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

|firstinit=G.A.GA

}}</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: # Before circumcision surgery can commence, the surgeon must first forcibly separate these two highly innervated body parts in an exquisitely painful procedure by the passage of a blunt probe between the two parts to rip and tear the [[synechiacircumcision]] apart.:<refname="bellini2022>{{REFjournal |last=OliverBellini |first=JE |init=CV

|title=Circumcision Neonatal infant pain scale in assessing pain and cruelty to childrenpain relief for newborn male circumcision

|pubmedID= 519233

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

|firstinit=RK |author-link= |etal=no

}}</ref> Nervous tissue requires a large blood supply, so the [[foreskin ]] is richly vascular vascularized with many blood vessels,<ref name="fleiss-hodges-vanhowe1998">{{REFjournal |last=Fleiss |first=P. |author-link=Paul M. Fleiss |last2=Hodges |first2=F. |author2-link=Frederick M. Hodges |last3=Van Howe |first3=R.S. |author3-link=Robert S. Van Howe |title=Immunological functions of the human prepuce |journal=Sex Trans Infect |date=FleissP HodgesF VanHoweRS 1998-10 |volume=74 |issue=5 |pages=364-67 |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758142/pdf/v074p00364.pdf |quote= |pubmedID=10195034 |pubmedCID= |DOI= |accessdate=2019-10-15}}</ref> therefore the foreskin must be crushed with one of several special clamps in yet another painful step before the [[circumcision ]] can be carried out.<ref name="bellini2022 /><ref>{{REFjournal

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

Lander ''et al''. (1997) conducted a comparison of no neonatal non-therapeutic [[circumcision]] without anesthesia (current practice in 1997), [[ring block]], [[dorsal penile nerve block]], and a topical eutectic mixture of local anesthetics ([[EMLA]]). <ref name="lander1997">{{LanderJ etal 1997}}</ref>

With no anesthesia, the infants cried screamed continuously. Newborns in the untreated placebo group exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the [[circumcision ]] and following. Two newborns in the placebo group became ill following circumcision (choking and apnea).One experienced projectile vomiting.<ref name="lander1997" />

[[EMLA ]] was the least effective pain control. [[Dorsal penile nerve block ]] (DPNB) was more effective, and [[ring block ]] was the most effective. The authors reported "[w]ithout exception, newborns in this study who did not receive an analgesic suffered great distress during and following the circumcision, and they were exposed to unnecessary risk (from choking or apnea)." The authors were so alarmed that they terminated the no anesthesia arm of the study early.<ref name="lander1997" />

None of the analgesic measures tested provided total pain relief. Any infant boy who undergoes neonatal circumcision will experience some pain and trauma. Boys who escape circumcision would have no pain or trauma. The author concluded that circumcision should be performed with anesthetic.<ref name="lander1997bellieni2013">{{REFjournal |last=LanderBellieni |first=JaniceCarlo V. |init=

|last2=Brady-FrererAlagna |first2=BarbaraMaria G. |init2=

|last3=MetcalfeBuonocore |first3=James B.Giuseppe |init3=

|title= Comparison of ring block, dorsal penile nerve block, and topical anesthesia Analgesia for neonatal infants’ circumcision

|language=English |journal=JAMAItal J Pediatr

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

|pubmedID=941700923759130 |pubmedCID=3702488 |DOI=10.1186/1824-7288-39-38 |accessdate=20202021-1105-1029}}</ref> Any infant boy who undergoes neonatal [[circumcision]] will experience some pain and [[trauma]]. Boys who escape circumcision would have no pain or [[trauma]]. The authors concluded that circumcision should be performed with ''anesthetic'', however the text makes clear that they meant ''analgesia'', since full anesthesia is unsafe for neonates.<ref name="lander1997" />

