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3,324 bytes added, 9 March
using template LanderJ etal 1997
The '''pain''' of [[circumcision ]] is extreme and traumatizing.<ref name="bollinger2019">{{REFdocument
|title=Child Genital Cutting as an Adverse Childhood Experience
|trans-title=
|language=English
|url=http://adversechildhoodexperiences.net/CGC_as_an_ACE.pdf
|archived=
{{Citation
|Text=Our attention has been focused on the distress cry of infants. We have recorded numerous distress cries resulting from routine medical procedures such as taking blood samples and minor surgery such as [[circumcision]]. The distress cry is louder, longer, and noisier than the hunger cry. In also tends to be irregular, with more interruptions and gagging.
|Author=Ostwall & Peltzman (1974)
|ref=<ref name="ostwald1974">{{REFjournal
}}</ref>
}}
 
==Infant circumcision==
}}</ref>
There are four painful steps in every infant [[circumcision]]:<ref name="bellini2022>{{REFjournal
|last=Bellini
|first=
}}</ref>
# Before [[circumcision ]] surgery can commence, the surgeon must first forcibly separate these two highly innervated body parts in an exquisitely painful procedure by forcing a blunt probe between the two parts to destroy, rip and tear the [[synechia]] apart.<ref name="bellini2022 /><ref>{{REFjournal
|last=Oliver
|init=JE
|DOI=
|accessdate=2020-11-08
}}</ref> Nervous tissue requires a large blood supply, so the [[foreskin ]] is richly vascularized with many blood vessels,<ref name="fleiss-hodges-vanhowe1998">{{FleissP HodgesF VanHoweRS 1998}}</ref> therefore the foreskin must be crushed with one of several special clamps in yet another painful step before the [[circumcision ]] can be carried out.<ref name="bellini2022 /><ref>{{REFjournal
|last=
|first=
# Finally, in another, painful step, the foreskin must be cut away.<ref name="bellini2022 />
Lander et al. (1997) conducted a comparison neonatal non-therapeutic [[circumcision ]] without anesthesia (current practice in 1997), [[ring block]], [[dorsal penile nerve block]], and a topical eutectic mixture of local anesthetics ([[EMLA]]).<ref name="lander1997">{{REFjournal |last=Lander |init=J |first=Janice |author-link= |last2=Brady-Frerer |init2=B |first2=Barbara |author2-link= |last3=Metcalfe |init3=JB |first3=James B. |author3-link= |last4=Nazerali |init4=S |first4=Shermin |author4-link= |last5=Muttit |init5=S |first5=Sarah |author5-link= |LanderJ etal=no |title= Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision |journal=JAMA |location= |date=1997-12-24 |volume=278 |issue=24 |pages=2157-64 |url=http://www.cirp.org/library/pain/lander/ |archived= |quote= |pubmedID=9417009 |pubmedCID= |DOI= |accessdate=2020-11-10}}</ref>
With no anesthesia, the infants screamed continuously. Newborns in the untreated placebo group exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the [[circumcision]] and following. Two newborns in the placebo group became ill following circumcision (choking and apnea). One experienced projectile vomiting.<ref name="lander1997" />
[[EMLA]] was the least effective pain control. [[Dorsal penile nerve block ]] (DPNB) was more effective, and [[ring block ]] was the most effective. The authors reported "[w]ithout exception, newborns in this study who did not receive an analgesic suffered great distress during and following the circumcision, and they were exposed to unnecessary risk (from choking or apnea)." The authors were so alarmed that they terminated the no anesthesia arm of the study early.<ref name="lander1997" /> 
None of the analgesic measures tested provided total pain relief.<ref name="bellieni2013">{{REFjournal
|last=Bellieni
|DOI=10.1186/1824-7288-39-38
|accessdate=2021-05-29
}}</ref> Any infant boy who undergoes neonatal [[circumcision ]] will experience some pain and [[trauma]]. Boys who escape circumcision would have no pain or [[trauma]]. The authors concluded that circumcision should be performed with ''anesthetic'', however the text makes clear that they meant ''analgesia'', since full anesthesia is unsafe for neonates.<ref name="lander1997" />
===Post-surgical pain===
[[Circumcision]] is an invasive cutting and [[amputation]]. Like other invasive operations, post-surgical pain persists after the surgery for days or weeks. Infant boys will not receive effective analgesia because their young age makes such drugs dangerous. Howard et al. (1994) studied male infants after their neonatal circumcision. They recorded the comfort scores of the infants at numerous periods after circumcision. They also observed and recorded feeding behavior.  It was found that feeding behavior deteriorated significantly after circumcision. Some breastfeed infants were unable to breastfeed and required formula feeding after circumcision. Acetaminophen was found to be almost totally ineffective against the post-circumcision pain. It did have some effect six hours after the circumcision. The authors concluded "that circumcision of the newborn causes severe and persistent pain."<ref name="howard1994agoglu2022">{{REFjournal |last=HowardAydoğlu |initfirst=CR |firstinit=Cynthia R.B
|author-link=
|last2=Aydoğlu |first2= |init2=M |author2-link= |last3=Okur |first3= |init3=MH |author3-link= |etal=no |title=Social and psychological effects of circumcision: A narrative review |trans-title= |language= |journal=Journal of Applied Nursing and Health |location= |date=2022-12 |volume=4 |issue=2 |pages=264-71 |url=https://janh.candle.or.id/index.php/janh/article/view/110/138 |archived= |quote= ||DOI=10.55018/janh.v4i2.110 |format=PDF |accessdate=2023-12-15}}</ref> Infant boys will not receive effective analgesia because their young age makes such drugs dangerous. Howard et al. (1994) studied male infants after their neonatal [[circumcision]]. They recorded the comfort scores of the infants at numerous periods after circumcision. They also observed and recorded feeding behavior.  It was found that feeding behavior deteriorated significantly after [[circumcision]]. Some breastfed infants were unable to [[Breastfeeding| breastfeed]] and required formula feeding after [[circumcision]]. Acetaminophen was found to be almost totally ineffective against the post-circumcision pain. It did have some effect six hours after the circumcision. The authors concluded "that circumcision of the newborn causes severe and persistent pain."<ref name="howard1994">{{REFjournal |last=Howard |init=CR |first=Cynthia R. |author-link= |last2=Howard
|init2=FM
|first2=Fred M.
===Traumatic effect of infant circumcision===
 When an infant boy is to be [[circumcised]], it is the usual practice to immobilize the infant for the painful surgery by securely tying his limbs to a molded plastic board , called the [[Circumstraint]], specially made for that purpose. The infant thus is preventing from fighting or fleeing, which is the [[trauma]]-producing situation of ''inescapable [[shock]]'', described as a "physical condition in which the organism cannot do anything to affect the inevitable."<ref name="vanderkolk2014">{{REFbook
|last=van der Kolk
|first=Bessel A.
|last=Anand
|init=KJS
|author-link=Kanwaljeet J. Singh Anand
|last2=Hickey
|init2=PR
|author2-link=
|etal=yesno
|title=Pain and its effects in the human neonate and fetus
|journal=N Engl J Med
}}</ref>
Bellini observed that [[circumcised ]] boys evidently remember pain.<ref name="bellini2022 /> Taddio & colleagues (1995)(1997) studied the effect of neonatal [[circumcision]] on the behavior of boys after surgery and at the time of vaccination. It was found that [[circumcised]] boys had a higher pain response at time of vaccination six months later as compared with [[intact]] boys,<ref name="taddio"1995">{{TaddioA etal 1995}}</ref><ref name="taddio1997">{{TaddioA KatzJ IlersichAL KorenG 1997}}</ref> showing that the nervous system had been permanently sensitized to heightened pain sensation.
Taddio et al. (1997) concluded:
 
{{Citation
|Text=Although postsurgical central sensitisation (allodynia and hyperalgesia) can extend to sites of the body distal from the wound, suggesting a supraspinal effect, the long-term consequences of surgery done without anaesthesia are likely to include post-traumatic stress as well as pain. It is, therefore, possible that the greater vaccination response in the infants circumcised without anaesthesia may represent an <u>infant analogue of a post-traumatic stress disorder</u> triggered by a traumatic and painful event and re-experienced under similar circumstances of pain during vaccination.
