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Fitzgerald & Walker 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" /> * 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.
Tye & Sardi advised:<blockquote>Thus, while there is literature * Emde et al. (1971) showed that addresses the ways "stress" of circumcision caused an increase in which pain experienced by neonates not only has negative shortthe amount of non- 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 adulthoodREM sleep.<ref name="tye2022emde1971">{{REFjournal |last=TyeEmde |firstinit=RN |initfirst=NCRobert N
</blockquote>
===History=======Investigating pain of circumcision==== Paul Emil Flechsig * Richards, Bernal & Brackbill (1976) reported behavioral differences between American boys (1847-1929circumcised) was an eminent nineteenth-century German neuroanatomist, psychiatrist and neuropathologist. He suggested in 1872 that infants could not feel pain because their nerves are not completely myelinatedBritish boys (genitally intact).<ref name="cope1998richards1976">{{REFjournal |last=CopeRichards |init=DKMPM
As a result* Luther, medical doctors performed all manners Kraybill & Potter (1976) compared the level of invasive, painful procedures on neonates without anesthesia or analgesia, including millions upon millions of painful circumcisions cortisol in infants before and even open heart surgeryafter circumcision. Open heart surgery was performed with curare to paralyze They found a substantial rise in the infant but without any anesthesia. Flechsig's bizarre opinion was not questioned until the 1970s. Several lines of empirical research carried out cortisol levels in the 1970s suggested that infants can in fact feel intense pain.<ref name=, which they said was due to the "vanhowe2008stress" /> * Anders et al. (1970) showed that measurement of serum cortisol is a useful indicator of pain for psychological investigation in infancycircumcision.<ref name="anders1970">{{REFjournal |last=AndersTalbert |init=TFLM |first=Thomas FLuther M.
|last4=Roffwarg
|init4=HP
|first4=Howard P.
|author4-link=
|last5=Hellman
|init5=L
|first5=Leon
|author5-link=
* RawlingsPorter, Miller & Engel Marshall (19801986) showed that as studied the nature of pain of cries during unanesthetized, non-therapeutic circumcision. the cries during circumcision increasedwere found to shorter, oxygenation with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; and greater variability of the [[skin]] decreasedfundamental. Adult listeners judged these cries to have an unusual degree of urgency.<ref name="rawlings1980porter1986">{{REFjournal |last=RawlingsPorter |initfirst=DJFran Lang |firstinit=David J.FL
* Gunnar et al. (1981) recorded serum cortisol and behavior state throughout Surgical operation on infants without anesthesia continued for well over a century, at least until 1987, when the unanesthetized, non-therapeutic circumcision process. Serum cortisol levels and behavioral distress were found [[American Academy of Pediatrics]] was forced to be closely related. The authors stated:{{Citation |Text=Neonatal circumcision is performed without anesthesia and it is clearly stressful issue a CYA statement that called for the infantuse of anesthesia. |Author=Gunnar et al. (1981) |ref=<ref name="Gunnar et al 1981poland1987">{{REFjournal |last=GunnarPoland |initfirst=MRRonald L. |firstinit=Megan R.RL
So great was FlechsigAnand & Hickey (1987) published a paper in the 's influence, the authors were still unwilling to use the word 'New England Journal of Medicine'pain'that totally demolished Flechsig' s ridiculous claims and substituted the word ''stress''conclusively proved that newborn infants are capable of feeling intense pain. After publication of this paper, no doubt about pain sensation in infants remained.<ref name="Gunnar et al 1981"/>The article stated:
* Marshall {{Citation |Text=Numerous lines of evidence suggest that even in the human [[fetus]], pain pathways as well as cortical and subcortical centers necessary for pain perception are well developed late in gestation, and the neurochemical systems now known to be associated with pain transmission and modulation are intact and functional. Physiologic responses to painful stimuli have been well documented in neonates of various gestational ages and are reflected in hormonal, metabolic, and cardiorespiratory changes similar to but greater than those observed in adult subjects. Other responses in newborn infants are suggestive of integrated emotional and behavioral responses to pain and are retained in memory long enough to modify subsequent behavior patterns. |Author=Anand & Hickey (1987) |ref=<ref name="anand1987"/><ref name="vanhowe2008"/>}} Gunnar et al. (19821988) studied mother-child interaction with regard to feeding behavior after circumcision without anesthesiaexamined the association between behavioral distress and adrenocortical activity. They It was found that [[circumcised]] boys had more interruptions of feeding differences in behavioral distress did not reliably the 24level of adrenocortical activity. Moreover, it was found that while non-hour period nutritive sucking reduces crying it did not reduce the adrenocortical response to the stressful stimulus of observationcircumcision pain.<ref name="marshall1982gunnar1988">{{REFjournal |last=MarshallGunnar |initfirst=REMegan |firstinit=Richard E.M
|last5=Anderson |init5=B |first5=Barbara |author5-link= |last6=Boxerman |first6=Stuart B. |init6=SB |author6-link= |etal=noyes |title=Circumcision: II: Effects upon mother-infant interactionAdrenocortical activity and behavioral distress in human newborns
PorterAlthough by 1989 it was totally clear that infants can feel intense pain, the [[American_Academy_of_Pediatrics#Third_policy_.281989.29 1989| American Academy of Pediatrics Circumcision Task Force]], Miller & Marshall (1986) studied under the nature leadership of pain cries during unanesthetizedthe infamous [[Edgar J. Schoen]], {{MD}}, declined to recommend the use of analgesics for non-therapeutic neonatal [[circumcision. the cries during circumcision were found to shorter]], with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; and greater variability thereby condemning millions of the fundamental. Adult listeners judged these cries newborn baby boys to have an unusual degree of urgencya painful, stressful, traumatizing circumcision.<ref name="porter1986">{{REFjournal |last=PorterSchoen |first=Fran LangEdgar J. |init=FLEJ |author-link=Edgar J. Schoen |last2=MillerAnderson |first2=Richard H.Glen |init2=RHG
Surgical operation on infants without anesthesia continued for well over ====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 centurydoubt that newborn baby boys can feel intense pain. Medical ethics and the standard of care now necessitated pain relief, at least until 1987, when the however it is dangerous to give general anesthesia to neonates. [[American Academy of PediatricsEdward Wallerstein]] was forced to issue a CYA statement (1985) had proposed that called for the use [[Routine Infant Circumcision| routine]] (non-therapeutic) circumcision of anesthesia.baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,<ref name="poland1987wallerstein1985">{{REFjournal |last=Poland Wallerstein |first=Ronald L.Edward |init=RLE |author-link= |last2=Roberts |first2=Ronald J |init2=RJ |author2-link= |last3=Gutierrez-Mazorra |first3=Juan F. |init3=JF |author3-link= |last4=Fonkalsrud |first4=Eric W. |init4=EW |author4-link=Edward Wallerstein
Gunnar et al* Application of [[EMLA]] Cream topical anesthetic. [[EMLA]] is a eutectic mixture of lidocaine 2. 5% and prilocaine 2.5%. [[EMLA]] Cream (1988lidocaine 2.5% and prilocaine 2.5%) examined , applied to intact [[skin]] under occlusive dressing, provides dermal analgesia by the association between behavioral distress release of lidocaine and adrenocortical activity. It was found that differences in behavioral distress did not reliably prilocaine from the cream into the level epidermal and dermal layers of adrenocortical activity. Moreover, it was found that while non-nutritive sucking reduces crying it did not reduce the adrenocortical response to [[skin]] and by the accumulation of lidocaine and prilocaine in the stressful stimulus vicinity of circumcision dermal painreceptors and nerve endings.<ref name="gunnar1988">{{REFjournalREFweb |url=https://www.drugs.com/pro/emla.html#s-34069-5 |lastarchived= |title=EMLA |trans-title= |language=GunnarEnglish |firstlast=Megan |initfirst=M
|last3=Isensee |first3=Jill |init3=J |author3-link= |last4=Wall |first4=Lee |init4=L |author4-link= |etal=yesno |title=Adrenocortical activity Neonatal circumcision and behavioral distress in human newbornspenile dorsal nerve block—a painless procedure.