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

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

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

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

|firstinit=PG

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

|firstinit=KJS |author-link=Kanwaljeet J. Singh Anand

|first2init2=PR

|etal=yesno

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

|author2-link=Ronald Goldman

|author3-link=J. Steven Svoboda

Bellini observed that [[circumcised]] boys evidently remember pain.<ref name="bellini2022 /> Taddio & colleagues (1995)(1997) studied the effect of neonatal [[circumcision ]] on the behavior of boys after surgery and at the time of vaccination. It was found that [[circumcised ]] boys had a higher pain response at time of vaccination six months later as compared with [[intact ]] boys.,<ref name="taddio"1995">{{REFjournal |last=Taddio |first=Anna |author-link= |last2=Goldbach |first2=Morton |author2-link= |last3=Ipp |first3=Moshe |author3-link= |last4=Stevens |first4=Bonnie |author4-link= |last5=Koren |first5=Gideon |author5-link= |TaddioA etal=no |title=Effect of neonatal circumcision on pain responses during vaccination in boys |trans-title= |language=English |journal=Lancet |location= |date=1995 |volume=344 |issue= |pages=291-2 |url=http://www.cirp.org/library/pain/taddio/ |archived= |quote= |pubmedID=7837863 |pubmedCID= |DOI=10.1016/s0140-6736(95)90278-3 |accessdate=2020-11-10}}</ref> <ref name="taddio1997">{{REFjournal |last=Taddio |first=Anna |author-link= |last2=Katz |first2=Joel |author2-link= |last3=Ilersich |first3=A Lane |author3-link= |last4=Gideon |first4=Koren |author4-link= |etal=no |title=Effect of neonatal circumcision on pain response during subsequent routine vaccination |trans-title= |language= |journal=Lancet |location= |date=TaddioA KatzJ IlersichAL KorenG 1997-03-01 |volume=342 |issue=9052 |pages=599-603 |url=https:}}<//yorkspace.library.yorku.ca/xmlui/bitstream/handle/10315/7941/KAT036ref> showing that the nervous system had been permanently sensitized to heightened pain sensation.pdf?sequence=1&origin=publication_detail |archived= |quote= |pubmedID=9057731 |pubmedCID= |DOI=10Taddio et al.1016/S0140-6736(961997)10316-0 |accessdate=2020-11-11}}</ref>concluded:

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

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

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

|firstinit=DK

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

Flechsig's bizarre opinion was not questioned until the 1970s. Several lines of empirical research carried out in the 1970s suggested that infants can in fact feel intense pain.<ref name="vanhowe2008" /> * Anders et al. (1970) showed that measurement of serum cortisol is a useful indicator of pain for psychological investigation in infancy.<ref name="anders1970">{{REFjournal |last=Anders |init=TF |first=Thomas F. |author-link= |last2=Sachar |init2=EJ |first2=Edward J. |author2-link= |last3=Kream |init3=J |first3=Jacob |author3-link= |last4=Roffwarg |init4=HP |first4=Howard P. |author4-link= |last5=Hellman |init5=L |first5=Leon |author5-link= |etal=no |title=Behavioral state and plasma cortisol response in the human neonate |journal=Pediatrics |location= |date=1970-10 |volume=46 |issue=4 |pages=532-7 |url=http://www.cirp.org/library/pain/anders1/ |archived= |quote= |pubmedID=4323242 |pubmedCID= |DOI= |accessdate=2020-11-13}}</ref>  * Emde et al. (1971) showed that the "stress" of circumcision caused an increase in the amount of non-REM sleep.<ref name="emde1971">{{REFjournal |last=Emde |init=RN |first=Robert N |author-link= |last2=Harmon |init2=RJ |first2=Robert J. |author2-link= |last3=Metcalf |init3=D |first3=David |author3-link= |last4=Koenig |init4=KL |first4=Kenneth L. |author4-link= |last5=Wagonfeld |init5=S |first5=Samuel |author5-link= |etal=no |title=Stress and neonatal sleep |journal=Psychosom Med |location= |date=1971 |volume=33 |issue=6 |pages=491-7 |url=http://www.cirp.org/library/birth/emde/ |archived= |quote= |pubmedID= |pubmedCID= |DOI= |accessdate=}}</ref> * Richards, Bernal, and & Brackbill (1976) discovered reported behavioral differences between American boys (circumcised) and British boys (genitally intact).<ref name="richards1976">{{REFjournal