}}
John Rhinehart, {{MD}} (1999), a clinical psychiatrist, reported finding numerous cases of [[PTSD]] in his adult male patients pursuant to infant [[circumcision]].<ref>{{REFjournal
|last=Rhinehart
|init=J
}}</ref>
===Effect History=== ====Investigating pain of extreme pain on developing nervous systemcircumcision====Several researchers have suggested that extreme pain in the newborn could cause neurological injury. Anand & Scalzo [[Paul Emil Flechsig]] (20001847-1929) concluded:{{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 messagewas an eminent nineteenth-century German neuroanatomist, it is also important for these effects to be investigated, particularly with a view to developing effective therapeutic strategies for the growing childen psychiatrist and adolescents who were exposed to abnormal conditions during the neonatal periodneuropathologist. He suggested in 1872 that infants could not feel pain because their nerves are not completely myelinated. |Author=Anand & Scalzo (2000) |ref=<ref name="anand2000cope1998">{{REFjournal |last=Anand |first=Cope |init=KJSDK
|author-link=
|last2title=Neonatal pain: the evolution of an idea. |journal=The American Association of Anesthesiologists Newsletter |date=1998-09 |volume= |issue= |pages= |url= |accessdate=2020-11-12}}</ref> Incredible as it may seem today, his idea was accepted without question and without being tested.<ref name="vanhowe2008">{{REFjournal |last=ScalzoVan Howe |first2first=Robert S. |init2init=FMRS |author2author-link=Robert S. Van Howe |last2=Svoboda |etalfirst2=noJ. Steven |titleinit2=Can adverse neonatal experiences alter brain development and subsequent behavior?JS |transauthor2-titlelink=J. Steven Svoboda |etal=no |languagetitle=Neonatal pain relief and the Helsinki Declaration |journal=Biol NeonateJournal of Law, Medicine, and Ethics
|location=
|date=20002008-0212 |volume=7736 |issue=24
|article=
|page=
|pages=69803-8223 |url=httphttps://www.cirpacademia.orgedu/librarydownload/pain/anand433981944/27_Van_Howe.pdf
|archived=
|quote=
|pubmedID=1065768219094008
|pubmedCID=
|DOI=10.11591111/000014197j.1748-720X.2008.00339.x |accessdate=2021-0810-0931
}}</ref>
}}
Fitzgerald & Walker As a result, medical doctors performed all manners of invasive, painful procedures on neonates without anesthesia or analgesia, including millions upon millions of painful circumcisions and even open heart surgery. Open heart surgery was performed with curare to paralyze the infant but without any anesthesia.  Flechsig's bizarre opinion was not questioned until the 1970s. Several lines of empirical research carried out in the 1970s suggested that infants can in fact feel intense pain.<ref name="vanhowe2008" /> * Anders et al. (20031970) argued showed that extreme measurement of serum cortisol is a useful indicator of pain (such as that caused by circumcision) may alter developing nervous tissue for psychological investigation in the very younginfancy.<refname="anders1970">{{REFbookREFjournal |last=FitzgeraldAnders |firstinit=MariaTF |initfirst=MThomas F.
|author-link=
|last2=WalkerSachar |first2init2=SuellenEJ |init2first2=SEdward J.
|author2-link=
|yearlast3=2003Kream |titleinit3=J |first3=Jacob |author3-link= |last4=Roffwarg |init4=The role of activity in developing pain pathwaysHP |urlfirst4=http://wwwHoward P.cirp.org/library/pain/fitzgerald2/ |workauthor4-link= |last5=Hellman |init5=L |first5=Leon |author5-link= |etal=no |title=Proceedings of Behavioral state and plasma cortisol response in the 10th World Congress on Painhuman neonate |editorjournal=Pediatrics |location=Dostovsky JO, Carr DB, Koltzenburg M (eds) |editiondate=1970-10 |volume=2446 |chapterissue=4 |pages=185532-967 |url=http://www.cirp.org/library/pain/anders1/ |archived= |locationquote=Seattle |publisherpubmedID=ASP Press4323242 |isbnpubmedCID= |quoteDOI=In common with other areas of the central nervous system, synaptic development of spinal sensory connections is experience or activity dependent. Evidence from both animal and human studies shows that alterations in the patterns of sensory activity that can arise from tissue injury and pain in early life may disrupt normal synaptic organization within the somatosensory system. While these studies are incomplete and more investigation is needed in this area, the potential clinical importance of neonatal plasticity in pain development is clear. |accessdate=2020-11-18 |note=13}}</ref> Tye & Sardi advised:<blockquote>Thus, while there is literature * Emde et al. (1971) showed that addresses the ways "stress" of circumcision caused an increase in which pain experienced by neonates not only has negative shortthe amount of non- and long term psychological consequences, policy making documents on neonatal circumcision do not address the fact that such pain is not adequately nor regularly controlled for during the procedure, and that failure to control for pain can have lasting effects on the child, possibly into adulthoodREM sleep.<ref name="tye2022emde1971">{{REFjournal |last=TyeEmde |firstinit=RN |initfirst=NCRobert N
|author-link=
|last2=SardiHarmon |first2init2=RJ |init2first2=LMRobert J.
|author2-link=
|etallast3=Metcalf |init3=D |first3=David |author3-link= |last4=Koenig |init4=KL |first4=Kenneth L. |author4-link=no |titlelast5=Psychological, psychosocial, and psychosexual aspects ofWagonfeld penile circumcision |init5=S |transfirst5=Samuel |author5-titlelink= |etal=no |languagetitle=Stress and neonatal sleep |journal=Int J Impot ResPsychosom Med
|location=
|date=2022-03-281971 |volume=33 |issue= |article= |page=6 |pages=491-7 |url=httpshttp://www.naturecirp.comorg/library/birth/articlesemde/s41443-022-00553-9
|archived=
|quote=
|pubmedID=35347302
|pubmedCID=
|DOI=10.1038/s41443-022-00553-9 |accessdate=2022-04-29
}}</ref>
</blockquote>
===History=======Investigating pain of circumcision==== Paul Emil Flechsig * Richards, Bernal & Brackbill (1976) reported behavioral differences between American boys (1847-1929circumcised) was an eminent nineteenth-century German neuroanatomist, psychiatrist and neuropathologist. He suggested in 1872 that infants could not feel pain because their nerves are not completely myelinatedBritish boys (genitally intact).<ref name="cope1998richards1976">{{REFjournal |last=CopeRichards |init=DKMPM
|author-link=
|titlelast2=Neonatal pain: the evolution of an idea.Bernal |journalinit2=The American Association of Anesthesiologists NewsletterJF |date=1998-09 |volume= |issue= |pages= |url= |accessdate=2020-11-12}}</ref> Incredible as it may seem today, his idea was accepted without question and without being tested.<ref name="vanhowe2008">{{REFjournal |last=Van Howe |first=Robert S. |init=RS |authorauthor2-link=Robert S. Van Howe |last2last3=SvobodaBrackbill |first2init3=J. StevenY |init2first3=JSYvonne |author2author3-link=J. Steven Svoboda
|etal=no
|title=Neonatal pain relief and the Helsinki DeclarationEarly behavioral differences: gender or circumcision? |journal=Journal of Law, Medicine, and EthicsDev Psychobiol
|location=
|date=20081976-1201 |volume=369 |issue=4 |article= |page=1 |pages=80389-2395 |url=httpshttp://www.academiacirp.eduorg/downloadlibrary/33981944psych/brackbill/27_Van_Howe.pdf
|archived=
|quote=
|pubmedID=19094008767183
|pubmedCID=
|DOI=10.1111/j.1748-720X.2008.00339.x |accessdate=20212020-1011-3113
}}</ref>
As a result* Luther, medical doctors performed all manners Kraybill & Potter (1976) compared the level of invasive, painful procedures on neonates without anesthesia or analgesia, including millions upon millions of painful circumcisions cortisol in infants before and even open heart surgeryafter circumcision. Open heart surgery was performed with curare to paralyze They found a substantial rise in the infant but without any anesthesia.  Flechsig's bizarre opinion was not questioned until the 1970s. Several lines of empirical research carried out cortisol levels in the 1970s suggested that infants can in fact feel intense pain.<ref name=, which they said was due to the "vanhowe2008stress" /> * Anders et al. (1970) showed that measurement of serum cortisol is a useful indicator of pain for psychological investigation in infancycircumcision.<ref name="anders1970">{{REFjournal |last=AndersTalbert |init=TFLM |first=Thomas FLuther M.
