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5,498 bytes added, 9 March
using template LanderJ etal 1997
The '''pain''' of [[circumcision ]] is extreme and traumatizing.<ref name="bollinger2019">{{REFdocument
|title=Child Genital Cutting as an Adverse Childhood Experience
|trans-title=
|language=English
|url=http://adversechildhoodexperiences.net/CGC_as_an_ACE.pdf
|archived=
{{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
}}</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
|last=Oliver
|init=JE
|accessdate=2020-11-08
}}</ref>
# 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 />
# The foreskin is erogenous tissue,<ref>{{REFjournal
|last=Falliers
|DOI=
|accessdate=2020-11-08
}}</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
|last=
|first=
|accessdate=2020-11-08
}}</ref>
# 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" />
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">{{REFjournal
|last=Lander
|init=J
|first=Janice
|author-link=
|last2=Brady-Frerer
|init2=B
|first2=Barbara
|author2-link=
|last3=Metcalfe
|init3=JB
|first3=James B.
|author3-link=
|last4=Nazerali
|init4=S
|first4=Shermin
|author4-link=
|last5=Muttit
|init5=S
|first5=Sarah
|author5-link=
|etal=no
|title= Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision
|journal=JAMA
|location=
|date=1997-12-24
|volume=278
|issue=24
|pages=2157-64
|url=https://canadiancrc.com/circumcision/AMA_journal_circumcision_1997.aspx
|archived=
|quote=
|pubmedID=9417009
|pubmedCID=
|DOI=
|accessdate=2020-11-10
}}</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=Bellieni
|DOI=10.1186/1824-7288-39-38
|accessdate=2021-05-29
}}</ref> 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" />
===Post-surgical pain===
[[Circumcision]] is an invasive cutting and [[amputation]]. Like other invasive operations, post-surgical pain persists after the surgery for days or weeks. 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 infants were unable to 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="howard1994agoglu2022">{{REFjournal |last=HowardAydoğlu |initfirst=CR |firstinit=Cynthia R.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 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 |last=Howard |init=CR |first=Cynthia R. |author-link= |last2=Howard |init2=FM
|first2=Fred M.
|author2-link=
}}</ref>
Parents who choose to have a son [[circumcised ]] may expect the infant boy to be uncomfortable and fussy for some time.
===Traumatic effect of infant circumcision===
 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=BesselA. |init=BBA |author-link=Bessel van der Kolk
|year=2014
|title=The Body Keeps the Score
}}</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
|last=Hepper
|init=PG
|DOI=10.1111/j.1651-2227.1996.tb14272.x.
|accessdate=2020-11-11
}}</ref> and infants are now known to feel pain intensely,<ref name="bellini2022 /><ref name="anand1987">{{REFjournal
|last=Anand
|init=KJS
|author-link=Kanwaljeet J. Singh Anand
|last2=Hickey
|init2=PR
|author2-link=
|etal=yesno
|title=Pain and its effects in the human neonate and fetus
|journal=N Engl J Med
|last=Boyle
|init=GJ
|first=Gregory J. |author-link=Gregory J. Boyle
|last2=Goldman
|init2=R
|first2=Ronald
|author2-link=Ronald Goldman
|last3=Svoboda
|init3=JS
|first3=J. Steven
|author3-link=J. Steven Svoboda
|last4=Fernandez
|init4=E
}}</ref>
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:
<blockquote>
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.<ref name="taddio1997" />
</blockquote>
John Rhinehart{{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, Mpossible 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. D |Author=Taddio et al.(1997) |ref=<ref name="taddio1997"/>}} John Rhinehart, {{MD}} (1999) , a clinical psychiatrist, reported finding numerous cases of [[PTSD ]] in his adult male patients pursuant to infant [[circumcision]].<ref>{{REFjournal
|last=Rhinehart
|init=J
}}</ref>
===Effect History=== ====Investigating pain of extreme pain on developing nervous systemcircumcision====Several researchers have suggested that extreme pain in the newborn could cause neurological injury. Anand & Scalzo [[Paul Emil Flechsig]] (20001847-1929) concluded:<blockquote>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 investigatedwas an eminent nineteenth-century German neuroanatomist, particularly with a view to developing effective therapeutic strategies for the growing childen psychiatrist and adolescents who were exposed to abnormal conditions during the neonatal periodneuropathologist. He suggested in 1872 that infants could not feel pain because their nerves are not completely myelinated.<ref name="anand2000cope1998">{{REFjournal |last=Anand |first=Cope |init=KJSDK
|author-link=
|last2title=Neonatal pain: the evolution of an idea. |journal=The American Association of Anesthesiologists Newsletter |date=1998-09 |volume= |issue= |pages= |url= |accessdate=2020-11-12}}</ref> Incredible as it may seem today, his idea was accepted without question and without being tested.<ref name="vanhowe2008">{{REFjournal |last=ScalzoVan Howe |first2first=Robert S. |init2init=FMRS |author2author-link=Robert S. Van Howe |last2=Svoboda |etalfirst2=noJ. Steven |titleinit2=Can adverse neonatal experiences alter brain development and subsequent behavior?JS |transauthor2-titlelink=J. Steven Svoboda |etal=no |languagetitle=Neonatal pain relief and the Helsinki Declaration |journal=Biol NeonateJournal of Law, Medicine, and Ethics
|location=
|date=20002008-0212 |volume=7736 |issue=24
|article=
|page=
|pages=69803-8223 |url=httphttps://www.cirpacademia.orgedu/librarydownload/pain/anand433981944/27_Van_Howe.pdf
|archived=
|quote=
|pubmedID=1065768219094008
|pubmedCID=
|DOI=10.11591111/000014197j.1748-720X.2008.00339.x |accessdate=2021-0810-0931
}}</ref>
 As a result, medical doctors performed all manners of invasive, painful procedures on neonates without anesthesia or analgesia, including millions upon millions of painful circumcisions and even open heart surgery. Open heart surgery was performed with curare to paralyze the infant but without any anesthesia.  Flechsig's bizarre opinion was not questioned until the 1970s. Several lines of empirical research carried out in the 1970s suggested that infants can in fact feel intense pain.<ref name="vanhowe2008" /blockquote>Fitzgerald & Walker * Anders et al. (20031970) argued showed that extreme measurement of serum cortisol is a useful indicator of pain (such as that caused by circumcision) may alter developing nervous tissue for psychological investigation in the very younginfancy.<refname="anders1970">{{REFbookREFjournal |last=FitzgeraldAnders |firstinit=MariaTF |initfirst=MThomas F.
|author-link=
|last2=WalkerSachar |first2init2=SuellenEJ |init2first2=SEdward J.
