Changes

The '''pain''' of [[circumcision ]] is extreme and traumatizing.<ref name="bollinger2019">{{REFdocument |title=Child Genital Cutting as an Adverse Childhood Experience |url=http://adversechildhoodexperiences.net/CGC_as_an_ACE.pdf |archived= |contribution= |quote= |trans-quote= |quote-lang= |last=Bollinger |first=Dan |author-link=Dan Bollinger |last2=Chapin |first2=Georganne |author2-link=Georganne Chapin |publisher=Intact America |location=Tarrytown, New York, USA |format=PDF |date=2019-08-01 |accessdate=2021-06-30}}</ref> Infant boys cry a special cry of distress. Ostwall & Peltzman (1974) noted: {{Citation |Text=Our attention has been focused on the distress cry of infants. We have recorded numerous distress cries resulting from routine medical procedures such as taking blood samples and minor surgery such as [[circumcision]]. The distress cry is louder, longer, and noisier than the hunger cry. In also tends to be irregular, with more interruptions and gagging. |Author=Ostwall & Peltzman (1974) |ref=<ref name="ostwald1974">{{REFjournal |last=Ostwald |first=Peter F. |init= |author-link= |last2=Peltzman |first2=Philip |init2= |author2-link= |etal=no |title=The cry of the human infant |journal=Scientific American |location= |date=1974-03 |volume=230 |issue=3 |article= |page= |pages=84-90 |url=https://www.jstor.org/stable/24950031 |archived= |quote= |pubmedID=4812887 |pubmedCID= |DOI=10.1038/scientificamerican0374-84 |accessdate=2021-06-21}}</ref>}}

There are four painful steps in every infant [[circumcision]]:<ref name="bellini2022>{{REFjournal |last=Bellini |first= |init=CV |author-link= |etal=no |title=Neonatal infant pain scale in assessing pain and pain relief for newborn male circumcision |trans-title= |language= |journal=Int J Impot Res |location= |date=2022-03-29 |volume= |issue= |article= |page= |pages= |url=https://www.nature.com/articles/s41443-022-00551-x |archived= |quote= |pubmedID=35352017 |pubmedCID= |DOI=10.1038/s41443-022-00551-x |accessdate=2023-04-29}}</ref>

# Before [[circumcision ]] surgery can commence, the surgeon must first forcibly separate these two highly innervated body parts in an exquisitely painful procedure by forcing a blunt probe between the two parts to destroy, rip and tear the [[synechia]] apart.<ref name="bellini2022 /><ref>{{REFjournal

# Next, in another painful step, a [[dorsal slit]] must be cut in the foreskin, so that a special clamp can be installed.<ref name="bellini2022 />

}}</ref> Nervous tissue requires a large blood supply, so the [[foreskin ]] is richly vascularized with many blood vessels,<ref name="fleiss-hodges-vanhowe1998">{{REFjournal |last=Fleiss |init=P |author-link=Paul M. Fleiss |last2=Hodges |init2=F |author2-link=Frederick M. Hodges |last3=Van Howe |init3=RS |author3-link=Robert S. Van Howe |title=Immunological functions of the human prepuce |journal=Sex Trans Infect |date=FleissP HodgesF VanHoweRS 1998-10 |volume=74 |issue=5 |pages=364-67 |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758142/pdf/v074p00364.pdf |quote= |pubmedID=10195034 |pubmedCID= |DOI= |accessdate=2019-10-15}}</ref> therefore the foreskin must be crushed with one of several special clamps in yet another painful step before the [[circumcision ]] can be carried out.<ref name="bellini2022 /><ref>{{REFjournal

# Finally, in another, painful step, the foreskin must be cut away.<ref name="bellini2022 />

Lander ''et al''. (1997) conducted a comparison neonatal non-therapeutic [[circumcision ]] without anesthesia (current practice in 1997), [[ring block]], [[dorsal penile nerve block]], and a topical eutectic mixture of local anesthetics ([[EMLA]]).<ref name="lander1997">{{LanderJ etal 1997}}</ref>  With no anesthesia, the infants screamed continuously. Newborns in the untreated placebo group exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the [[circumcision]] and following. Two newborns in the placebo group became ill following circumcision (choking and apnea). One experienced projectile vomiting.<ref name="lander1997" /> [[EMLA]] was the least effective pain control. [[Dorsal penile nerve block]] (DPNB) was more effective, and [[ring block]] was the most effective. The authors reported "[w]ithout exception, newborns in this study who did not receive an analgesic suffered great distress during and following the circumcision, and they were exposed to unnecessary risk (from choking or apnea)." The authors were so alarmed that they terminated the no anesthesia arm of the study early.<ref name="lander1997" /> None of the analgesic measures tested provided total pain relief.<ref name="bellieni2013">{{REFjournal |last=LanderBellieni |initfirst=JCarlo V. |firstinit=Janice

|last2=Brady-FrererAlagna |init2first2=BMaria G. |first2init2=Barbara

|last3=MetcalfeBuonocore |init3first3=JBGiuseppe |first3init3=James B.