|author-link=
|last2=SacharKraybill |init2=EJEN |first2=Edward JErnest N.
|author2-link=
|last3=KreamPotter |init3=J |first3=JacobHD
|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 Adrenal cortical response to circumcision in the human neonate. |trans-title= |language=English |journal=PediatricsObstet Gynecol
|location=
|date=19701976-1008
|volume=46
|issue=42 |pages=532208-710 |url=http://www.cirp.org/library/pain/anders1talbert/
|archived=
|quote=
|pubmedID=4323242940653
|pubmedCID=
|DOI=
|accessdate=2020-11-13
}}</ref>
* Emde et al. Rawlings, Miller & Engel (19711980) showed that as the "stress" pain of circumcision caused an increase in increased, oxygenation of the amount of non-REM sleep[[skin]] decreased.<ref name="emde1971rawlings1980">{{REFjournal |last=EmdeRawlings |init=RNDJ |first=Robert NDavid J.
|author-link=
|last2=HarmonMiller |init2=RJPA |first2=Robert J.Patricia Anne
|author2-link=
|last3=MetcalfEngel |init3=DRR |first3=DavidRolf R.
|author3-link=
|last4etal=Koenigno |init4=KL |first4title=Kenneth L.The effect of circumcision on transcutaneous PO2 in term infants |author4trans-link= |last5=Wagonfeld |init5=S |first5=Samuel |author5-link= |etaltitle=no |titlelanguage=Stress and neonatal sleepEnglish |journal=Psychosom Med Am J Dis Child
|location=
|date=19711980-07 |volume=33134 |issue=67 |pages=491676-78 |url=http://www.cirp.org/library/birthpain/emderawlings1/
|archived=
|quote=
|pubmedID=7395829
|pubmedCID=
|DOI=10.1001/archpedi.1980.02130190044011 |accessdate=2020-11-13
}}</ref>
* Richards, Bernal & Brackbill Gunnar et al. (19761981) reported recorded serum cortisol and behavior state throughout the unanesthetized, non-therapeutic circumcision process. Serum cortisol levels and behavioral differences between American boys (circumcised) distress were found to be closely related. The authors stated:{{Citation |Text=Neonatal circumcision is performed without anesthesia and British boys it is clearly stressful for the infant. |Author=Gunnar et al. (genitally intact1981). |ref=<ref name="richards1976Gunnar et al 1981">{{REFjournal |last=RichardsGunnar |init=MPMMR |first=Megan R.
|author-link=
|last2=BernalFisch |init2=JFRO |first2=Robert O.
|author2-link=
|last3=BrackbillKorsvick |init3=YS |first3=YvonneSherry
|author3-link=
|last4=Donhowe
|init4=JM
|first4=John M.
|author4-link=
|etal=no
|title=Early behavioral differences: gender or The effects of circumcision?on serum cortisol and behavior. |trans-title= |language=English |journal=Dev PsychobiolPsychoneuroendocrinology
|location=
|date=1976-011981 |volume=96 |issue=13 |pages=89260-9575 |url=http://www.cirp.org/library/psychpain/brackbillgunnar/
|archived=
|quote=
|pubmedID=7671837291435
|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"/>
* Luther, Kraybill & Potter Marshall et al. (19761982) compared the level of cortisol in infants before and studied mother-child interaction with regard to feeding behavior after circumcisionwithout anesthesia. They found a substantial rise in the cortisol levels that [[circumcised]] boys had more interruptions of feeding in the infants, which they said was due to the "stress" 24-hour period of circumcisionobservation.<refname="marshall1982">{{REFjournal |last=TalbertMarshall |init=LMRE |first=Luther MRichard E.
|author-link=
|last2=KraybillPorter |init2=ENFL |first2=Ernest NFran L.
|author2-link=
|last3=PotterRogers |init3=HDAG |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=Adrenal cortical response to circumcision in the neonate.Circumcision: II: Effects upon mother-infant interaction |trans-title= |language=English |journal=Obstet Gynecol Early Hum Dev
|location=
|date=1976-081982 |volume=467 |issue=24 |pages=208367-1074 |url=http://www.cirp.org/library/painbirth/talbertmarshall2/
|archived=
|quote=
|pubmedID=9406537169032
|pubmedCID=
|DOI=10.1016/0378-3782(82)90038-x |accessdate=2020-11-1314
}}</ref>
* RawlingsPorter, Miller & Engel Marshall (19801986) showed that as studied the nature of pain of cries during unanesthetized, non-therapeutic circumcision. the cries during circumcision increasedwere found to shorter, oxygenation with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; and greater variability of the [[skin]] decreasedfundamental. Adult listeners judged these cries to have an unusual degree of urgency.<ref name="rawlings1980porter1986">{{REFjournal |last=RawlingsPorter |initfirst=DJFran Lang |firstinit=David J.FL
|author-link=
|last2=Miller
|init2first2=PARichard H. |first2init2=Patricia AnneRH
|author2-link=
|last3=EngelMarshal |init3first3=RRRichard E |first3init3=Rolf R.RE
|author3-link=
|etal=no
|title=The Neonatal pain cries: effect of circumcision on transcutaneous PO2 in term infantsacoustic features and perceived urgency
|trans-title=
|language=English
|journal=Am J Dis ChildDev
|location=
|date=19801986-0706 |volume=13457 |issue=73 |pages=676790-8802 |url=httphttps://www.cirpjstor.org/library/pain/rawlings1stable/1130355?seq=1
|archived=
|quote=
|pubmedID=73958293720404
|pubmedCID=
|DOI=10.10012307/archpedi.1980.021301900440111130355 |accessdate=2020-11-1315
}}</ref>
* Gunnar et al. (1981) recorded serum cortisol and behavior state throughout Surgical operation on infants without anesthesia continued for well over a century, at least until 1987, when the unanesthetized, non-therapeutic circumcision process. Serum cortisol levels and behavioral distress were found [[American Academy of Pediatrics]] was forced to be closely related. The authors stated:{{Citation |Text=Neonatal circumcision is performed without anesthesia and it is clearly stressful issue a CYA statement that called for the infantuse of anesthesia. |Author=Gunnar et al. (1981) |ref=<ref name="Gunnar et al 1981poland1987">{{REFjournal |last=GunnarPoland |initfirst=MRRonald L. |firstinit=Megan R.RL
|author-link=
|last2=FischRoberts |init2first2=RORonald J |first2init2=Robert O.RJ
|author2-link=
|last3=KorsvickGutierrez-Mazorra |init3first3=SJuan F. |first3init3=SherryJF
|author3-link=
|last4=DonhoweFonkalsrud |init4first4=JMEric W. |first4init4=John M.EW
|author4-link=
|etal=no
|title=The effects of circumcision on serum cortisol and behavior.Neonatal anesthesia
|trans-title=
|language=English
|journal=PsychoneuroendocrinologyPediatrics
|location=
|date=19811987-09 |volume=680
|issue=3
|pages=260-75446 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/pain80/gunnar3/446
|archived=
|quote=
|pubmedID=7291435
|pubmedCID=
|DOI=10.1016/0306-4530(81)90037-8 |accessdate=2020-11-1312}}</ref><ref name="vanhowe2008"/> Anand & Hickey (1987) published a paper in the ''New England Journal of Medicine'' that totally demolished Flechsig's ridiculous claims and conclusively proved that newborn infants are capable of feeling intense pain. After publication of this paper, no doubt about pain sensation in infants remained. The article stated: {{Citation |Text=Numerous lines of evidence suggest that even in the human [[fetus]], pain pathways as well as cortical and subcortical centers necessary for pain perception are well developed late in gestation, and the neurochemical systems now known to be associated with pain transmission and modulation are intact and functional. Physiologic responses to painful stimuli have been well documented in neonates of various gestational ages and are reflected in hormonal, metabolic, and cardiorespiratory changes similar to but greater than those observed in adult subjects. Other responses in newborn infants are suggestive of integrated emotional and behavioral responses to pain and are retained in memory long enough to modify subsequent behavior patterns. |Author=Anand & Hickey (1987) |ref=<ref name="anand1987"/><ref name="vanhowe2008"/>
}}
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. (19821988) studied mother-child interaction with regard to feeding behavior after circumcision without anesthesiaexamined the association between behavioral distress and adrenocortical activity. They It was found that circumcised boys had more interruptions of feeding differences in behavioral distress did not reliably the 24level of adrenocortical activity. Moreover, it was found that while non-hour period nutritive sucking reduces crying it did not reduce the adrenocortical response to the stressful stimulus of observationcircumcision pain.<ref name="marshall1982gunnar1988">{{REFjournal |last=MarshallGunnar |initfirst=REMegan |firstinit=Richard E.M
