Circumcision

"Male circumcision (from Latin circumcidere, meaning "to cut around") is the surgical removal of the foreskin (prepuce) from the human penis. [...] The procedure is most often an elective surgery performed on neonates and children for religious and cultural reasons, but in other cases may be indicated for both therapeutic and prophylactic reasons. It is a treatment option for pathological phimosis, refractory balanoposthitis and chronic urinary tract infections (UTIs); it is contraindicated in cases of certain genital structure abnormalities or poor general health." (Source: Wikipedia)

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The following text is taken from the Circumpendium.

Contents

Non-medical indications for circumcision

Apart from the medical indication of pathological phimosis, there also are other reasons for circumcision.

Aesthetic reasons

The visual appearance of the penis is changed radically after circumcision. In this case, personal taste is decisive whether an intact or a cut penis is more appealing. Since a circumcision cannot be undone, it is essential to be fully informed about the risks and possible later complications before embarking on an aesthetically motivated circumcision, to decide whether the appearance will justify such bodily modification.

Since this modification and its possible late effects will be the lifelong burden of the person who undertakes an aesthetically motivated circumcision to suit his personal preferences, a valid decision to proceed can only be made by the person to be circumcised himself, once he has reached the necessary age and level of maturity to make that decision. This should normally be the case when adulthood is reached.

Moral reasons

With the foreskin, circumcision removes approximately 70% of the sensitive tissue of the penis, lowering the potential for sexual stimulation accordingly. Due to the loss of around 50% of the entire penile skin, the penis loses the reserve skin that provides cutaneous mobility in the erect penis and the gliding action.

In the past, this circumstance was used to make it harder for boys to masturbate, as masturbation was viewed as immoral and was assumed to cause a variety of diseases. More on that can be found in the chapter "historical background". Today, it is known that masturbation has no negative health effects, but can contribute positively to the child's sexual development. Sexuality is no longer a taboo nowadays, while masturbation is considered to be a natural part of human sexuality and is no longer seen as immoral. Therefore, circumcision for moral reasons - which would only affect boys too young to give informed consent - is no longer justifiable nowadays.

Hygiene reasons

A common reason stated for circumcision is the assumption of hygienic benefits. This argument has to be viewed in the context of the environment the person in question grows up in. It is commonly known that bad hygienic circumstances, especially insufficient access to clean drinking water, pose a serious problem. The situation in disaster areas or refugee camps in the so-called third world keep reminding us of that.

In western industrial nations, however, this problem does not exist, in view of the availability of clean water for daily personal hygiene. If the cleaning of the genitals is performed on a daily basis - and that may be assumed - no pathogens can accumulate under the foreskin. Cleaning of the glans and the area underneath the foreskin is easy - they are simply washed along with the rest of the body, just like the areas between the toes.

In small boys, where the foreskin cannot be retracted yet, cleaning is not necessary, since the membrane that fuses the foreskin to the glans prevents the accumulation of micro-organisms. The so-called "ballooning", where the foreskin inflates during urination, is not a serious problem.

The opening of the foreskin in small boys is often quite narrow and serves as a one-way valve, allowing the urine to flow out, but preventing entry of microbes, for example from a dirty diaper. As long as the child is able to pass water, everything works as nature intended.

But even in areas where there are poorer hygienic conditions and an insufficient access to medical care, the benefits of easier cleaning of a circumcised penis are to be viewed with a critical eye. Although even longer periods without personal hygiene will not result in an accumulation of germs under the foreskin, circumcision itself is not without risk of complications. If the operation is carried out without proper sterility, there is a high risk of an infection of the wound. This also applies to the treatment of common complications like post-operative bleeding.

The benefit of easier cleaning must be balanced against the risk of promoting serious infections - among others HIV - during the operation. In parts of Africa, several dozen of one tribe's boys die each year as a result of their circumcision.

Prophylactic reasons

Some people claim that circumcision has prophylactic benefits. Especially in the USA those arguments have persisted for more then a 100 years, with ever changing diseases circumcision is said to protect against. At first, these were diseases where masturbation was believed to be the cause. After bacteria and viruses had been discovered, arguments changed, and one after another miscellaneous diseases were cited.

• Phimosis: as mentioned earlier, true phimosis is rare and can be treated effectively without surgery. According to a study by Blalock et.al. (2003), 2.9% of those circumcised develop a post-operative phimosis, in which the circumcision scar constricts. In intact patients, the rate of phimosis is only 1% (see also the study by Jakob Øster above). Therefore, circumcision is not a preventive measure for phimosis.
• Sexually Transmitted Diseases (STDs): a vast number of studies has been conducted on the subject of transmission of STDs.
• First, it has to be noted that any form of protection against these diseases only affects people who are sexually active. Circumcision in childhood cannot be justified on these grounds, since any assumed protective effect will not occur before the boy is already old enough to decide about circumcision for himself.
• As mentioned above, the foreskin keeps the glans moist. This subpreputial moisture contains, among other substances, the enzyme lysozyme, which breaks up the cell wall of bacteria, thereby providing a natural antibacterial screen. This explains the results of several studies, such as Laumann et.al., which found a higher rate of infection with bacterial venereal diseases in circumcised than in intact men.
• The studies by Fleiss et.al. support this. According to the AAP, the general sexual behaviour of the male - such as frequent change in partners and the use of condoms - has a much higher impact on sexually transmitted diseases then the circumcision status.
• HIV / AIDS: in the recent past, the argument that circumcision could help to contain the spread of HIV has been stated numerous times.