|firstinit=M.P.M.MPM

|first2init2=J.F.JF

* Luther, Kraybill & Potter (1976) compared the level of cortisol in infants before and after circumcision. They found a substantial rise in the cortisol levels in the infants, which they said was due to the "stress" of circumcision.<ref>{{REFjournal

|first3init3=H. D.HD

This * Rawlings, Miller & Engel (1980) showed that as the pain of circumcision increased, oxygenation of the [[skin]] decreased.<ref name="rawlings1980">{{REFjournal |last=Rawlings |init=DJ |first=David J. |author-link= |last2=Miller |init2=PA |first2=Patricia Anne |author2-link= |last3=Engel |init3=RR |first3=Rolf R. |author3-link= |etal=no |title=The effect of circumcision on transcutaneous PO2 in term infants |trans-title= |language=English |journal=Am J Dis Child |location= |date=1980-07 |volume=134 |issue=7 |pages=676-8 |url=http://www.cirp.org/library/pain/rawlings1/ |archived= |quote= |pubmedID=7395829 |pubmedCID= |DOI=10.1001/archpedi.1980.02130190044011 |accessdate=2020-11-13}}</ref> * Gunnar et al. (1981) recorded serum cortisol and behavior state throughout the unanesthetized, non-therapeutic circumcision process. Serum cortisol levels and behavioral distress were found to be closely related. The authors stated:{{Citation |Text=Neonatal circumcision is performed without anesthesia and it is clearly stressful for the infant. |Author=Gunnar et al. (1981) |ref=<ref name="Gunnar et al 1981">{{REFjournal |last=Gunnar |init=MR |first=Megan R. |author-link= |last2=Fisch |init2=RO |first2=Robert O. |author2-link= |last3=Korsvick |init3=S |first3=Sherry |author3-link= |last4=Donhowe |init4=JM |first4=John M. |author4-link= |etal=no |title=The effects of circumcision on serum cortisol and behavior. |trans-title= |language=English |journal=Psychoneuroendocrinology |location= |date=1981 |volume=6 |issue=3 |pages=260-75 |url=http://www.cirp.org/library/pain/gunnar/ |archived= |quote= |pubmedID=7291435 |pubmedCID= |DOI=10.1016/0306-4530(81)90037-8 |accessdate=2020-11-13}}</ref>}} So great was Flechsig's influence, the authors were still unwilling to use the word ''pain'' and substituted the word ''stress''.<ref name="Gunnar et al 1981"/> * Marshall et al. (1982) studied mother-child interaction with regard to feeding behavior after circumcision without anesthesia. They found that [[circumcised]] boys had more interruptions of feeding in the 24-hour period of observation.<ref name="marshall1982">{{REFjournal |last=Marshall |init=RE |first=Richard E. |author-link= |last2=Porter |init2=FL |first2=Fran L. |author2-link= |last3=Rogers |init3=AG |first3=Ann G. |author3-link= |last4=Moore |init4=J |first4=JoAnn |author4-link= |last5=Anderson |init5=B |first5=Barbara |author5-link= |last6=Boxerman |first6=Stuart B. |init6=SB |author6-link= |etal=no |title=Circumcision: II: Effects upon mother-infant interaction |trans-title= |language=English |journal=Early Hum Dev |location= |date=1982 |volume=7 |issue=4 |pages=367-74 |url=http://www.cirp.org/library/birth/marshall2/ |archived= |quote= |pubmedID=7169032 |pubmedCID= |DOI=10.1016/0378-3782(82)90038-x |accessdate=2020-11-14}}</ref> Porter, Miller & Marshall (1986) studied the nature of pain cries during unanesthetized, non-therapeutic circumcision. the cries during circumcision were found to shorter, with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; and greater variability of the fundamental. Adult listeners judged these cries to have an unusual degree of urgency.<ref name="porter1986">{{REFjournal |last=Porter |first=Fran Lang |init=FL |author-link= |last2=Miller |first2=Richard H. |init2=RH |author2-link= |last3=Marshal |first3=Richard E |init3=RE |author3-link= |etal=no |title=Neonatal pain cries: effect of circumcision on acoustic features and perceived urgency |trans-title= |language=English |journal=Child Dev |location= |date=1986-06 |volume=57 |issue=3 |pages=790-802 |url=https://www.jstor.org/stable/1130355?seq=1 |archived= |quote= |pubmedID= 3720404 |pubmedCID= |DOI=10.2307/1130355 |accessdate=2020-11-15}}</ref> Surgical operation on infants without anesthesia continued for well over a century, at least until 1987, when the [[American Academy of Pediatrics]] was forced to issue a CYA statement that called for the use of anesthesia.<refname="poland1987">{{REFjournal

|pages=447446 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/pain80/aap3/446

