men who have sex with men, reviews have found poor evidence for protection against
sexually transmitted infections other than HIV, with the possible exception of syphilis.
Phimosis, balanitis and balanoposthitis
Phimosis is the inability to retract the foreskin over the glans penis. At birth, the foreskin cannot be retracted due to
adhesions between the foreskin and glans, and this is considered normal (physiological phimosis). Over time,
the foreskin naturally separates from the glans, and a majority of boys are able to retract the foreskin by age four.
If the inability to do so becomes problematic (pathological phimosis), which is commonly due to the skin disease
balanitis xerotica obliterans (BXO), circumcision is the preferred treatment option.The procedure may also be used
prophylactically to prevent the development of phimosis.
An inflammation of the glans penis and foreskin is called balanoposthitis; that affecting the glans alone is called
balanitis. Most cases of these conditions occur in uncircumcised males,affecting 4–11% of that group.
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. Both conditions are usually treated with topical antibiotics
(metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. Circumcision is a
treatment option for refractory or recurrent balanoposthitis, but in recent years the availability of these other
treatments have made it less necessary.
Urinary tract infections
A UTI affects parts of the urinary system including the urethra, bladder, and kidneys. There is about a 1% 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 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,but prevention of UTIs does not justify
routine use of the procedure.] Circumcision is most likely to benefit boys who have a high risk of UTIs due to
anatomical defects, and may be used to treat recurrent UTIs.
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
bacteria population
Cancers
Circumcision has a protective effect against the risks of penile cancer in men, and cervical cancer in the female
sexual partners of heterosexual men. Penile cancer is rare, with about 1 new case per 100,000 people per year
in developed countries, and higher incidence rates per 100,000 in sub-Saharan Africa (for example, 1.6 in
Zimbabwe, 2.7 in Uganda and 3.2 in Swaziland). 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.
Childhood or adolescent circumcision is associated with a reduced risk of invasive squamous cell carcinoma
in particular.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.Penile cancer has been observed to be nearly
eliminated in populations of males circumcised neonatally.
Important risk factors for penile cancer include phimosis and HPV infection, both of which are mitigated by
circumcision. 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
Adverse effects
Neonatal circumcision is generally safe when done by an experienced practitioner.[55] The most common acute
complications are bleeding, infection and the removal of either too much or too little foreskin.[5][17]
These complications occur in less than 1% of procedures, and constitute the vast majority of all acute
circumcision complications in the United States.[17] Minor complications are reported to occur in 3% of
procedures.[55] A specific complication rate is difficult to determine due to scant data on complications and
inconsistencies in their classification.[5]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.[16]
Significant acute complications happen rarely,[5][16] occurring in about 1 in 500 newborn procedures in the United
States.[5] Severe to catastrophic complications are sufficiently rare that they are reported only as individual case
reports.[5] The mortality risk is estimated at 1 in every 500,000 neonatal procedures conducted within the United
States.[17]
Circumcision does not appear to decrease the sensitivity of the penis, harm sexual function or reduce sexual
satisfaction.[18] The Royal Dutch Medical Association's 2010 Viewpoint mentions that "complications in the area
of sexuality" have been reported.[56] Additionally, the procedure may carry the risks of heightened pain response
for newborns, castration anxiety for boys in thephallic stage, and dissatisfaction with the result.[25]
Prevalence
Main article: Prevalence of circumcision
Circumcision is probably the world's most widely performed procedure.[57] Approximately one-third of males
worldwide are circumcised, most often for reasons other than medical indication.[1][16] It is commonly practiced
between infancy and the early twenties.[1] The WHO estimated in 2007 that 664,500,000 males aged 15 and
over were circumcised (30% global prevalence), almost 70% of whom wereMuslim.[1] Circumcision is most
prevalent in the Muslim world, Israel, South Korea, the United States and parts of Southeast Asia and Africa.