|author2-link=
|yearlast3=2003Kream |titleinit3=J |first3=Jacob |author3-link= |last4=Roffwarg |init4=The role of activity in developing pain pathwaysHP |urlfirst4=http://wwwHoward P.cirp.org/library/pain/fitzgerald2/ |workauthor4-link= |last5=Hellman |init5=L |first5=Leon |author5-link= |etal=no |title=Proceedings of Behavioral state and plasma cortisol response in the 10th World Congress on Painhuman neonate |editorjournal=Dostovsky JO, Carr DB, Koltzenburg M (eds)Pediatrics |editionlocation= |date=1970-10 |volume=2446 |chapterissue=4 |pages=185532-967 |locationurl=http://www.cirp.org/library/pain/anders1/ |archived= |quote=Seattle |publisherpubmedID=ASP Press4323242 |isbnpubmedCID= |quoteDOI=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=13}}</ref>
===History=======Investigating pain * Emde et al. (1971) showed that the "stress" of circumcision==== Paul Emil Flechsig (1847-1929) was caused an eminent nineteenthincrease in the amount of non-century German neuroanatomist, psychiatrist and neuropathologist. He suggested in 1872 that infants could not feel pain because their nerves are not completely myelinatedREM sleep.<ref name="cope1998emde1971">{{REFjournal |last=CopeEmde |init=DKRN |first=Robert N
|author-link=
|titlelast2=Neonatal pain: the evolution of an idea.Harmon |journalinit2=The American Association of Anesthesiologists NewsletterRJ |datefirst2=1998-09Robert J. |volumeauthor2-link= |issuelast3=Metcalf |pagesinit3=D |urlfirst3=David |accessdate=2020author3-11-12}}</ref> Incredible as it may seem today, his idea was accepted without question and without being tested.<ref namelink="vanhowe2008">{{REFjournal |lastlast4=Van HoweKoenig |firstinit4=Robert SKL |initfirst4=Kenneth L. |authorauthor4-link=Robert S. Van Howe |last2last5=SvobodaWagonfeld |first2init5=J. StevenS |init2first5=Samuel |author2author5-link=J. Steven Svoboda
|etal=no
|title=Neonatal pain relief Stress and the Helsinki Declaration |trans-title= |language=neonatal sleep |journal=Journal of Law, Medicine, and EthicsPsychosom Med
|location=
|date=2008-121971 |volume=3633 |issue=4 |article= |page=6 |pages=803491-237 |url=httpshttp://www.academiacirp.eduorg/downloadlibrary/33981944birth/emde/27_Van_Howe.pdf
|archived=
|quote=
|pubmedID=19094008
|pubmedCID=
|DOI=10.1111/j.1748-720X.2008.00339.x |accessdate=2021-10-31
}}</ref>
As a result* Richards, medical doctors performed all manners of invasive, painful procedures on neonates without anesthesia or analgesia, including millions upon millions of painful circumcisions Bernal & Brackbill (1976) reported behavioral differences between American boys (circumcised) and even open heart surgery. Open heart surgery was performed with curare to paralyze the infant but without any anesthesia.  Flechsig's bizarre opinion was not questioned until the 1970s. Several lines of empirical research carried out in the 1970s suggested that infants can in fact feel intense pain.<ref name="vanhowe2008" /> * Anders et al. British boys (1970genitally intact) showed that measurement of serum cortisol is a useful indicator of pain for psychological investigation in infancy.<ref name="anders1970richards1976">{{REFjournal |last=AndersRichards |init=TF |first=Thomas F.MPM
|author-link=
|last2=SacharBernal |init2=EJ |first2=Edward J.JF
|author2-link=
|last3=KreamBrackbill |init3=JY |first3=JacobYvonne
|author3-link=
|last4=Roffwarg |init4=HP |first4=Howard P. |author4-link= |last5=Hellman |init5=L |first5=Leon |author5-link= |etal=no |title=Behavioral state and plasma cortisol response in the human neonateEarly behavioral differences: gender or circumcision? |journal=PediatricsDev Psychobiol
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|date=19701976-1001 |volume=469 |issue=41 |pages=53289-795 |url=http://www.cirp.org/library/painpsych/anders1brackbill/
|archived=
|quote=
|pubmedID=4323242767183
|pubmedCID=
|DOI=
|accessdate=2020-11-13
}}</ref>
* Emde et al. Luther, Kraybill & Potter (19711976) showed that compared the level of cortisol in infants before and after circumcision. They found a substantial rise in the cortisol levels in the infants, which they said was due to the "stress" of circumcision caused an increase in the amount of non-REM sleep.<ref name="emde1971">{{REFjournal |last=EmdeTalbert |init=RNLM |first=Robert NLuther M.
|author-link=
|last2=HarmonKraybill |init2=RJEN |first2=Robert JErnest N.
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|last3=MetcalfPotter |init3=D |first3=DavidHD
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|last4etal=Koenigno |init4=KL |first4title=Kenneth LAdrenal cortical response to circumcision in the neonate. |author4trans-link= |last5=Wagonfeld |init5=S |first5=Samuel |author5-link= |etaltitle=no |titlelanguage=Stress and neonatal sleepEnglish |journal=Psychosom Med Obstet Gynecol
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|date=19711976-08 |volume=3346 |issue=62 |pages=491208-710 |url=http://www.cirp.org/library/birthpain/emdetalbert/
|archived=
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|DOI=
|accessdate=2020-11-13
}}</ref>
* RichardsRawlings, Bernal Miller & Brackbill Engel (1976) reported behavioral differences between American boys (circumcised) and British boys (genitally intact1980)showed that as the pain of circumcision increased, oxygenation of the [[skin]] decreased.<ref name="richards1976rawlings1980">{{REFjournal |last=RichardsRawlings |init=MPMDJ |first=David J.
|author-link=
|last2=BernalMiller |init2=JFPA |first2=Patricia Anne
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|last3=BrackbillEngel |init3=YRR |first3=YvonneRolf R.
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|etal=no
|title=Early behavioral differences: gender or The effect of circumcision?on transcutaneous PO2 in term infants |trans-title= |language=English |journal=Dev PsychobiolAm J Dis Child
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|date=19761980-0107 |volume=9134 |issue=17 |pages=89676-958 |url=http://www.cirp.org/library/psychpain/brackbillrawlings1/
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|DOI=10.1001/archpedi.1980.02130190044011
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}}</ref>
* Luther, Kraybill & Potter Gunnar et al. (19761981) compared the level of recorded serum cortisol in infants before and after behavior state throughout the unanesthetized, non-therapeutic circumcisionprocess. They found a substantial rise in the Serum cortisol levels in the infants, which they said was due and behavioral distress were found to be closely related. The authors stated:{{Citation |Text=Neonatal circumcision is performed without anesthesia and it is clearly stressful for the "stress" of circumcisioninfant. |Author=Gunnar et al.(1981) |ref=<refname="Gunnar et al 1981">{{REFjournal |last=TalbertGunnar |init=LMMR |first=Luther MMegan R.
|author-link=
|last2=KraybillFisch |init2=ENRO |first2=Ernest NRobert O.
|author2-link=
|last3=PotterKorsvick |init3=HDS |first3=Sherry
|author3-link=
|last4=Donhowe
|init4=JM
|first4=John M.