|title= Comparison of ring block, dorsal penile nerve block, and topical anesthesia Analgesia for neonatal infants’ circumcision |trans-title= |language= |journal=JAMAItal J Pediatr

|date=19972013-1206-2413 |volume=27839 |issue=24 |article= |page=39 |pages=2157-64 |url=https://canadiancrcwww.academia.comedu/circumcision16945402/AMA_journal_circumcision_1997.aspxcircumcision_and_pain?email_work_card=view-paper

|pubmedID=941700923759130 |pubmedCID=3702488 |DOI=10.1186/1824-7288-39-38 |accessdate=20202021-1105-1029}}</ref>  With no anesthesia, the infants screamed continuously. Newborns in the untreated placebo group exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the circumcision and following. Two newborns in the placebo group became ill following circumcision (choking and apnea). One experienced projectile vomiting.<ref name="lander1997" /> EMLA was the least effective pain control. Dorsal penile nerve block (DPNB) was more effective, and ring block was the most effective. The authors reported "[w]ithout exception, newborns in this study who did not receive an analgesic suffered great distress during and following the circumcision, and they were exposed to unnecessary risk (from choking or apnea)." The authors were so alarmed that they terminated the no anesthesia arm of the study early.<ref name="lander1997" />None of the analgesic measures tested provided total pain relief. Any infant boy who undergoes neonatal [[circumcision ]] will experience some pain and [[trauma]]. Boys who escape circumcision would have no pain or [[trauma]]. The authors concluded that circumcision should be performed with ''anesthetic'', however the text makes clear that they meant ''analgesia'', since full anesthesia is unsafe for neonates.<ref name="lander1997" />

[[Circumcision ]] is an invasive cutting and [[amputation]]. Like other invasive operations, post-surgical pain persists after the surgery for days or weeks. <ref name="agoglu2022">{{REFjournal |last=Aydoğlu |first= |init=B |author-link= |last2=Aydoğlu |first2= |init2=M |author2-link= |last3=Okur |first3= |init3=MH |author3-link= |etal=no |title=Social and psychological effects of circumcision: A narrative review |trans-title= |language= |journal=Journal of Applied Nursing and Health |location= |date=2022-12 |volume=4 |issue=2 |pages=264-71 |url=https://janh.candle.or.id/index.php/janh/article/view/110/138 |archived= |quote= ||DOI=10.55018/janh.v4i2.110 |format=PDF |accessdate=2023-12-15}}</ref> Infant boys will not receive effective analgesia because their young age makes such drugs dangerous.

Howard ''et al''. (1994) studied male infants after their neonatal [[circumcision]]. They recorded the comfort scores of the infants at numerous periods after circumcision. They also observed and recorded feeding behavior.

It was found that feeding behavior deteriorated significantly after [[circumcision]]. Some breastfeed breastfed infants were unable to [[Breastfeeding| breastfeed ]] and required formula feeding after [[circumcision]]. Acetaminophen was found to be almost totally ineffective against the post-circumcision pain. It did have some effect six hours after the circumcision. The authors concluded "that circumcision of the newborn causes severe and persistent pain."<ref name="howard1994">{{REFjournal

When an infant boy is to be [[circumcised]], it is the usual practice to immobilize the infant for the painful surgery by securely tying his limbs to a molded plastic board, called the [[Circumstraint]], specially made for that purpose. The infant thus is preventing from fighting or fleeing, which is the [[trauma]]-producing situation of ''inescapable [[shock]]'', described as a "physical condition in which the organism cannot do anything to affect the inevitable."<ref name="vanderkolk2014">{{REFbook |last=van der Kolk |first=Bessel A. |init=BA |author-link=Bessel van der Kolk |year=2014 |title=The Body Keeps the Score |url= |pages=76 |isbn=978-0-14-312774-1 |accessdate=2021-08-10 }}</ref> There is now substantial evidence that the extreme pain of infant circumcision causes [[Posttraumatic stress disorder| post -traumatic stress disorder]] ̪(PTSD). Preverbal memory starts to function before birth and continues to function in the newborn period,<ref>{{REFjournal

