Changes

The '''pain''' of [[circumcision ]] is extreme and traumatizing.<ref name="bollinger2019">{{REFdocument

|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.

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">{{FleissP HodgesF VanHoweRS 1998}}</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-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 |first=Carlo V. |init= |author-link= |last2=Alagna

}}</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" />

[[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 |last=Howard

Parents who choose to have a son [[circumcised ]] may expect the infant boy to be uncomfortable and fussy for some time.

 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

|first=BesselA. |init=BBA |author-link=Bessel van der Kolk

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 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

|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

|date=20002008-0212 |volume=7736 |issue=24

|pages=69803-8223 |url=httphttps://www.cirpacademia.orgedu/librarydownload/pain/anand433981944/27_Van_Howe.pdf

|pubmedID=1065768219094008

|DOI=10.11591111/000014197j.1748-720X.2008.00339.x |accessdate=2021-0810-0931

 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.

|last2=WalkerSachar |first2init2=SuellenEJ |init2first2=SEdward J.

|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

|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 S.KL |initfirst4=RSKenneth L. |authorauthor4-link=Robert S. Van Howe |last2last5=SvobodaWagonfeld |first2init5=J. StevenS |init2first5=JSSamuel |author2author5-link=J. Steven Svoboda

|title=Neonatal pain relief Stress and the Helsinki Declarationneonatal sleep |journal=Journal of Law, Medicine, and EthicsPsychosom Med

|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

|pubmedID=19094008

|DOI=10.1111/j.1748-720X.2008.00339.x |accessdate=2021-10-31

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

|last3=KreamBrackbill |init3=JY |first3=JacobYvonne

|title=Behavioral state and plasma cortisol response in the human neonateEarly behavioral differences: gender or circumcision? |journal=PediatricsDev Psychobiol

|date=19701976-1001 |volume=469 |issue=41 |pages=53289-795 |url=http://www.cirp.org/library/painpsych/anders1brackbill/

|pubmedID=4323242767183

}}</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.

|last2=HarmonKraybill |init2=RJEN |first2=Robert JErnest N.

|last3=MetcalfPotter |init3=D |first3=DavidHD

|title=Stress and neonatal sleepAdrenal cortical response to circumcision in the neonate. |trans-title= |language=English |journal=Psychosom Med Obstet Gynecol

|date=19711976-08 |volume=3346 |issue=62 |pages=491208-710 |url=http://www.cirp.org/library/birthpain/emdetalbert/

|pubmedID=940653

|accessdate=2020-11-13

* 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.

|last2=BernalMiller |init2=JFPA |first2=Patricia Anne

|last3=BrackbillEngel |init3=YRR |first3=YvonneRolf R.

|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

|date=19761980-0107 |volume=9134 |issue=17 |pages=89676-958 |url=http://www.cirp.org/library/psychpain/brackbillrawlings1/

|pubmedID=7671837395829

|DOI=10.1001/archpedi.1980.02130190044011

* 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.

|last2=KraybillFisch |init2=ENRO |first2=Ernest NRobert O.

|last3=PotterKorsvick |init3=HDS |first3=Sherry

|title=Adrenal cortical response to The effects of circumcision in the neonateon serum cortisol and behavior.

|journal=Obstet Gynecol Psychoneuroendocrinology

|date=1976-081981 |volume=466 |issue=23 |pages=208260-1075 |url=http://www.cirp.org/library/pain/talbertgunnar/

|pubmedID=9406537291435

|DOI=10.1016/0306-4530(81)90037-8

* 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.

|last2=MillerPorter |init2=PAFL |first2=Patricia AnneFran L.

|last3=EngelRogers |init3=RRAG |first3=Rolf RAnn G.

|title=The effect of circumcision on transcutaneous PO2 in term infantsCircumcision: II: Effects upon mother-infant interaction

|journal=Am J Dis ChildEarly Hum Dev

|date=1980-071982 |volume=1347 |issue=74 |pages=676367-874 |url=http://www.cirp.org/library/painbirth/rawlings1marshall2/

|pubmedID=73958297169032

|DOI=10.10011016/archpedi.1980.021301900440110378-3782(82)90038-x |accessdate=2020-11-1314