  First, two notes: for one, the use of condoms is still by far the most effective protection against an infection. During intercourse with that preventive measure, circumcision status does not make a difference.

  Secondly, the assumed protection would only affect healthy men who have intercourse with an infected woman. An infected man can infect a women by transmission of his bodily fluids, so that his circumcision status is irrelevant. Therefore, the use of condoms remains vital in containing the spread of HIV, which in return renders circumcision unnecessary

• Due to the inevitable loss of sensitivity as a result of circumcision, there is also the temptation to go without condoms, in order not to lose even more sensitivity.
• Two studies that have been published in early 2007, which investigated the effectiveness of circumcision as a means of reducing the spread of HIV from infected women to heterosexual men in African high risk areas, have been repeatedly subjected to strong criticism. Both studies were ended prematurely, which distorted the results. The men who had been circumcised for the study had to stay sexually inactive during the wound healing, which gave the intact control group more relative opportunity to become infected. The fact that the USA has both the highest rate of circumcised males in the western world, as well as the highest HIV infection rate, makes the studies look dubious. Besides that, several other studies concluded that circumcision does not have a significant impact on the risk of infection with HIV.
• Urinary tract infections (UTI): a UTI can be effectively treated with antibiotics, this was also proven by studies. A Swedish study found that, during the first 6 years of life, the incidence of UTIs in boys was 1.8%, but in girls was 6.6%. UTIs are less common in boys after the first year of life. Mueller et.al. did not find a significant difference in UTI rates between circumcised and intact boys with normal urinary tract anatomy.
• Other studies suggest that circumcision is more likely to raise than to lower the generally low risk of acquiring UTI: multiple studies from Israel showed a strong correlation between ritual circumcision on the 8th day of life and postoperative UTI.
• It can be concluded that circumcision is ineffective as a preventive measure against UTIs.
• Penile and cervical cancer / HPV: first studies on those diseases and their assumed prevention by circumcision date back to 1932, a time when the cause for those illnesses was not yet fully understood

. Today, it is known that sexually transmitted human papillomavirus (HPV) is a major risk factor, as well as smoking. Studies have shown that there is no significant difference in the risk of getting penile cancer between circumcised and intact men. To prevent a single case of penile cancer, it would statistically take 600 to 900 circumcisions. The influence of circumcision on the infection risk of the female partner with cervical cancer has been refuted several times as well. HPV vaccination is an effective measure against carcinoma of the cervix.

In conclusion, circumcision does not provide any proven benefits in preventive medicine.

Circumcision in detail: Styles, techniques and instruments

During circumcision, the foreskin of the penis is partly or completely removed. The exact amount and type of skin removed depends on the style and technique used, and therefore also on the tools being used.

First, a look on the common styles:

High & Tight

This style is the most common in the USA. In this style, the outer foreskin, parts of the inner foreskin and parts of the shaft skin are removed.

The remaining part of the inner foreskin is folded back and sewed to the shaft skin. The scar is located closer to the body, hence the term "high".

The inner foreskin, which originally faced inwards lying on the glans, now faces outward; this causes the differently coloured section between glans and shaft skin which is characteristic for this style.

Of all styles, the tight ones remove the most skin. They already limit the mobility of the penile skin to a great extent when the penis is flaccid, and during an erection the skin is fully stretched and immobile. An insufficient amount of reserve skin can hamper a complete erection and lead to painful tension. Also, a skewed penis can occur due to an uneven distribution of the remaining skin, often caused by an inaccurately placed cut or a uneven growth during wound healing. Due to the extensive shortening of the inner foreskin, this style also means the loss of large amounts of sensitive tissue.

Low & Tight

In this style, both the inner and outer foreskin are completely removed. The shaft skin is sewed just below the rim of the glans. The scar is located close the glans, hence the term "low".

This style is the most radical, as it removes the entire sensitive tissue of the foreskin. As in the high & tight style, large amounts of skin are removed. In a flaccid state, the skin is barely movable, and in an erect state it is totally immobile.

An insufficient amount of reserve skin can hamper an erection and lead to painful tension and a skewed penis in this style as well.

High & Loose

hence the term "high". Unlike the high & tight style, the inner foreskin is less reduced, and lies in folds behind the glans.

There is enough remaining reserve skin to ensure a complete and unhindered erection. Of all variants, this one removes the smallest amount of sensitive tissue.

Low & Loose

The inner foreskin is removed, the outer foreskin is sewed on below the glans. The scar is therefore located close to the glans, hence the term "low". The outer foreskin lies in folds behind the glans. Enough skin is left in place to ensure a complete and unhindered erection.

Since, in contrast to the high & loose style, the inner instead of the outer foreskin is removed, this style results in the loss of almost all of the sensitive tissue.

Techniques and instruments

Over time, a vast variety of methods has been developed to remove the foreskin. A multitude of clamps and tools is available to ease the work of the circumciser, to improve the chance for visually symmetrical results and to prevent injuries to the glans from inexpert cuts. I will introduce some of the most widely spread variants.

Freehand-techniques

The oldest method of removing the foreskin uses just a few instruments. In the simplest case, the foreskin is pulled out with a cord, a knife is placed directly above the glans, and the skin finally cut with a hit on the blunt edge of the knife. No stitches are placed and the skin is left to grow together naturally.