}}</ref> and infants are now known to feel pain intensely,<ref name="bellini2022 /><ref name="anand1987">{{REFjournal

|author-link=Kanwaljeet J. Singh Anand

|etal=yesno

|first=Gregory J. |author-link=Gregory J. Boyle

|author2-link=Ronald Goldman

|author3-link=J. Steven Svoboda

Bellini observed that [[circumcised]] boys evidently remember pain.<ref name="bellini2022 /> Taddio & colleagues (1995)(1997) studied the effect of neonatal [[circumcision ]] on the behavior of boys after surgery and at the time of vaccination. It was found that [[circumcised ]] boys had a higher pain response at time of vaccination six months later as compared with [[intact ]] boys,<ref name="taddio"1995">{{REFjournal |last=Taddio |init=A |first=Anna |author-link= |last2=Goldbach |init2=M |first2=Morton |author2-link= |last3=Ipp |init3=M |first3=Moshe |author3-link= |last4=Stevens |init4=S |first4=Bonnie |author4-link= |last5=Koren |init5=G |first5=Gideon |author5-link= |TaddioA etal=no |title=Effect of neonatal circumcision on pain responses during vaccination in boys |journal=Lancet |location= |date=1995 |volume=344 |issue= |pages=291-2 |url=http://www.cirp.org/library/pain/taddio/ |archived= |quote= |pubmedID=7837863 |pubmedCID= |DOI=10.1016/s0140-6736(95)90278-3 |accessdate=2020-11-10}}</ref> <ref name="taddio1997">{{REFjournal |last=Taddio |init=A |first=Anna |author-link= |last2=Katz |init2=J |first2=Joel |author2-link= |last3=Ilersich |init3=AL |first3=A. Lane |author3-link= |last4=Gideon |init4=K |first4=Koren |author4-link= |etal=no |title=Effect of neonatal circumcision on pain response during subsequent routine vaccination |journal=Lancet |location= |date=TaddioA KatzJ IlersichAL KorenG 1997-03-01 |volume=342 |issue=9052 |pages=599-603 |url=https://yorkspace.library.yorku.ca/xmlui/bitstream/handle/10315/7941/KAT036.pdf?sequence=1&origin=publication_detail |archived= |quote= |pubmedID=9057731 |pubmedCID= |DOI=10.1016/S0140-6736(96)10316-0 |accessdate=2020-11-11}}</ref> showing that the nervous system had been permanently sensitized to heightened pain sensation. Taddio et al. (1997) concluded:

Taddio ''et al''. (1997) concluded:<blockquote>{{Citation |Text=Although postsurgical central sensitisation (allodynia and hyperalgesia) can extend to sites of the body distal from the wound, suggesting a supraspinal effect, the long-term consequences of surgery done without anaesthesia are likely to include post-traumatic stress as well as pain. It is, therefore, possible that the greater vaccination response in the infants circumcised without anaesthesia may represent an <u>infant analogue of a post-traumatic stress disorder</u> triggered by a traumatic and painful event and re-experienced under similar circumstances of pain during vaccination. |Author=Taddio et al. (1997) |ref=<ref name="taddio1997" /></blockquote>}}

John Rhinehart, M. D., {{MD}} (1999) , a clinical psychiatrist, reported finding numerous cases of [[PTSD ]] in his adult male patients pursuant to infant [[circumcision]].<ref>{{REFjournal

===Effect of extreme pain on developing nervous systemHistory=== Fitzgerald & Walker (2003) argued that extreme pain (such as that caused by circumcision) may alter developing nervous tissue in the very young.<ref>{{REFbook |last=Fitzgerald |first=Maria |author-link= |last2=Walker |first2=Suellen |author2-link= |year=2003 |title=The role of activity in developing pain pathways |url=http://www.cirp.org/library/pain/fitzgerald2/ |work=Proceedings of the 10th World Congress on Pain |editor=Dostovsky JO, Carr DB, Koltzenburg M (eds) |edition= |volume=24 |chapter= |pages=185-96 |location=Seattle |publisher=ASP Press |isbn= |quote=In common with other areas of the central nervous system, synaptic development of spinal sensory connections is experience or activity dependent. Evidence from both animal and human studies shows that alterations in the patterns of sensory activity that can arise from tissue injury and pain in early life may disrupt normal synaptic organization within the somatosensory system. While these studies are incomplete and more investigation is needed in this area, the potential clinical importance of neonatal plasticity in pain development is clear. |accessdate=2020-11-18 |note=}}</ref>

[[Paul Emil Flechsig ]] (1847-1929) was an eminent nineteenth-century German neuroanatomist, psychiatrist and neuropathologist. He suggested in 1872 that infants could not feel pain because their nerves are not completely myelinated.<ref name="cope1998">{{REFjournal

}}</ref> Incredible as it may seem today, his idea was accepted without question and without being tested.<ref name="vanhowe2008">{{REFjournal |last=Van Howe |first=Robert S. |init=RS |author-link=Robert S. Van Howe |last2=Svoboda |first2=J. Steven |init2=JS |author2-link=J. Steven Svoboda |etal=no |title=Neonatal pain relief and the Helsinki Declaration |journal=Journal of Law, Medicine, and Ethics |location= |date=2008-12 |volume=36 |issue=4 |article= |page= |pages=803-23 |url=https://www.academia.edu/download/33981944/27_Van_Howe.pdf |archived= |quote= |pubmedID=19094008 |pubmedCID= |DOI=10.1111/j.1748-720X.2008.00339.x |accessdate=2021-10-31}}</ref>