* 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

|last2=FischMiller |init2first2=RORichard H. |first2init2=Robert O.RH

|last3=KorsvickMarshal |init3first3=SRichard E |first3init3=SherryRE

|title=The effects Neonatal pain cries: effect of circumcision on serum cortisol acoustic features and behavior.perceived urgency

|journal=PsychoneuroendocrinologyChild Dev

|date=19811986-06 |volume=657

|pages=260790-75802 |url=httphttps://www.cirpjstor.org/library/pain/gunnarstable/1130355?seq=1

|pubmedID=72914353720404

|DOI=10.10162307/0306-4530(81)90037-81130355 |accessdate=2020-11-1315

* 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

|last2=PorterRoberts |init2first2=FLRonald J |first2init2=Fran L.RJ

|last3=RogersGutierrez-Mazorra |init3first3=AGJuan F. |first3init3=Ann G.JF

|last4=MooreFonkalsrud |init4first4=JEric W. |first4init4=JoAnnEW

|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=

|journal=Early Hum DevPediatrics

|date=19821987-09 |volume=780 |issue=43 |pages=367-74446 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/birth80/marshall23/446

|pubmedID=7169032

|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

|last2=MillerConnors |first2=Richard H.Joan |init2=RHJ

|last3=MarshalIsensee |first3=Richard EJill |init3=REJ

|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

|journal=Child DevPsychobiol

|date=19861988-0605 |volume=5721 |issue=34 |pages=790297-802310 |url=httpshttp://www.jstorcirp.org/stablelibrary/pain/gunnar1988/1130355?seq=1

|pubmedID= 37204043378676

|DOI=10.23071002/1130355 dev.420210402

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

|last3=Gutierrez-MazorraBohon |first3=Juan F.Constance |init3=JFC

|last4=FonkalsrudHinman Jr |first4=Eric W.Frank |init4=EWF

|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

|date=19871989-0910 |volume=8089 |issue=34 |pages=446388-91 |url=httpshttp://pediatricswww.aappublicationscirp.org/contentlibrary/80statements/3aap/446#a1989

|pubmedID=2664697

|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

|journal=Dev PsychobiolUrol Clin North Am

|date=1988-051985 |volume=2112 |issue=41 |pages=297123-31032 |url=http://www.cirp.org/library/paingeneral/gunnar1988wallerstein/

|pubmedID=33786763883617

|DOI=10.1002/dev.420210402

}}</ref> Although by 1989 it was totally clear that infants can feel intense pain, however this clearly would not do for the 1989 American Academy of Pediatrics Circumcision Task Force, under the leadership of the infamous 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. [[Edgar J. SchoenDan Bollinger]], M. D., declined to recommend (2012) estimated that the use total annual cost of analgesics for non-therapeutic neonatal circumcisionto Americans is $3, thereby condemning million of newborn baby boys to a painful647,000, stressful circumcision000.<ref>{{REFjournalREFweb |lasturl=Schoenhttps://www.academia.edu/6442587/High_Cost_of_Circumcision_3_6_Billion_Annually |firstarchived=Edgar J. |inittitle=EJHigh cost of circumcision |authortrans-linktitle=Edgar J. Schoen |last2language=AndersonEnglish |first2last=GlenBollinger |init2first=GDan |author2author-link=Dan Bollinger |last3publisher=BohonAcademia |first3website=Constance |init3date=C2012 |author3accessdate=2020-11-link=15 |last4format=Hinman JrPDF |first4quote=Frank |init4=F |author4}}</ref> The avaricious American [[circumcision industry]] is simply not willing to give that lucrative income up, so a way to make non-link= |last5=Poland |first5=Ronald Ltherapeutic circumcisions in infancy acceptable had to be found. |init5=RL |author5-link=Three methods were proposed: |last6=Wakeman |first6=Maurice* 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 |init6url=ME |author6https://www.drugs.com/pro/emla.html#s-34069-link=5 |etalarchived=no |title=Report of the Task Force of CircumcisionEMLA

|journallast=Pediatrics |locationfirst= |dateauthor-link=1989-10 |volumepublisher=89Drugs.com |issuewebsite=4 |pagesdate=3882020-04-9121 |urlaccessdate=http://www.cirp.org/library/statements/aap/#a19892020-11-21 |archivedformat=

|pubmedID=2664697 |pubmedCID= |DOI= |accessdate=2020-11-18}}</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 WallersteinDorsal penile nerve block| Dorsal Penile Nerve Block]] (1985DPNB) had as proposed that [[Routine Infant Circumcision| routine]] by Kirya & Werthman (non-therapeutic1978) circumcision of baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,.<ref name="wallerstein1985kirya1978">{{REFjournal |last=WallersteinKirya |first=EdwardChristopher |init=EC |author-link=Edward Wallerstein |last2=Werthman Jr |first2=Milton W. |init2=MW |author2-link=

|title=Circumcision: the uniquely American medical enigmaNeonatal circumcision and penile dorsal nerve block—a painless procedure.