Although by 1989 it was totally clear that infants can feel intense pain, the [[American_Academy_of_Pediatrics#Third_policy_.281989.29 1989| American Academy of Pediatrics Circumcision Task Force]], under the leadership of the infamous [[Edgar J. Schoen]], {{MD}}, declined to recommend the use of analgesics for non-therapeutic neonatal [[circumcision]], thereby condemning millions of newborn baby boys to a painful, stressful, traumatizing circumcision.<ref>{{REFjournal |last=Schoen |first=VideoEdgar J. |init=EJ |author-link=Edgar J. Schoen |last2=Anderson |first2=Glen |init2=G |author2-link= |last3=Bohon |first3=Constance |init3=C |author3-link= |last4=Hinman Jr |first4=Frank |init4=F |author4-link= |last5=Poland |first5=Ronald L. |init5=RL |author5-link= |last6=Wakeman |first6=Maurice |init6=ME |author6-link= |etal=no |title=Report of the Task Force of Circumcision |trans-title= |language=English |journal=Pediatrics |location= |date=1989-10 |volume=89 |issue=4 |pages=388-91 |url=http://www.cirp.org/library/statements/aap/#a1989 |archived= |quote= |pubmedID=2664697 |pubmedCID= |DOI= |accessdate=2020-11-18}}</ref>

<b>Infant ====Finding an ethical way to do painful non-therapeutic circumcision procedure</b>====