Flechsig's bizarre opinion was not questioned until the 1970s. Several lines of empirical of research carried out in the 1970s suggested that infants can in fact feel intense pain.<ref name="vanhowe2008" />

* Anders ''et al''. (1970) showed that measurement of serum cortisol is a useful indicator of pain for psychological investigation in infancy.<ref name="anders1970">{{REFjournal

* Emde ''et al''. (1971) showed that the "stress" of circumcision caused an increase in the amount of non-REM sleep.<ref name="emde1971">{{REFjournal

* Rawlings, Miller & Engel (1980) showed that as the pain of circumcision increased, oxygenation of the [[skin ]] decreased.<ref name="rawlings1980">{{REFjournal

* Gunnar ''et al''. (1981) recorded serum cortisol and behavior state throughout the unanesthetized, non-therapeutic circumcision process. Serum cortisol levels and behavioral distress were found to be closely related. The authors stated:<blockquote>{{Citation |Text=Neonatal circumcision is performed without anesthesia and it is clearly stressful for the infant.</blockquote> |Author=Gunnar et al. (1981)So great was Flechsig's influence, the authors were still unwilling to use the word ''pain'' and substituted the word ''stress''. |ref=<refname="Gunnar et al 1981">{{REFjournal

* Marshall ''et al''. (1982) studied mother-child interaction with regard to feeding behavior after circumcision without anesthesia. They found that [[circumcised ]] boys had more interruptions of feeding in the 24-hour period of observation.<ref name="marshall1982">{{REFjournal

|pages=447446 |url=https://pediatrics.aappublications.org/content/4680/43/532446

}}</ref><ref name="vanhowe2008"/>

{{Citation |Text=Numerous lines of evidence suggest that even in the human [[fetus]], pain pathways as well as cortical and subcortical centers necessary for pain perception are well developed late in gestation, and the neurochemical systems now known to be associated with pain transmission and modulation are intact and functional. Physiologic responses to painful stimuli have been well documented in neonates of various gestational ages and are reflected in hormonal, metabolic, and cardiorespiratory changes similar to but greater than those observed in adult subjects. Other responses in newborn infants are suggestive of integrated emotional and behavioral responses to pain and are retained in memory long enough to modify subsequent behavior patterns. |Author=Anand & Hickey (1987) |ref=<ref name="anand1987"/><ref name="vanhowe2008"/>}} Gunnar ''et al''. (1988) examined the association between behavioral distress and adrenocortical activity. It was found that differences in behavioral distress did not reliably the level of adrenocortical activity. Moreover, it was found that while non-nutritive sucking reduces crying it did not reduce the adrenocortical response to the stressful stimulus of circumcision pain.<ref name="gunnar1988">{{REFjournal

Although by 1989 it was totally clear that infants can feel intense pain, the [[American_Academy_of_Pediatrics#Third_policy_.281989.29 1989 | American Academy of Pediatrics Circumcision Task Force]], under the leadership of the infamous [[Edgar J. Schoen]], M. D.{{MD}}, declined to recommend the use of analgesics for non-therapeutic neonatal [[circumcision]], thereby condemning million millions of newborn baby boys to a painful, stressful , traumatizing circumcision.<ref>{{REFjournal

The finacially financially and psychologically vested circumcision industry suddenly found itself in a predicament. It was now suddenly proven beyond any shadow of a doubt that newborn baby boys can feel intense pain. Medical ethics and the standard of care now necessitated pain relief, however it is dangerous to give general anesthesia to neonates. [[Edward Wallerstein ]] (1985) had proposed that [[Routine Infant Circumcision| routine ]] (non-therapeutic) circumcision of baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,<ref name="wallerstein1985">{{REFjournal

}}</ref> however this clearly would not do for the avid pro-circumcision lobby. No circumcision equals no fee for surgery. The financial gain from discontinuing non-therapeutic circumcision is just too high to discard. [[Dan Bollinger ]] (2012) estimated that the total annual cost of non-therapeutic circumcision to Americans is $3,647,000,000.<ref>{{REFweb

|author-link=Dan Bollinger

}}</ref> The avaricious American [[circumcision industry ]] is simply not willing to give that lucrative income up, so a way to make non-therapeutic circumcisions in infancy acceptable had to be found.