|journal=Urol Clin North AmJ Pediatr

|date=19851978-06 |volume=1292 |issue=16 |pages=123998-321000 |url=http://www.cirp.org/library/generalpain/wallersteinkirya1/

|pubmedID=3883617 660375

|DOI=10.1016/s0022-3476(78)80386-2 |accessdate=2020-11-1516}}</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 BollingerRing block| Ring Block]] . Broadman et al. (20121987) estimated that the total annual cost of proposed ring block for neonatal non-therapeutic circumcision to Americans is $3,647,000,000.<refname="broadman1987">{{REFwebREFjournal |last=Broadman |urlinit=https://www.academia.edu/6442587/High_Cost_of_Circumcision_3_6_Billion_AnnuallyLM |archivedauthor-link= |titlelast2=High cost of circumcisionHannallah |trans-titleinit2=RS |languageauthor2-link=English |lastlast3=BollingerBelman |firstinit3=DanAB |authorauthor3-link=Dan Bollinger |publisherlast4=AcademiaElder |websiteinit4=PT |dateauthor4-link=2012 |accessdatelast5=2020-11-15Ruttiman |formatinit5=PDFU |quoteauthor5-link=}}</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: * 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 |urllast6=https://www.drugs.com/pro/emla.html#s-34069-5Epstein |archivedinit6=BS |titleauthor6-link=EMLA |trans-titleetal=no |languagetitle=EnglishPost-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penis |lastjournal=Anesthesiology |firstlocation= |authordate=1987-08-link=31 |publishervolume=Drugs.com67 |websiteissue=3 |datepages=2020399-04-21402 |accessdateurl=2020-11-21 |formatarchived=

|pubmedID=3307533 |pubmedCID= |DOI=10.1097/00000542-198709000-00019 |accessdate=2020-11-18}}</ref> * Dorsal Penile Nerve Block (DPNB) as proposed by Kirya & Werthman (1978)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="kirya1978lander1997"/><ref name="stang1997">{{REFjournal |last=KiryaStang |first=ChristopherHoward J. |init=CHJ

|last2=Werthman JrSnellman |first2=Milton Leonard W. |init2=MWLW

|last3=Condon |first3=Lawrence M |init3=LM |author3-link= |last4=Conroy |first4=Mary Margaret |init4=MM |author4-link= |last5=Liebo |first5=Rhoda |init5=R |author5-link= |last6=Brodersen |first6=Laurie |init6=L |author6-link= |last7=Gunnar |first7=Megan R. |init7=MR |author7-link= |etal=no |title= Neonatal circumcision and Beyond dorsal penile dorsal nerve block—a painless procedure.block: A more humane circumcision |trans-title= |language=English |journal=J PediatrPediatrics |location= |date=19781997-0608 |volume=92100 |issue=62 |pages=998-1000e3 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/pain100/kirya12/e3

|pubmedID=6603759233974

|DOI=10.10161542/s0022-3476(78)80386-peds.100.2 .e3 |accessdate=2020-11-1618

* Ring Block{{Box|Boxtext=<big><b>However, none of the above three procedures totally eliminate pain. Broadman et alA baby boy will still experience some pain and [[trauma]] despite any of those analgesic procedures. (1987) proposed ring block for <ref name="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 name="broadman1987">{{REFjournal |last=BroadmanWallerstein |initfirst=LMEdward |author-linkinit= |last2=Hannallah |init2=RS |author2-link= |last3=Belman |init3=AB |author3-link= |last4=Elder |init4=PT |author4-link= |last5=Ruttiman |init5=U |author5-link= |last6=Epstein |init6=BS |author6author-link=Edward Wallerstein

|title=PostIs non-religious circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penisnecessary? |trans-title= |language= |journal=AnesthesiologyJ Am Acad Child Psychiatr

|date=19871985-08-3105 |volume=6724

|article= |page= |pages=399364-4025 |url=http://www.cirp.org/library/pain/gunnar1984/#wallerstein

|pubmedID=3307533

|DOI=10.1097/00000542-198709000-00019 |accessdate=20202021-1107-180}}</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[[Robert S.Van Howe|Van Howe]] & Cold (1998)<ref name="lander1997" /> <ref name="stang1997">{{REFjournal |last=StangVan Howe |first=Howard JRobert S. |init=HJRS |author-link=Robert S. Van Howe |last2=SnnellmanCold |first2=Leonard WChristopher J. |init2=LWCJ |author2-link= |last3=Condon |first3=Lawrence M |init3=LM |author3-link= |last4=Conroy |first4=Mary Margaret |init4=MM |author4-link= |last5=Liebo |first5=Rhoda |init5=R |author5-link= |last6=Brodersen |first6=Laurie |init6=L |author6-link= |last7=Gunnar |first7=Megan RChristopher J. |init7=MR |author7-link=Cold |etal=no |title=Beyond dorsal penile nerve block: A more humane circumcisionLocal Anesthesia For Infants Undergoing Circumcision |trans-titlejournal=JAMA |languagelocation= |journaldate=Pediatrics1998-04-15 |locationvolume=299 |dateissue=1997-0815 |volumearticle=100 |issuepage=2 |pages=e31169-71 |url=httpshttp://pediatricswww.aappublicationscirp.org/contentlibrary/100pain/2lander/e3letters.html

|pubmedID=9233974

|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]].1542<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://pedswww.100dailymail.2co.uk/health/article-5998771/Circumcising-newborn-boys-increases-risk-cot-death-stress-procedure.e3html |last=Thompson |first=Alexandra |coauthors= |publisher=Daily Mail |website= |date=2021-07-27 |accessdate=20202021-1108-1802 |quote=