In modern operating theatres the foreskin is first grasped with forceps, pulled out and clamped above the glans for a while to reduce bleeding. Next, the skin is cut along the forceps with a scalpel. Following that, the remaining skin is manually trimmed according to the desired style and finally sutured.

Completely freehand techniques are also common. The penile skin is first cut in two places along the circumference, in the area of the shaft skin and foreskin. After that the skin area between the cuts is removed and the remaining skin sutured.

Also among the freehand techniques are the shield variants.

Jewish clamp

In ritual Jewish circumcision the foreskin in inserted into the slit of the shield (left) and then cut on the upper side of the shield.

Mogen-clamp

The Mogen-Clamp works in a similar way (middle), with the difference that it is locked shut after the foreskin is inserted, thus clamping it. After a few minutes the foreskin is cut in the same fashion as with the simple shield. The clamping is meant to reduce or prevent bleeding from the wound.

Sheldon-Clamp

The Sheldon-Clamp (right) works in a similar way. The inner clamp grasps the tip of the foreskin, pulling it into the outer clamp which is closed. The outer clamp then grips the skin. After a few minutes of pressure, the foreskin is cut between the two clamps.

The use of a shield, rather than forceps, is meant to provide a better protection of the glans from cutting injuries. However, if used improperly both the Mogen and the Sheldon clamp are subject to the risk of the tip of the glans being accidentally clamped and being cut into or severed.

Complex clamps

Gomco clamp

One of the most widely used clamps in the USA is the Gomco clamp. First, a cut is placed into the foreskin, then the metal bell is placed over the glans. After that, the bell, together with the foreskin, is pulled through the opening in the base plate and hung into the lever. By fastening the screw the lever pulls the bell upwards, jamming the foreskin between bell and base plate. After several minutes of clamping, the skin is cut off with a scalpel along the upper side of the base plate and the clamp removed.

plastibell method

In the plastibell method, the skin is first cut lengthwise, then a plastic ring is placed over the glans and the foreskin pulled over it. A tightly tied string is used to fix the foreskin to a rim in the ring, thereby strangulating it.

The tissue beyond the string is cut off and the bell's handle cracked off. The strangulated tissue dies off in the following days, and the ring falls off on its own. Since this form of circumcision means part of the process goes on without medical supervision, it may not be possible to intervene promptly in the event of swelling; also there is a risk of the ring being removed prematurely due to external influence. This may cause the healing wound to burst open, necessitating additional suturing.

Smartclamp

The Smartclamp and a couple of similar designs are one way clamps, representing a mixture of the Gomco and Plastibell methods. The glans is inserted into the plastic tube, the foreskin pulled over it. The base plate of the outer clamping mechanism is pushed over the foreskin and cocked shut, jamming the foreskin between the bulging lower rim of the tube and the lower base plate. The foreskin is now cut off along the upper side of the base plate. The entire clamping mechanism remains on the penis, until it - like the plastibell - falls off by itself after the clamped skin dies off in the following days.

All of these methods have in common that the foreskin has to be separated from the glans first. In case of the circumcision of a child, it is in most cases (see chart above) necessary to forcibly tear apart the balanopreputial membrane, which fuses the foreskin to the glans, either by violently retracting the foreskin or separating it by pushing a blunt instrument underneath the foreskin, both of which can result in injuries and inflammations of the glans.

Risks and late effects

Just like tonsil or appendix surgery, circumcision is a surgical intervention and brings the usual risks related to surgical operations, alongside several specific risks of complications and late effects.

Possible operative and postoperative complications

• Intolerance or allergic reactions to the narcotics used.
• Especially in newborns, where the bodily pain reduction mechanisms are not yet fully developed, local anaesthesia is often insufficient for the operation. Even in conjunction with regional anaesthesia of the dorsal nerve of the penis, the rate of failure to provide sufficient anaesthetic even for experienced anaesthetists is still 5-10%. The general anaesthesia that would be needed for newborns, however, poses significant risks for the child, and, therefore, is only likely to be used in emergencies. A surgical operation without proper pain control can lead to the development of a specific pain memory. In unsedated and partially sedated infants increased secretion of the stress hormone cortisol could be observed for months after the operation. Overall, their pain threshold was lower and the risk of chronic pain increased. Regardless of these findings, infant circumcisions with insufficient or no anaesthetic are still common practice. During procedures which take several minutes, babies tend to fall into a state of stupor, which in the past was falsely interpreted as peaceful sleep, nurturing the belief that babies felt no pain. Measurements taken in those cases revealed a typically 3- to 4-fold increase in cortisol levels, which equals a state of severe shock.
• Postoperative wound pain, in the case of children's circumcisions conceivably worsened by the forceful breaking of the preputial adhesions.
• Postoperative bleeding of the wound. This can have severe consequences especially for very young infants, if they are not treated promptly. Their blood volume is only about 85 ml per kilogram of body weight, and even moderate blood loss can lead to hypovolaemia, hypovolaemic shock and even death.
• Postoperative infections. This includes both local infections, which can be treated with local therapy, and systemic infections, requiring systemic antibiotic treatment.
• Wound dehiscence, meaning the separation of the edges of the wound or the tissue after suturing.
• Adhesion between the surface or rim of the glans with the neighbouring penile skin, causing skin pockets and bridges, as well as visually unpleasant results like uneven scars, which make a re-circumcision necessary.
• Postoperative phimosis: a phimotic ring can develop during scarring, which makes a re-circumcision necessary. According to a study by Blalock et.al., the prevalence is 2.9%, according to Leitch 5.5%.
• Meatal stenosis, a pathological narrowing of the opening of the urethra, which mostly occurs in infancy and early childhood. It is one of the most common complications of infant circumcision. A study from 2006 found meatal stenosis exclusively in previously circumcised boys. The incidence rate after a circumcision is at approximately 10%.
• Knot formation of the veins. If the dorsal vein, which originates in the tip of the foreskin, is cut during circumcision without being clamped and sutured at its origin separately, it starts to develop new branches over time, which can lead to the development of knots.
• Possible deformities due to circumcision include hypoplasia of the penis (micro-penis) and induratio penis plastica (skewed penis).
• Medical malpractice can also not be ruled out. Injuries, partly or entirely severing the glans or the penis can occur.
• In rare cases, necrosis, gangrene, ischaemia, keloid formation and circulatory problems may also occur.
• When the circumcision is followed by the ultra-orthodox Jewish ritual of Metzitzah B'Peh (which consists of sucking blood from the wound with the mouth), there is a risk of infection with herpes simplex type 1, which can lead to brain damage or death.