* Application of [[EMLA ]] Cream topical anesthetic. [[EMLA ]] is a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%. [[EMLA ]] Cream (lidocaine 2.5% and prilocaine 2.5%), applied to intact [[skin ]] under occlusive dressing, provides dermal analgesia by the release of lidocaine and prilocaine from the cream into the epidermal and dermal layers of the [[skin ]] and by the accumulation of lidocaine and prilocaine in the vicinity of dermal pain receptors and nerve endings.<ref>{{REFweb

* [[Dorsal penile nerve block| Dorsal Penile Nerve Block ]] (DPNB) as proposed by Kirya & Werthman (1978).<ref name="kirya1978">{{REFjournal

* [[Ring block| Ring Block]]. Broadman ''et al''. (1987) proposed ring block for neonatal non-therapeutic circumcision.<ref name="broadman1987">{{REFjournal

}}</ref> Ring block is considered the most effective analgesic procedure for neonatal non-therapeutic circumcision. Infant boys feel less pain and suffer less trauma than with the other two pain reduction procedures.<ref name="lander1997" /> <ref name="stang1997">{{REFjournal

|last2=SnnellmanSnellman

The standard {{Box|Boxtext=<big><b>However, none of the above three procedures totally eliminate pain. A baby boy will still experience some pain and [[trauma]] despite any of care now those analgesic procedures.<ref name="bellini2022 /> Prevention of pain requires analgesia if protecting a boy from elective neonatal non-therapeutic circumcision is to be carried out.Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or [[trauma]].</b><ref name="poland1987" /big> }} Wallerstein (1985)<ref name="aap1999">{{REFjournal |last=LannonWallerstein |initfirst=CMEdward |firstinit=Carole M. |author-link= |last2=Bailey |init2=AGD |first2=Ann Geryl Doll |author2-link= |last3=Fleischman |init3=AR |first3=Alan R. |author3-link= |last4=Kaplan |init4=G |first4=George |author4-link=Edward Wallerstein |etal=yesno |title=Circumcision policy statementIs non-religious circumcision necessary?

|language=English |journal=PediatricsJ Am Acad Child Psychiatr

|date=19991985-0905 |volume=10324

|article= |page= |pages=364-5 |url=http://www.cirp.org/library/pain/gunnar1984/#wallerstein |archived= |quote= |pubmedID= |pubmedCID= |DOI= |accessdate=2021-07-0}}</ref> and [[Robert S. Van Howe|Van Howe]] & Cold (1998)<ref>{{REFjournal |last=Van Howe |first=Robert S. |init=RS |author-link=Robert S. Van Howe |last2=Cold |first2=Christopher J. |init2=CJ |author2-link=Christopher J. Cold |etal=no |title=Local Anesthesia For Infants Undergoing Circumcision |journal=JAMA |location= |date=1998-04-15 |volume=299 |issue=15 |article= |page= |pages=6871169-9371 |url=http://www.cirp.org/library/statementspain/aap1999lander/letters.html

|pubmedID=22926180

|DOI=10 |accessdate=2021-07-08}}</ref> have suggested that it would be better to abandon the practice of non-therapeutic infant circumcision because of the pain associated with it. The ''Daily Mail'' (2021) reported the pain stress of non-therapeutic neonatal circumcision increases the risk of [[SIDS]], and that the incidence of Sudden Infant Death Syndrome (SIDS) is lower where baby boys are not [[circumcised]].1016<ref name="thompson2021">{{REFnews |title=Circumcising newborn boys increases their risk of cot death due to the stress of the procedure - and could explain why it is more common in boys than girls, study finds |url=https://jwww.jurodailymail.2013co.06uk/health/article-5998771/Circumcising-newborn-boys-increases-risk-cot-death-stress-procedure.094html |last=Thompson |first=Alexandra |coauthors= |publisher=Daily Mail |website= |date=2021-07-27 |accessdate=20202021-1108-1902 |quote=

<b>However, none of the above three procedures totally eliminate The painthat infant boys experience would not be acceptable in older boys and adults. A baby boy will It is not clear why infant boys are still experience some pain despite any of those analgesic procedures. Prevention subjected to a lesser standard of care with regard to pain requires protecting a boy from elective neonatal non-therapeutic circumcision. Only than older boys who are protected from the medically unnecessary circumcision surgery experience no pain or traumaand adults.</b>

Wellington & Rieder (1993) conducted a survey of physicians in London, Ontario. They found that only 4 percent used [[dorsal penile nerve block| DPNB]]. They concluded:<blockquote>{{Citation |Text=Despite evidence that neonates perceive pain and that there is a physiologic stress response to circumcision which can be reduced if analgesia is employed, the vast majority of physicians performing newborn circumcisions either do not employ analgesics or employ analgesics of questionable efficacy. Lack of familiarity with the use of analgesics among neonates and with dorsal penile block in particular are the most common reasons cited for lack of analgesic use. Educational efforts and research into less invasive techniques of analgesia for newborn circumcision are urgently required. |Author=Wellington & Rieder (1993) |ref=<ref>{{REFjournal