{{Box|Boxtext=<big><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></big>}}

Wallerstein ==Attitudes and practices regarding analgesia for newborn circumcision== ===Historic attitudes and practices=== 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: {{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 (19851993) |ref=<ref>{{REFjournal |last=WallersteinWellington |first=EdwardNancy |init=N |author-link=Edward Wallerstein |last2=Rieder |first2=Michael J. |init2=MJ |author2-link=

|title=Is non-religious Attitudes and practices regarding analgesia for newborn circumcision necessary?

|language=English |journal=J Am Acad Child PsychiatrPediatrics

|date=19851993-0510 |volume=2492 |issue=3 |article= |page=4 |pages=364541-53 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/pain92/gunnar19844/#wallerstein541?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token

|pubmedID=8414824

|accessdate=20212020-0711-018}}</ref> and }} Ryan & Finer (1994) 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 that 66 percent of physicians who perform non-therapeutic neonatal circumcisions had started to use analgesia during the procedure. This applies to one hospital in [Robert S. Van Howe|Van Howe[Canada]] & Cold (1998).<refname="ryan1994">{{REFjournal |last=Van HoweRyan |first=Robert SC.Anthony |init=RSCA |author-link=Robert S. Van Howe |last2=ColdFiner |first2=Christopher JNeil N. |init2=CJNN |author2-link=Christopher J. Cold

|title=Local Anesthesia For Infants Undergoing CircumcisionChanging attitudes and practices regarding local analgesia for newborn circumcision. |trans-title= |language=English |journal=JAMAPedatrics

|date=19981994-04-1508 |volume=29994 |issue=15 |article= |page=2 |pages=1169230-713 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/pain94/lander2/letters.html230

|pubmedID=8036079

|accessdate=20212020-0711-0819}}</ref> have suggested that it would be better (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 abandon the practice of use analgesia during neonatal non-therapeutic infant circumcision because of the pain associated with it.surgery, saying:

The ''Daily Mail'' (2021) reported {{Citation |Text=DESPITE THE DEBATE that continues over the pain stress benefits and risks of non-therapeutic nonritual neonatal circumcision increases the risk of SIDS, and that it remains a commonly performed surgical procedure in the incidence of Sudden Infant Death Syndrome (SIDS) is lower where baby boys are not circumcisedUnited States.<ref name="thompson2021">{{REFnews |title=Circumcising newborn boys increases their risk of cot death due to To the stress best of our knowledge, it is the only surgical procedure - and could explain why it that is more common in boys than girls, study finds |url=https://www.dailymail.co.uk/health/article-5998771/Circumcising-newborn-boys-increases-risk-cot-death-stress-procedure.html |last=Thompson |routinely performed without first=Alexandra |coauthors= |publisher=Daily Mail |website= |date=2021-07-27 |accessdate=2021-08-02 |quote=}}</ref> ==Attitudes and practices regarding administering analgesia for newborn circumcision== ===Historic attitudes and practices=== Wellington & Rieder (1993) conducted a survey or anesthesia. This unconscionable state of physicians in Londonaffairs exists, Ontario. They found despite the overwhelming evidence that only 4 percent used DPNBnewborns, even those born prematurely, are capable of experiencing pain. They concluded:<blockquote>Despite evidence Indeed, anyone present during a circumcision realizes that neonates perceive the newborn feels and responds to pain and that there is a physiologic stress response will attempt to circumcision which can be reduced withdraw if analgesia is employedunrestrained. In addition, this pain has physiologic correlates: elevated heart rate and blood pressure, lowered arterial oxygen saturation, the vast majority and elevated levels of physicians performing newborn circumcisions either do not employ analgesics or employ analgesics of questionable efficacyadrenocortical hormones. Lack During the past 15 years, results of familiarity with the use a multitude of analgesics among neonates studies have demonstrated that effective analgesia can prevent this pain and with dorsal penile block in particular are ameliorate the most common reasons cited for lack of analgesic useassociated stress response. Educational efforts and research into less invasive techniques of Furthermore, the failure to provide anesthesia or analgesia for newborn circumcision are urgently requiredhas been shown to cause not only short-term physiologic perturbations but also longer-term behavioral changes. |Author=Maxwell & Yaster (1999) |ref=<ref>{{REFjournal |last=WellingtonMaxwell |firstinit=Nancy |initfirst=N

|last2=RiederYaster |first2init2=Michael J. |init2first2=MJ

|title=Attitudes and practices regarding analgesia Analgesia for newborn circumcisionneonatal circumcisionː No more studies, just do tt