Although by 1989 it was totally clear that infants can feel intense pain, the 1989 American Academy of Pediatrics Circumcision Task Force, under the leadership of the infamous * [[Edgar J. SchoenRing block| Ring Block]], {{MD}}, declined to recommend the use of analgesics . Broadman et al. (1987) proposed ring block for neonatal non-therapeutic neonatal [[circumcision]], thereby condemning millions of newborn baby boys to a painful, stressful' traumatizing circumcision.<refname="broadman1987">{{REFjournal |last=Schoen |first=Edgar J.Broadman |init=EJLM |author-link=Edgar J. Schoen |last2=Anderson |first2=GlenHannallah |init2=GRS
* 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== ===Historic attitudes and practices=== Wellington & Rieder (1993) conducted a survey of physicians in London, Ontario. They found that only 4 percent used [[Ring dorsal penile nerve block| Ring BlockDPNB]]. Broadman et alThey 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. (1987) proposed ring 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 neonatal non-therapeutic newborn circumcisionare urgently required. |Author=Wellington & Rieder (1993) |ref=<ref name="broadman1987">{{REFjournal |last=BroadmanWellington |first=Nancy |init=LMN |author-link= |last2=HannallahRieder |first2=Michael J. |init2=RSMJ
|last3=Belman
|init3=AB
|author3-link=
|last4=Elder
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|last5=Ruttiman
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|last6=Epstein
|init6=BS
|author6-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 R.
|init7=MR
|author7-link=
{{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="bellini2022 /> Prevention of pain requires protecting a boy from elective Maxwell & Yaster (1999) called on physicians to use analgesia during neonatal non-therapeutic circumcision. Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or [[trauma]].</b></big>}}, saying:
Wallerstein {{Citation |Text=DESPITE THE DEBATE that continues over the benefits and risks of nonritual neonatal circumcision, it remains a commonly performed surgical procedure in the United States. To the best of our knowledge, it is the only surgical procedure that is routinely performed without first administering analgesia or anesthesia. This unconscionable state of affairs exists, despite the overwhelming evidence that newborns, even those born prematurely, are capable of experiencing pain. Indeed, anyone present during a circumcision realizes that the newborn feels and responds to pain and will attempt to withdraw if unrestrained. In addition, this pain has physiologic correlates: elevated heart rate and blood pressure, lowered arterial oxygen saturation, and elevated levels of adrenocortical hormones. During the past 15 years, results of a multitude of studies have demonstrated that effective analgesia can prevent this pain and ameliorate the associated stress response. Furthermore, the failure to provide anesthesia or analgesia has been shown to cause not only short-term physiologic perturbations but also longer-term behavioral changes. |Author=Maxwell & Yaster (19851999) |ref=<ref>{{REFjournal |last=Wallerstein |first=EdwardMaxwell
The pain that infant boys experience would not be acceptable in older boys ===Contemporary attitudes 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.practices===
==Attitudes Little is known about current attitudes and practices regarding the use of analgesia for 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.
Wellington & Rieder (1993) conducted It is now clear that boys are born with a survey of physicians in London, Ontario. They found that only 4 percent used healthy [[dorsal penile nerve block| DPNBforeskin]]without evidence of disease. They concluded:{{Citation |Text=Despite evidence that neonates perceive pain and that Therefore there is a physiologic stress response to are no indications for 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 the use of analgesics among neonates a non-therapeutic and with dorsal penile block in particular are the most common reasons cited for lack of analgesic usemedically-unnecessary surgical operation. Educational efforts and research into less invasive techniques of analgesia for newborn circumcision are urgently required. |Author=Wellington & Rieder (1993) |<refname=<ref"cps1996">{{REFjournal |last=WellingtonEugene |first=NancyOuterbridge |init=N
|last2=Rieder
|first2=Michael J.