|author4-link=
|etal=no
|title=Adrenal cortical response to The effects of circumcision in the neonateon serum cortisol and behavior.
|trans-title=
|language=English
|journal=Obstet Gynecol Psychoneuroendocrinology
|location=
|date=1976-081981 |volume=466 |issue=23 |pages=208260-1075 |url=http://www.cirp.org/library/pain/talbertgunnar/
|archived=
|quote=
|pubmedID=9406537291435
|pubmedCID=
|DOI=10.1016/0306-4530(81)90037-8
|accessdate=2020-11-13
}}</ref>
}}
So great was Flechsig's influence, the authors were still unwilling to use the word ''pain'' and substituted the word ''stress''.<ref name="Gunnar et al 1981"/> * Rawlings, Miller & Engel Marshall et al. (19801982) showed studied mother-child interaction with regard to feeding behavior after circumcision without anesthesia. They found that as the pain of circumcision increased, oxygenation of the [[skincircumcised]] decreasedboys had more interruptions of feeding in the 24-hour period of observation.<ref name="rawlings1980marshall1982">{{REFjournal |last=RawlingsMarshall |init=DJRE |first=David JRichard E.
|author-link=
|last2=MillerPorter |init2=PAFL |first2=Patricia AnneFran L.
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|last3=EngelRogers |init3=RRAG |first3=Rolf RAnn G.
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|last4=Moore |init4=J |first4=JoAnn |author4-link= |last5=Anderson |init5=B |first5=Barbara |author5-link= |last6=Boxerman |first6=Stuart B. |init6=SB |author6-link= |etal=no |title=The effect of circumcision on transcutaneous PO2 in term infantsCircumcision: II: Effects upon mother-infant interaction |trans-title=
|language=English
|journal=Am J Dis ChildEarly Hum Dev
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|date=1980-071982 |volume=1347 |issue=74 |pages=676367-874 |url=http://www.cirp.org/library/painbirth/rawlings1marshall2/
|archived=
|quote=
|pubmedID=73958297169032
|pubmedCID=
|DOI=10.10011016/archpedi.1980.021301900440110378-3782(82)90038-x |accessdate=2020-11-1314
}}</ref>
* Gunnar et al. Porter, Miller & Marshall (19811986) recorded serum cortisol and behavior state throughout studied the nature of pain cries during unanesthetized, non-therapeutic circumcision process. Serum cortisol levels and behavioral distress the cries during circumcision were found to be closely related. The authors stated:<blockquote>Neonatal circumcision is performed without anesthesia shorter, with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; and it is clearly stressful for greater variability of the infantfundamental.</blockquote>So great was Flechsig's influence, the authors were still unwilling Adult listeners judged these cries to use the word ''pain'' and substituted the word ''stress''have an unusual degree of urgency.<refname="porter1986">{{REFjournal |last=GunnarPorter |initfirst=MRFran Lang |firstinit=Megan R.FL
|author-link=
|last2=FischMiller |init2first2=RORichard H. |first2init2=Robert O.RH
|author2-link=
|last3=KorsvickMarshal |init3first3=SRichard E |first3init3=SherryRE
|author3-link=
|last4=Donhowe
|init4=JM
|first4=John M.
|author4-link=
|etal=no
|title=The effects Neonatal pain cries: effect of circumcision on serum cortisol acoustic features and behavior.perceived urgency
|trans-title=
|language=English
|journal=PsychoneuroendocrinologyChild Dev
|location=
|date=19811986-06 |volume=657
|issue=3
|pages=260790-75802 |url=httphttps://www.cirpjstor.org/library/pain/gunnarstable/1130355?seq=1
|archived=
|quote=
|pubmedID=72914353720404
|pubmedCID=
|DOI=10.10162307/0306-4530(81)90037-81130355 |accessdate=2020-11-1315
}}</ref>
* Marshall et al. (1982) studied mother-child interaction with regard to feeding behavior after circumcision Surgical operation on infants without anesthesia. They found continued for well over a century, at least until 1987, when the [[American Academy of Pediatrics]] was forced to issue a CYA statement that circumcised boys had more interruptions of feeding in called for the 24-hour period use of observationanesthesia.<ref name="marshall1982poland1987">{{REFjournal |last=MarshallPoland |initfirst=RERonald L. |firstinit=Richard E.RL
|author-link=
|last2=PorterRoberts |init2first2=FLRonald J |first2init2=Fran L.RJ
|author2-link=
|last3=RogersGutierrez-Mazorra |init3first3=AGJuan F. |first3init3=Ann G.JF
|author3-link=
|last4=MooreFonkalsrud |init4first4=JEric W. |first4init4=JoAnnEW
|author4-link=
|last5=Anderson |init5=B |first5=Barbara |author5-link= |last6=Boxerman |first6=Stuart B. |init6=SB |author6-link= |etal=no |title=Circumcision: II: Effects upon mother-infant interactionNeonatal anesthesia |trans-title=
|language=English
|journal=Early Hum DevPediatrics
|location=
|date=19821987-09 |volume=780 |issue=43 |pages=367-74446 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/birth80/marshall23/446
|archived=
|quote=
|pubmedID=7169032
|pubmedCID=
|DOI=10.1016/0378-3782(82)90038-x |accessdate=2020-11-1412}}</ref><ref name="vanhowe2008"/> Anand & Hickey (1987) published a paper in the ''New England Journal of Medicine'' that totally demolished Flechsig's ridiculous claims and conclusively proved that newborn infants are capable of feeling intense pain. After publication of this paper, no doubt about pain sensation in infants remained. The article stated: {{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"/>}}
Porter, Miller & Marshall Gunnar et al. (19861988) studied examined the association between behavioral distress and adrenocortical activity. It was found that differences in behavioral distress did not reliably the nature level of pain cries during unanesthetizedadrenocortical activity. Moreover, it was found that while non-therapeutic circumcision. nutritive sucking reduces crying it did not reduce the cries during circumcision were found adrenocortical response to shorter, with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; and greater variability of the fundamental. Adult listeners judged these cries to have an unusual degree stressful stimulus of urgencycircumcision pain.<ref name="porter1986gunnar1988">{{REFjournal |last=PorterGunnar |first=Fran LangMegan |init=FLM
|author-link=
|last2=MillerConnors |first2=Richard H.Joan |init2=RHJ
|author2-link=
|last3=MarshalIsensee |first3=Richard EJill |init3=REJ
|author3-link=
|last4=Wall |first4=Lee |init4=L |author4-link= |etal=noyes |title=Neonatal pain cries: effect of circumcision on acoustic features Adrenocortical activity and perceived urgencybehavioral distress in human newborns
|trans-title=
|language=English
|journal=Child DevPsychobiol
|location=
|date=19861988-0605 |volume=5721 |issue=34 |pages=790297-802310 |url=httpshttp://www.jstorcirp.org/stablelibrary/pain/gunnar1988/1130355?seq=1
|archived=
|quote=
|pubmedID= 37204043378676
|pubmedCID=
|DOI=10.23071002/1130355 dev.420210402
|accessdate=2020-11-15
}}</ref>
Surgical operation on Although by 1989 it was totally clear that infants without anesthesia continued for well over a centurycan feel intense pain, at least until 1987, when the [[American_Academy_of_Pediatrics#Third_policy_.281989.29 1989| American Academy of PediatricsCircumcision Task Force]], under the leadership of the infamous [[Edgar J. Schoen]] was forced , {{MD}}, declined to issue a CYA statement that called for recommend the use of anesthesiaanalgesics for non-therapeutic neonatal [[circumcision]], thereby condemning millions of newborn baby boys to a painful, stressful, traumatizing circumcision.<ref name="poland1987">{{REFjournal |last=Poland Schoen |first=Ronald LEdgar J. |init=RLEJ |author-link=Edgar J. Schoen |last2=Roberts Anderson |first2=Ronald JGlen |init2=RJG
|author2-link=
|last3=Gutierrez-MazorraBohon |first3=Juan F.Constance |init3=JFC
|author3-link=
|last4=FonkalsrudHinman Jr |first4=Eric W.Frank |init4=EWF
|author4-link=
|last5=Poland
|first5=Ronald L.