It is relatively rare in Europe, Latin America, parts of Southern Africa and Oceania and most of Asia. Prevalence is
near-universal in the Middle East and Central Asia.[1][58] Non-religious circumcision in Asia, outside of the
Republic of Korea and the Philippines, is rare,[1] and prevalence is generally low (less than 20%) across Europe
Estimates for individual countries include Taiwan at 9%[60]and Australia 58.7%.[61] Prevalence in the United States
and Canada is estimated at 75% and 30% respectively.[1] Prevalence in Africa varies from less than 20% in
some southern African countries to near universal in North and West Africa.[58]
The rates of routine neonatal circumcision over time have varied significantly by country. In the United States,
hospital discharge surveys estimated rates at 48.3% around the year 1990,[62] 61% in 2000,[1] and around 56.6%
in 2008. These estimates are lower than the actual rates, as they do not account for non-hospital circumcisions,
[62] or for procedures performed for medical need;[1] community surveys have reported higher neonatal prevalence
.[1] Canada has seen a slow decline since the early 1970s, possibly influenced by statements from the AAP and
the Canadian Pediatric Society issued in the 1970s saying that the procedure was not medically indicated.[1] In
Australia, the rate declined in the 1970s and 80s, but has been increasing slowly as of 2004.[1] In the United
Kingdom, prevalence was roughly 25% in the 1940s, but declined dramatically after the National Health Service
(NHS) did not cover the costs of the procedure.[1] The prevalence in South Korea has increased markedly in the
second half of the 20th century, rising from near zero around 1950 to about 60% in 2000, with the most significant
jumps in the last two decades of that time period.[1] This is probably due to the influence of the United States,
which established a trusteeship for the country following World War II.[1]
Medical organizations can affect the neonatal circumcision rate of a country by influencing whether the costs of the
procedure are borne by the parents or are covered by insurance or a national health care system. Policies that
require the costs to be paid by the parents yield lower neonatal circumcision rates. The decline in the rates in the
UK is one example; another is that in the United States, the individual states where insurance or Medicaid covers
the costs have higher rates. Changes to policy are driven by the results of new research, and moderated by the
politics, demographics, and culture of the communities.[7]
History
Main article: History of male circumcision
Circumcision is the world's oldest planned surgical procedure, suggested by anatomist and hyperdiffusionist
historian Grafton Elliot Smith to be over 15,000 years old, pre-dating recorded history. There is no firm consensus
as to how it came to be practiced worldwide. One theory is that it began in one geographic area and spread from
there; another is that several different cultural groups began its practice independently. In his 1891 work History
of Circumcision, physician Peter Charles Remondino suggested that it began as a less severe form of
emasculating a captured enemy:penectomy or castration would likely have been fatal, while some form of
circumcision would permanently mark the defeated yet leave him alive to serve as a slave.
The history of the migration and evolution of the practice of circumcision is followed mainly through the cultures and peoples in two separate regions. In the lands south and east of theMediterranean, 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 traveled to and was adopted by the
There is also evidence that it was practiced in the Americas, but little detail is available about its history[
Middle East, Africa and Europe
Evidence suggests that circumcision was practiced in the Arabian Peninsula by the 4th millennium BCE, when
the Sumerians and the Semites moved into the area that is modern-day Iraq.[57] 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 A
kh-Mahor at Saqqara, dating to about 2400–2300 BCE. Circumcision was done by the Egyptians possibly 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 into adulthood, 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.
Circumcision features prominently in the Hebrew Bible. The narrative in Genesis chapter 17 describes the
circumcision of Abraham and his relatives and slaves, making him the first named individual to undergo the
procedure. In the same chapter, Abraham's descendants are commanded to circumcise their sons on the eighth
Day of life. Many generations later, Moses was raised by the Egyptian elite, so circumcision was doubtless
familiar
to him. For the Jews of the time, circumcision was not as much a spiritual act as it was a physical sign of their
covenant with God, and a prerequisite for the fulfillment of the commandment to produce offspring. In addition to
proposing that circumcision was taken up by the Jews 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.
Alexander the Great conquered the Middle East in the 4th 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. Antiochus Epiphanes outlawed circumcision,
as did Hadrian, which helped cause theBar Kokhba revolt. During this period in history, Jewish circumcision called
for the removal of only a part of the prepuce, and some Hellenized Jews 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 2nd century CE they changed the requirements of Jewish circumcision to call for the complete removal
of the foreskin, 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.
A narrative in the Christian Gospel of Luke makes a brief mention of the
circumcision of Jesus, but the subject of physical circumcision itself is
not part of the received teachings of Jesus. Paul the Apostle reinterpreted
circumcision as a spiritual concept, arguing the physical one to be no
longer necessary. The teaching that physical circumcision was
unnecessary for membership in a divine covenant was instrumental in the
separation of Christianity from Judaism. Although it is not mentioned in the
Quran (early 6th 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.
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 conquest of Spain. In the second half of the 1st millennium CE, inhabitants from the
North East 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.