|journal=PediatricsArch Pediatr Adolesc Med

|date=19931999-1005 |volume=92153 |issue=45 |pages=541444-35 |url=https://pediatricsjamanetwork.aappublications.orgcom/contentjournals/92jamapediatrics/4article-abstract/541?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token346832

|pubmedID=841482410323622

|DOI=10.1001/archpedi.153.5.444 |accessdate=2020-11-1821

Ryan & Finer (1994) carried out The [[American Academy of Pediatrics]] convened a training program for physicians in new task force on circumcision under the newborn nurseries chair of Carole M. Lannon, {{MD}}. That task force reversed the Womens' Pavilion, position previously taken under [[https://wwwEdgar J.albertahealthservices.ca/rah/rah.aspx Royal Alexandra HospitalSchoen]], Edmonton, Alberta, Canada. After a training program, they found It clearly stated that 66 percent of physicians who perform non-therapeutic neonatal circumcisions had started infant circumcision is "not essential to use analgesia during the procedurechild’s current well-being. This applies to one hospital in [[Canada]]" 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="ryan1994aap1999">{{REFjournal |last=RyanLannon |first=CCarole M. Anthony |init=CA

|last2=Finer |first2=Neil N. |init2=NN |author2-link= |etal=no |title=Changing attitudes and practices regarding local analgesia for newborn circumcision.yes |trans-title=Circumcision policy statement |languagejournal=EnglishPediatrics |journaldate=Pedatrics1999-03 |locationvolume=103 |dateissue=1994-083 |volumearticle=94 |issuepage=2 |pages=230686-393 |url=https://pediatrics.aappublications.org/content/94103/23/230686

|pubmedID=803607910049981

|DOI=https://doi.org/10.1542/peds.103.3.686 |accessdate=20202021-1107-1912}}</ref> (Non-therapeutic neonatal circumcisions are no longer performed in most Canadian hospitals.)<ref name="jamesloewen2019">[[James Loewen]] (2019). Personal communication.</ref>

Maxwell & Yaster Kraft (19992003) called on physicians to use analgesia during neonatal non-therapeutic circumcision surgery, saying:<blockquote>DESPITE THE DEBATE reported that continues over the benefits and risks of nonritual neonatal circumcision, it remains a commonly performed surgical "many health care practitioners routinely perform this procedure in without the United States. To the best use of our knowledge, it is the only surgical procedure that is routinely performed without first administering analgesia any or with inadequate 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 ineffective 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."<refname="kraft2003">{{REFjournal |last=MaxwellKraft |init=NL |first=Nancy L

|title=Analgesia for neonatal circumcisionː No more studies, just do tt |trans-title= |language=EnglishA pictorial and video guide to circumcision without pain |journal=Arch Pediatr Adolesc MedAdv Neonatal Care

|date=19992003-0504 |volume=1533 |issue=52 |pages=44450-562 |url=https://jamanetworkjournals.lww.com/journalsadvancesinneonatalcare/Abstract/jamapediatrics2003/article-abstract04000/346832A_PICTORIAL_AND_VIDEO_GUIDE_TO_CIRCUMCISION.2.aspx

|pubmedID=1032362212881947

|DOI=10.10011053/archpediadnc.1532003.550015.444 |accessdate=2020-11-2118

The [[American Academy ===Contemporary attitudes and practices=== Little is known about current attitudes and practices regarding the use of Pediatrics]] convened a new task force on analgesia in circumcision under of the chair newborn. Application of Carole M. Lannonanalgesia prior to neonatal nontherapeutic circumcision takes additional physician time, Mso there may be a tendency to skip it. D. That task force reversed the position previously taken under  ==Standard of care== It is now clear that boys are born with a healthy [[Edgar J. Schoenforeskin]]without evidence of disease. It clearly stated that non-therapeutic Therefore there are no indications for infant [[circumcision ]], which is "not essential to the child’s current wella non-being." It provided an extensive discussion of procedural analgesia therapeutic and said, quite strongly, that, if a circumcision is done, procedural analgesia should be providedmedically-unnecessary surgical operation.<ref name="aap1999cps1996">{{REFjournal |last=LannonEugene |first=Carole M.Outerbridge

|last2= |first2= |init2= |author2-link= |last3= |first3= |init3= |author3-link= |last4= |first4= |init4= |author4-link= |last5= |first5= |init5= |author5-link= |last6= |first6= |init6= |author6-link= |last7= |first7= |init7= |author7-link= |last8= |first8= |init8= |author8-link= |last9= |first9= |init9= |author9-link= |etal=yesno |title=Circumcision policy statement |trans-title= |language=Neonatal circumcision revisited |journal=PediatricsCMAJ