|init5=RL
|author5-link=
|last6=Wakeman
|first6=Maurice
|init6=ME
|author6-link=
|etal=no
|title=Neonatal anesthesiaReport of the Task Force of Circumcision
|trans-title=
|language=English
|journal=Pediatrics
|location=
|date=19871989-0910 |volume=8089 |issue=34 |pages=446388-91 |url=httpshttp://pediatricswww.aappublicationscirp.org/contentlibrary/80statements/3aap/446#a1989
|archived=
|quote=
|pubmedID=2664697
|pubmedCID=
|DOI=
|accessdate=2020-11-1218}}</ref> <ref name="vanhowe2008" />
Anand & Hickey (1987) published a paper in the ''New England Journal of Medicine'' that totally demolished Flechsig's ridiculous claims and conclusively proved that newborn infants are capable of feeling intense pain. After publication of this paper, no doubt about pain sensation in infants remained. The article stated:<blockquote><i>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 ====Finding an ethical way to do 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.</i><ref namenon-therapeutic circumcision==="anand1987" /> <ref name="vanhowe2008"/></blockquote></i>
Gunnar et al. (1988) examined the association between behavioral distress The financially and adrenocortical activitypsychologically vested circumcision industry suddenly found itself in a predicament. It was found now suddenly proven beyond any shadow of a doubt that differences in behavioral distress did not reliably newborn baby boys can feel intense pain. Medical ethics and the level standard of adrenocortical activity. Moreovercare now necessitated pain relief, however it was found is dangerous to give general anesthesia to neonates. [[Edward Wallerstein]] (1985) had proposed that while [[Routine Infant Circumcision| routine]] (non-nutritive sucking reduces crying it did not reduce the adrenocortical response to the stressful stimulus therapeutic) circumcision of circumcision pain.baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,<ref name="gunnar1988wallerstein1985">{{REFjournal |last=GunnarWallerstein |first=MeganEdward |init=ME |author-link= |last2=Connors |first2=Joan |init2=J |author2-link= |last3=Isensee |first3=Jill |init3=J |author3-link= |last4=Wall |first4=Lee |init4=L |author4-link=Edward Wallerstein |etal=yesno |title=Adrenocortical activity and behavioral distress in human newbornsCircumcision: the uniquely American medical enigma |trans-title= |language=English |journal=Dev PsychobiolUrol Clin North Am |location= |date=1988-051985 |volume=2112 |issue=41 |pages=297123-31032 |url=http://www.cirp.org/library/paingeneral/gunnar1988wallerstein/
|archived=
|quote=
|pubmedID=33786763883617
|pubmedCID=
|DOI=10.1002/dev.420210402
|accessdate=2020-11-15
}}</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 |url=https://www.academia.edu/6442587/High_Cost_of_Circumcision_3_6_Billion_Annually |archived= |title=High cost of circumcision |trans-title= |language=English |last=Bollinger |first=Dan |author-link=Dan Bollinger |publisher=Academia |website= |date=2012 |accessdate=2020-11-15 |format=PDF |quote=}}</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. Three methods were proposed:
Although * 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 1989 it was totally clear that infants can feel intense pain, the 1989 American Academy release of Pediatrics Circumcision Task Force, under lidocaine and prilocaine from the cream into the leadership epidermal and dermal layers of the infamous [[Edgar J. Schoenskin]], Mand by the accumulation of lidocaine and prilocaine in the vicinity of dermal pain receptors and nerve endings.<ref>{{REFweb |url=https://www.drugs.com/pro/emla. Dhtml#s-34069-5 |archived= |title=EMLA |trans-title= |language=English |last= |first= |author-link= |publisher=Drugs., declined to recommend the use of analgesics for noncom |website= |date=2020-04-21 |accessdate=2020-11-therapeutic neonatal circumcision, thereby condemning million of newborn baby boys to a painful, stressful circumcision21 |format= |quote=}}</ref> * [[Dorsal penile nerve block| Dorsal Penile Nerve Block]] (DPNB) as proposed by Kirya & Werthman (1978).<refname="kirya1978">{{REFjournal |last=SchoenKirya |first=Edgar J.Christopher |init=EJC |author-link=Edgar J. Schoen |last2=AndersonWerthman Jr |first2=GlenMilton W. |init2=GMW
|author2-link=
|last3=Bohon
|first3=Constance
|init3=C
|author3-link=
|last4=Hinman Jr
|first4=Frank
|init4=F
|author4-link=
|last5=Poland
|first5=Ronald L.
|init5=RL
|author5-link=
|last6=Wakeman
|first6=Maurice
|init6=ME
|author6-link=
|etal=no
|title=Report of the Task Force of CircumcisionNeonatal circumcision and penile dorsal nerve block—a painless procedure.