Physical late effects

• An unavoidable late effect of any circumcision is the permanent loss of sexual sensitivity. This is partly due to the removal of sensory tissue. The foreskin contains approximately 20,000 nerve endings and touch receptors, which account for the major part of male sexual sensation. If the foreskin is removed, they can no longer provide sexual stimulation. It is also partly due to the fact that the surface of the glans reacts to the missing protection from friction and drying out by developing a callus layer. This reduces the sensitivity of the remaining nerves in the glans gradually over the years. The study conducted by Sorrells et.al. found a significant reduction of sensitivity to touch for circumcised compared to intact penises in adult males. Other studies revealed that circumcised men use condoms significantly less often than intact men, since they further limit the sexual sensitivity (see above).
• Painful tension can occur when there is too little reserve skin left to support a full erection. This risk is partly dependent on the anatomy of the penis. While some penises already have the majority of their full size when flaccid (Flesh Penis, or "shower"), others are rather short when flaccid and double or more their size during an erection (Blood Penis, or "grower"). Especially in children's circumcision, where the penis is not yet fully developed, the amount of reserve skin needed in adulthood cannot be estimated.
• Erectile dysfunction: Both the damage inflicted to the blood vessels in the foreskin and the reduced sexual sensitivity can be causes for reduced erectile function with advancing age.
• Orgasm problems: In the wake of reduced sexual sensitivity, due to the loss of sensory tissue and gradual keratinization of the surface of the glans, orgasm problems may develop with increasing age. In this case, the sexual arousal created by intercourse or masturbation is not enough to achieve orgasm. A preliminary stage of this late effect is the prolonged time circumcised men need to reach an orgasm. This is often fielded as the "cut men have more endurance" argument for circumcision.
• Vaginal dryness: Due to the loss of the natural gliding action, which comes from the mobility of the fore- and shaft skin, a much increased friction between penis and vagina occurs during intercourse. This can make intercourse painful for both partners and lead to abrasions The prolonged time it takes circumcised men to reach orgasm, as well as the often longer and more vigorous thrusting movements - compared to intact men - play a part in this.

Psychological late effects

Psychological late effects are also possible after a circumcision, especially if the operation was carried out in childhood. On this occasion a variety of trauma may occur, which depend, among others, on age and circumstances of the circumcision. For example, whether the circumcision took place with or without sufficient anaesthesia, if the individual has been informed about the operation beforehand, if he was circumcised against his will or without his consent, and also, in the case of infant circumcision, if he was told about it during childhood or had to find it out coincidentally on his own.

The psychological late effects of circumcision are not yet fully researched, and many studies took place on rather a small scale. This situation needs to be rectified, because the available studies, as well as the histories of negatively affected men, suggest that these late effects may have more impact than previously assumed.

• It was observed that infants, following circumcision without pain control, had a disturbed bond with their mother, as well as problems with nurturing, up to the point of refusal to be fed. The sleeping habits of these babies were also disturbed, with prolonged non-REM sleep and increased waking.
• In boys circumcised in childhood, post traumatic stress disorder (PTSD) could be diagnosed. In a study on Philippine boys, in whom no PTSD was found prior to the operation, 69% of the boys circumcised in the traditional ritual and 51% of those circumcised by standard medical procedures (including anaesthesia) fulfilled the DSM-IV criteria for PTSD following the operation.
• Circumcisions, especially those that happen without consent, can spark feelings of helplessness and alienation, which can persist as trauma. These feeling can also be triggered later, when someone circumcised as an infant becomes aware of his circumcision. In an online study, interviewed men stated they felt betrayed - 55% by the mother, 50% by the father, and 58% by the doctor, and 73% felt that their human rights had been violated.
• It can frequently be found that the loss is denied, much as happens with the loss of other body parts. This denial can lead to fathers having their sons circumcised in order not to be reminded of their own loss. In this process, their own body is defined as "normal" and the foreskin redefined as a foreign object. Their own parents are seen as "good", so that this image is projected onto the circumcision their parents carried out as well, in order to keep the positive emotion intact. The father wants to be a "good" father later in life as well, and so, following an idealised image of his own parents, circumcision, which has been redefined as a "good thing", is passed on to his son by having him circumcised as well.
• If the circumcised male feels incomplete, or due to the missing foreskin disadvantaged compared to intact males, an inferiority complex and depression may occur. This can be accompanied by conscious recognition of his own incompleteness, or the deficiency may remain completely subconscious. In an online study, 75% of those interviewed stated that they felt incomplete, and 66% said they felt inferior compared with intact males.
• Cases in which children felt ill treated or punished have been documented as well. G. Cansever found in her study on 12 boys aged between 4 and 7 years, who had previously been prepared for their impending circumcision, that the children experienced the operation as an aggressive assault on their bodies.
• Fear of being alone or darkness.
• Fear of doctors, clinics and also closed rooms.
• Relapse into the state of bed-wetting, even if the child was already dry before.