|author-link=
|last2=PorterConnors |init2first2=FLJoan |first2init2=Fran L.J
|author2-link=
|last3=RogersIsensee |init3first3=AGJill |first3init3=Ann G.J
|author3-link=
|last4=MooreWall |init4first4=JLee |first4init4=JoAnnL
|author4-link=
|last5=Anderson |init5=B |first5=Barbara |author5-link= |last6=Boxerman |first6=Stuart B. |init6=SB |author6-link= |etal=noyes |title=Circumcision: II: Effects upon mother-infant interactionAdrenocortical activity and behavioral distress in human newborns
|trans-title=
|language=English
|journal=Early Hum DevPsychobiol
|location=
|date=19821988-05 |volume=721
|issue=4
|pages=367297-74310 |url=http://www.cirp.org/library/birthpain/marshall2gunnar1988/
|archived=
|quote=
|pubmedID=71690323378676
|pubmedCID=
|DOI=10.10161002/0378-3782(82)90038-x dev.420210402 |accessdate=2020-11-1415
}}</ref>
PorterAlthough by 1989 it was totally clear that infants can feel intense pain, the [[American_Academy_of_Pediatrics#Third_policy_.281989.29 1989| American Academy of Pediatrics Circumcision Task Force]], Miller & Marshall (1986) studied under the nature leadership of pain cries during unanesthetizedthe infamous [[Edgar J. Schoen]], {{MD}}, declined to recommend the use of analgesics for non-therapeutic neonatal [[circumcision. the cries during circumcision were found to shorter]], with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; and greater variability thereby condemning millions of the fundamental. Adult listeners judged these cries newborn baby boys to have an unusual degree of urgencya painful, stressful, traumatizing circumcision.<ref name="porter1986">{{REFjournal |last=PorterSchoen |first=Fran LangEdgar J. |init=FLEJ |author-link=Edgar J. Schoen |last2=MillerAnderson |first2=Richard H.Glen |init2=RHG
|author2-link=
|last3=MarshalBohon |first3=Richard EConstance |init3=REC
|author3-link=
|last4=Hinman Jr
|first4=Frank
|init4=F
|author4-link=
|last5=Poland
|first5=Ronald L.
|init5=RL
|author5-link=
|last6=Wakeman
|first6=Maurice
|init6=ME
|author6-link=
|etal=no
|title=Neonatal pain cries: effect Report of circumcision on acoustic features and perceived urgencythe Task Force of Circumcision
|trans-title=
|language=English
|journal=Child DevPediatrics
|location=
|date=19861989-0610 |volume=5789 |issue=34 |pages=790388-80291 |url=httpshttp://www.jstorcirp.org/stablelibrary/1130355?seq=1statements/aap/#a1989
|archived=
|quote=
|pubmedID= 37204042664697
|pubmedCID=
|DOI=10.2307/1130355 |accessdate=2020-11-1518
}}</ref>
Surgical operation on infants without anesthesia continued for well over ====Finding an ethical way to do painful non-therapeutic circumcision==== The financially and psychologically vested circumcision industry suddenly found itself in a predicament. It was now suddenly proven beyond any shadow of a centurydoubt that newborn baby boys can feel intense pain. Medical ethics and the standard of care now necessitated pain relief, at least until 1987, when the however it is dangerous to give general anesthesia to neonates. [[American Academy of PediatricsEdward Wallerstein]] was forced to issue a CYA statement (1985) had proposed that called for the use [[Routine Infant Circumcision| routine]] (non-therapeutic) circumcision of anesthesia.baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,<ref name="poland1987wallerstein1985">{{REFjournal |last=Poland Wallerstein |first=Ronald L.Edward |init=RLE |author-link= |last2=Roberts |first2=Ronald J |init2=RJ |author2-link= |last3=Gutierrez-Mazorra |first3=Juan F. |init3=JF |author3-link= |last4=Fonkalsrud |first4=Eric W. |init4=EW |author4-link=Edward Wallerstein
|etal=no
|title=Neonatal anesthesiaCircumcision: the uniquely American medical enigma
|trans-title=
|language=English
|journal=PediatricsUrol Clin North Am
|location=
|date=1987-091985 |volume=8012 |issue=31 |pages=446123-32 |url=httpshttp://pediatricswww.aappublicationscirp.org/contentlibrary/80general/3wallerstein/446
|archived=
|quote=
|pubmedID=3883617
|pubmedCID=
|DOI=
|accessdate=2020-11-1215}}</ref>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 name>{{REFweb |url="vanhowe2008" 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.
Anand & Hickey (1987) published a paper in the ''New England Journal of Medicine'' that totally demolished Flechsig's ridiculous claims and conclusively proved that newborn infants are capable of feeling intense pain. After publication of this paper, no doubt about pain sensation in infants remained. The article statedThree methods were proposed:{{Citation |Text=Numerous lines of evidence suggest that even in the human [[fetus]], pain pathways as well as cortical and subcortical centers necessary for pain perception are well developed late in gestation, and the neurochemical systems now known to be associated with pain transmission and modulation are intact and functional. Physiologic responses to painful stimuli have been well documented in neonates of various gestational ages and are reflected in hormonal, metabolic, and cardiorespiratory changes similar to but greater than those observed in adult subjects. Other responses in newborn infants are suggestive of integrated emotional and behavioral responses to pain and are retained in memory long enough to modify subsequent behavior patterns. |Author=Anand & Hickey (1987) |ref=<ref name="anand1987"/><ref name="vanhowe2008"/>}}
Gunnar et al* Application of [[EMLA]] Cream topical anesthetic. [[EMLA]] is a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%. [[EMLA]] Cream (1988lidocaine 2.5% and prilocaine 2.5%) examined , applied to intact [[skin]] under occlusive dressing, provides dermal analgesia by the association between behavioral distress release of lidocaine and adrenocortical activity. It was found that differences in behavioral distress did not reliably prilocaine from the cream into the level epidermal and dermal layers of adrenocortical activity. Moreover, it was found that while non-nutritive sucking reduces crying it did not reduce the adrenocortical response to [[skin]] and by the accumulation of lidocaine and prilocaine in the stressful stimulus vicinity of circumcision dermal painreceptors and nerve endings.<ref name="gunnar1988">{{REFjournalREFweb |lasturl=Gunnar |first=Megan |init=M |authorhttps://www.drugs.com/pro/emla.html#s-link= |last2=Connors |first2=Joan |init2=J |author234069-link= |last3=Isensee |first3=Jill |init3=J5 |author3-linkarchived= |last4=Wall |first4=Lee |init4=L |author4-link= |etal=yes |title=Adrenocortical activity and behavioral distress in human newbornsEMLA
|trans-title=
|language=English
|journallast=Dev Psychobiol |locationfirst= |dateauthor-link=1988-05 |volumepublisher=21Drugs.com |issuewebsite=4 |pagesdate=2972020-31004-21 |urlaccessdate=http://www.cirp.org/library/pain/gunnar1988/2020-11-21 |archivedformat=
|quote=
|pubmedID=3378676
|pubmedCID=
|DOI=10.1002/dev.420210402
|accessdate=2020-11-15
}}</ref>
Although by 1989 it was totally clear that infants can feel intense pain, the 1989 American Academy of Pediatrics Circumcision Task Force, under the leadership of the infamous * [[Edgar J. SchoenDorsal penile nerve block| Dorsal Penile Nerve Block]], {{MD}}, declined to recommend the use of analgesics for non-therapeutic neonatal circumcision, thereby condemning million of newborn baby boys to a painful, stressful circumcision(DPNB) as proposed by Kirya & Werthman (1978).<refname="kirya1978">{{REFjournal |last=SchoenKirya |first=Edgar J.Christopher |init=EJC |author-link=Edgar J. Schoen |last2=AndersonWerthman Jr |first2=GlenMilton W. |init2=GMW
|author2-link=
|last3=Bohon
|first3=Constance
|init3=C
|author3-link=
|last4=Hinman Jr
|first4=Frank
|init4=F
|author4-link=
|last5=Poland
|first5=Ronald L.