|init2=MJ
|author2-link=
|pubmedID=8036079 |pubmedCID= |DOI= |accessdate=20202024-1101-1931}}</ref> (Non-therapeutic neonatal circumcisions are no longer performed </blockquote> Several later researchers suggested that extreme pain in most Canadian hospitalsthe newborn could cause neurological injury.)<ref name="jamesloewen2019">[[James LoewenKanwaljeet J. Singh Anand| Anand]] & Scalzo (20192000). Personal communication.</ref>concluded:
Maxwell & Yaster (1999) called on physicians to use analgesia during neonatal non-therapeutic circumcision surgery, saying:
The Fitzgerald & Walker (2003) argued that extreme pain (such as that caused by [[American Academy of Pediatrics]] convened a new task force on circumcision under the chair of Carole M. Lannon, {{MD}}. That task force reversed the position previously taken under [[Edgar J. Schoen]]. It clearly stated that non-therapeutic infant circumcision is "not essential to ) may alter developing nervous tissue in 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 providedvery young.<ref name="aap1999">{{REFjournalREFbook |last=LannonFitzgerald |first=Carole M.Maria |init=M
Kraft (2003) reported 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 "many health care practitioners routinely perform this such pain is not adequately nor regularly controlled for during the procedure without , and that failure to control for pain can have lasting effects on the use of any or with inadequate or ineffective analgesia and anesthesiachild, possibly into adulthood."<ref name="kraft2003tye2022">{{REFjournal |last=KraftTye |first= |init=NLNC |firstauthor-link= |last2=Sardi |first2= |init2=Nancy LLM |authorauthor2-link=
===Contemporary attitudes and practices===Little This is known about current attitudes and practices regarding the use a video of analgesia in an actual infant [[circumcision ]]. It has a sound tract so one can hear the comments of the newborndoctor and the sounds made by the infant. Application The doctor gives an injection of analgesia prior to neonatal nontherapeutic circumcision takes additional physician timelocal anesthetic that apparently does not stop any pain at all. The infant goes silent at about 6:15 on the video, so there he may be a tendency to skip ithave gone into [[shock]] at that time.Not for the squeamish:
==Standard of care==It is now clear that boys are born with a healthy [[foreskin]] without evidence of disease. Therefore there are no indications for infant [[circumcision]], which is a non-therapeutic and medically-unnecessary surgical operation.<ref name="cps1996">* {{REFjournalREFweb |lasturl=Eugenehttps://www.reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ |firstarchived=Outerbridge |init= |author-link= |etal=no |title=Neonatal circumcision revisitedTrained medical professionals restrain infant to amputate part of its body while baby kicks and screams in pain
|pubmedID=8634956 |pubmedCID=1487803 |DOI= |accessdate=2021-07-11}}</ref><ref name="racp2010">{{REFdocument |title=Circumcision of Infant Males |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 |contribution= |last= |first= |publisher=[[Royal Australasian College of Physicians]Circumcision video] |format=PDF |date=2010-09-01 |accessdate=2021-07-11}}</refyoutube>SLhEoOQhsVw<ref/youtube>{{REFdocument |title=Non-therapeutic Here is an infant circumcision video of male minors |url=https://pool.intactiwiki.org/images/KNMG-viewpoint-Non-therapeutic-an Islamic circumcision-of-male-minors-27-05-2010-v2from the Russian Federation.pdf |contribution= |last= |first= |publisher=Royal Dutch Medical Association (KNMG) |format=PDFThe surgical technique is different but the pain is no less: |date=2010-05-27 |accessdate=2021-07-11}}</refvimeo> Circumcision excises the highly functional foreskin, which provides numerous protective, immunological, sensory, and sexual functions,<ref name="cold1999">{{ColdCJ TaylorJR 1999}}259674034</refvimeo> 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 Here is a video of boys will continue to be performed for religious reasons, ethnic reasons, and Dr. Paul Fleiss speaking about the[[Adamant father syndrome| emotional needs harm of parents]]. When a [[circumcision]] is to be performed, the standard of care requires that analgesia be provided to reduce the extreme level of including pain and trauma.<ref name="poland1987"/><ref name="cps1996"/><ref name="lander1997"/><ref name="aap1999"/> (Total anesthesia cannot be used with infants.)
==Videos==<youtube>ouHSz-OmOH8</youtube>
* {{REFweb |url=https://www.reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ |archived= |title=Trained medical professionals restrain infant to amputate part of its body while baby kicks and screams in pain |trans-title= |language= |last= |first= |author-link= |publisher= |website= |date= |accessdate=2022-03-11 |format= |quote=}} *[https://www.reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ Circumcision video] <youtube>SLhEoOQhsVw</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: <vimeo>259674034</vimeo><br>Here is a video of Dr. Paul Fleiss speaking about the harm of circumcision, including pain and trauma.<youtube>ouHSz-OmOH8</youtube><br> ===Ronald Goldman===[[Ronald Goldman]] discussed pain and trauma in a video by [[Brendon Marotta]]:
}}
* {{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.
Pain
,→Intraoperative pain: Add text and citation,.
The '''pain''' of [[circumcision]] is extreme and traumatizing.<ref name="bollinger2019">{{REFdocument
|title=Child Genital Cutting as an Adverse Childhood Experience
|url=http://adversechildhoodexperiences.net/CGC_as_an_ACE.pdf
|archived=
}}</ref>
}}
==Infant circumcision==
|DOI=https://doi.org/10.1002/ar.1090570409
|accessdate=2020-11-08
}}</ref> Winkelmann (1956) stated the human newborn prepuce "is a region of great sensitivity and possessed of an abundant nerve supply."<ref name="winkelmann1956">{{REFjournal |last=Winkelmann |init=RK |author-link=R. K. Winkelmann |title=The cutaneous innervation of human newborn prepuce |journal=Journal of investigative dermatology |volume=26 |issue=1 |pages=53–67 |url=http://www.cirp.org/library/anatomy/winkelmann2/ |pubmedID=http://www.ncbi.nlm.nih.gov/pubmed/13295637?dopt=Abstract |date=1956 |accessdate=2024-05-14}}</ref>
There are four painful steps in every infant [[circumcision]]:<ref name="bellini2022>{{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">{{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= |LanderJ 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=http://www.cirp.org/library/pain/lander/ |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
}}</ref>
Parents who choose to have a son [[circumcised]] may expect the infant boy to be uncomfortable and fussy for some time.The surgical pain may be expected to last for three weeks.<ref name="garrett2024">{{REFweb |url=https://intactamerica.org/timeline-of-circumcision-suffering/ |title=A Timeline of Circumcision Suffering: A Detailed Look |last=Garrett |first= |init=C |publisher=Intact America |date=2024-02-02 |accessdate=2024-05-09}}</ref>
===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
Taddio et al. (1997) concluded:
{{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.