}}</ref> (Non-therapeutic neonatal circumcisions are no longer performed in most Canadian hospitals.)<ref name="jamesloewen2019">[[James Loewen]] (2019). Personal communication.</ref>

<blockquote>{{Citation |Text=DESPITE THE DEBATE that continues over the benefits and risks of nonritual neonatal circumcision, it remains a commonly performed surgical procedure in the United States. To the best of our knowledge, it is the only surgical procedure that is routinely performed without first administering analgesia or anesthesia. This unconscionable state of affairs exists, despite the overwhelming evidence that newborns, even those born prematurely, are capable of experiencing pain. Indeed, anyone present during a circumcision realizes that the newborn feels and responds to pain and will attempt to withdraw if unrestrained. In addition, this pain has physiologic correlates: elevated heart rate and blood pressure, lowered arterial oxygen saturation, and elevated levels of adrenocortical hormones. During the past 15 years, results of a multitude of studies have demonstrated that effective analgesia can prevent this pain and ameliorate the associated stress response. Furthermore, the failure to provide anesthesia or analgesia has been shown to cause not only short-term physiologic perturbations but also longer-term behavioral changes. |Author=Maxwell & Yaster (1999) |ref=<ref>{{REFjournal

The [[American Academy of Pediatrics]] convened a new task force on circumcision under the chair of Carole M. Lannon, M. D{{MD}}. That task force reversed the position previously taken under [[Edgar J. Schoen]]. It clearly stated that non-therapeutic infant circumcision is "not essential to the child’s current well-being." It provided an extensive discussion of procedural analgesia and said, quite strongly, that, if a circumcision is done, procedural analgesia should be provided.<ref name="aap1999" >{{REFjournal |last=Lannon |first=Carole M. |init= |author-link= |etal=yes |title=Circumcision policy statement |journal=Pediatrics |date=1999-03 |volume=103 |issue=3 |article= |page= |pages=686-93 |url=https://pediatrics.aappublications.org/content/103/3/686 |archived= |quote= |pubmedID=10049981 |pubmedCID= |DOI=https://doi.org/10.1542/peds.103.3.686 |accessdate=2021-07-12}}</ref>