|init5=RL
|author5-link=
|last6=Wakeman
|first6=Maurice
|init6=ME
|author6-link=
|etal=no
|title=Report of the Task Force of CircumcisionNeonatal circumcision and penile dorsal nerve block—a painless procedure.
|trans-title=
|language=English
|journal=PediatricsJ Pediatr
|location=
|date=19891978-1006 |volume=8992 |issue=46 |pages=388998-911000 |url=http://www.cirp.org/library/statementspain/aapkirya1/#a1989
|archived=
|quote=
|pubmedID=2664697660375
|pubmedCID=
|DOI=10.1016/s0022-3476(78)80386-2 |accessdate=2020-11-1816
}}</ref>
====Finding an ethical way to do painful non-therapeutic circumcision==== The financially and psychologically vested circumcision industry suddenly found itself in a predicament. It was now suddenly proven beyond any shadow of a doubt that newborn baby boys can feel intense pain. Medical ethics and the standard of care now necessitated pain relief, however it is dangerous to give general anesthesia to neonates. * [[Edward WallersteinRing block| Ring Block]] . Broadman et al. (19851987) had proposed that [[Routine Infant Circumcision| routine]] (ring block for neonatal non-therapeutic) circumcision of baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,.<ref name="wallerstein1985broadman1987">{{REFjournal |last=WallersteinBroadman |init=LM |firstauthor-link=Edward |initlast2=Hannallah |init2=RS |author2-link= |last3=Belman |init3=AB |author3-link= |last4=Elder |init4=PT |author4-link= |last5=Ruttiman |init5=EU |authorauthor5-link=Edward Wallerstein |etallast6=noEpstein |titleinit6=Circumcision: the uniquely American medical enigmaBS |transauthor6-titlelink= |languageetal=Englishno |title=Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penis |journal=Urol Clin North AmAnesthesiology
|location=
|date=19851987-08-31 |volume=1267 |issue=13 |pages=123399-32402 |url=http://www.cirp.org/library/general/wallerstein/
|archived=
|quote=
|pubmedID=3883617 3307533
|pubmedCID=
|DOI=10.1097/00000542-198709000-00019 |accessdate=2020-11-1518}}</ref> however this clearly would not do for Ring block is considered the avid pro-circumcision lobby. No circumcision equals no fee most effective analgesic procedure for surgery. The financial gain from discontinuing neonatal non-therapeutic circumcision is just too high to discard. [[Dan Bollinger]] (2012) estimated that Infant boys feel less pain and suffer less trauma than with the total annual cost of non-therapeutic circumcision to Americans is $3,647,000,000other two pain reduction procedures.<refname="lander1997"/><ref name="stang1997">{{REFwebREFjournal |urllast=Stang |first=https://wwwHoward J.academia.edu/6442587/High_Cost_of_Circumcision_3_6_Billion_Annually |archivedinit=HJ |author-link= |last2=Snellman |first2=Leonard W. |titleinit2=High cost of circumcisionLW |transauthor2-titlelink= |languagelast3=EnglishCondon |lastfirst3=BollingerLawrence M |firstinit3=DanLM |authorauthor3-link=Dan Bollinger |publisherlast4=Conroy |first4=AcademiaMary Margaret |websiteinit4=MM |dateauthor4-link=2012 |accessdatelast5=2020-11-15Liebo |formatfirst5=PDFRhoda |quoteinit5=R}}</ref> The avaricious American circumcision industry is simply not willing to give that lucrative income up, so a way to make non |author5-therapeutic circumcisions in infancy acceptable had to be found.link= |last6=Brodersen |first6=Laurie |init6=LThree methods were proposed: |author6-link= |last7=Gunnar* Application of [[EMLA]] Cream topical anesthetic. [[EMLA]] is a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%. [[EMLA]] Cream (lidocaine 2.5% and prilocaine 2 |first7=Megan R.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 |urlinit7=https://www.drugs.com/pro/emla.html#sMR |author7-34069-5link= |archivedetal=no |title=EMLABeyond dorsal penile nerve block: A more humane circumcision |trans-title= |language=English |lastjournal=Pediatrics |firstlocation= |authordate=1997-link=08 |publishervolume=Drugs.com100 |websiteissue=2 |datepages=2020-04-21e3 |accessdateurl=2020-11-21https://pediatrics.aappublications.org/content/100/2/e3 |formatarchived=
|quote=
|pubmedID=9233974
|pubmedCID=
|DOI=10.1542/peds.100.2.e3
|accessdate=2020-11-18
}}</ref>
* Dorsal Penile Nerve Block (DPNB) as proposed by Kirya & Werthman (1978){{Box|Boxtext=<big><b>However, none of the above three procedures totally eliminate pain. A baby boy will still experience some pain and [[trauma]] despite any of those analgesic procedures.<ref name="kirya1978"bellini2022 /> Prevention of pain requires protecting a boy from elective neonatal non-therapeutic circumcision. Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or [[trauma]].</b></big>}} Wallerstein (1985)<ref>{{REFjournal |last=KiryaWallerstein |first=ChristopherEdward |init=C |author-link= |last2=Werthman Jr |first2=Milton W. |init2=MW |author2-link=Edward Wallerstein
|etal=no
|title= Neonatal Is non-religious circumcision and penile dorsal nerve block—a painless procedure.necessary?