}}</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. [[Kanwaljeet J. Singh Anand| AnandPaul Emil Flechsig]] & Scalzo (20001847-1929) concluded:was an eminent nineteenth-century German neuroanatomist, psychiatrist and neuropathologist. He suggested in 1872 that infants could not feel pain because their nerves are not completely myelinated.<ref name="cope1998">{{CitationREFjournal |last=Cope |init=DK |author-link= |Texttitle=Neonatal pain: the evolution of an idea. |journal=The public health importance American Association of abnormal stimulation during the neonatal period cannot be overemphasized. While programs for formulating appropriate health policies and public education campaigns must disseminate this message, it is also important for these effects to be investigated, particularly with a view to developing effective therapeutic strategies for the growing childen and adolescents who were exposed to abnormal conditions during the neonatal period.Anesthesiologists Newsletter |date=1998-09 |volume= |issue= |pages= |Authorurl=Anand & Scalzo (2000) |accessdate=2020-11-12}}</ref=> Incredible as it may seem today, his idea was accepted without question and without being tested.<ref name="anand2000vanhowe2008">{{REFjournal |last=AnandVan Howe |first=Robert S. |init=KJSRS |author-link=Kanwaljeet JRobert S. Singh AnandVan Howe |last2=ScalzoSvoboda |first2=J. Steven |init2=FMJS |author2-link=J. Steven Svoboda
|etal=no
|title=Can adverse neonatal experiences alter brain development Neonatal pain relief and subsequent behavior? |trans-title= |language=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>
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|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>
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|init5=S
|first5=Samuel
|author5-link=
|etal=no
|title=Psychological, psychosocial, Stress and psychosexual aspects ofpenile circumcision |trans-title= |language=neonatal sleep |journal=Int J Impot ResPsychosom Med
|location=
|date=2022-03-281971 |volume=33 |issue= |article= |page=6 |pages=491-7 |url=httpshttp://www.naturecirp.comorg/library/birth/articlesemde/s41443-022-00553-9
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|author-link=
|titlelast2=Neonatal pain: the evolution of an idea.Bernal |journalinit2=The American Association of Anesthesiologists NewsletterJF |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=Van Howe |first=Robert S. |init=RS |authorauthor2-link=Robert S. Van Howe |last2last3=SvobodaBrackbill |first2init3=J. StevenY |init2first3=JSYvonne |author2author3-link=J. Steven Svoboda
|etal=no
|title=Neonatal pain relief and the Helsinki DeclarationEarly behavioral differences: gender or circumcision? |journal=Journal of Law, Medicine, and EthicsDev Psychobiol
|location=
|date=20081976-1201 |volume=369 |issue=4 |article= |page=1 |pages=80389-2395 |url=httpshttp://www.academiacirp.eduorg/downloadlibrary/33981944psych/brackbill/27_Van_Howe.pdf
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|author-link=
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|author2-link=
|last3=KreamPotter |init3=J |first3=JacobHD
|author3-link=
|etal=no
|title=Behavioral state and plasma cortisol Adrenal cortical response to circumcision in the human neonate. |trans-title= |language=English |journal=PediatricsObstet Gynecol
|location=
|date=19701976-1008
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|issue=42 |pages=532208-710 |url=http://www.cirp.org/library/pain/anders1talbert/
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* Emde et al. Rawlings, Miller & Engel (19711980) showed that as the "stress" pain of circumcision caused an increase in increased, oxygenation of the amount of non-REM sleep[[skin]] decreased.<ref name="emde1971rawlings1980">{{REFjournal |last=EmdeRawlings |init=RNDJ |first=Robert NDavid J.
|author-link=
|last2=HarmonMiller |init2=RJPA |first2=Robert J.Patricia Anne
|author2-link=
|last3=MetcalfEngel |init3=DRR |first3=DavidRolf R.
|author3-link=
|last4etal=Koenigno |init4=KL |first4title=Kenneth L.The effect of circumcision on transcutaneous PO2 in term infants |author4trans-link= |last5=Wagonfeld |init5=S |first5=Samuel |author5-link= |etaltitle=no |titlelanguage=Stress and neonatal sleepEnglish |journal=Psychosom Med Am J Dis Child
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* Richards, Bernal & Brackbill Gunnar et al. (19761981) reported recorded serum cortisol and behavior state throughout the unanesthetized, non-therapeutic circumcision process. Serum cortisol levels and behavioral differences between American boys (circumcised) distress were found to be closely related. The authors stated:{{Citation |Text=Neonatal circumcision is performed without anesthesia and British boys it is clearly stressful for the infant. |Author=Gunnar et al. (genitally intact1981). |ref=<ref name="richards1976Gunnar et al 1981">{{REFjournal |last=RichardsGunnar |init=MPMMR |first=Megan R.
|author-link=
|last2=BernalFisch |init2=JFRO |first2=Robert O.
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|last3=BrackbillKorsvick |init3=YS |first3=YvonneSherry
|author3-link=
|last4=Donhowe
|init4=JM
|first4=John M.
|author4-link=
|etal=no
|title=Early behavioral differences: gender or The effects of circumcision?on serum cortisol and behavior. |trans-title= |language=English |journal=Dev PsychobiolPsychoneuroendocrinology
|location=
|date=1976-011981 |volume=96 |issue=13 |pages=89260-9575 |url=http://www.cirp.org/library/psychpain/brackbillgunnar/
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|DOI=10.1016/0306-4530(81)90037-8
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}}</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"/> * Luther, Kraybill & Potter Marshall et al. (19761982) compared the level of cortisol in infants before and studied mother-child interaction with regard to feeding behavior after circumcisionwithout anesthesia. They found a substantial rise that [[circumcised]] boys had more interruptions of feeding in the cortisol levels in the infants, which they said was due to the "stress" 24-hour period of circumcisionobservation.<refname="marshall1982">{{REFjournal |last=TalbertMarshall |init=LMRE |first=Luther MRichard E.
|author-link=
|last2=KraybillPorter |init2=ENFL |first2=Ernest NFran L.