|trans-title=
|language=English
|journal=PediatricsJ Pediatr
|location=
|date=19891978-1006 |volume=8992 |issue=46 |pages=388998-911000 |url=http://www.cirp.org/library/statementspain/aapkirya1/#a1989
|archived=
|quote=
|pubmedID=2664697660375
|pubmedCID=
|DOI=10.1016/s0022-3476(78)80386-2 |accessdate=2020-11-1816
}}</ref>
====Finding an ethical way to do painful non-therapeutic circumcision==== The 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 WallersteinRing block| Ring Block]] . Broadman et al. (19851987) had proposed that [[Routine Infant Circumcision| routine]] (ring block for neonatal non-therapeutic) circumcision of baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,.<ref name="wallerstein1985broadman1987">{{REFjournal |last=WallersteinBroadman |init=LM |firstauthor-link=Edward |initlast2=Hannallah |init2=RS |author2-link= |last3=Belman |init3=AB |author3-link= |last4=Elder |init4=PT |author4-link= |last5=Ruttiman |init5=EU |authorauthor5-link=Edward Wallerstein |etallast6=noEpstein |titleinit6=Circumcision: the uniquely American medical enigmaBS |transauthor6-titlelink= |languageetal=Englishno |title=Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penis |journal=Urol Clin North AmAnesthesiology
|location=
|date=19851987-08-31 |volume=1267 |issue=13 |pages=123399-32402 |url=http://www.cirp.org/library/general/wallerstein/
|archived=
|quote=
|pubmedID=3883617 3307533
|pubmedCID=
|DOI=10.1097/00000542-198709000-00019 |accessdate=2020-11-1518}}</ref> however this clearly would not do for Ring block is considered the avid pro-circumcision lobby. No circumcision equals no fee most effective analgesic procedure for surgery. The financial gain from discontinuing neonatal non-therapeutic circumcision is just too high to discard. [[Dan Bollinger]] (2012) estimated that Infant boys feel less pain and suffer less trauma than with the total annual cost of non-therapeutic circumcision to Americans is $3,647,000,000other two pain reduction procedures.<refname="lander1997"/><ref name="stang1997">{{REFwebREFjournal |urllast=https://wwwStang |first=Howard J.academia.edu/6442587/High_Cost_of_Circumcision_3_6_Billion_Annually |archivedinit=HJ |author-link= |last2=Snellman |first2=Leonard W. |titleinit2=High cost of circumcisionLW |transauthor2-titlelink= |languagelast3=EnglishCondon |lastfirst3=BollingerLawrence M |firstinit3=DanLM |authorauthor3-link=Dan Bollinger |publisherlast4=Conroy |first4=AcademiaMary Margaret |websiteinit4=MM |dateauthor4-link=2012 |accessdatelast5=2020-11-15Liebo |formatfirst5=PDFRhoda |quoteinit5=R}}</ref> The avaricious American circumcision industry is simply not willing to give that lucrative income up, so a way to make non |author5-therapeutic circumcisions in infancy acceptable had to be found.link= |last6=Brodersen |first6=LaurieThree methods were proposed: |init6=L |author6-link= |last7=Gunnar* 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 |first7=Megan R.<ref>{{REFweb |urlinit7=https://www.drugs.com/pro/emla.html#sMR |author7-34069-5link= |archivedetal=no |title=EMLABeyond dorsal penile nerve block: A more humane circumcision
|trans-title=
|language=English |lastjournal=Pediatrics |firstlocation= |authordate=1997-link=08 |publishervolume=Drugs.com100 |websiteissue=2 |datepages=2020-04-21e3 |accessdateurl=2020-11-21https://pediatrics.aappublications.org/content/100/2/e3 |formatarchived=
|quote=
|pubmedID=9233974
|pubmedCID=
|DOI=10.1542/peds.100.2.e3
|accessdate=2020-11-18
}}</ref>
* Dorsal Penile Nerve Block (DPNB) as proposed by Kirya & Werthman (1978){{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 those analgesic procedures.<ref name="kirya1978"bellini2022 /> Prevention of pain requires protecting a boy from elective neonatal non-therapeutic circumcision. Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or [[trauma]].</b></big>}} Wallerstein (1985)<ref>{{REFjournal |last=KiryaWallerstein |first=ChristopherEdward |init=C |author-link= |last2=Werthman Jr |first2=Milton W. |init2=MW |author2-link=Edward Wallerstein
|etal=no
|title= Neonatal Is non-religious circumcision and penile dorsal nerve block—a painless procedure.necessary?
|trans-title=
|language=English |journal=J PediatrAm Acad Child Psychiatr
|location=
|date=19781985-0605 |volume=9224 |issue=63 |article= |page= |pages=998364-10005 |url=http://www.cirp.org/library/pain/kirya1gunnar1984/#wallerstein
|archived=
|quote=
|pubmedID=660375
|pubmedCID=
|DOI=10.1016/s0022-3476(78)80386-2 |accessdate=20202021-1107-160}}</ref> * Ring Block. Broadman et aland [[Robert S. Van Howe|Van Howe]] & Cold (19871998) proposed ring block for neonatal non-therapeutic circumcision.<ref name="broadman1987">{{REFjournal |last=BroadmanVan Howe |initfirst=LMRobert S. |author-link= |last2=Hannallah |init2init=RS |author2author-link=Robert S. Van Howe |last3last2=BelmanCold |init3first2=ABChristopher J. |author3-linkinit2=CJ |last4=Elder |init4=PT |author4-link= |last5=Ruttiman |init5=U |author5-link= |last6=Epstein |init6=BS |author6author2-link=Christopher J. Cold |etal=no |title=Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penisLocal Anesthesia For Infants Undergoing Circumcision |journal=AnesthesiologyJAMA
|location=
|date=19871998-0804-3115 |volume=67299 |issue=315 |article= |page= |pages=3991169-40271 |url=http://www.cirp.org/library/pain/lander/letters.html
|archived=
|quote=
|pubmedID=3307533
|pubmedCID=
|DOI=10.1097/00000542-198709000-00019 |accessdate=20202021-1107-1808}}</ref> Ring block is considered have suggested that it would be better to abandon the most effective analgesic procedure for neonatal practice of non-therapeutic infant circumcisionbecause of the pain associated with it. Infant boys feel less  The ''Daily Mail'' (2021) reported the pain stress of non-therapeutic neonatal circumcision increases the risk of [[SIDS]], and suffer less trauma than with that the other two pain reduction proceduresincidence of Sudden Infant Death Syndrome (SIDS) is lower where baby boys are not [[circumcised]].<ref name="lander1997" /> <ref name="stang1997thompson2021">{{REFjournalREFnews |lasttitle=StangCircumcising 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 |firsturl=Howard Jhttps://www.dailymail.co.uk/health/article-5998771/Circumcising-newborn-boys-increases-risk-cot-death-stress-procedure.html |initlast=HJThompson |author-linkfirst=Alexandra |last2coauthors=Snnellman |first2publisher=Leonard W.Daily Mail |init2website=LW |author2date=2021-07-link=27 |last3accessdate=Condon2021-08-02 |first3quote=Lawrence M |init3}}</ref> The pain that infant boys experience would not be acceptable in older boys and adults. It is not clear why infant boys are still subjected to a lesser standard of care with regard to pain than older boys and adults. ==Attitudes and practices regarding analgesia for newborn circumcision==LM |author3-link===Historic attitudes and practices== |last4=Conroy |first4=Mary Margaret Wellington & Rieder (1993) conducted a survey of physicians in London, Ontario. They found that only 4 percent used [[dorsal penile nerve block|init4=MMDPNB]]. They concluded: |author4-link= |last5=Liebo{{Citation |first5Text=RhodaDespite 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. |init5Author=RWellington & Rieder (1993) |author5-linkref=<ref>{{REFjournal |last6last=BrodersenWellington |first6first=LaurieNancy |init6init=LN |author6author-link= |last7last2=GunnarRieder |first7first2=Megan RMichael J. |init7init2=MRMJ |author7author2-link=
|etal=no
|title=Beyond dorsal penile nerve block: A more humane Attitudes and practices regarding analgesia for newborn circumcision
|trans-title=
|language=English
|journal=Pediatrics
|location=
|date=19971993-0810 |volume=10092 |issue=24 |pages=e3541-3 |url=https://pediatrics.aappublications.org/content/10092/24/e3541?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
|archived=
|quote=
|pubmedID=92339748414824
|pubmedCID=
|DOI=10.1542/peds.100.2.e3
|accessdate=2020-11-18
}}</ref>
}}
{{Box|Boxtext=<big><b>However, none Ryan & Finer (1994) carried out a training program for physicians in the newborn nurseries of the above three procedures totally eliminate painWomens' Pavilion, [https://www.albertahealthservices.ca/rah/rah. A baby boy will still experience some pain despite any of those analgesic proceduresaspx Royal Alexandra Hospital], Edmonton, Alberta, Canada. Prevention After a training program, they found that 66 percent of pain requires protecting a boy from elective neonatal physicians who perform non-therapeutic circumcisionneonatal circumcisions had started to use analgesia during the procedure. Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or traumaThis applies to one hospital in [[Canada]].</b></big>}} Wallerstein (1985)<refname="ryan1994">{{REFjournal |last=WallersteinRyan |first=EdwardC. Anthony |init=CA |author-link=Edward Wallerstein |last2=Finer |first2=Neil N. |init2=NN |author2-link=
|etal=no
|title=Is non-religious Changing attitudes and practices regarding local analgesia for newborn circumcision necessary?.