|date=19991996-03-15 |volume=103154 |issue=36

|pages=686769-9380 |url=https://pediatricswww.aappublicationsncbi.orgnlm.nih.gov/contentpmc/103articles/3PMC1487803/686pdf/cmaj00090-0027.pdf

|pubmedID=100499818634956 |pubmedCID=1487803 |DOI=https://doi.org/10.1542/peds.103.3.686 |accessdate=2021-07-1211}}</ref> Kraft (2003) reported that "many health care practitioners routinely perform this procedure without the use of any or with inadequate or ineffective analgesia and anesthesia."<ref name="kraft2003racp2010">{{REFjournalREFdocument |lasttitle=KraftCircumcision of Infant Males |initurl=NL |firsthttps://www.racp.edu.au//docs/default-source/advocacy-library/circumcision-of-infant-males.pdf?sfvrsn=Nancy Leaa32f1a_10 |author-linkcontribution= |etallast=no |titlefirst=A pictorial and video guide to circumcision without pain |journalpublisher=Adv Neonatal Care[[Royal Australasian College of Physicians]] |locationformat=PDF |date=20032010-0409-01 |volumeaccessdate=32021-07-11 |issue=2}}</ref><ref>{{REFdocument |pagestitle=50Non-62therapeutic circumcision of male minors |url=https://journalspool.lwwintactiwiki.comorg/advancesinneonatalcareimages/Abstract/2003/04000/A_PICTORIAL_AND_VIDEO_GUIDE_TO_CIRCUMCISIONKNMG-viewpoint-Non-therapeutic-circumcision-of-male-minors-27-05-2010-v2.2.aspxpdf |contribution= |archivedlast= |quotefirst= |pubmedIDpublisher=12881947Royal Dutch Medical Association (KNMG) |pubmedCIDformat=PDF |DOIdate=10.1053/adnc.2003.50015.2010-05-27 |accessdate=20202021-07-11-18}}</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=Contemporary attitudes and practices="lander1997"/><ref name==Little is known about current attitudes and practices regarding "aap1999"/> (Total anesthesia cannot be used with infants.) The Australian Association of Paediatric Surgeons (AAPS) (1996) opposed the use practice of analgesia infant circumcision, but recognized that it would be performed for religious, cultural, or family reasons, in circumcision of which case, the newborn. Application of analgesia prior to neonatal nontherapeutic non-therapeutic [[circumcision takes additional physician time]] should be deferred for six months, so there that general anesthesia may be a tendency to skip itused.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=Standard https://www.cirp.org/library/statements/aaps/ |contribution= |last=Leditshke |first=JF |publisher=Australasian Association of carePaediatric Surgeons |location=Herston, QLD, Australia |format= |date=1996-04 |accessdate=2024-01-22It is now clear that boys are born with healthy foreskins without evidence }}</ref></blockquote> The practice of disease. Therefore there are no indications for infant circumcision, which is a 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 medically-unnecessary surgical operationfeel it more intensely than adults.<ref name="cps1996anand1987"/> 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=EugeneFitzgerald |first=Outerbridge |init=M

|title=Neonatal circumcision revisitedThe Birth of Pain

|journal=CMAJMRC News

|date=1996-03-151998 |season=Summer |volume=154 |issue=6

|pages=76920-8023 |url=https://www.ncbicirp.nlm.nih.govorg/pmclibrary/articlespain/PMC1487803fitzgerald/pdf/cmaj00090-0027.pdf

|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=2010-092024-01 |accessdate=2021-07-1131}}</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}}</refblockquote> 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. 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 Several later researchers suggested that extreme pain in thenewborn could cause neurological injury. [[Adamant father syndromeKanwaljeet J. Singh Anand| emotional needs of parentsAnand]]. 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" /> & Scalzo (Total anesthesia cannot be used with infants.2000)concluded:

==Videos=={{Citation |Text=== Infant circumcision procedure ===This is a video The public health importance of an actual infant circumcisionabnormal stimulation during the neonatal period cannot be overemphasized. It has 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 sound tract so one can hear the comments of view to developing effective therapeutic strategies for the doctor growing children and adolescents who were exposed to abnormal conditions during 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 timeneonatal period. Not for the squeamish: |Author=Anand & Scalzo (2000)* |ref=<ref name="anand2000">{{REFwebREFjournal |last=Anand |first= |urlinit=https://wwwKJS |author-link=Kanwaljeet J.reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/Singh Anand |last2=Scalzo |first2= |init2=FM |author2-link= |archivedetal=no |title=Trained medical professionals restrain infant to amputate part of its body while baby kicks Can adverse neonatal experiences alter brain development and screams in painsubsequent behavior?

|lastjournal=Biol Neonate |firstlocation= |authordate=2000-link02 |volume=77 |publisherissue=2 |websitearticle= |datepage= |accessdatepages=202269-03-1182 |url=http://www.cirp.org/library/pain/anand4/ |formatarchived=