Historical background

The amputation of the foreskin is a very old ritual, whose exact origin cannot be verified beyond doubt. Medical historians assume that circumcision already served in ancient history as a way to control the sexuality of slaves and members of the lower classes without compromising their ability to reproduce. In religious history circumcision may be seen as a substitute for human sacrifice. In prehistoric times it was not uncommon to placate the gods with human sacrifice. Castration of slaves or conquered enemies was common as well. Following religious changes this sacrifice was altered, and only a part of the very organ responsible for the creation of new life was sacrificed.

For the Aborigines, the Australian natives, the tradition of circumcision is said to go back to 10,000 BC. On the African continent, the first circumcisions are assumed to have emerged around 6000 BC. From ancient Egypt hints of various forms of circumcision date back to the time around 3000-2000 BC. The oldest known depiction is an Egyptian tomb relief from the 6th dynasty, approximately 2300-2000 BC. It is not known precisely who was circumcised and why in those times.

In many cultures circumcision during puberty serves as a rite of passage, bringing adolescents into the community. As with other painful or humiliating initiation rites, proof of courage and mastering of critical situations are the key motivations. From some African tribes it is also known that the amputation of the foreskin is seen as the removal of an inborn piece of femininity from the boys, thus making them men.

In the Jewish religion, the tradition of circumcision goes back to a passage in the Book of Genesis (17, 10-14). It is seen as a covenant between God and man, dating back to the patriarch Abraham.

“

10 This is my covenant with you and your descendants after you, the covenant you are to keep: Every male among you shall be circumcised. 11 You are to undergo circumcision, and it will be the sign of the covenant between me and you. 12 For the generations to come every male among you who is eight days old must be circumcised, including those born in your household or bought with money from a foreigner—those who are not your offspring. 13 Whether born in your household or bought with your money, they must be circumcised. My covenant in your flesh is to be an everlasting covenant. 14 Any uncircumcised male, who has not been circumcised in the flesh, will be cut off from his people; he has broken my covenant.” – Bible (Gen 17, 10-14, NIV)

According to the anthropologist and sociologist Nissan Rubin, the Jewish form of circumcision, called brit mila, during the first two millennia did not include the later customary periah, namely the complete scraping of the inner foreskin from the glans. This was only added around 135 AD, to make it impossible to restore the foreskin by stretching, which became popular in the wake of Hellenic influence. While originally only the tip of the foreskin was cut off, periah removes the entire foreskin. In the Greek society of the day, a denuded glans was considered obscene and risible. In ultra-orthodox communities, circumcision is followed by the mohel, the ritual circumciser, sucking blood from the wound with his mouth. This practice is highly controversial, as it can result in an infection with herpes simplex type 1. In New York City, between 2000 and 2011 eleven children were infected with herpes, 10 of whom had to be treated in hospital. Two of them suffered permanent brain damage, two others died. In the 12th century, the Jewish philosopher and doctor Maimonides pointed out that circumcision was necessary, as it diminished sexual desires and reduced the pleasure to a degree just sufficient for mere reproduction.

In Islam, circumcision is also religiously founded, even though there is no mention of it in the Koran itself. According to tradition, the Prophet Mohammed was born without a foreskin. It is seen as a sign of prophets that they are born without a foreskin already. It is considered an honour to "resemble the example of the Prophet", meaning to be circumcised. In Islam, unlike Judaism, there is no specific age at which the circumcision should be performed. Most circumcisions take place at ages between 6 and 10 years, but the range goes from birth to adulthood.

In Christianity, circumcision is only common in a few orthodox churches. Nevertheless, Christian moral notions had decisive influence on the spread of this practice. In the puritan influenced USA, circumcision of children was popular in the 19th century as a means to prevent masturbation. In those days, this so-called ‘self-abuse‘ was not only considered immoral, but was supposedly responsible for a variety of diseases. Even the mere existence of a foreskin was linked to many illnesses. Among them one could find syphilis, epilepsy, paralysis of the spine, bed wetting, scoliosis (spinal deformity), paralysis of the bladder, club foot, nerve pain in the lower abdomen, tuberculosis and lazy eye. One of the best known advocates of child circumcision was John Harvey Kellogg, co-inventor of the Corn Flakes bearing his name. In 1888, he wrote:

“

A remedy which is almost always successful in small boys is circumcision, especially when there is any degree of phimosis. The operation should be performed by a surgeon without administering an anaesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement, and preventing the recurrence of the practice in those whose will-power has become so weakened that the patient is unable to exercise entire self-control. – John Harvey Kellogg

Following the discovery of bacteria as a cause of many diseases – such as tuberculosis – the search began for other illnesses that could be prevented by circumcision.