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|init6=SB
|author6-link=
|etal=no
|title=Adrenal cortical response to circumcision in the neonate.Circumcision: II: Effects upon mother-infant interaction
|trans-title=
|language=English
|journal=Obstet Gynecol Early Hum Dev
|location=
|date=1976-081982 |volume=467 |issue=24 |pages=208367-1074 |url=http://www.cirp.org/library/painbirth/talbertmarshall2/
|archived=
|quote=
|pubmedID=9406537169032
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|DOI=10.1016/0378-3782(82)90038-x |accessdate=2020-11-1314
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|author-link=
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|init2first2=PARichard H. |first2init2=Patricia AnneRH
|author2-link=
|last3=EngelMarshal |init3first3=RRRichard E |first3init3=Rolf R.RE
|author3-link=
|etal=no
|title=The Neonatal pain cries: effect of circumcision on transcutaneous PO2 in term infantsacoustic features and perceived urgency
|trans-title=
|language=English
|journal=Am J Dis ChildDev
|location=
|date=19801986-0706 |volume=13457 |issue=73 |pages=676790-8802 |url=httphttps://www.cirpjstor.org/library/pain/rawlings1stable/1130355?seq=1
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|DOI=10.10012307/archpedi.1980.021301900440111130355 |accessdate=2020-11-1315
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|author-link=
|last2=FischRoberts |init2first2=RORonald J |first2init2=Robert O.RJ
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|last3=KorsvickGutierrez-Mazorra |init3first3=SJuan F. |first3init3=SherryJF
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|last4=DonhoweFonkalsrud |init4first4=JMEric W. |first4init4=John M.EW
|author4-link=
|etal=no
|title=The effects of circumcision on serum cortisol and behavior.Neonatal anesthesia
|trans-title=
|language=English
|journal=PsychoneuroendocrinologyPediatrics
|location=
|date=19811987-09 |volume=680
|issue=3
|pages=260-75446 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/pain80/gunnar3/446
|archived=
|quote=
|pubmedID=7291435
|pubmedCID=
|DOI=10.1016/0306-4530(81)90037-8 |accessdate=2020-11-1312}}</ref>}}<ref name="vanhowe2008"/>
|author-link=
|last2=PorterConnors |init2first2=FLJoan |first2init2=Fran L.J
|author2-link=
|last3=RogersIsensee |init3first3=AGJill |first3init3=Ann G.J
|author3-link=
|last4=MooreWall |init4first4=JLee |first4init4=JoAnnL
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|trans-title=
|language=English
|journal=Early Hum DevPsychobiol
|location=
|date=19821988-05 |volume=721
|issue=4
|pages=367297-74310 |url=http://www.cirp.org/library/birthpain/marshall2gunnar1988/
|archived=
|quote=
|pubmedID=71690323378676
|pubmedCID=
|DOI=10.10161002/0378-3782(82)90038-x dev.420210402 |accessdate=2020-11-1415
}}</ref>
|author2-link=
|last3=MarshalBohon |first3=Richard EConstance |init3=REC
|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=Neonatal pain cries: effect Report of the Task Force of circumcision on acoustic features and perceived urgencyCircumcision |trans-title= |language=English |journal=Child DevPediatrics
|location=
|date=19861989-0610 |volume=5789 |issue=34 |pages=790388-80291 |url=httpshttp://www.jstorcirp.org/stablelibrary/1130355?seq=1statements/aap/#a1989
|archived=
|quote=
|pubmedID= 37204042664697
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|DOI=10.2307/1130355 |accessdate=2020-11-1518
}}</ref>
|etal=no
|title=Neonatal anesthesiaCircumcision: the uniquely American medical enigma
|trans-title=
|language=English
|journal=PediatricsUrol Clin North Am
|location=
|date=1987-091985 |volume=8012 |issue=31 |pages=446123-32 |url=httpshttp://pediatricswww.aappublicationscirp.org/contentlibrary/80general/3wallerstein/446
|archived=
|quote=
|pubmedID=3883617
|pubmedCID=
|DOI=
|accessdate=2020-11-1215}}</ref><ref name="vanhowe2008" /> Anand & Hickey 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]] (19872012) published a paper in estimated that the ''New England Journal total annual cost 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 papernon-therapeutic circumcision to Americans is $3,647,000, no doubt about pain sensation in infants remained000. The article stated:<ref>{{CitationREFweb |Texturl=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 functionalhttps://www. 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 subjectsacademia. Other responses in newborn infants are suggestive edu/6442587/High_Cost_of_Circumcision_3_6_Billion_Annually |archived= |title=High cost of integrated emotional and behavioral responses to pain and are retained in memory long enough to modify subsequent behavior patterns.circumcision |trans-title= |language=English |last=Bollinger |first=Dan |author-link=Dan Bollinger |publisher=Academia |website= |date=2012 |accessdate=2020-11-15 |Authorformat=Anand & Hickey (1987)PDF |refquote=}}<ref name="anand1987"/><ref name="vanhowe2008"/>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:
|author-link=
|publisher=Drugs.com |website= |date=2020-04-21 |accessdate=2020-11-21 |format= |quote=}}</ref> * [[Dorsal penile nerve block| Dorsal Penile Nerve Block]] (DPNB) as proposed by Kirya & Werthman (1978).<ref name="kirya1978">{{REFjournal |last=Kirya |first=Christopher |init=C |author-link= |last2=Connors Werthman Jr |first2=JoanMilton W. |init2=JMW
|author2-link=
|trans-title=
|language=English
|journal=Dev PsychobiolJ Pediatr
|location=
|date=19881978-0506 |volume=2192 |issue=46 |pages=297998-3101000 |url=http://www.cirp.org/library/pain/gunnar1988kirya1/
|archived=
|quote=
|pubmedID=3378676660375
|pubmedCID=
|DOI=10.10021016/dev.420210402s0022-3476(78)80386-2 |accessdate=2020-11-1516
}}</ref>
|author2-link=
|last3=Bohon |first3=ConstanceBelman |init3=CAB
|author3-link=
|last4=Hinman Jr |first4=FrankElder |init4=FPT
|author4-link=
|last5=Poland |first5=Ronald L.Ruttiman |init5=RLU
|author5-link=
|last6=Wakeman |first6=MauriceEpstein |init6=MEBS
|author6-link=
|etal=no