|trans-title=
|language=English |journal=J Am Acad Child PsychiatrPedatrics
|location=
|date=19851994-0508 |volume=2494 |issue=3 |article= |page=2 |pages=364230-53 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/pain94/gunnar19842/#wallerstein230
|archived=
|quote=
|pubmedID=8036079
|pubmedCID=
|DOI=
|accessdate=20212020-0711-019}}</ref> (Non-therapeutic neonatal circumcisions are no longer performed in most Canadian hospitals.)<ref name="jamesloewen2019">[[James Loewen]] (2019). Personal communication.</ref> Maxwell & Yaster (1999) called on physicians to use analgesia during neonatal non-therapeutic circumcision surgery, saying: {{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 Van Howe 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 & Cold Yaster (19981999) |ref=<ref>{{REFjournal |last=Van Howe |first=Robert S.Maxwell
|init=
|first= |author-link=Robert S. Van Howe |last2=ColdYaster |first2init2=Christopher J. |init2first2=CJ |author2-link=Christopher J. Cold
|etal=no
|title=Local Anesthesia For Infants Undergoing CircumcisionAnalgesia for neonatal circumcisionː No more studies, just do tt |trans-title= |language=English |journal=JAMAArch Pediatr Adolesc Med
|location=
|date=19981999-04-1505 |volume=299153 |issue=15 |article= |page=5 |pages=1169444-715 |url=httphttps://wwwjamanetwork.cirp.orgcom/libraryjournals/painjamapediatrics/landerarticle-abstract/letters.html346832
|archived=
|quote=
|pubmedID=10323622
|pubmedCID=
|DOI= |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 circumcised10.<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:/1001/wwwarchpedi.dailymail153.co.uk/health/article-5998771/Circumcising-newborn-boys-increases-risk-cot-death-stress-procedure5.html |last=Thompson |first=Alexandra |coauthors= |publisher=Daily Mail |website= |date=2021-07-27444 |accessdate=20212020-0811-02 |quote=21
}}</ref>
}}
==Attitudes and practices regarding analgesia for newborn The [[American Academy of Pediatrics]] convened a new task force on circumcision== ===Historic attitudes and practices=== Wellington & Rieder (1993) conducted a survey under the chair of physicians in LondonCarole M. Lannon, Ontario{{MD}}. That task force reversed the position previously taken under [[Edgar J. They found that only 4 percent used DPNBSchoen]]. They concluded:<blockquote>Despite evidence It clearly stated that neonates perceive pain and that there is a physiologic stress response to non-therapeutic infant 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 essential to the use of analgesics among neonates and with dorsal penile block in particular are the most common reasons cited for lack of analgesic usechild’s current well-being. Educational efforts and research into less invasive techniques " It provided an extensive discussion of procedural analgesia for newborn and said, quite strongly, that, if a circumcision are urgently requiredis done, procedural analgesia should be provided.<refname="aap1999">{{REFjournal |last=WellingtonLannon |first=NancyCarole M. |init=N |author-link= |last2=Rieder |first2=Michael J. |init2=MJ |author2-link= |etal=noyes |title=Attitudes and practices regarding analgesia for newborn circumcision |trans-title= |language=EnglishCircumcision policy statement
|journal=Pediatrics
|locationdate=1999-03 |volume=103 |dateissue=1993-103 |volumearticle=92 |issuepage=4 |pages=541686-393 |url=https://pediatrics.aappublications.org/content/92103/43/541?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token686
|archived=
|quote=
|pubmedID=841482410049981
|pubmedCID=
|DOI=https://doi.org/10.1542/peds.103.3.686 |accessdate=20202021-1107-1812
}}</ref>
</blockquote>
Ryan & Finer Kraft (19942003) carried out a training program for physicians in the newborn nurseries of the Womens' Pavilion, [https://www.albertahealthservices.ca/rah/rah.aspx Royal Alexandra Hospital], Edmonton, Alberta, Canada. After a training program, they found reported that 66 percent of physicians who "many health care practitioners routinely perform non-therapeutic neonatal circumcisions had started to this procedure without the use of any or with inadequate or ineffective analgesia during the procedure. This applies to one hospital in [[Canada]]and anesthesia."<ref name="ryan1994kraft2003">{{REFjournal |last=RyanKraft |firstinit=C. AnthonyNL |initfirst=CANancy L
|author-link=
|last2=Finer
|first2=Neil N.