In the 1920s it was penile cancer, in the 1940 prostate- and tongue cancer as well as STDs, in the 1950s it was cervical cancer, in the late 1960s it was neuroses, in the 1970s bladder- and rectal cancer, nd in the 1980s UTIs and AIDS followed. Retrospectively, circumcision was always advertised as a cure for whatever disease was in the public spotlight at the time.

The sheer mass of studies and publications that were released during those almost 180 years on this topic are the reason that even arguments that have been disproved multiple times, especially regarding infant and child circumcision, tenaciously persist up until today.

An ever-recurring element of initiation rites found in many different cultures is the fixation upon the genitalia.

It reflects the fascination that emerges from the ability to create new life. In most cultures, fertility is seen as the most precious good, and the body parts involved frequently find themselves in the focus of ritual acts. In many parts of the world, those rites take place when the boy reaches puberty, and are meant to symbolize his transition from boy to man. The removal of the male foreskin is just one of many phenomena that developed in this context. They range from the removal of the frenulum in boys and men through partial or complete removal of the foreskin up to radical operations. Australian Aborigines, as mentioned above, have their foreskins removed. It is also usual that, a few weeks later, young men have their penises sliced open, resulting in a partly or completely divided urethra.

Another known, particularly massive, intervention is the stripping of the entire skin off the penis. In Indonesia, boys have metal or bamboo balls inserted into their penis shaft or glans at the beginning of puberty, which form little "humps".

For many cultures it is also common to perform similar rituals on girls. This can range from relatively small interventions such as piercing or cutting the clitoral hood, to its complete removal and up to radical removal of clitoral hood, clitoris, inner and outer labia followed by sewing up the vagina.

Rights and Ethics

Non-therapeutic circumcision of children is not only one of the most widespread surgical operations in the world, but also one of the oldest. It is probably due to this long tradition, that despite its violating the common basic rights to bodily integrity and medical ethics in the western world, it is still widely tolerated there, even though there are barely any legal exemptions in place. The few regulations, which mostly emerged in the recent past, usually only deal with the basic conditions. They regulate how and under what conditions the operation should be carried out, while the general compatibility with basic human rights is rarely questioned, let alone taken into consideration.

Examples of legal regulations

Germany

Generally, circumcision of children met the criteria of bodily assault until December 2012. Practically, however, it was not legally pursued, since it was considered unclear whether parents had the right to consent to the operation on behalf of their children (see §228 StGB).

In 2004, the Landgericht (regional court) of Frankenthal ruled in a case of a circumcision done by non-medical people, that parental consent was not legally valid.

In August 2007 the Oberlandesgericht (upper regional court) Frankfurt/Main found that the decision about a circumcision, because of the "bodily modifications that cannot be reversed [...] belongs to the core of a person's rights to decide upon for themselves".

The Landgericht (regional court) of Cologne, in a second trial, ruled on May 7th, 2012, that circumcision is a bodily assault, which is not justified by the religious motivation and wishes of the parents and is not in the interest of a child's well-being.

The ruling from May 2012 sparked fierce protests by representatives of religious groups, which were instantly answered by politicians with the assurance that religiously motivated circumcision of underage Muslim and Jewish boys in Germany would remain legal.

On August 23rd, 2012, the Deutscher Ethikrat (German Council of Ethics), during a publicly held plenary session, came to terms "despite profound differences" (!) upon four minimum requirements for legal regulation of circumcision:

• Fully informed consent by the legal guardians
• Qualified pain management
• The operation to be performed by a professional and
• Approval of a right of veto depending on the maturity of the affected boy

The explicitly mentioned profound differences point out the difficulty of legally regulating the circumcision of underaged boys. The legislative procedure led to a broad public debate over the legitimacy and legality of circumcision of minors in German society. Despite the fierce resistance of medical associations, jurists, constitution experts, child and human rights activists as well as 100 Members of Parliament, the following Act was adopted in December 2012:

§ 1631d BGB

Circumcision of the male child

(1) Personal Care also includes the right to consent to the circumcision of the male child who lacks competence and understanding, if it is to be performed according to proper medical standards. This does not apply when the circumcision, also considering the motivation, endangers the child's well-being.

(2) During the first 6 months of life, persons appointed by a religious group may perform circumcisions according to paragraph 1, if they are specially trained and, without being a medical doctor, are similarly competent to perform circumcision.

Therefore, a non-therapeutic circumcision of a male child lacking competence and understanding for whatever reason is generally legal. A right of veto for the affected boys was turned down in parliament, as well as a proposed change destined to introduce an evaluation of the regulations after five years. Giving the Ministry of Heath the right to determine more specific guidance - for example regarding pain management and the qualification and training of non-medical circumcisers - by issuing additional regulations was also rejected. A call for mandatory documentation of non-therapeutic circumcisions was ignored. Merely stating the intent to have the operation performed according to proper medical standards was considered sufficient.

In December 2012, a representative poll done by Infratest dimap revealed that only 24 percent of the interviewed citizens were in favour of the law, while 70 percent explicitly disapproved of it.