|title=Report Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the Task Force of Circumcision |trans-title= |language=Englishpenis |journal=PediatricsAnesthesiology
|location=
|date=19891987-1008-31 |volume=8967 |issue=43 |pages=388399-91402 |url=http://www.cirp.org/library/statements/aap/#a1989
|archived=
|quote=
|pubmedID=26646973307533
|pubmedCID=
|DOI=10.1097/00000542-198709000-00019
|accessdate=2020-11-18
}}</ref> ====Finding an ethical way to do painful Ring block is considered the most effective analgesic procedure for neonatal 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 Infant boys can feel intense less pain. Medical ethics and suffer less trauma than with the standard of care now necessitated other two pain relief, however it is dangerous to give general anesthesia to neonatesreduction procedures. [[Edward Wallerstein]] (1985) had proposed that [[Routine Infant Circumcision| routine]] (non-therapeutic) circumcision of baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,<ref name="wallerstein1985lander1997"/><ref name="stang1997">{{REFjournal |last=WallersteinStang |first=EdwardHoward J. |init=EHJ |author-link=Edward Wallerstein |last2=Snellman |first2=Leonard W. |init2=LW |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 R. |init7=MR |author7-link=
|etal=no
|title=CircumcisionBeyond dorsal penile nerve block: the uniquely American medical enigmaA more humane circumcision
|trans-title=
|language=English |journal=Urol Clin North AmPediatrics
|location=
|date=19851997-08 |volume=12100 |issue=12 |pages=123-32e3 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/general100/wallerstein2/e3
|archived=
|quote=
|pubmedID=3883617 9233974
|pubmedCID=
|DOI=10.1542/peds.100.2.e3 |accessdate=2020-11-1518}}</ref> however this clearly would not do for {{Box|Boxtext=<big><b>However, none of the avid pro-circumcision lobbyabove three procedures totally eliminate pain. No circumcision equals no fee for surgeryA baby boy will still experience some pain and [[trauma]] despite any of those analgesic procedures. The financial gain <ref name="bellini2022 /> Prevention of pain requires protecting a boy from discontinuing elective neonatal non-therapeutic circumcision is just too high to discard. Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or [[Dan Bollingertrauma]] .</b></big>}} Wallerstein (20121985) estimated that the total annual cost of non-therapeutic circumcision to Americans is $3,647,000,000.<ref>{{REFwebREFjournal |url=https://www.academia.edu/6442587/High_Cost_of_Circumcision_3_6_Billion_Annually |archivedlast=Wallerstein |title=High cost of circumcision |trans-title= |language=English |lastfirst=BollingerEdward |firstinit=Dan |author-link=Dan BollingerEdward Wallerstein |publisheretal=Academiano |websitetitle= |date=2012 |accessdate=2020Is non-11-15 |format=PDF |quote=}}</ref> The avaricious American [[religious 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 |url=https://www.drugs.com/pro/emla.html#s-34069-5 |archived= |title=EMLAnecessary?
|trans-title=
|language=English |lastjournal=J Am Acad Child Psychiatr |firstlocation= |authordate=1985-link05 |volume=24 |issue=3 |publisherarticle=Drugs.com |websitepage= |datepages=2020-04364-215 |accessdateurl=2020-11-21http://www.cirp.org/library/pain/gunnar1984/#wallerstein |formatarchived=
|quote=
|pubmedID= |pubmedCID= |DOI= |accessdate=2021-07-0}}</ref> * and [[Dorsal penile nerve blockRobert S. Van Howe| Dorsal Penile Nerve BlockVan Howe]] (DPNB) as proposed by Kirya & Werthman Cold (19781998).<ref name="kirya1978">{{REFjournal |last=KiryaVan Howe |first=ChristopherRobert S. |init=CRS |author-link=Robert S. Van Howe |last2=Werthman JrCold |first2=Milton WChristopher J. |init2=MWCJ |author2-link=Christopher J. Cold
|etal=no
|title= Neonatal circumcision and penile dorsal nerve block—a painless procedure. |trans-title= |language=EnglishLocal Anesthesia For Infants Undergoing Circumcision |journal=J PediatrJAMA
|location=
|date=19781998-0604-15 |volume=92299 |issue=615 |article= |page= |pages=9981169-100071 |url=http://www.cirp.org/library/pain/kirya1lander/letters.html
|archived=
|quote=
|pubmedID=660375
|pubmedCID=
|DOI=10.1016 |accessdate=2021-07-08}}</s0022ref> have suggested that it would be better to abandon the practice of non-3476therapeutic infant circumcision because of the pain associated with it. The ''Daily Mail'' (782021)80386reported the pain stress of non-2 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]].<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://www.dailymail.co.uk/health/article-5998771/Circumcising-newborn-boys-increases-risk-cot-death-stress-procedure.html |last=Thompson |first=Alexandra |coauthors= |publisher=Daily Mail |website= |date=2021-07-27 |accessdate=20202021-1108-1602 |quote=
}}</ref>
|author2-link=
|etal=no
|title=PostAttitudes and practices regarding analgesia for newborn circumcision |trans-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penistitle= |language=English |journal=AnesthesiologyPediatrics
|location=
|date=19871993-08-3110 |volume=6792 |issue=34 |pages=399541-4023 |url=https://pediatrics.aappublications.org/content/92/4/541?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
|archived=
|quote=
|pubmedID=33075338414824
|pubmedCID=
|DOI=10.1097/00000542-198709000-00019
|accessdate=2020-11-18
}}</ref> Ring block is considered }} Ryan & Finer (1994) carried out a training program for physicians in the most effective analgesic procedure for neonatal 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 circumcisionneonatal circumcisions had started to use analgesia during the procedure. Infant boys feel less pain and suffer less trauma than with the other two pain reduction proceduresThis applies to one hospital in [[Canada]].<ref name="lander1997"/><ref name="stang1997ryan1994">{{REFjournal |last=StangRyan |first=Howard JC.Anthony |init=HJCA
|author-link=
|last2=SnellmanFiner |first2=Leonard WNeil N. |init2=LWNN
|author2-link=
|etal=no
|title=Beyond dorsal penile nerve block: A more humane Changing attitudes and practices regarding local analgesia for newborn circumcision.