|trans-title=
|language=English |journal=J PediatrAm Acad Child Psychiatr
|location=
|date=19781985-0605 |volume=9224 |issue=63 |article= |page= |pages=998364-10005 |url=http://www.cirp.org/library/pain/kirya1gunnar1984/#wallerstein
|archived=
|quote=
|pubmedID=660375
|pubmedCID=
|DOI=10.1016/s0022-3476(78)80386-2 |accessdate=20202021-1107-160}}</ref> * Ring Block. Broadman et aland [[Robert S. Van Howe|Van Howe]] & Cold (19871998) proposed ring block for neonatal non-therapeutic circumcision.<ref name="broadman1987">{{REFjournal |last=BroadmanVan Howe |initfirst=LMRobert S. |author-link= |last2=Hannallah |init2init=RS |author2author-link=Robert S. Van Howe |last3last2=BelmanCold |init3first2=ABChristopher J. |author3-linkinit2=CJ |last4=Elder |init4=PT |author4-link= |last5=Ruttiman |init5=U |author5-link= |last6=Epstein |init6=BS |author6author2-link=Christopher J. Cold
|etal=no
|title=Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penisLocal Anesthesia For Infants Undergoing Circumcision |journal=AnesthesiologyJAMA
|location=
|date=19871998-0804-3115 |volume=67299 |issue=315 |article= |page= |pages=3991169-40271 |url=http://www.cirp.org/library/pain/lander/letters.html
|archived=
|quote=
|pubmedID=3307533
|pubmedCID=
|DOI=10.1097/00000542-198709000-00019 |accessdate=20202021-1107-1808}}</ref> Ring block is considered have suggested that it would be better to abandon the most effective analgesic procedure for neonatal practice of non-therapeutic infant circumcisionbecause of the pain associated with it. Infant boys feel less  The ''Daily Mail'' (2021) reported the pain stress of non-therapeutic neonatal circumcision increases the risk of [[SIDS]], and suffer less trauma than with that the other two pain reduction proceduresincidence of Sudden Infant Death Syndrome (SIDS) is lower where baby boys are not [[circumcised]].<ref name="lander1997"/><ref name="stang1997thompson2021">{{REFjournalREFnews |lasttitle=StangCircumcising newborn boys increases their risk of cot death due to the stress of the procedure - and could explain why it is more common in boys than girls, study finds |firsturl=Howard Jhttps://www.dailymail.co.uk/health/article-5998771/Circumcising-newborn-boys-increases-risk-cot-death-stress-procedure.html |initlast=HJThompson |author-linkfirst=Alexandra |last2coauthors=Snnellman |first2publisher=Leonard W.Daily Mail |init2website=LW |author2date=2021-07-link=27 |last3accessdate=Condon2021-08-02 |first3quote=Lawrence M |init3}}</ref> The pain that infant boys experience would not be acceptable in older boys and adults. It is not clear why infant boys are still subjected to a lesser standard of care with regard to pain than older boys and adults. ==Attitudes and practices regarding analgesia for newborn circumcision==LM |author3-link===Historic attitudes and practices== |last4=Conroy |first4=Mary Margaret Wellington & Rieder (1993) conducted a survey of physicians in London, Ontario. They found that only 4 percent used [[dorsal penile nerve block|init4=MMDPNB]]. They concluded: |author4-link= |last5=Liebo{{Citation |first5Text=RhodaDespite evidence that neonates perceive pain and that there is a physiologic stress response to circumcision which can be reduced if analgesia is employed, the vast majority of physicians performing newborn circumcisions either do not employ analgesics or employ analgesics of questionable efficacy. Lack of familiarity with the use of analgesics among neonates and with dorsal penile block in particular are the most common reasons cited for lack of analgesic use. Educational efforts and research into less invasive techniques of analgesia for newborn circumcision are urgently required. |init5Author=RWellington & Rieder (1993) |author5-linkref=<ref>{{REFjournal |last6last=BrodersenWellington |first6first=LaurieNancy |init6init=LN |author6author-link= |last7last2=GunnarRieder |first7first2=Megan RMichael J. |init7init2=MRMJ |author7author2-link=
|etal=no
|title=Beyond dorsal penile nerve block: A more humane Attitudes and practices regarding analgesia for newborn circumcision
|trans-title=
|language=English
|journal=Pediatrics
|location=
|date=19971993-0810 |volume=10092 |issue=24 |pages=e3541-3 |url=https://pediatrics.aappublications.org/content/10092/24/e3541?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
|archived=
|quote=
|pubmedID=92339748414824
|pubmedCID=
|DOI=10.1542/peds.100.2.e3
|accessdate=2020-11-18
}}</ref>
}}
{{Box|Boxtext=<big><b>However, none Ryan & Finer (1994) carried out a training program for physicians in the newborn nurseries of the above three procedures totally eliminate painWomens' Pavilion, [https://www. A baby boy will still experience some pain and [[traumaalbertahealthservices.ca/rah/rah.aspx Royal Alexandra Hospital]] despite any of those analgesic procedures, Edmonton, Alberta, Canada.<ref name="bellini2022 /> Prevention After a training program, they found that 66 percent of pain requires protecting a boy from elective neonatal physicians who perform non-therapeutic circumcisionneonatal circumcisions had started to use analgesia during the procedure. Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or This applies to one hospital in [[traumaCanada]].</b></big>}} Wallerstein (1985)<refname="ryan1994">{{REFjournal |last=WallersteinRyan |first=EdwardC. Anthony |init=CA |author-link=Edward Wallerstein |last2=Finer |first2=Neil N. |init2=NN |author2-link=
|etal=no
|title=Is non-religious Changing attitudes and practices regarding local analgesia for newborn circumcision necessary?.
|trans-title=
|language=English |journal=J Am Acad Child PsychiatrPedatrics
|location=
|date=19851994-0508 |volume=2494 |issue=3 |article= |page=2 |pages=364230-53 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/pain94/gunnar19842/#wallerstein230
|archived=
|quote=
|pubmedID=8036079
|pubmedCID=
|DOI=
|accessdate=20212020-0711-019}}</ref> and (Non-therapeutic neonatal circumcisions are no longer performed in most Canadian hospitals.)<ref name="jamesloewen2019">[[Robert SJames 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. Van HoweFurthermore, the failure to provide anesthesia or analgesia has been shown to cause not only short-term physiologic perturbations but also longer-term behavioral changes. |Van Howe]] Author=Maxwell & Cold Yaster (19981999) |ref=<ref>{{REFjournal |last=Van HoweMaxwell |firstinit=Robert S. |initfirst=RS |author-link=Robert S. Van Howe |last2=ColdYaster |first2init2=Christopher J. |init2first2=CJ |author2-link=Christopher J. Cold
|etal=no
|title=Local Anesthesia For Infants Undergoing CircumcisionAnalgesia for neonatal circumcisionː No more studies, just do tt |trans-title= |language=English |journal=JAMAArch Pediatr Adolesc Med
|location=
|date=19981999-04-1505 |volume=299153 |issue=15 |article= |page=5 |pages=1169444-715 |url=httphttps://wwwjamanetwork.cirp.orgcom/libraryjournals/painjamapediatrics/landerarticle-abstract/letters.html346832
|archived=
|quote=
|pubmedID=10323622
|pubmedCID=
|DOI= |accessdate=2021-07-08}}</ref> have suggested that it would be better to abandon the practice of non-therapeutic infant circumcision because of the pain associated with it. The ''Daily Mail'' (2021) reported the pain stress of non-therapeutic neonatal circumcision increases the risk of SIDS, and that the incidence of Sudden Infant Death Syndrome (SIDS) is lower where baby boys are not [[circumcised]]10.<ref name="thompson2021">{{REFnews |title=Circumcising newborn boys increases their risk of cot death due to the stress of the procedure - and could explain why it is more common in boys than girls, study finds |url=https:/1001/wwwarchpedi.dailymail153.co.uk/health/article-5998771/Circumcising-newborn-boys-increases-risk-cot-death-stress-procedure5.html |last=Thompson |first=Alexandra |coauthors= |publisher=Daily Mail |website= |date=2021-07-27444 |accessdate=20212020-0811-02 |quote=21
}}</ref>
}}
==Attitudes and practices regarding analgesia for newborn The [[American Academy of Pediatrics]] convened a new task force on circumcision== ===Historic attitudes and practices=== Wellington & Rieder (1993) conducted a survey under the chair of physicians in LondonCarole M. Lannon, Ontario{{MD}}. That task force reversed the position previously taken under [[Edgar J. They found that only 4 percent used DPNBSchoen]]. They concluded:{{Citation |Text=Despite evidence It clearly stated that neonates perceive pain and that there is a physiologic stress response to non-therapeutic infant circumcision which can be reduced if analgesia is employed, the vast majority of physicians performing newborn circumcisions either do "not employ analgesics or employ analgesics of questionable efficacy. Lack of familiarity with essential to the use of analgesics among neonates and with dorsal penile block in particular are the most common reasons cited for lack of analgesic usechild’s current well-being. Educational efforts and research into less invasive techniques " It provided an extensive discussion of procedural analgesia for newborn and said, quite strongly, that, if a circumcision are urgently requiredis done, procedural analgesia should be provided. |Author=Wellington & Rieder (1993) |<refname=<ref"aap1999">{{REFjournal |last=WellingtonLannon |first=NancyCarole M. |init=N