Austria

In Austria, bodily assault is, as in Germany, punishable, without any specific regulations regarding circumcision. There is, however – unlike in Germany - no specific basic right to an unharmed body in the constitution. It is regulated in §146a ABGB that "the application of bodily violence and the infliction of bodily or mental suffering" by the parents is unlawful. According to §90 (3) StGB it is impossible to consent to "a mutilation or other injuring of the genitals, that is able to inflict a lasting impairment of the sexual sensitivity" even for adults. On the other hand, the "Israelitengesetz" (Law for the Israelites) entitles the Jewish religious group and their members to "bring their children and juveniles, also outside of school, through all traditional rites and to educate them according to their religious commandments". Circumcision of boys for religious reasons is not considered punishable by the Austrian Ministry of Justice, and is justified by the parental rights.

France

In France, there is no specific regulation for circumcision. The question of parental consent is neither debated under religious aspects nor by the parenting laws. Article 16.3 of the civil code states that "the integrity of the human body may not be harmed, other then in cases of medical necessity for those affected". However, there is a "silent toleration" of the circumcision of minors.

Italy

In Italy, there is a basic agreement between the State and the Jewish communities that was formulated in 1987 and secured in the law in 1989. It implies that the Jewish way of circumcision is in accord with the Italian system of laws. According to Article 19 of the Italian constitution, religious freedom is to be respected, as long as no acts are performed that contradict good manners.

In a ruling by the "High Court of Cassation" from Nov. 24th, 2011, a mother was found not guilty, whose son almost bled to death after being circumcised by a medically unqualified layman.

Finland

At the end of 1999, the Finnish parliament issued a declaration regarding ritual circumcision. Ombudsman Riita-Leena Paunio stated, that the operation could not be recommended without a medical indication, and that the affected children should be consulted and give consent. She said, the Finnish parliament had to weigh the religious rights of the parents against the responsibility of the society to protect their children from ritual operations that have no immediate benefit for them. Since then, the written consent of both parents is mandatory.

Sweden

In Sweden, non-therapeutic circumcision of boys under 18 years of age is regulated since 2001 by the "Lag (2001:499) om omskärelse av pojkar" (Law regarding circumcision of boys). According to it, such circumcisions are a surgical procedure and have to be carried out by a qualified doctor and under anaesthesia. For boys under 2 month of age, circumcision may also be carried out by another competent person with a government license. This applies to persons that have been nominated by religious groups in which circumcision is part of the religious tradition. Persons who perform a circumcision without the necessary qualification or license face a fine or prison sentence of up to six months. The circumcision requires the consent of the legal guardians. It may not be carried out against the child's will, if he has the age and level of maturity for such a statement.

USA

The USA have by far the highest rate of circumcision among the western nations. In many maternity wards the routine circumcision of newborn boys is common. The US paediatric society, AAP, is the only major medical society in the world still advocating the non-therapeutic circumcision of newborns and children.

In the autumn of 2010, Californian intactivists called for a ban of routine infant circumcision and thereby sparked a nation-wide discussion of the topic.

• • •

It is noteworthy that, despite the wide spread of non-therapeutic circumcision of children and the fact that it contradicts many national laws, there is barely a country that has issued explicit exemptions. The principle of "silent toleration" is, regardless of a possible illegality, common practice.

Legal and ethical issues

Considering the severity of the intrusion into the body of the affected person, the question arises, whether it is both legally and morally acceptable to leave the decision about a non-therapeutic operation on a child too young to understand or give valid consent, to the parents alone. In Germany, several basic rights are concerned:

• the right to bodily integrity
• the right to sexual self-determination
• the right to equal treatment of genders (circumcision/FGM of females is illegal)
• the right to religious freedom (where the circumcision has a religious motive)

These four basic rights are relevant from the legal as well as the ethical point of view.

Let us begin with the most obvious intrusion - the one into the bodily integrity. Under German law, children enjoy far-reaching protection, that limits the parental rights and the powers delegated to third persons overseeing the upbringing (such as kindergarten staff or teachers). Methods of upbringing that may cause physical or mental harm are prohibited. This is not only corporal punishment, which was common in families, schools and vocational training for ages, which may cause direct (and sometimes severe) bodily harm - it also covers spanking, which is included under degrading treatment. It is assumed that not only does the immediate injury harm the child, but also the feeling of helplessness and of being at someone's mercy at the time of punishment by an authority figure. This also applies to other treatment that harms the dignity of a child - for example being forced to publicly change clothes in front of the kindergarten group after wetting his pants.

If you take a look at the list of possible bodily and mental harms and late-effects listed in "Risks and late effects", the imbalance becomes apparent. Spanking is already unlawful, but the irreversible amputation of an important, healthy part of the genital organ is not. The inevitable and possible consequences of this operation are ignored to a degree that is in harsh contrast to the established protection of children. Legalization, therefore, represents a considerable limitation of the male child's right to bodily integrity and protection from potentially harmful methods of upbringing.

There are also ethical problems. Can a child be denied the right to determine the visible appearance and degree of functionality of his body? Should a circumcised boy later in life decide that he would prefer to have an intact penis, he has no means of reversing the decision his parents made. Other people's ideas about his body‘s appearance and functionality are imposed upon him irreversibly. He is denied the possibility of deciding upon that according to his own preferences, which can lead to inferiority complexes and depression - regardless of the parents‘ reasons or their idea of what would be best for their child. So great a level of paternalism regarding such a severe intrusion, especially in the most intimate area of the child, cannot be justified by the parents‘ will.