Please note how The financially and psychologically vested circumcision industry suddenly found itself in a predicament. It was now suddenly proven beyond any shadow of a doubt that newborn baby boys can feel intense pain. Medical ethics and the standard of care now necessitated pain relief, however it is dangerous to give general anesthesia to neonates. [[Edward Wallerstein]] (1985) had proposed that [[Routine Infant Circumcision| routine]] (non-therapeutic) circumcision of baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,<ref name="wallerstein1985">{{REFjournal |last=Wallerstein |first=Edward |init=E |author-link=Edward Wallerstein |etal=no |title=Circumcision: the uniquely American medical enigma |trans-title= |language=English |journal=Urol Clin North Am |location= |date=1985 |volume=12 |issue=1 |pages=123-32 |url=http://www.cirp.org/library/general/wallerstein/ |archived= |quote= |pubmedID=3883617 |pubmedCID= |DOI= |accessdate=2020-11-15}}</ref> however this clearly would not do for the avid pro-circumcision lobby. No circumcision equals no fee for surgery. The financial gain from discontinuing non-therapeutic circumcision is just too high to discard. [[Dan Bollinger]] (2012) estimated that the total annual cost of non-therapeutic circumcision to Americans is $3,647,000,000.<ref>{{REFweb |url=https://www.academia.edu/6442587/High_Cost_of_Circumcision_3_6_Billion_Annually |archived= |title=High cost of circumcision |trans-title= |language=English |last=Bollinger |first=Dan |author-link=Dan Bollinger |publisher=Academia |website= |date=2012 |accessdate=2020-11-15 |format=PDF |quote=}}</ref> The avaricious American [[circumcision industry]] is simply not willing to give that lucrative income up, so a way to make non-therapeutic circumcisions in infancy acceptable had to be found. Three methods were proposed: * 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=EMLA |trans-title= |language=English |last= |first= |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=Werthman Jr |first2=Milton W. |init2=MW |author2-link= |etal=no |title= Neonatal circumcision and penile dorsal nerve block—a painless procedure. |trans-title= |language=English |journal=J Pediatr |location= |date=1978-06 |volume=92 |issue=6 |pages=998-1000 |url=http://www.cirp.org/library/pain/kirya1/ |archived= |quote= |pubmedID=660375 |pubmedCID= |DOI=10.1016/s0022-3476(78)80386-2 |accessdate=2020-11-16}}</ref> * [[Ring block| Ring Block]]. Broadman et al. (1987) proposed ring block for neonatal non-therapeutic circumcision.<ref name="broadman1987">{{REFjournal |last=Broadman |init=LM |author-link= |last2=Hannallah |init2=RS |author2-link= |last3=Belman |init3=AB |author3-link= |last4=Elder |init4=PT |author4-link= |last5=Ruttiman |init5=U |author5-link= |last6=Epstein |init6=BS |author6-link= |etal=no |title=Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penis |journal=Anesthesiology |location= |date=1987-08-31 |volume=67 |issue=3 |pages=399-402 |url= |archived= |quote= |pubmedID=3307533 |pubmedCID= |DOI=10.1097/00000542-198709000-00019 |accessdate=2020-11-18}}</ref> Ring block is considered the most effective analgesic procedure for neonatal non-therapeutic circumcision. Infant boys feel less pain and suffer less trauma than with the other two pain reduction procedures.<ref name="lander1997"/><ref name="stang1997">{{REFjournal |last=Stang |first=Howard J. |init=HJ |author-link= |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=Beyond dorsal penile nerve block: A more humane circumcision |trans-title= |language= |journal=Pediatrics |location= |date=1997-08 |volume=100 |issue=2 |pages=e3 |url=https://pediatrics.aappublications.org/content/100/2/e3 |archived= |quote= |pubmedID=9233974 |pubmedCID= |DOI=10.1542/peds.100.2.e3 |accessdate=2020-11-18}}</ref> {{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 neonatal non-therapeutic circumcision. Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or [[trauma]].</b></big>}} Wallerstein (1985)<ref>{{REFjournal |last=Wallerstein |first=Edward |init= |author-link=Edward Wallerstein |etal=no |title=Is non-religious circumcision necessary? |trans-title= |language= |journal=J Am Acad Child Psychiatr |location= |date=1985-05 |volume=24 |issue=3 |article= |page= |pages=364-5 |url=http://www.cirp.org/library/pain/gunnar1984/#wallerstein |archived= |quote= |pubmedID= |pubmedCID= |DOI= |accessdate=2021-07-0}}</ref> and [[Robert S. Van Howe|Van Howe]] & Cold (1998)<ref>{{REFjournal |last=Van Howe |first=Robert S. |init=RS |author-link=Robert S. Van Howe |last2=Cold |first2=Christopher J. |init2=CJ |author2-link=Christopher J. Cold |etal=no |title=Local Anesthesia For Infants Undergoing Circumcision |journal=JAMA |location= |date=1998-04-15 |volume=299 |issue=15 |article= |page= |pages=1169-71 |url=http://www.cirp.org/library/pain/lander/letters.html |archived= |quote= |pubmedID= |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]].