==VideoStandard of care== It is now clear that boys are born with a healthy [[foreskin]] without evidence of disease. Therefore there are no indications for infant [[circumcision]], which is a non-therapeutic and medically-unnecessary surgical operation.<ref name="cps1996">{{REFjournal |last=Eugene |first=Outerbridge |init= |author-link= |etal=no |title=Neonatal circumcision revisited |journal=CMAJ |location= |date=1996-03-15 |volume=154 |issue=6 |article= |page= |pages=769-80 |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1487803/pdf/cmaj00090-0027.pdf |archived= |quote= |pubmedID=8634956 |pubmedCID=1487803 |DOI= |accessdate=2021-07-11}}</ref><ref name="racp2010">{{REFdocument |title=Circumcision of Infant Males |url=https://www.racp.edu.au//docs/default-source/advocacy-library/circumcision-of-infant-males.pdf?sfvrsn=eaa32f1a_10 |contribution= |last= |first= |publisher=[[Royal Australasian College of Physicians]] |format=PDF |date=2010-09-01 |accessdate=2021-07-11}}</ref><ref>{{REFdocument |title=Non-therapeutic circumcision of male minors |url=https://pool.intactiwiki.org/images/KNMG-viewpoint-Non-therapeutic-circumcision-of-male-minors-27-05-2010-v2.pdf |contribution= |last= |first= |publisher=Royal Dutch Medical Association (KNMG) |format=PDF |date=2010-05-27 |accessdate=2021-07-11}}</ref> Circumcision excises the highly functional foreskin, which provides numerous protective, immunological, sensory, and sexual functions,<ref name="cold1999">{{ColdCJ TaylorJR 1999}}</ref> so it is an irreversible, lasting injury. Bellini (2022) considered that the pain of neonatal circumcision "can have long term consequences for the developing child."<ref name="bellini2022 /> Non-therapeutic circumcision of male minors is ''not'' the standard of care. Nevertheless, some non-therapeutic circumcisions of boys will continue to be performed for religious reasons, ethnic reasons, and the[[Adamant father syndrome| emotional needs of parents]]. When a [[circumcision]] is to be performed, the standard of care requires that analgesia be provided to reduce the extreme level of pain and trauma.<ref name="poland1987"/><ref name="cps1996"/><ref name="lander1997"/><ref name="aap1999"/> (Total anesthesia cannot be used with infants.) The Australian Association of Paediatric Surgeons (AAPS) (1996) opposed the practice of infant circumcision, but recognized that it would be performed for religious, cultural, or family reasons, in which case, the non-therapeutic [[circumcision]] should be deferred for six months, so that general anesthesia may be used. The AAPS stated: <blockquote>In this event the procedure should be performed electively after six months of age. When performed, it should be carried out by a surgeon performing circumcisions on children on a regular basis with an anaesthetist using appropriate techniques. This would imply that the anaesthetist is fully trained in the art of paediatric anaesthesia, including the ability to perform caudal and penile regional or local anaesthesia. The operation should be carried out in a paediatrically orientated environment, designed to reduce the risk to the child and providing support to the parents or caregivers.<ref>{{REFdocument |title=Guidelines for Circumcision |url=https://www.cirp.org/library/statements/aaps/ |contribution= |last=Leditshke |first=JF |publisher=Australasian Association of Paediatric Surgeons |location=Herston, QLD, Australia |format= |date=1996-04 |accessdate=2024-01-22}}</ref></blockquote> The practice of non-therapeutic circumcision of boys has nearly died out in [[Australia]]. == Pain's injury to the infant nervous system == Anand & Hickey (1985) conclusively demonstrated that infants feel pain and feel it more intensely than adults.<ref name="anand1987"/> Pain researcher Maria Fitzgerald (1998) reported the sensitivity of the infant nervous system to extreme pain: <blockquote>We and others have established that the developing nervous system is even more vulnerable to injury than in adults and that changes to the pathways induced shortly after birth can become permanent. This is because newborn nerve damage not only results in the death of sensory nerve cells, but causes other sensory nerve terminals to sprout extensively and occupy areas normally exclusively devoted to the damaged nerve.<ref>{{REFjournal |last=Fitzgerald |first= |init=M |author-link= |etal=no |title=The Birth of Pain |trans-title= |language= |journal=MRC News |location= |date=1998 |season=Summer |volume= |issue= |article= |page= |pages=20-23 |url=https://www.cirp.org/library/pain/fitzgerald/ |archived= |quote= |accessdate=2024-01-31}}</ref></blockquote> Several later researchers suggested that extreme pain in the newborn could cause neurological injury. [[Kanwaljeet J. Singh Anand| Anand]] & Scalzo (2000) concluded: {{Citation |Text=The public health importance of abnormal stimulation during the neonatal period cannot be overemphasized. While programs for formulating appropriate health policies and public education campaigns must disseminate this message, it is also important for these effects to be investigated, particularly with a view to developing effective therapeutic strategies for the growing children and adolescents who were exposed to abnormal conditions during the neonatal period. |Author=Anand & Scalzo (2000) |ref=<ref name="anand2000">{{REFjournal |last=Anand |first= |init=KJS |author-link=Kanwaljeet J. Singh Anand |last2=Scalzo |first2= |init2=FM |author2-link= |etal=no |title=Can adverse neonatal experiences alter brain development and subsequent behavior? |trans-title= |language= |journal=Biol Neonate |location= |date=2000-02 |volume=77 |issue=2 |article= |page= |pages=69-82 |url=http://www.cirp.org/library/pain/anand4/ |archived= |quote= |pubmedID=10657682 |pubmedCID= |DOI=10.1159/000014197 |accessdate=2021-08-09}}</ref>}} Fitzgerald & Walker (2003) argued that extreme pain (such as that caused by [[circumcision]]) may alter developing nervous tissue in the very young.<ref>{{REFbook |last=Fitzgerald |first=Maria |init=M |author-link= |last2=Walker |first2=Suellen |init2=S |author2-link= |year=2003 |title=The role of activity in developing pain pathways |url=http://www.cirp.org/library/pain/fitzgerald2/ |work=Proceedings of the 10th World Congress on Pain |editor=Dostovsky JO, Carr DB, Koltzenburg M (eds) |edition= |volume=24 |chapter= |pages=185-96 |location=Seattle |publisher=ASP Press |isbn= |quote=In common with other areas of the central nervous system, synaptic development of spinal sensory connections is experience or activity dependent. Evidence from both animal and human studies shows that alterations in the patterns of sensory activity that can arise from tissue injury and pain in early life may disrupt normal synaptic organization within the somatosensory system. While these studies are incomplete and more investigation is needed in this area, the potential clinical importance of neonatal plasticity in pain development is clear. |accessdate=2020-11-18 |note=}}</ref> Tye & Sardi advised: <blockquote>Thus, while there is literature that addresses the ways in which pain experienced by neonates not only has negative short- and long term psychological consequences, policy making documents on neonatal circumcision do not address the fact that such pain is not adequately nor regularly controlled for during the procedure, and that failure to control for pain can have lasting effects on the child, possibly into adulthood.<ref name="tye2022">{{REFjournal |last=Tye |first= |init=NC |author-link= |last2=Sardi |first2= |init2=LM |author2-link= |etal=no |title=Psychological, psychosocial, and psychosexual aspects ofpenile circumcision |trans-title= |language= |journal=Int J Impot Res |location= |date=2022-03-28 |volume= |issue= |article= |page= |pages= |url=https://www.nature.com/articles/s41443-022-00553-9 |archived= |quote= |pubmedID=35347302 |pubmedCID= |DOI=10.1038/s41443-022-00553-9 |accessdate=2022-04-29}}</ref></blockquote> ==Videos==