It is not much different with the right to sexual self-determination. Here, the consequences that circumcision has and can have for the body, play a significant role. Normally, a man has free choice as to how he wants to experience his sexuality. It is solely up to him to decide in which way he wants to be stimulated, and he can - if he so desires - limit his sexual experience without a problem. A circumcised man does not have these options. The full range of his sexual experience and sensation is not available to him due the to bodily modification.

An intact penis enables many men to reach orgasm just by manipulation of the foreskin. During masturbation, the man can choose whether he wants to stimulate the glans directly or indirectly through the movement of the foreskin. Since he has the full, naturally given potential of sensitivity at his disposal, he can use it to according to his own preferences. The circumcised man, however, does not have that freedom of choice. He has neither the opportunity to include the foreskin into the stimulation, nor can he utilize its nerves and touch receptors. He also only has access to 15-50% of the potential sensitivity of an intact man, depending on the amount and kind of tissue that was removed, and the degree of keratinization of the glans. In some cases, the limitation can be even more severe. On a heavily desensitized penis, condoms can limit the sexual stimulation to the point where not enough arousal can be built up to reach an orgasm - which means that fulfilling safer sex is not possible.

In particular, the tight styles of circumcision bear the risk, that the loss of the friction-reducing gliding effect leads to unpleasant feelings or even pain for both partners during intercourse. The ability to masturbate without aid - for example, from lubricants - can be significantly reduced or even be lost in such a case. In a study, 63% of the men interviewed reported problems with masturbation after being circumcised. If a boy or man is circumcised, without him making that decision for himself after thorough consideration and in full knowledge and understanding of all possible consequences, he is denied his constitutionally guaranteed freedom to experience his sexuality according to his own preferences. This is much like parental interference to promote a prohibition of masturbation, or to inhibit a homosexual relationship - with the key difference that the parental intervention in form of a circumcision, unlike prohibitions during childhood, will have an irreversible, lifelong effect. Both do not comply with modern views of children's well-being and accepting the child as an autonomous individual, and are, therefore, not ethically justifiable.

The basic right to equal treatment of the sexes is also breached, since girls are legally protected from violations of their genital integrity, while boys are not. This not only contradicts the constitution, but also is contrary to all efforts of equal treatment. Because in this case, decisions are made during childhood that will affect the entire later life, it equals the attempt to have certain educational grades open to one gender unconditionally, while giving parents the right to deny them to the other gender for life. That such an unequal treatment of genders is not justifiable, neither legally nor morally, is obvious.

Last not least, religious freedom is impaired. If a boy is circumcised for religious reasons as a child before he reaches the age of competence, he will carry the sign of that religion on his body for his entire life - even if he decides to abjure that religion in the course of his life.

While his condition will not keep him from changing his religion, or to renounce it entirely, he has no way to discard the symbol of his old religion. This could be compared to a tattoo in the form of a religious symbol, with the difference that such a tattoo could still be removed by laser or covered with a new tattoo, if need be.

Therefore a circumcision does not impair the ability to change religion, but it makes it impossible to discard one's old religion entirely. This is not only a violation of the basic law, it is also ethically unjustifiable to force someone to carry a religious symbol for his entire life - especially in his most private body area.

So why is circumcision tolerated as a means of upbringing, and even explicitly legalized? In Germany, this stems from - although it is not stated in the law for legal reasons - the belief that a ban would impair the religious freedom of the parents. Even though it is stated in Art.140 GG (German basic law):

(1) Civic rights and duties are neither dependant on, nor impaired by, the exercise of religious freedom.

[...]

(4) No one may be forced to take part in a religious act or ceremony, or to participation in religious rites or to the use of a religious oath.

Still, it was considered intolerable for the parents to be unable to perform a religious rite that involved interference with the body of another person - in the case of that person being their son. While normally the religious freedom ends "at someone else‘s nose", an exemption was legalized to enable parents to comply with their own, personal, religious duties, even if that means that several of their son's basic rights are impaired. This does, however, not apply for other religious traditions, so that a ritual beating - no matter how religiously important it may be to the parents - is still considered child abuse and would likely result in the loss of child custody here.

Business Interests

Only very few will supposedly know that circumcision has become a lucrative business. Not only the operation itself, but also the potentially needed aftercare, bring profits. But while this is still obvious, there are also other trades that make money from it.

Baby foreskins are a coveted resource. Under the name "Apligraf" an artificial skin product is marketed worldwide, which is used - among other uses - as an alternative to skin grafts using the patient’s own skin. It is grown from the foreskins of children as young as possible. Since they are also mostly free of pathogenic organisms, they are also used as the basis for collagen, which is, among other purposes, used for anti wrinkle therapy and for lip augmentation. The manufacturer of the british product "Vavelta" advertised with the use of "freshly harvested (!) foreskins". It is inter alia used as a replacement for animal experiments testing the compatibility of cosmetic products. In the face of the falling numbers of routine infant circumcisions in the USA, manufacturers have already expressed concerns that they might not "bring in enough harvest" more than 10 years ago. The parents of the circumcised boys, however, very rarely know of the "secondary use" of their son's "donated" body parts. While preimplantation genetic diagnosis, stem cell research and genetic engineering are time and again critically questioned and discussed, the lifelong, significant modification of infant bodies for the good of the cosmetic industry is still common practice - supposedly partly because many women do not know what their augmented lips and wrinkle-free cheeks are made of - baby foreskin. An ethical justification cannot be valid here.

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See also

• FGM
• MGM
• Circumpendium