<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=2021-08-02 |quote=}}</ref> The pain that infant boys experience would not be acceptable in older boys and adults. It is not clear why infant boys are still subjected to a lesser standard of care with regard to pain than older boys and adults. ==Attitudes and practices regarding analgesia for newborn circumcision== ===Historic attitudes and practices=== Wellington & Rieder (1993) conducted a survey of physicians in London, Ontario. They found that only 4 percent used [[dorsal penile nerve block| DPNB]]. They concluded: {{Citation |Text=Despite evidence that neonates perceive pain and that there is a physiologic stress response to circumcision which can be reduced if analgesia is employed, the vast majority of physicians performing newborn circumcisions either do not employ analgesics or employ analgesics of questionable efficacy. Lack of familiarity with the use of analgesics among neonates and with dorsal penile block in particular are the most common reasons cited for lack of analgesic use. Educational efforts and research into less invasive techniques of analgesia for newborn circumcision are urgently required. |Author=Wellington & Rieder (1993) |ref=<ref>{{REFjournal |last=Wellington |first=Nancy |init=N |author-link= |last2=Rieder |first2=Michael J. |init2=MJ |author2-link= |etal=no |title=Attitudes and practices regarding analgesia for newborn circumcision |trans-title= |language=English |journal=Pediatrics |location= |date=1993-10 |volume=92 |issue=4 |pages=541-3 |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=8414824 |pubmedCID= |DOI= |accessdate=2020-11-18}}</ref>}} Ryan & Finer (1994) carried out a training program for physicians in the newborn nurseries of the Womens' Pavilion, [https://www.albertahealthservices.ca/rah/rah.aspx Royal Alexandra Hospital], Edmonton, Alberta, Canada. After a training program, they found that 66 percent of physicians who perform non-therapeutic neonatal circumcisions had started to use analgesia during the procedure. This applies to one hospital in [[Canada]].<ref name="ryan1994">{{REFjournal |last=Ryan |first=C. Anthony |init=CA |author-link= |last2=Finer |first2=Neil N. |init2=NN |author2-link= |etal=no |title=Changing attitudes and practices regarding local analgesia for newborn circumcision. |trans-title= |language=English |journal=Pedatrics |location= |date=1994-08 |volume=94 |issue=2 |pages=230-3 |url=https://pediatrics.aappublications.org/content/94/2/230 |archived= |quote= |pubmedID=8036079 |pubmedCID= |DOI= |accessdate=2020-11-19}}</ref> (Non-therapeutic neonatal circumcisions are no longer performed in most Canadian hospitals.)<ref name="jamesloewen2019">[[James Loewen]] (2019). Personal communication.</ref> Maxwell & Yaster (1999) called on physicians to use analgesia during neonatal non-therapeutic circumcision surgery, saying: {{Citation |Text=DESPITE THE DEBATE that continues over the benefits and risks of nonritual neonatal circumcision, it remains a commonly performed surgical procedure in the United States. To the best of our knowledge, it is the only surgical procedure that is routinely performed without first administering analgesia or anesthesia. This unconscionable state of affairs exists, despite the overwhelming evidence that newborns, even those born prematurely, are capable of experiencing pain. Indeed, anyone present during a circumcision realizes that the newborn feels and responds to pain and will attempt to withdraw if unrestrained. In addition, this pain has physiologic correlates: elevated heart rate and blood pressure, lowered arterial oxygen saturation, and elevated levels of adrenocortical hormones. During the past 15 years, results of a multitude of studies have demonstrated that effective analgesia can prevent this pain and ameliorate the associated stress response. Furthermore, the failure to provide anesthesia or analgesia has been shown to cause not only short-term physiologic perturbations but also longer-term behavioral changes. |Author=Maxwell & Yaster (1999) |ref=<ref>{{REFjournal |last=Maxwell |init= |first= |author-link= |last2=Yaster |init2= |first2= |author2-link= |etal=no |title=Analgesia for neonatal circumcisionː No more studies, just do tt |trans-title= |language=English |journal=Arch Pediatr Adolesc Med |location= |date=1999-05 |volume=153 |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=686-93 |url=https://pediatrics.aappublications.org/content/103/3/686 |archived= |quote= |pubmedID=10049981 |pubmedCID= |DOI=https://doi.org/10.1542/peds.103.3.686 |accessdate=2021-07-12}}</ref> Kraft (2003) reported that "many health care practitioners routinely perform this procedure without the use of any or with inadequate or ineffective analgesia and anesthesia."