|trans-title=
|language=English |journal=PediatricsPedatrics
|location=
|date=19971994-08 |volume=10094
|issue=2
|pages=e3230-3 |url=https://pediatrics.aappublications.org/content/10094/2/e3230
|archived=
|quote=
|pubmedID=92339748036079
|pubmedCID=
|DOI=10.1542/peds.100.2.e3 |accessdate=2020-11-1819}}</ref> (Non-therapeutic neonatal circumcisions are no longer performed in most Canadian hospitals.)<ref name="jamesloewen2019">[[James Loewen]] (2019). Personal communication.</ref>
|init=
|first= |author-link=Edward Wallerstein |last2=Yaster |init2= |first2= |author2-link=
|etal=no
|title=Is non-religious circumcision necessary?Analgesia for neonatal circumcisionː No more studies, just do tt
|trans-title=
|language=English |journal=J Am Acad Child PsychiatrArch Pediatr Adolesc Med
|location=
|date=19851999-05 |volume=24153 |issue=5 |pages=444-5 |url=https://jamanetwork.com/journals/jamapediatrics/article-abstract/346832 |archived= |quote= |pubmedID=10323622 |pubmedCID= |DOI=10.1001/archpedi.153.5.444 |accessdate=2020-11-21}}</ref>}} The [[American Academy of Pediatrics]] convened a new task force on circumcision under the chair of Carole M. Lannon, {{MD}}. That task force reversed the position previously taken under [[Edgar J. Schoen]]. It clearly stated that non-therapeutic infant circumcision is "not essential to the child’s current well-being." It provided an extensive discussion of procedural analgesia and said, quite strongly, that, if a circumcision is done, procedural analgesia should be provided.<ref name="aap1999">{{REFjournal |last=Lannon |first=Carole M. |init= |author-link= |etal=yes |title=Circumcision policy statement |journal=Pediatrics |date=1999-03 |volume=103 |issue=3 |article= |page= |pages=364686-593 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/pain103/gunnar19843/#wallerstein686
|archived=
|quote=
|pubmedID=10049981
|pubmedCID=
|DOI=https://doi.org/10.1542/peds.103.3.686 |accessdate=2021-07-012}}</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 [[Robert Sanesthesia. Van Howe|Van Howe]] & Cold (1998)"<refname="kraft2003">{{REFjournal |last=Van HoweKraft |firstinit=Robert S.NL |initfirst=RSNancy L |author-link=Robert S. Van Howe |last2=Cold |first2=Christopher J. |init2=CJ |author2-link=Christopher J. Cold
|etal=no
|title=Local Anesthesia For Infants Undergoing CircumcisionA pictorial and video guide to circumcision without pain |journal=JAMAAdv Neonatal Care
|location=
|date=19982003-04-15 |volume=2993 |issue=15 |article= |page=2 |pages=116950-7162 |url=httphttps://wwwjournals.cirplww.orgcom/libraryadvancesinneonatalcare/painAbstract/lander2003/letters04000/A_PICTORIAL_AND_VIDEO_GUIDE_TO_CIRCUMCISION.2.htmlaspx
|archived=
|quote=
|pubmedID=12881947
|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 [[circumcised]]10.<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:/1053/wwwadnc.dailymail2003.co.uk/health/article-5998771/Circumcising-newborn-boys-increases-risk-cot-death-stress-procedure50015.html |last=Thompson |first=Alexandra |coauthors= |publisher=Daily Mail |website= |date=2021-07-27 |accessdate=20212020-0811-02 |quote=18
}}</ref>
===Historic attitudes and practices=Standard of care==
|author-link=
|etal=no
|title=Attitudes and practices regarding analgesia for newborn Neonatal circumcision |trans-title= |language=Englishrevisited |journal=PediatricsCMAJ
|location=
|date=19931996-1003-15 |volume=92154 |issue=46 |article= |page= |pages=541769-380 |url=https://pediatricswww.aappublicationsncbi.orgnlm.nih.gov/contentpmc/92articles/4PMC1487803/541?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000pdf/cmaj00090-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token0027.pdf
|archived=
|quote=
|pubmedID=84148248634956 |pubmedCID=1487803
|DOI=
|accessdate=20202021-07-11-18}}</ref><ref name="racp2010">{{REFdocument |title=Circumcision of Infant Males |url=https://www.racp.edu.au//docs/default-source/advocacy-library/circumcision-of-infant-males.pdf?sfvrsn=eaa32f1a_10 |contribution= |last= |first= |publisher=[[Royal Australasian College of Physicians]] |format=PDF |date=2010-09-01 |accessdate=2021-07-11}}</ref><ref>{{REFdocument |title=Non-therapeutic circumcision of male minorsRyan & Finer (1994) carried out a training program for physicians in the newborn nurseries of the Womens' Pavilion, [ |url=https://wwwpool.albertahealthservicesintactiwiki.caorg/rahimages/rahKNMG-viewpoint-Non-therapeutic-circumcision-of-male-minors-27-05-2010-v2.aspx pdf |contribution= |last= |first= |publisher=Royal Alexandra Hospital]Dutch Medical Association (KNMG) |format=PDF |date=2010-05-27 |accessdate=2021-07-11}}</ref> Circumcision excises the highly functional foreskin, which provides numerous protective, immunological, sensory, Edmontonand sexual functions, Alberta<ref name="cold1999">{{ColdCJ TaylorJR 1999}}</ref> so it is an irreversible, Canadalasting injury. After a training program, they found Bellini (2022) considered that 66 percent the pain of neonatal circumcision "can have long term consequences for the developing child."<ref name="bellini2022 /> Non-therapeutic circumcision of physicians who perform male minors is ''not'' the standard of care. Nevertheless, some non-therapeutic neonatal circumcisions had started of boys will continue to use analgesia during be performed for religious reasons, ethnic reasons, and the procedure[[Adamant father syndrome| emotional needs of parents]]. This applies to one hospital in When a [[Canadacircumcision]]is to be performed, the standard of care requires that analgesia be provided to reduce the extreme level of pain and trauma.<ref name="ryan1994poland1987"/><ref name="cps1996"/><ref name="lander1997"/><ref name="aap1999"/> (Total anesthesia cannot be used with infants.) The Australian Association of Paediatric Surgeons (AAPS) (1996) opposed the practice of infant circumcision, but recognized that it would be performed for religious, cultural, or family reasons, in which case, the non-therapeutic [[circumcision]] should be deferred for six months, so that general anesthesia may be used. The AAPS stated: <blockquote>In this event the procedure should be performed electively after six months of age. When performed, it should be carried out by a surgeon performing circumcisions on children on a regular basis with an anaesthetist using appropriate techniques. This would imply that the anaesthetist is fully trained in the art of paediatric anaesthesia, including the ability to perform caudal and penile regional or local anaesthesia. The operation should be carried out in a paediatrically orientated environment, designed to reduce the risk to the child and providing support to the parents or caregivers.