|init2=NN
|author2-link=
|etal=no
|title=Changing attitudes A pictorial and practices regarding local analgesia for newborn video guide to circumcision. |trans-title= |language=Englishwithout pain |journal=PedatricsAdv Neonatal Care |location= |date=19942003-0804 |volume=943
|issue=2
|pages=23050-362 |url=https://pediatricsjournals.aappublicationslww.orgcom/contentadvancesinneonatalcare/94Abstract/2003/04000/A_PICTORIAL_AND_VIDEO_GUIDE_TO_CIRCUMCISION.2/230.aspx
|archived=
|quote=
|pubmedID=803607912881947
|pubmedCID=
|DOI=10.1053/adnc.2003.50015. |accessdate=2020-11-1918}}</ref> (Non-therapeutic neonatal circumcisions are no longer performed  ===Contemporary attitudes and practices=== Little is known about current attitudes and practices regarding the use of analgesia in most Canadian hospitalscircumcision of the newborn.)<ref name="jamesloewen2019">[[James Loewen]] (2019)Application of analgesia prior to neonatal nontherapeutic circumcision takes additional physician time, so there may be a tendency to skip it. Personal communication.</ref>
Maxwell & Yaster (1999) called on physicians to use analgesia during neonatal non-therapeutic circumcision surgery, saying:==Standard of care==<blockquote>DESPITE THE DEBATE It is now clear that continues over the benefits and risks of nonritual neonatal circumcision, it remains boys are born with 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 healthy [[foreskin]] 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 paindisease. Indeed, anyone present during a Therefore there are no indications for infant [[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 which is a multitude of studies have demonstrated that effective analgesia can prevent this pain non-therapeutic and ameliorate the associated stress response. Furthermore, the failure to provide anesthesia or analgesia has been shown to cause not only shortmedically-term physiologic perturbations but also longer-term behavioral changesunnecessary surgical operation.<refname="cps1996">{{REFjournal |last=MaxwellEugene |first=Outerbridge
|init=
|first=
|author-link=
|last2=Yaster
|init2=
|first2=
|author2-link=
|etal=no
|title=Analgesia for neonatal circumcisionː No more studies, just do tt |trans-title= |language=EnglishNeonatal circumcision revisited |journal=Arch Pediatr Adolesc MedCMAJ
|location=
|date=19991996-0503-15 |volume=153154 |issue=56 |article= |page= |pages=444769-580 |url=https://jamanetworkwww.comncbi.nlm.nih.gov/journalspmc/jamapediatricsarticles/articlePMC1487803/pdf/cmaj00090-abstract/3468320027.pdf
|archived=
|quote=
|pubmedID=103236228634956 |pubmedCID=1487803 |DOI=10.1001/archpedi.153.5.444 |accessdate=20202021-07-11-21}}</ref></blockquote> The [[American Academy of Pediatrics]] convened a new task force on circumcision under the chair of Carole M. Lannon, M. D. 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="aap1999racp2010">{{REFjournalREFdocument |lasttitle=LannonCircumcision of Infant Males |firsturl=Carole Mhttps://www.racp.edu.au//docs/default-source/advocacy-library/circumcision-of-infant-males.pdf?sfvrsn=eaa32f1a_10 |initcontribution= |author-linklast= |last2first= |first2publisher=[[Royal Australasian College of Physicians]] |init2format=PDF |author2date=2010-link=09-01 |last3accessdate=2021-07-11}}</ref><ref>{{REFdocument |first3title=Non-therapeutic circumcision of male minors |init3url=https://pool.intactiwiki.org/images/KNMG-viewpoint-Non-therapeutic-circumcision-of-male-minors-27-05-2010-v2.pdf |author3-linkcontribution= |last4last= |first4first= |init4publisher=Royal Dutch Medical Association (KNMG) |author4-linkformat=PDF |last5date=2010-05-27 |first5accessdate=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. |init5Bellini (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|author5emotional 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-link=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 |last6title=Guidelines for Circumcision |first6url=https://www.cirp.org/library/statements/aaps/ |init6contribution= |author6-linklast=Leditshke |last7first=JF |first7publisher=Australasian Association of Paediatric Surgeons |init7location=Herston, QLD, Australia |author7-linkformat= |last8date=1996-04 |first8accessdate=2024-01-22}}</ref></blockquote>  |init8The practice of non-therapeutic circumcision of boys has nearly died out in [[Australia]]. == Pain's injury to the infant nervous system == |author8-linkAnand & 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 |last9last=Fitzgerald |first9first= |init9init=M |author9author-link= |etal=yesno |title=Circumcision policy statementThe Birth of Pain
|trans-title=
|language=
|journal=PediatricsMRC News
|location=
|date=1999-031998 |season=Summer |volume=103 |issue=3
|article=
|page=
|pages=68620-9323 |url=https://pediatricswww.aappublicationscirp.org/contentlibrary/103pain/3fitzgerald/686
|archived=
|quote=
|pubmedID=10049981 |pubmedCID= |DOI=https://doi.org/10.1542/peds.103.3.686 |accessdate=20212024-0701-1231
}}</ref>
</blockquote>
 
Several later researchers suggested that extreme pain in the newborn could cause neurological injury. [[Kanwaljeet J. Singh Anand| Anand]] & Scalzo (2000) concluded:
Kraft (2003) reported that "many {{Citation |Text=The public health importance of abnormal stimulation during the neonatal period cannot be overemphasized. While programs for formulating appropriate health care practitioners routinely perform policies and public education campaigns must disseminate this procedure without message, it is also important for these effects to be investigated, particularly with a view to developing effective therapeutic strategies for the use of any or with inadequate or ineffective analgesia growing children and anesthesiaadolescents who were exposed to abnormal conditions during the neonatal period." |Author=Anand & Scalzo (2000) |ref=<ref name="kraft2003anand2000">{{REFjournal |last=KraftAnand |first= |init=NLKJS |firstauthor-link=Kanwaljeet J. Singh Anand |last2=Scalzo |first2= |init2=Nancy LFM |authorauthor2-link=
|etal=no
|title=A pictorial Can adverse neonatal experiences alter brain development and video guide to circumcision without pain subsequent behavior? |trans-title= |language= |journal=Adv Neonatal CareBiol Neonate
|location=
|date=20032000-0402 |volume=377
|issue=2
|article= |page= |pages=5069-6282 |url=httpshttp://journalswww.lwwcirp.comorg/advancesinneonatalcarelibrary/Abstractpain/2003anand4/04000/A_PICTORIAL_AND_VIDEO_GUIDE_TO_CIRCUMCISION.2.aspx
|archived=
|quote=
|pubmedID=1288194710657682
|pubmedCID=
|DOI=10.10531159/adnc.2003.50015.000014197 |accessdate=20202021-1108-1809
}}</ref>
}}
===Contemporary attitudes and practices===Little is known about current attitudes and practices regarding the use of analgesia Fitzgerald & Walker (2003) argued that extreme pain (such as that caused by [[circumcision]]) may alter developing nervous tissue in circumcision of the newborn. Application of analgesia prior to neonatal nontherapeutic circumcision takes additional physician time, so there may be a tendency to skip it. ==Standard of care==It is now clear that boys are born with healthy foreskins without evidence of disease. Therefore there are no indications for infant circumcision, which is a non-therapeutic and medically-unnecessary surgical operationvery young.<ref name="cps1996">{{REFjournalREFbook |last=EugeneFitzgerald |first=OuterbridgeMaria |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=Neonatal Psychological, psychosocial, and psychosexual aspects ofpenile circumcision revisited