<ref name="kraft2003">{{REFjournal |last=Kraft |init=NL |first=Nancy L |author-link= |etal=no |title=A pictorial and video guide to circumcision without pain |journal=Adv Neonatal Care |location= |date=2003-04 |volume=3 |issue=2 |pages=50-62 |url=https://journals.lww.com/advancesinneonatalcare/Abstract/2003/04000/A_PICTORIAL_AND_VIDEO_GUIDE_TO_CIRCUMCISION.2.aspx |archived= |quote= |pubmedID=12881947 |pubmedCID= |DOI=10.1053/adnc.2003.50015. |accessdate=2020-11-18}}</ref> ===Contemporary attitudes and practices=== Little is known about current attitudes and practices regarding the use of analgesia in circumcision of the newborn. Application of analgesia prior to neonatal nontherapeutic circumcision takes additional physician time, so there may be a tendency to skip it. ==Standard of care== It is now clear that boys are born with a healthy [[foreskin]] without evidence of disease. Therefore there are no indications for infant [[circumcision]], which is a non-therapeutic and medically-unnecessary surgical operation.<ref name="cps1996">{{REFjournal |last=Eugene |first=Outerbridge |init= |author-link= |etal=no |title=Neonatal circumcision revisited |journal=CMAJ |location= |date=1996-03-15 |volume=154 |issue=6 |article= |page= |pages=769-80 |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1487803/pdf/cmaj00090-0027.pdf |archived= |quote= |pubmedID=8634956 |pubmedCID=1487803 |DOI= |accessdate=2021-07-11}}</ref><ref name="racp2010">{{REFdocument |title=Circumcision of Infant Males |url=https://www.racp.edu.au//docs/default-source/advocacy-library/circumcision-of-infant-males.pdf?sfvrsn=eaa32f1a_10 |contribution= |last= |first= |publisher=[[Royal Australasian College of Physicians]] |format=PDF |date=2010-09-01 |accessdate=2021-07-11}}</ref><ref>{{REFdocument |title=Non-therapeutic circumcision of male minors |url=https://pool.intactiwiki.org/images/KNMG-viewpoint-Non-therapeutic-circumcision-of-male-minors-27-05-2010-v2.pdf |contribution= |last= |first= |publisher=Royal Dutch Medical Association (KNMG) |format=PDF |date=2010-05-27 |accessdate=2021-07-11}}</ref> Circumcision excises the highly functional foreskin, which provides numerous protective, immunological, sensory, and sexual functions,<ref name="cold1999">{{ColdCJ TaylorJR 1999}}</ref> so it is an irreversible, lasting injury. Bellini (2022) considered that the pain of neonatal circumcision "can have long term consequences for the developing child."<ref name="bellini2022 /> Non-therapeutic circumcision of male minors is ''not'' the standard of care. Nevertheless, some non-therapeutic circumcisions of boys will continue to be performed for religious reasons, ethnic reasons, and the[[Adamant father syndrome| emotional needs of parents]]. When a [[circumcision]] is to be performed, the standard of care requires that analgesia be provided to reduce the extreme level of pain and trauma.<ref name="poland1987"/><ref name="cps1996"/><ref name="lander1997"/><ref name="aap1999"/> (Total anesthesia cannot be used with infants.) The Australian Association of Paediatric Surgeons (AAPS) (1996) opposed the practice of infantcircumcision, but recognized that it would be performed for religious, cultural, or family reasons, in which case, the non-therapeutic [[circumcision]] should be deferred for six months, so that general anesthesia may be used. The AAPS stated: <blockquote>In this event the procedure should be performed electively after six months of age. When performed, it should be carried out by a surgeon performing circumcisions on children on a regular basis with an anaesthetist using appropriate techniques. This would imply that the anaesthetist is fully trained in the art of paediatric anaesthesia, including the ability to perform caudal and penile regional or local anaesthesia. The operation should be carried out in a paediatrically orientated environment, designed to reduce the risk to the child and providing support to the parents or caregivers.<ref>{{REFdocument |title=Guidelines for Circumcision |url=https://www.cirp.org/library/statements/aaps/ |contribution= |last=Leditshke |first=JF |publisher=Australasian Association of Paediatric Surgeons |location=Herston, QLD, Australia |format= |date=1996-04 |accessdate=2024-01-22}}</ref></blockquote> The practice of non-therapeutic circumcision of boys has nearly died out in [[Australia]]. == Pain's lips quiver injury to the infant nervous system == Anand & Hickey (1985) conclusively demonstrated that infants feel pain and feel it more intensely than adults.