Aboriginals
Compared to the available history of circumcision in the Middle East, there is little verifiable evidence for its history
among the Aboriginal Australians and Polynesians. What is known comes from their oral histories and accounts of
missionaries and explorers. 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. The removal of the foreskin was done with seashells, and it is theorized that the bleeding was stopped with eucalyptus smoke.[57][66]
Some groups in the Americas are known to have a history of circumcision. Christopher Columbus found circumcision
in practice by the native Americans. It was also practiced by the Incas, Aztecs and Mayans. It probably started
among South American tribes as a blood sacrifice or ritual mutilation to test bravery and endurance, and its use later
evolved into a rite of initiation.[57]
Modern times
Circumcision has only been thought of as a common medical procedure since late Victorian times. In 1870,
the influential orthopedic surgeon Lewis Sayre, a founder of the American Medical Association, began using
circumcision as a purported cure for several cases of young boys presenting with paralysis or significant gross motor
problems. He thought the procedure ameliorated such problems based on a "reflex neurosis" theory of disease,
with the understanding that a tight foreskin inflamed the nerves and caused systemic problems. The use of
circumcision to promote good health also fit in with the germ theory of disease, which saw validation during the same
time period: the foreskin was seen as harboring infection-causing smegma (a mixture of shed skin cells and oils).
Sayre published works on the subject and promoted it energetically in speeches. Contemporary physicians picked up
on Sayre's new treatment, which they believed could prevent or cure a wide-ranging array of medical problems and
social ills, including masturbation (considered by the Victorians to be a serious problem), syphilis, epilepsy, hernia,
headache, clubfoot, alcoholism and gout. Its popularity spread with publications such as Peter Charles Remondino's
History of Circumcision. By the turn of the century, in both America and Great Britain, infant circumcision was nearly
universally recommended
After the end of World War II, Britain moved to a nationalized health care system, and so looked to ensure that each
medical procedure covered by the new system was cost-effective. Douglas Gairdner's 1949 article "The Fate of the
Foreskin" argued persuasively that the evidence available at that time showed that the risks outweighed the known
benefits. The procedure was not covered by the national health care system, and circumcision rates dropped in
Britain and in the rest of Europe. 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.
In the United States, the American Academy of Pediatrics has, over the decades, issued a series of policy
statements regarding circumcision, sometimes positive and sometimes negative.[
An association between circumcision and reduced heterosexual HIV infection rates was suggested in 1986.[19]
Experimental evidence was needed to establish a causal relationship, so threerandomized controlled trials were
commissioned as a means to reduce the effect of any confounding factors.[68] Trials took place in South Africa,
Kenya and Uganda.[10] All three trials were stopped early by their monitoring boards on ethical grounds, because
those in the circumcised group had a lower rate of HIV contraction than the control group.[10] Subsequently, the
World Health Organization promoted circumcision in high-risk populations as part of an overall program to reduce the
spread of HIV,[12] although some have challenged the validity of the African randomized controlled trials, prompting
a number of researchers to question the effectiveness of circumcision as an HIV prevention strategy
The Male Circumcision Clearinghouse website was formed by WHO, UNAIDS, FHI and AVAC to provide current
evidence-based guidance, information and resources to support the delivery of safe male circumcision services in
countries that choose to scale up the procedure as one component of comprehensive HIV prevention services.
Society and cultureCultures and religions
See also: Religious male circumcision
In some cultures, males must be circumcised shortly after birth, during childhood or around puberty as part of a rite
of passage. Circumcision is commonly practiced in the Jewish and Islamic faiths.
Judaism
Main article: Brit milah
Circumcision is very important to Judaism, with over 90% of adherents having the procedure performed as a religious
obligation. 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 leave the glans bare when the penis is
flaccid. Converts to 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 adherents foresee
serious negative spiritual consequences if it is neglected
Islam
Main article: Khitan (circumcision)
Although there is debate within Islam over whether it is a religious requirement, 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 mentioned in the Quran, but rather adherents
believe it is a tradition established by Islam's prophet Muhammad directly (following Abraham), and so its practice
is considered a sunnah (prophet's tradition). For Muslims, circumcision is a matter of cleanliness, purification and
control over one's baser self (nafs). 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, with it most often
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.
Christianity
The New Testament chapter Acts 15 records that Christianity does not require circumcision; Christianity does not
forbid it either. In 1442, the leadership of the Catholic Church declared that circumcision was not necessary. Coptic
Christians practice circumcision as a rite of passage.[1][21][78][79] The Ethiopian Orthodox Church calls for
circumcision, with near-universal prevalence among Orthodox men in Ethiopia.[1] In South Africa, some Christian
churches disapprove of the practice, while others require it of their members.[1]
African cultures
Certain African cultural groups, such as the Yoruba and Igbo of Nigeria, customarily circumcize their infant sons.