|author-link=
|last2=Rieder |first2=Michael J. |init2=MJ |author2-link= |etal=no |title=Attitudes and practices regarding analgesia for newborn circumcisionyes |trans-title= |language=EnglishCircumcision policy statement
|journal=Pediatrics
|locationdate=1999-03 |volume=103 |dateissue=1993-103 |volumearticle=92 |issuepage=4 |pages=541686-393 |url=https://pediatrics.aappublications.org/content/92103/43/541?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token686
|archived=
|quote=
|pubmedID=841482410049981
|pubmedCID=
|DOI=https://doi.org/10.1542/peds.103.3.686 |accessdate=20202021-1107-1812
}}</ref>
}}
Ryan & Finer Kraft (19942003) carried out a training program for physicians in the newborn nurseries of the Womens' Pavilion, [https://www.albertahealthservices.ca/rah/rah.aspx Royal Alexandra Hospital], Edmonton, Alberta, Canada. After a training program, they found reported that 66 percent of physicians who "many health care practitioners routinely perform non-therapeutic neonatal circumcisions had started to this procedure without the use of any or with inadequate or ineffective analgesia during the procedure. This applies to one hospital in [[Canada]]and anesthesia."<ref name="ryan1994kraft2003">{{REFjournal |last=RyanKraft |firstinit=C. AnthonyNL |initfirst=CANancy L
|author-link=
|last2=Finer |first2=Neil N. |init2=NN |author2-link= |etal=no |title=Changing attitudes A pictorial and practices regarding local analgesia for newborn video guide to circumcision. |trans-title= |language=Englishwithout pain |journal=PedatricsAdv Neonatal Care
|location=
|date=19942003-0804 |volume=943
|issue=2
|pages=23050-362 |url=https://pediatricsjournals.aappublicationslww.orgcom/contentadvancesinneonatalcare/94Abstract/2003/04000/A_PICTORIAL_AND_VIDEO_GUIDE_TO_CIRCUMCISION.2/230.aspx
|archived=
|quote=
|pubmedID=803607912881947
|pubmedCID=
|DOI=10.1053/adnc.2003.50015. |accessdate=2020-11-1918}}</ref> (Non-therapeutic neonatal circumcisions are no longer performed in most Canadian hospitals.)<ref name="jamesloewen2019">[[James Loewen]] (2019). Personal communication.</ref>
Maxwell & Yaster (1999) called on physicians to ===Contemporary attitudes and practices=== Little is known about current attitudes and practices regarding the use of analgesia during neonatal non-therapeutic in circumcision surgery, saying:{{Citation |Text=DESPITE THE DEBATE that continues over of the benefits and risks newborn. Application of nonritual analgesia prior to neonatal nontherapeutic circumcisiontakes additional physician time, so there may be a tendency to skip it remains a commonly performed surgical procedure in the United States. To the best  ==Standard of our knowledge, it care== It is the only surgical procedure now clear that is routinely performed boys are born with a healthy [[foreskin]] without first administering analgesia or anesthesia. This unconscionable state of affairs exists, despite the overwhelming evidence that newborns, even those born prematurely, are capable of experiencing paindisease. Indeed, anyone present during a Therefore there are no indications for infant [[circumcision realizes that the newborn feels and responds to pain and will attempt to withdraw if unrestrained. In addition]], this pain has physiologic correlates: elevated heart rate and blood pressure, lowered arterial oxygen saturation, and elevated levels of adrenocortical hormones. During the past 15 years, results of which is a multitude of studies have demonstrated that effective analgesia can prevent this pain non-therapeutic and ameliorate the associated stress response. Furthermore, the failure to provide anesthesia or analgesia has been shown to cause not only shortmedically-term physiologic perturbations but also longer-term behavioral changesunnecessary surgical operation. |Author=Maxwell & Yaster (1999) |<refname=<ref"cps1996">{{REFjournal |last=MaxwellEugene |first=Outerbridge
|init=
|first=
|author-link=
|last2=Yaster
|init2=
|first2=
|author2-link=
|etal=no
|title=Analgesia for neonatal circumcisionː No more studies, just do tt |trans-title= |language=EnglishNeonatal circumcision revisited |journal=Arch Pediatr Adolesc MedCMAJ
|location=
|date=19991996-0503-15 |volume=153154 |issue=56 |article= |page= |pages=444769-580 |url=https://jamanetworkwww.comncbi.nlm.nih.gov/journalspmc/jamapediatricsarticles/articlePMC1487803/pdf/cmaj00090-abstract/3468320027.pdf
|archived=
|quote=
|pubmedID=103236228634956 |pubmedCID=1487803 |DOI=10.1001/archpedi.153.5.444 |accessdate=20202021-07-11-21}}</ref>}} 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="aap1999racp2010">{{REFjournalREFdocument |lasttitle=LannonCircumcision of Infant Males |firsturl=Carole Mhttps://www.racp.edu.au//docs/default-source/advocacy-library/circumcision-of-infant-males.pdf?sfvrsn=eaa32f1a_10 |initcontribution= |author-linklast= |last2first= |first2publisher=[[Royal Australasian College of Physicians]] |init2format=PDF |author2date=2010-09-link=01 |last3accessdate=2021-07-11}}</ref><ref>{{REFdocument |first3title=Non-therapeutic circumcision of male minors |init3url=https://pool.intactiwiki.org/images/KNMG-viewpoint-Non-therapeutic-circumcision-of-male-minors-27-05-2010-v2.pdf |author3-linkcontribution= |last4last= |first4first= |init4publisher=Royal Dutch Medical Association (KNMG) |author4-linkformat=PDF |last5date=2010-05-27 |first5accessdate=2021-07-11}}</ref> Circumcision excises the highly functional foreskin, which provides numerous protective, immunological, sensory, and sexual functions,<ref name="cold1999">{{ColdCJ TaylorJR 1999}}</ref> so it is an irreversible, lasting injury. |init5Bellini (2022) considered that the pain of neonatal circumcision "can have long term consequences for the developing child."<ref name="bellini2022 /> Non-therapeutic circumcision of male minors is ''not'' the standard of care.  Nevertheless, some non-therapeutic circumcisions of boys will continue to be performed for religious reasons, ethnic reasons, and the[[Adamant father syndrome|author5emotional needs of parents]]. When a [[circumcision]] is to be performed, the standard of care requires that analgesia be provided to reduce the extreme level of pain and trauma.<ref name="poland1987"/><ref name="cps1996"/><ref name="lander1997"/><ref name="aap1999"/> (Total anesthesia cannot be used with infants.) The Australian Association of Paediatric Surgeons (AAPS) (1996) opposed the practice of infant circumcision, but recognized that it would be performed for religious, cultural, or family reasons, in which case, the non-link=therapeutic [[circumcision]] should be deferred for six months, so that general anesthesia may be used. The AAPS stated: <blockquote>In this event the procedure should be performed electively after six months of age. When performed, it should be carried out by a surgeon performing circumcisions on children on a regular basis with an anaesthetist using appropriate techniques. This would imply that the anaesthetist is fully trained in the art of paediatric anaesthesia, including the ability to perform caudal and penile regional or local anaesthesia. The operation should be carried out in a paediatrically orientated environment, designed to reduce the risk to the child and providing support to the parents or caregivers.<ref>{{REFdocument |last6title=Guidelines for Circumcision |first6url=https://www.cirp.org/library/statements/aaps/ |init6contribution= |author6-linklast=Leditshke |last7first=JF |first7publisher=Australasian Association of Paediatric Surgeons |init7location=Herston, QLD, Australia |author7-linkformat= |last8date=1996-04 |first8accessdate=2024-01-22}}</ref></blockquote>  |init8The practice of non-therapeutic circumcision of boys has nearly died out in [[Australia]]. == Pain's injury to the infant nervous system == |author8-linkAnand & Hickey (1985) conclusively demonstrated that infants feel pain and feel it more intensely than adults.<ref name="anand1987"/> Pain researcher Maria Fitzgerald (1998) reported the sensitivity of the infant nervous system to extreme pain: <blockquote>We and others have established that the developing nervous system is even more vulnerable to injury than in adults and that changes to the pathways induced shortly after birth can become permanent. This is because newborn nerve damage not only results in the death of sensory nerve cells, but causes other sensory nerve terminals to sprout extensively and occupy areas normally exclusively devoted to the damaged nerve.<ref>{{REFjournal |last9last=Fitzgerald |first9first= |init9init=M |author9author-link= |etal=yesno |title=Circumcision policy statementThe Birth of Pain