<ref name="anand1987"/> Pain researcher Maria Fitzgerald (1998) reported the sensitivity of the infant nervous system to extreme pain: <blockquote>We and others have established that the developing nervous system is even more vulnerable to injury than in adults and that changes to the pathways induced shortly after birth can become permanent. This is because newborn nerve damage not only results in the death of sensory nerve cells, but causes other sensory nerve terminals to sprout extensively and occupy areas normally exclusively devoted to the damaged nerve.<ref>{{REFjournal |last=Fitzgerald |first= |init=M |author-link= |etal=no |title=The Birth of Pain |trans-title= |language= |journal=MRC News |location= |date=1998 |season=Summer |volume= |issue= |article= |page= |pages=20-23 |url=https://www.cirp.org/library/pain/fitzgerald/ |archived= |quote= |accessdate=2024-01-31}}</ref></blockquote> Several later researchers suggested that extreme pain in the newborn could cause neurological injury. [[Kanwaljeet J. Singh Anand| Anand]] & Scalzo (2000) concluded: {{Citation |Text=The public health importance of abnormal stimulation during the neonatal period cannot be overemphasized. While programs for formulating appropriate health policies and public education campaigns must disseminate this message, it is also important for these effects to be investigated, particularly with a view to developing effective therapeutic strategies for the growing children and adolescents who were exposed to abnormal conditions during the neonatal period. |Author=Anand & Scalzo (2000) |ref=<ref name="anand2000">{{REFjournal |last=Anand |first= |init=KJS |author-link=Kanwaljeet J. Singh Anand |last2=Scalzo |first2= |init2=FM |author2-link= |etal=no |title=Can adverse neonatal experiences alter brain development and subsequent behavior? |trans-title= |language= |journal=Biol Neonate |location= |date=2000-02 |volume=77 |issue=2 |article= |page= |pages=69-82 |url=http://www.cirp.org/library/pain/anand4/ |archived= |quote= |pubmedID=10657682 |pubmedCID= |DOI=10.1159/000014197 |accessdate=2021-08-09}}</ref>}} Fitzgerald & Walker (2003) argued that extreme pain (such as that caused by [[circumcision]]) may alter developing nervous tissue in the very young.<ref>{{REFbook |last=Fitzgerald |first=Maria |init=M |author-link= |last2=Walker |first2=Suellen |init2=S |author2-link= |year=2003 |title=The role of activity in developing painpathways |url=http://www.cirp.org/library/pain/fitzgerald2/ |work=Proceedings of the 10th World Congress on Pain |editor=Dostovsky JO, Carr DB, Koltzenburg M (eds) |edition= |volume=24 |chapter= |pages=185-96 |location=Seattle |publisher=ASP Press |isbn= |quote=In common with other areas of the central nervous system, synaptic development of spinal sensory connections is experience or activity dependent. Evidence from both animal and human studies shows that alterations in the patterns of sensory activity that can arise from tissue injury and pain in early life may disrupt normal synaptic organization within the somatosensory system. While these studies are incomplete and more investigation is needed in this area, the potential clinical importance of neonatal plasticity in pain development is clear. |accessdate=2020-11-18 |note=}}</ref> Tye & Sardi advised: <blockquote>Thus, while there is literature that addresses the ways in which pain experienced by neonates not only has negative short- and long term psychological consequences, policy making documents on neonatal circumcision do not address the fact that such pain is not adequately nor regularly controlled for during the procedure, and that failure to control for pain can have lasting effects on the child, possibly into adulthood.<ref name="tye2022">{{REFjournal |last=Tye |first= |init=NC |author-link= |last2=Sardi |first2= |init2=LM |author2-link= |etal=no |title=Psychological, psychosocial, and psychosexual aspects ofpenile circumcision |trans-title= |language= |journal=Int J Impot Res |location= |date=2022-03-28 |volume= |issue= |article= |page= |pages= |url=https://www.nature.com/articles/s41443-022-00553-9 |archived= |quote= |pubmedID=35347302 |pubmedCID= |DOI=10.1038/s41443-022-00553-9 |accessdate=2022-04-29}}</ref></blockquote> ==Videos== === Infant circumcision procedure === This is a video of an actual infant [[circumcision]]. It has a sound tract so one can hear the comments of the doctor and the sounds made by the infant. The doctor gives an injection of local anesthetic that apparently does not stop any pain at all. The infant goes silent at about 6:15 on the video, so he may have gone into [[shock]] at that time. Not for the squeamish: * {{REFweb |url=https://www.reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ |archived= |title=Trained medical professionals restrain infant 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]

[[Category:Circumcision risk]][[Category:Circumcision risksPain]]