The procedure is also practiced by some cultural groups or individual family lines in the Sudan, Zaire, Uganda and in
southern Africa. For some of these groups, circumcision appears to be purely cultural, done with no particular
religious significance or intention to distinguish members of a group. For others, circumcision might be done for
purification, or it may be interpreted as a mark of subjugation. Among these groups, even when circumcision is done
for reasons of tradition, it is often done in hospitals.[80]
Australian cultures
Some Australian Aboriginies 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.[80]
Ethical and legal issues
Main article: Ethics of circumcision
See also: Circumcision controversies and Circumcision and law
There is a long-running and vigorous debate over ethical concerns regarding circumcision, particularly neonatal
circumcision for reasons other than intended direct medical benefit. There are three parties involved in the decision to
circumcise a minor: the minor as the patient, the parents (or other guardians) and the physician. The physician is
bound under the ethical principles of beneficence (promoting well-being) and non-maleficence ("first, do no harm"),
and so is charged with the responsibility to promote the best interests of the patient while minimizing unnecessary
harms. Those involved must weigh the factors of what is in the best interest of the minor against the potential harms
of the procedure.[8]
With a newborn involved, the decision is made more complex due the principles of respect for autonomy and consent,
as a newborn cannot understand or engage in a logical discussion of his own values and best interests.[8][9]
A mentally more mature child can understand the issues involved to some degree, and the physician and parents may elicit input from the child and weigh it appropriately in the decision-making process, although the law may not treat such input as legally informative. Ethicists and legal theorists also state that it is questionable for parents to make a decision for the child that precludes the child from making a
different decision for himself later. Such a question can be raised for the decision by the parents either to circumcise
or not to circumcise the child.[8]
Generally, circumcision on a minor is not ethically controversial or legally questionable when there is a clear and
pressing medical indication for which it is the accepted best practice to resolve. Where circumcision is the chosen
intervention, the physician has an ethical responsibility to ensure the procedure is performed competently and safely
to minimize potential harms.[8][9] Worldwide, most legal jurisdictions do not have specific laws concerning the
circumcision of males,[1] but infant circumcision is considered legal under the existing laws in countries such as
Australia, Canada, New Zealand, the UK and the US.[81] A few countries have passed legislation on the procedure:
Germany allows non-therapeutic circumcision under certain conditions,[82] while non-religious routine circumcision
Societally, circumcision is often considered for reasons other than medical need. Public health advocates of
circumcision consider it to be a net benefit overall, and therefore feel increasing the circumcision rate to be an
ethical imperative. They recommend performing the procedure during the neonatal period, when it is less expensive
and has a lower risk of complications.[9] While studies show there is a modest epidemiological benefit to
circumcision, critics argue that the number of circumcisions that would have be performed would yield an overall
negative public health outcome due to the resulting number of complications or other negative effects (such as pain).
Pinto (2012) writes "sober proponents and detractors of circumcision agree that there is no overwhelming medical
evidence to support either side."[9] This type of cost-benefit analysis is highly dependent on the kinds and frequencies
of health problems in the population under discussion and how circumcision affects those health problems.[8]
Parents are assumed to have the child's best interests in mind. Ethically, it is imperative that the medical practitioner
inform the parents about the benefits and risks of the procedure and obtain informed consent before performing it.
Practically, however, many parents come to a decision about circumcising the child before he is born, and a
discussion of the benefits and risks of the procedure with a physician has not been shown to have a significant effect
on the decision. Some parents request to have their newborn or older child circumcised for non-theraeputic reasons,
such as the parents' desires to adhere to family tradition, cultural norms or religious beliefs. In considering such a
request, the physician may consider (in addition to any potential medical benefits and harms) such non-medical
factors in determining the child's best interests and may ethically perform the procedure. Equally, without a clear
medical benefit relative to the potential harms, a physician may take the ethical position that non-medical factors
do not contribute enough as benefits to outweigh the potential harms and refuse the perform the procedure.
Medical organization such as the British Medical Association state that their member physicians are not obliged
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.[83] Several analyses have
concluded that circumcision programs for adult men in Africa are cost-effective and in some cases are cost-saving.[11] In Rwanda, circumcision has been found to be cost-effective across a wide range of age groups from newborn to adult,[44][84] with the greatest savings achieved when the procedure is
performed in the newborn period due to the lower cost per procedure and greater time frame for HIV infection
protection.[33][84] 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.[83] 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.[85]
The overall cost-effectiveness of neonatal circumcision has also been studied in the United States, which has a
significantly different cost setting from Africa in areas such as public health infrastructure, availability of medications,
and medical technology and the willingness to use it.[86] 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 heterosexual
transmission of HIV alone, without considering any other cost benefits.[5] 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.[5] A Johns Hopkins study (2012) that considered reported benefits of circumcision such
as reduced risks from HIV, HPV, HSV-2 and UTIs calculated that if the circumcision rate in the United States were
to drop from 55% to 10% (the rate in Europe), it would "increase lifetime health care costs by $407 per male and $43
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