<ref>{{REFjournalREFdocument |title=Guidelines for Circumcision |url=https://www.cirp.org/library/statements/aaps/ |contribution= |last=RyanLeditshke |first=C. AnthonyJF |publisher=Australasian Association of Paediatric Surgeons |location=Herston, QLD, Australia |format= |initdate=CA1996-04 |authoraccessdate=2024-01-22}}</ref></blockquote> The practice of non-linktherapeutic circumcision of boys has nearly died out in [[Australia]]. == Pain's injury to the infant nervous system == Anand & Hickey (1985) conclusively demonstrated that infants feel pain and feel it more intensely than adults.<ref name="anand1987"/> Pain researcher Maria Fitzgerald (1998) reported the sensitivity of the infant nervous system to extreme pain: <blockquote>We and others have established that the developing nervous system is even more vulnerable to injury than in adults and that changes to the pathways induced shortly after birth can become permanent. This is because newborn nerve damage not only results in the death of sensory nerve cells, but causes other sensory nerve terminals to sprout extensively and occupy areas normally exclusively devoted to the damaged nerve.<ref>{{REFjournal |last2last=FinerFitzgerald |first2first=Neil N. |init2init=NNM |author2author-link= |etal=no |title=Changing attitudes and practices regarding local analgesia for newborn circumcision.The Birth of Pain |trans-title= |language=English |journal=PedatricsMRC News |location= |date=1994-081998 |season=Summer |volume=94 |issue=2 |article= |page= |pages=23020-323 |url=https://pediatricswww.aappublicationscirp.org/contentlibrary/94pain/2fitzgerald/230
|archived=
|quote=
{{Citation
|Text=DESPITE THE DEBATE that continues over The public health importance of abnormal stimulation during the benefits and risks of nonritual neonatal circumcision, it remains a commonly performed surgical procedure in the United Statesperiod cannot be overemphasized. To the best of our knowledgeWhile programs for formulating appropriate health policies and public education campaigns must disseminate this message, 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 prematurelyalso important for these effects to be investigated, are capable of experiencing pain. Indeed, anyone present during particularly with a circumcision realizes that view to developing effective therapeutic strategies for the newborn feels growing children and responds adolescents who were exposed 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 abnormal conditions 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 changesneonatal period. |Author=Maxwell Anand & Yaster Scalzo (19992000) |ref=<refname="anand2000">{{REFjournal |last=Maxwell |init=Anand
|first=
|init=KJS |author-link=Kanwaljeet J. Singh Anand |last2=Yaster |init2=Scalzo
|first2=
|init2=FM
|author2-link=
|etal=no
|title=Analgesia for Can adverse neonatal circumcisionː No more studies, just do ttexperiences alter brain development and subsequent behavior?
|trans-title=
|language=English |journal=Arch Pediatr Adolesc MedBiol Neonate
|location=
|date=19992000-0502 |volume=15377 |issue=52 |article= |page= |pages=44469-582 |url=httpshttp://jamanetworkwww.cirp.comorg/journalslibrary/jamapediatricspain/article-abstractanand4/346832
|archived=
|quote=
|pubmedID=1032362210657682
|pubmedCID=
|DOI=10.10011159/archpedi.153.5.444000014197 |accessdate=20202021-1108-2109
}}</ref>
}}
|author-link=
|last2=Walker |first2=Suellen |init2=S
|author2-link=
|last3year= |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=yes2003 |title=Circumcision policy statementThe role of activity in developing pain pathways |trans-title= |languageurl=http://www.cirp.org/library/pain/fitzgerald2/ |journalwork=PediatricsProceedings of the 10th World Congress on Pain |locationeditor=Dostovsky JO, Carr DB, Koltzenburg M (eds) |dateedition=1999-03 |volume=103 |issue=3 |article=24 |pagechapter= |pages=686185-9396 |urllocation=https://pediatrics.aappublications.org/content/103/3/686Seattle |archivedpublisher=ASP Press |quoteisbn= |pubmedID=10049981 |pubmedCIDquote= |DOI=https://doi.org/10In common with other areas of the central nervous system, synaptic development of spinal sensory connections is experience or activity dependent.1542/pedsEvidence 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.103While these studies are incomplete and more investigation is needed in this area, the potential clinical importance of neonatal plasticity in pain development is clear.3.686 |accessdate=20212020-0711-1218 |note=
}}</ref>
|etal=no
|title=A pictorial Psychological, psychosocial, and video guide to psychosexual aspects ofpenile circumcision without pain |trans-title= |language= |journal=Adv Neonatal CareInt J Impot Res
|location=
|date=20032022-0403-28 |volume=3 |issue=2 |article= |page= |pages=50-62 |url=https://journalswww.lwwnature.com/advancesinneonatalcarearticles/Abstract/2003/04000/A_PICTORIAL_AND_VIDEO_GUIDE_TO_CIRCUMCISION.2.aspxs41443-022-00553-9
|archived=
|quote=
|pubmedID=1288194735347302
|pubmedCID=
|DOI=10.10531038/adnc.2003.50015.s41443-022-00553-9 |accessdate=20202022-1104-1829
}}</ref>
</blockquote>
==Videos==
=== Infant circumcision procedure ===
|trans-title=
|language=
|journallast=CMAJ |locationfirst= |date=1996-03author-15 |volumelink=154 |issuepublisher=6 |articlewebsite= |pagedate= |pagesaccessdate=7692022-80 |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1487803/pdf/cmaj0009003-0027.pdf11 |archivedformat=
|quote=
=== Infant circumcision procedure Ronald Goldman===This is a video of an actual infant circumcision. It has a sound tract so one can hear the comments of the doctor and the sounds made by the infant. The doctor gives an injection of local anesthetic that apparently does not stop any pain at all. The infant goes silent at about 6:15 on the video, so he may have gone into [[shock]] at that time. Not for the squeamish:
<youtube>lNItNHs9PR8</youtube>
|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 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.
{{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
|format=PDF
|accessdate=2023-10-09
}}
* {{REFweb
|accessdate=2023-08-18
}}
* {{REFweb
|url=https://intactamerica.org/timeline-of-circumcision-suffering/
|title=A Timeline of Circumcision Suffering: A Detailed Look
|last=Garrett
|first=Connor
|init=
|publisher=Intact America
|date=2024-02-02
|accessdate=2024-02-09
}}
{{ABBR}}
{{REF}}