<b>=== Infant circumcision procedure</b>===

Please note how This is a video of an actual infant [[circumcision]]. It has a sound tract so one can hear the comments of the doctor and the sounds made by the infant. The doctor gives an injection of local anesthetic that apparently does not stop any pain at all. The infant goes silent at about 6:15 on the video, so he may have gone into [[shock]] at that time. Not for the squeamish: * {{REFweb |url=https://www.reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ |archived= |title=Trained medical professionals restrain infant's lips quiver with to amputate part of its body while baby kicks and screams in pain |trans-title= |language= |last= |first= |author-link= |publisher= |website= |date= |accessdate=2022-03-11 |format= |quote=}} *[https://www.reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ Circumcision video]

}}</ref> so the pain of the surgery is not usually a concern. That does not mean that the operation is pain free. It is notpain free.<ref name="bellini2022/>

* The recovery period for adolescent and adult circumcision is usually placed at six weeks. During that period of time, many patients experience pain when they they have involuntary nocturnal erections [[erection]]s and the [[erection ]] tightens the residual [[skin ]] and pulls at the incision and suture.<ref>{{REFjournal

}}</ref> In a few cases, the erections [[erection]]s may cause [[wound dehiscence]] which requires additional surgery to re-close the surgical wound.

* That is not the only source of pain. [[Circumcision]] amputates the protective [[foreskin]]. In cases of [[phimosis]], the [[glans penis]] may never have been exposed before, so there frequently is severe pain when the [[glans penis ]] touches anything. Many men complain that they are unable to wear trousers for an extended period of time. Only time and [[keratinization]] can ease this pain.

* Circumcision is inexact surgery. Surgeons have to guess at how much [[skin ]] to amputate, so they frequently get it wrong. If sufficient [[skin ]] is not available to permit [[penis ]] expansion during times of [[erection]], then taut, painful erections [[erection]]s are the result. This complication may be treated by [[tissue expansion]]. The tension may also cause [[wound dehiscence]], which would cause additional pain.

* Neuromas may form at the [[circumcision scar]]. Cold & Taylor (1999) reported that they are "notorious for generating pain.".<ref name="cold-taylor1999">{{REFjournal |last=Cold |first=C.J. |author-link= |last2=Taylor |first2=J.R. |author2-link=John R. Taylor |title=The prepuce |journal=BJU Int |date=ColdCJ TaylorJR 1999-01-01 |volume=83 Suppl 1 |issue= |pages=34-44 |url=https://onlinelibrary.wiley.com/doi/epdf/10.1046/j.1464-410x.1999.0830s1034.x |quote= |pubmedID=1034941 |pubmedCID= |DOI=10.1046/j.1464-410x.1999.0830s1034.x |accessdate=2020-11-29}}</ref>

* [[Circumstraint]]* [[Does Cosmetic Surgery Harm Babies?]]* [[Posttraumatic Post-traumatic stress disorder]]

|accessdate=2020-11-17}}* {{REFjournal |last=Bellieni |first= |init=CV |etal=no |title=Neonatal Infant Pain Scale in assessing pain and pain relief for newborn male circumcision |trans-title= |language= |journal=Int J Impot Res |location= |date=2023-05 |volume=35 |issue=3 |article= |page= |pages=282-5 |url=https://www.researchgate.net/publication/359693934_Neonatal_Infant_Pain_Scale_in_assessing_pain_and_pain_relief_for_newborn_male_circumcision |archived= |quote= |pubmedID=35352017 |pubmedCID= |DOI=10.1038/s41443-022-00551-x |doi= |format=PDF |accessdate=2023-10-09}}

|url=http://www.cirpdrmomma.org/library2009/pain10/mri-studies-brain-permanently-altered.html

|title=Pain of circumcision and pain controlMRI Studies: The Brain Permanently Altered From Infant Circumcision

|language=English |last=HillTinari |first=GeorgePaul D. |author-link=Paul Tinari |publisher=Circumcision Reference LibraryPeaceful Parenting

|date=2006-09-112008 |accessdate=20202021-1110-0822

|quote=Circumcision is A neurologist who saw the results to postulated that the data indicated that circumcision affected most stressful surgical procedure commonly performed intensely the portions of the victim's brain associated with reasoning, perception and emotions. Follow up tests on newbornsthe infant one day, one week and one month after the surgery indicated that the child's brain never returned to its baseline configuration. In other words, the evidence generated by this research indicated that the brain of the circumcised infant was permanently changed by the surgery.

|publisher={{UNI|Oxford University of Oxford |Oxon}} News