*Fitzgerald & Walker (2003) argued that extreme pain (such as that caused by [[httpscircumcision]]) 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.redditcirp.comorg/rlibrary/Intactivismpain/commentsfitzgerald2/qbpzqr/trained_medical_professionals_restrain_infant_to/ Circumcision video] |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<youtube>SLhEoOQhsVw</youtube> |publisher=ASP Press |isbn=Here |quote=In common with other areas of the central nervous system, synaptic development of spinal sensory connections is an infant circumcision video experience or activity dependent. Evidence from both animal and human studies shows that alterations in the patterns of an Islamic circumcision sensory activity that can arise from tissue injury and pain in early life may disrupt normal synaptic organization within the Russian Federationsomatosensory system. The surgical technique While these studies are incomplete and more investigation is different but needed in this area, the potential clinical importance of neonatal plasticity in pain development is no less:clear. |accessdate=2020-11-18 |note=<vimeo>259674034}}</vimeoref>

===Ronald Goldman===[[Ronald Goldman]] discussed pain and trauma in a video by [[Brendon Marotta]]Tye & Sardi advised:

<youtube>lNItNHs9PR8</youtubeblockquote> ==Adolescent Thus, while there is literature that addresses the ways in which pain experienced by neonates not only has negative short- and adult circumcision== [[Adolescent and adult long term psychological consequences, policy making documents on neonatal circumcision]] do not address the fact that such pain is usually carried out under total anesthesianot adequately nor regularly controlled for during the procedure, either by local or regional nerve block or by general anesthesiaand that failure to control for pain can have lasting effects on the child,possibly into adulthood.<refname="tye2022">{{REFjournal |last=HolmanTye |initfirst= |firstinit=John R.NC |author-link= |last2=StuessiSardi |init2first2= |first2init2=Keith A.LM |author2-link=

|title=Adult Psychological, psychosocial, and psychosexual aspects ofpenile circumcision

|language=English |journal=American Family PhysicianInt J Impot Res

|date=19992022-03-1528 |volume=59 |issue=6 |article= |page= |pages=1514-8 |url=https://www.aafpnature.orgcom/afparticles/1999/0315/p1514.htmls41443-022-00553-9

|pubmedID=10193593 35347302

|DOI=10.1038/s41443-022-00553-9 |accessdate=20202022-1104-1929}}</ref> so the pain of the surgery is not usually a concern. That does not mean that the operation is pain free. It is not.</blockquote> ==Videos== === Infant circumcision procedure ===

* There 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 course, post-surgical local anesthetic that apparently does not stop any painat all. The infant goes silent at about 6:15 on the video, which so he may be relieved by a potent oral analgesic. One should have a two-week supply of analgesic medicinegone into [[shock]] at that time.Not for the squeamish:

* The recovery period for adolescent and adult circumcision is usually placed at six weeks{{REFweb |url=https://www.reddit. During that period com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ |archived= |title=Trained medical professionals restrain infant to amputate part of time, many patients experience its body while baby kicks and screams in pain when they they have involuntary nocturnal [[erection]]s and the [[erection]] tightens the residual [[skin]] and pulls at the incision and suture.<ref>{{REFjournal |lasttrans-title= |language=Dai |initlast= |first=A-Juan

|last2publisher=Li |init2website= |first2=Miao |author2-link= |last3=Wang |init3= |first3=Li-Li |author3-link= |last4=Wang |init4= |first4=Xiao-Hua |author4-link= |last5=Huang |init5date= |first5accessdate=Yu-Hua |author52022-link= |etal=no |title=Improvement of erection related incision pain in circumcision patients using interrupted rapid eye movement sleep: A randomized controlled study |journal=Urol J |location= |date=2018 |volume=15 |issue=3 |pages=12603-31 |url=https://journals.sbmu.ac.ir/urolj/index.php/uj/article/view/398111 |archivedformat=

|pubmedID=29308579}} |pubmedCID= |DOI=10*[https://www.22037reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ujCircumcision video] <youtube>SLhEoOQhsVw</youtube> Here is an infant circumcision video of an Islamic circumcision from the Russian Federation.v0i0.3981 The surgical technique is different but the pain is no less: |accessdate=2020-11-28}}<vimeo>259674034</refvimeo> In  Here is a few casesvideo of Dr. Paul Fleiss speaking about the harm of circumcision, the [[erection]]s may cause [[wound dehiscence]] which requires additional surgery to re-close the surgical woundincluding pain and trauma.