|trans-title=
|language=
|journal=PediatricsMRC News
|location=
|date=1999-031998 |season=Summer |volume=103 |issue=3
|article=
|page=
|pages=68620-9323 |url=https://pediatricswww.aappublicationscirp.org/contentlibrary/103pain/3fitzgerald/686
|archived=
|quote=
|pubmedID=10049981 |pubmedCID= |DOI=https://doi.org/10.1542/peds.103.3.686 |accessdate=20212024-0701-1231
}}</ref>
</blockquote>
Kraft Several later researchers suggested that extreme pain in the newborn could cause neurological injury. [[Kanwaljeet J. Singh Anand| Anand]] & Scalzo (20032000) reported that "many concluded: {{Citation |Text=The public health importance of abnormal stimulation during the neonatal period cannot be overemphasized. While programs for formulating appropriate health care practitioners routinely perform policies and public education campaigns must disseminate this procedure without message, it is also important for these effects to be investigated, particularly with a view to developing effective therapeutic strategies for the use of any or with inadequate or ineffective analgesia growing children and anesthesiaadolescents who were exposed to abnormal conditions during the neonatal period." |Author=Anand & Scalzo (2000) |ref=<ref name="kraft2003anand2000">{{REFjournal |last=KraftAnand |first= |init=NLKJS |author-link=Kanwaljeet J. Singh Anand |last2=Scalzo |firstfirst2= |init2=Nancy LFM |authorauthor2-link=
|etal=no
|title=A pictorial Can adverse neonatal experiences alter brain development and video guide to circumcision without pain subsequent behavior? |trans-title= |language= |journal=Adv Neonatal CareBiol Neonate
|location=
|date=20032000-0402 |volume=377
|issue=2
|article= |page= |pages=5069-6282 |url=httpshttp://journalswww.lwwcirp.comorg/advancesinneonatalcarelibrary/Abstractpain/2003anand4/04000/A_PICTORIAL_AND_VIDEO_GUIDE_TO_CIRCUMCISION.2.aspx
|archived=
|quote=
|pubmedID=1288194710657682
|pubmedCID=
|DOI=10.10531159/adnc.2003.50015.000014197 |accessdate=20202021-1108-1809
}}</ref>
}}
===Contemporary attitudes and practices===Little is known about current attitudes and practices regarding the use of analgesia 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 Fitzgerald & Walker (2003) argued that extreme pain (such as that boys are born with a healthy [[foreskin]] without evidence of disease. Therefore there are no indications for infant caused by [[circumcision]], which is a non-therapeutic and medically-unnecessary surgical operation) may alter developing nervous tissue in the very young.<ref name="cps1996">{{REFjournalREFbook |last=EugeneFitzgerald |first=OuterbridgeMaria |init=M
|author-link=
|etallast2=noWalker |titlefirst2=Neonatal circumcision revisitedSuellen |trans-titleinit2=S |languageauthor2-link= |journalyear=CMAJ2003 |locationtitle=The role of activity in developing pain pathways |dateurl=1996-03-15http://www.cirp.org/library/pain/fitzgerald2/ |volumework=154Proceedings of the 10th World Congress on Pain |issueeditor=6Dostovsky JO, Carr DB, Koltzenburg M (eds) |articleedition= |pagevolume=24 |pageschapter=769-80 |urlpages=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1487803/pdf/cmaj00090185-0027.pdf96 |archivedlocation=Seattle |quotepublisher=ASP Press |pubmedIDisbn=8634956 |pubmedCIDquote=1487803 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. |DOIaccessdate=2020-11-18 |accessdatenote=2021-07-11}}</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="racp2010tye2022">{{REFdocumentREFjournal |last=Tye |titlefirst=Circumcision of Infant Males |urlinit=https://www.racp.edu.au//docs/defaultNC |author-source/advocacylink= |last2=Sardi |first2= |init2=LM |author2-library/circumcision-of-infant-males.pdf?sfvrsnlink= |etal=eaa32f1a_10no |contributiontitle=Psychological, psychosocial, and psychosexual aspects ofpenile circumcision |lasttrans-title= |firstlanguage= |publisherjournal=[[Royal Australasian College of Physicians]]Int J Impot Res |formatlocation=PDF |date=20102022-0903-0128 |accessdatevolume= |issue= |article=2021-07-11}}</ref><ref>{{REFdocument |page= |titlepages=Non-therapeutic circumcision of male minors |url=https://poolwww.intactiwikinature.orgcom/imagesarticles/KNMG-viewpoint-Nons41443-therapeutic022-circumcision00553-of-male-minors-27-05-2010-v2.pdf9 |contributionarchived= |lastquote= |firstpubmedID=35347302 |publisherpubmedCID=Royal Dutch Medical Association (KNMG) |formatDOI=PDF |date=201010.1038/s41443-022-0500553-279 |accessdate=20212022-0704-1129}}</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"/blockquote> (Total anesthesia cannot be used with infants.)
==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
*[https://www.reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ Circumcision video]
 
<youtube>SLhEoOQhsVw</youtube>
<vimeo>259674034</vimeo>
<br>
Here is a video of Dr. Paul Fleiss speaking about the harm of circumcision, including pain and trauma.
 
<youtube>ouHSz-OmOH8</youtube>
<br>
===Ronald Goldman===
 
[[Ronald Goldman]] discussed pain and trauma in a video by [[Brendon Marotta]]:
|DOI=
|accessdate=2020-11-19
}}</ref> so the pain of the surgery is not usually a concern. That does not mean that the operation is pain free. It is not pain free.<ref name="bellini2022 />
* There is, of course, post-surgical pain, which may be relieved by a potent oral analgesic. One should have a two-week supply of analgesic medicine.
}}</ref> In a few cases, the [[erection]]s may cause [[wound dehiscence]] which requires additional surgery to re-close the surgical wound.
* That is not the only source of pain. [[Circumcision]] amputates the protective [[foreskin]]. In cases of [[phimosis]], the [[glans penis]] may never have been exposed before, so there frequently is severe pain when the [[glans penis ]] touches anything. Many men complain that they are unable to wear trousers for an extended period of time. Only time and [[keratinization]] can ease this pain.
* Circumcision is inexact surgery. Surgeons have to guess at how much [[skin]] to amputate, so they frequently get it wrong. If sufficient [[skin]] is not available to permit [[penis ]] expansion during times of [[erection]], then taut, painful [[erection]]s are the result. This complication may be treated by [[tissue expansion]]. The tension may also cause [[wound dehiscence]], which would cause additional pain.
* Neuromas may form at the [[circumcision scar]]. Cold & Taylor (1999) reported that they are "notorious for generating pain.".<ref name="cold-taylor1999">{{ColdCJ TaylorJR 1999}}</ref>
{{LINKS}}
* {{REFweb
|url=http://www.cirp.org/library/pain/
|archived=
|title=Pain of circumcision and pain control
|trans-title=
|language=English
|last=Hill
|first=George
|author-link=
|publisher=Circumcision Reference Library
|website=
|date=2006-09-11
|accessdate=2020-11-08
|format=
|quote=Circumcision is the most stressful surgical procedure commonly performed on newborns.
}}
* {{REFjournal
|etal=no
|accessdate=2020-11-17
}}
* {{REFwebREFjournal |last=Bellieni |first= |init=CV |etal=no |title=Neonatal Infant Pain Scale in assessing pain and pain relief for newborn male circumcision |trans-title= |language= |journal=Int J Impot Res |location= |date=2023-05 |volume=35 |issue=3 |article= |page= |pages=282-5 |url=httphttps://www.cirpresearchgate.org/librarynet/painpublication/359693934_Neonatal_Infant_Pain_Scale_in_assessing_pain_and_pain_relief_for_newborn_male_circumcision
|archived=
|titlequote=Pain of circumcision and pain control |trans-titlepubmedID=35352017 |languagepubmedCID=English |lastDOI=Hill |first=George |author10.1038/s41443-022-00551-link=x |publisherdoi=Circumcision Reference Library |websiteformat= |date=2006-09-11PDF |accessdate=20202023-1110-08 |format= |quote=Circumcision is the most stressful surgical procedure commonly performed on newborns.09
}}
* {{REFweb
|accessdate=2023-08-18
}}
* {{REFweb
|url=https://intactamerica.org/timeline-of-circumcision-suffering/
|title=A Timeline of Circumcision Suffering: A Detailed Look
|last=Anonymous
|first=
|init=
|publisher=Intact America
|date=2024-02-02
|accessdate=2024-02-09
}}
 
{{ABBR}}
{{REF}}
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