|trans-title=
|language=
|journal=CMAJInt J Impot Res
|location=
|date=19962022-03-1528 |volume=154 |issue=6
|article=
|page=
|pages=769-80 |url=https://www.ncbinature.nlm.nih.gov/pmccom/articles/PMC1487803/pdf/cmaj00090s41443-022-00553-0027.pdf9
|archived=
|quote=
|pubmedID=863495635347302 |pubmedCID=1487803 |DOI=10.1038/s41443-022-00553-9 |accessdate=20212022-0704-1129}}</ref> <ref name/blockquote> ==Videos=="racp2010">{{REFdocument |title=== Infant circumcision procedure ===Circumcision  This is a video of an actual infant [[circumcision]]. It has a sound tract so one can hear the comments of Infant Malesthe 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.racpreddit.edu.aucom/r/Intactivism/docscomments/default-sourceqbpzqr/advocacy-librarytrained_medical_professionals_restrain_infant_to/circumcision-of-infant-males.pdf?sfvrsn=eaa32f1a_10 |contributionarchived= |lasttitle= |first= |publisher=[[Royal Australasian College Trained medical professionals restrain infant to amputate part of Physicians]]its body while baby kicks and screams in pain |format=PDF |date=2010-09trans-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 |contributionlanguage=
|last=
|first=
|author-link= |publisher=Royal Dutch Medical Association (KNMG) |formatwebsite=PDF |date=2010-05-27 |accessdate=20212022-0703-11}}</ref> Circumcision excises the highly functional foreskin, which provides numerous protective, immunological, sensory, and sexual functions,<ref name |format= |quote="cold1999">{{ColdCJ TaylorJR 1999}}</ref> so it is an irreversible, lasting injury. 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]]https://www. When a circumcision is to be performed, the standard of care requires that analgesia be provided to reduce the extreme level of pain and traumareddit.<ref name="poland1987" com/> <ref name="cps1996" r/> <ref name="lander1997" Intactivism/> <ref name="aap1999" comments/> (Total anesthesia cannot be used with infants.)qbpzqr/trained_medical_professionals_restrain_infant_to/ Circumcision video]
==Videos==<youtube>SLhEoOQhsVw</youtube>
=== Infant Here is an infant circumcision procedure ===Not for video of an Islamic circumcision from the Russian Federation. The surgical technique is different but the squeamishpain is no less:
* [https:<vimeo>259674034<//www.reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ Circumcision video]vimeo>
Please note how Here is a video of Dr. Paul Fleiss speaking about the infant's lips quiver with harm of circumcision, including painand trauma.
<youtube>SLhEoOQhsVwouHSz-OmOH8</youtube>
Here is an infant circumcision video of an Islamic circumcision from the Russian Federation. The surgical technique is different but the pain is no less:===Ronald Goldman===
<vimeo>259674034</vimeo>
 
===Ronald Goldman===
[[Ronald Goldman]] discussed pain and trauma in a video by [[Brendon Marotta]]:
|DOI=
|accessdate=2020-11-19
}}</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/>
* There is, of course, post-surgical pain, which may be relieved by a potent oral analgesic. One should have a two-week supply of analgesic medicine.
}}</ref> In a few cases, the [[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 [[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">{{ColdCJ TaylorJR 1999}}</ref>
{{SEEALSO}}
* [[Circumstraint]]
* [[Does Cosmetic Surgery Harm Babies?]]
* [[Posttraumatic Post-traumatic stress disorder]]
* [[Psychological issues of male circumcision]]
* [[Shock]]
* [[Sudden Infant Death Syndrome]]
* [[Trauma]]
{{LINKS}}
* {{REFweb
|url=http://www.cirp.org/library/pain/
|archived=
|title=Pain of circumcision and pain control
|trans-title=
|language=English
|last=Hill
|first=George
|author-link=
|publisher=Circumcision Reference Library
|website=
|date=2006-09-11
|accessdate=2020-11-08
|format=
|quote=Circumcision is the most stressful surgical procedure commonly performed on newborns.
}}
* {{REFjournal
|etal=no
|pubmedCID=
|DOI=10.1542/peds.108.3.793.
|accessdate=2020-11-17}} * {{REFwebREFjournal |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=httphttps://www.cirpresearchgate.org/librarynet/painpublication/359693934_Neonatal_Infant_Pain_Scale_in_assessing_pain_and_pain_relief_for_newborn_male_circumcision
|archived=
|titlequote=Pain of circumcision and pain control |trans-titlepubmedID=35352017 |languagepubmedCID=English |lastDOI=Hill |first=George |author10.1038/s41443-022-00551-link=x |publisherdoi=Circumcision Reference Library |websiteformat= |date=2006-09-11PDF |accessdate=20202023-1110-08 |format= |quote=Circumcision is the most stressful surgical procedure commonly performed on newborns.09
}}
 
* {{REFweb
|url=http://www.drmomma.org/2009/10/mri-studies-brain-permanently-altered.html
|last=Tinari
|first=Paul D.
|author-link=Paul Tinari
|publisher=Peaceful Parenting
|website=
|quote=A neurologist who saw the results to postulated that the data indicated that circumcision affected most intensely the portions of the victim's brain associated with reasoning, perception and emotions. Follow up tests on the 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.
}}
 
* {{REFweb
|url=http://www.circinfo.org/news_2018.html#babies
|quote=
}}
* {{REFweb |url=http://www.circumstitions.com/Pain.html |title=Circumcision and Pain |last=Young |first=High |date=2014 |accessdate=2021-10-17}}
* {{REFweb
|url=https://www.intactamerica.org/american-academy-of-pediatrics-end-the-pain/
|trans-title=
|language=
|last=Chapin |first=Georganne |author-link=Georganne Chapin |publisher=Intact America |website= |date=2016-02-13 |accessdate=2021-04-02 |format= |quote=}}* {{REFjournal |last=Carpenter |first=Llaura M. |init=LM |author-link= |url=https://onlinelibrary.wiley.com/doi/full/10.1111/1468-0424.12472 |title=If You Prick Us: Masculinity and Circumcision Pain in the United States and Canada, 1960–2000 |journal=Gender & History |date=2020-03-25 |volume=31 |issue=1 |pages=54-69- |DOI=10.1111/1468-0424.12472 |accessdate=2022-08-24}}* {{REFweb |url=httphttps://wwwdocs.circumstitionsgoogle.com/Paindocument/d/1YVlNQlwDKnRfUgMbqKa9uth7-JNsEpIl/edit |title=The pain that never goes away. |last=Anonymous |first= |init= |publisher=Google |date= |accessdate=2023-08-18}}* {{REFweb |url=https://intactamerica.htmlorg/timeline-of-circumcision-suffering/ |title=A Timeline of Circumcision and PainSuffering: A Detailed Look |last=YoungAnonymous |first=High |init= |publisher=Intact America |date=2024-02-02 |accessdate=20212024-1002-1709}} {{ABBR}}{{REF}} [[Category:Circumcision risk]][[Category:Pain]][[Category:Parental information]][[Category:Psychology]][[Category:Penile surgery]][[Category:Male circumcision]][[Category:Breastfeeding]][[Category:Trauma]]
{{REF}} [[Categoryde:Circumcision risk]][[Category:Pain]][[Category:Parental information]][[Category:Psychology]][[Category:Penile surgery]][[Category:Male circumcisionSchmerz]]
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