* Neuromas may form at the [[circumcision scarRonald Goldman]]. Cold & Taylor (1999) reported that they are "notorious for generating discussed pain.".<ref name="cold-taylor1999">{{ColdCJ TaylorJR 1999}}</ref>and trauma in a video by [[Brendon Marotta]]:

{{LINKS}}==Adolescent and adult circumcision== * [[Adolescent and adult circumcision]] is usually carried out under total anesthesia, either by local or regional nerve block or by general anesthesia,<ref>{{REFjournal |etallast=Holman |init=no |lastfirst=American Academy of PediatricsJohn R. |author-link=American Academy of Pediatrics |last2=Stuessi |init2= |first2=Keith A. |author2-link= |etal=no |title=Adult circumcision |trans-title=The assessment and management of acute pain in infants, children, and adolescents |language=English |journal=PediatricsAmerican Family Physician

|date=20011999-0903-15 |volume=10859 |issue=36 |pages=7931514-78 |url=httphttps://www.cirpaafp.org/libraryafp/pain1999/re99330315/p1514.html

|pubmedID=1153335410193593

|DOI=10.1542/peds.108.3.793. |accessdate=2020-11-1719}}</ref> so the pain of the surgery is not usually a concern. That does not mean that the operation is pain free. It is not pain 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.

* {{REFweb |url=http://wwwThe recovery period for adolescent and adult circumcision is usually placed at six weeks.cirp.org/library/During that period of time, many patients experience pain/ |archived= |title=Pain of circumcision when they they have involuntary nocturnal [[erection]]s and the [[erection]] tightens the residual [[skin]] and pulls at the incision and pain controlsuture.<ref>{{REFjournal |trans-title= |languagelast=EnglishDai |lastinit=Hill |first=GeorgeA-Juan

|publisherlast2=Circumcision Reference LibraryLi |websiteinit2= |datefirst2=Miao |author2-link= |last3=Wang |init3= |first3=2006Li-09Li |author3-11link= |last4=Wang |accessdateinit4=2020 |first4=Xiao-11Hua |author4-08link= |last5=Huang |formatinit5= |quotefirst5=Circumcision is the most stressful surgical procedure commonly performed on newborns.Yu-Hua |author5-link= |etal=no |title=Improvement of erection related incision pain in circumcision patients using interrupted rapid eye movement sleep: A randomized controlled study |journal=Urol J |location= |date=2018}} |volume=15 |issue=3* {{REFweb |pages=126-31 |url=httphttps://wwwjournals.drmommasbmu.orgac.ir/urolj/index.php/uj/2009article/10view/mri-studies-brain-permanently-altered.html3981

|titlequote= |pubmedID=29308579 |pubmedCID= |DOI=10.22037/uj.v0i0.3981 |accessdate=MRI Studies: 2020-11-28}}</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 Brain Permanently Altered From 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?]]* [[Post-traumatic stress disorder]]* [[Psychological issues of male circumcision]]* [[Shock]]* [[Sudden Infant CircumcisionDeath Syndrome]]* [[Trauma]] {{LINKS}}* {{REFweb |url=http://www.cirp.org/library/pain/ |archived= |title=Pain of circumcision and pain control

|language=English |last=TinariHill |first=Paul D.George

|publisher=Peaceful ParentingCircumcision Reference Library

|date=20082006-09-11 |accessdate=20212020-1011-2208

|quote=A neurologist who saw Circumcision is 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 stressful surgical procedure commonly performed 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 surgerynewborns.

 * {{REFwebREFjournal |etal=no |last=American Academy of Pediatrics |author-link=American Academy of Pediatrics |title=The assessment and management of acute pain in infants, children, and adolescents |journal=Pediatrics |location= |date=2001-09 |volume=108 |issue=3 |pages=793-7 |url=http://www.circinfocirp.org/news_2018.html#babieslibrary/pain/re9933/

|quote= |pubmedID=11533354 |pubmedCID= |DOI=10.1542/peds.108.3.793. |accessdate=2020-11-17}}* {{REFjournal |last=Bellieni |first= |init=CV |etal=no |title=Babies more sensitive to Neonatal Infant Pain Scale in assessing pain and pain than adultsrelief for newborn male circumcision |trans-title=

|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}}* {{REFweb |url=http://www.drmomma.org/2009/10/mri-studies-brain-permanently-altered.html |archived= |title=MRI Studies: The Brain Permanently Altered From Infant Circumcision |trans-title= |language= |last=Tinari |first=Paul D. |author-link=Paul Tinari |publisher=Peaceful Parenting |website= |date=2008 |accessdate=2021-10-22 |format= |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 |archived= |title=Babies more sensitive to pain than adults |trans-title= |language= |last= |first= |author-link=

|accessdate=2021-03-18 |format= |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/ |archived= |title=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=https://docs.google.com/document/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.org/timeline-of-circumcision-suffering/ |title=A Timeline of Circumcision Suffering: A Detailed Look |last=Anonymous |first= |init=

|website= |date=20162024-02-1302 |accessdate=2021-042024-02 |format= |quote=}} * {{REFweb |url=http://www.circumstitions.com/Pain.html |title=Circumcision and Pain |last=Young |first=High |accessdate=2021-10-1709