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"Male '''circumcision''' (from Latin ''circumcidere'', meaning "to cut around") is the surgical removal or [[amputation]] of the [[foreskin]] (prepuce) , a major part of the human [[penis]]. The foreskin comprises ''more than fifty percent'' of the epithelium of the [[penis]].<ref name="taylor1996">{{TaylorJR LockwoodAP TaylorAJ 1996}}</ref> When the "cutting around" is performed, the foreskin falls off, so [[amputation]] and [[mutilation]] is the result. The amputation destroys the [[Foreskin#Physiological_functions| many protective, immunological, sexual, and sensory physiological functions]] of the foreskin, so it is a very harmful and [[Pain| painful]] surgery.
'''Posthectomy''' is the more accurate medical term that more accurately reflects the injury and loss of functional body tissue, but the Biblical [[euphemism]], ''circumcision'', is more commonly used.
}}</ref>
Circumcision was popularized in English-speaking nationns in the nineteeth century. The practice of non-therapeutic circumcision of boys now has greatly declined in [[Australia]], [[Canada]], [[New Zealand]] and the [[United Kingdom]]. It has been gradually declining since 1985 in the [[United States]]. It has ''never'' been a popular practice in other western nations.
== Historical background ==
===Judaism===
In [[Judaism]], the tradition of [[Brit Milah| circumcision]] goes back to the [[Abrahamic covenant]] in a passage in the Book of Genesis (17:10-14). It is was seen as a covenant between God and man, dating back to the patriarch Abraham. The validity of this passage is increasingly being questioned.
{{Citation
According to the anthropologist and sociologist Rabbi Nissan Rubin, the [[Jewish circumcision| Jewish form of circumcision]], called ''[[Brit Milah| brit mila]]'', during the first two millennia did not include the later customary ''[[periah]]'', namely the complete scraping of the inner [[foreskin]] from the [[Glans penis|glans]]. This was only added around 135 AD, to make it almost impossible to restore the [[foreskin]] by [[stretching]], which became popular in the wake of Hellenic influence. While originally only the tip of the [[foreskin]] was cut off, ''[[periah]]'' removes the entire [[foreskin]].
In the Greek society of the day, a denuded [[Glans penis|glans]] was considered obscene and risible. In ultra-orthodox communities, circumcision is followed by the ''[[mohel]]'', the ritual circumciser, sucking blood from the wound with his mouth. This practice is highly controversial, as it can result in an [[infection ]] with [[herpes]] simplex type 1. In New York City, between 2000 and 2011 eleven children were infected with [[herpes]], 10 of whom had to be treated in hospital. Two of them suffered permanent brain damage, two others died. In the 12th century, the Jewish philosopher and doctor [[Moses Maimonides| Maimonides]] claimed that circumcision was necessary, as it diminished sexual desires and reduced the pleasure to a degree just sufficient for mere reproduction.
===Christianity===
Jesus was born into a Jewish family in [[Israel]], where [[Judaism]] was the prevailing religion, so He was [[circumcised]] on the eighth day.<ref>{{REFweb
|url=https://www.biblegateway.com/passage/?search=Luke+2%3A21&version=NASB
|title=Gospel of Luke
Nevertheless, Christian moral notions had decisive influence on the spread of this practice. In the puritan influenced USA, circumcision of children was popular in the 19th century as a means to prevent [[masturbation]]. In those days, this so-called ‘self-abuse‘ was not only considered immoral, but was supposedly responsible for a variety of diseases. Masturbation, however, is not mentioned anywhere in the Holy Bible, so there is no support for the belief that it is somehow immoral or sinful.
Even the mere existence of a [[foreskin]] was falsoly linked to many illnesses. Among them one could find syphilis, epilepsy, paralysis of the spine, bed wetting, scoliosis (spinal deformity), paralysis of the bladder, club foot, nerve pain in the lower abdomen, tuberculosis and lazy eye. One of the best known advocates of child circumcision was [[John Harvey Kellogg]], co-inventor of the corn flakes bearing his name. In 1888, he wrote:
{{Citation
Many cultures perform circumcision as a rite of passage into manhood. This is common in the Middle East and amongst some indigenous African and Southeast Asian peoples.
The [[United States]] and [[Israel ]] are the only industrialized countries in the world to have a high incidence of non-therapeutic infant male circumcision. The vast majority of infant circumcisions performed in the United States are for non-religious, non-medical reasons. See [[History of circumcision]].
===Religious===
=== Medical indication ===
There are no [[medical indication| medical indications]] for circumcision of the newborn. The [[circumcision industry ]] offers circumcision of the newborn to the public because of the [[financial incentive]].
The form of circumcision adopted by the medical community essentially was equivalent to the Jewish form with ''[[periah]]'', so it inflicted the maximum injury.
''The following text is taken from the [[Circumpendium]].''
-->
=== Prophylactic reasons ===
|url=https://www.cirp.org/library/general/laumann/
|accessdate=2019-11-06
}}</ref>, which found a higher rate of infection with bacterial venereal diseases in [[circumcised ]] than in [[intact ]] men.* The studies by Fleiss et al. (1998) support this.<ref name="fleiss-hodges-vanhowe1998">{{FleissP HodgesF VanHoweRS 1998}}</ref> According to the [[AAP]], the general sexual behaviour of the male - — such as frequent change in partners and the use of condoms - — has a much higher impact on sexually transmitted diseases then the circumcision status.<ref>{{REFjournal
|last=Task Force on Circumcision
|first=
|accessdate=
}}</ref> did not find a significant difference in UTI rates between [[circumcised]] and [[intact]] boys with normal urinary tract anatomy.
* Other studies suggest that circumcision is more likely to raise than to lower the generally low risk of acquiring UTI: multiple studies from [[Israel ]] showed a strong correlation between ritual circumcision on the 8th day of life and postoperative UTI.<ref>{{REFjournal
|last=Menahem
|init=S
''Hygiene'' refers to health and only secondarily to cleanliness.
One should note that the human [[foreskin ]] is endowed by nature with [[Foreskin#Immunological_functions| immunological functions]] that serve to protect the human body from disease.<ref name="fleiss-hodges-vanhowe1998"/> The [[glans penis ]] receives blood through the frenular artery.<ref>{{REFjournal
|last=Persad
|init=R
A common reason stated for circumcision is the assumption of hygienic benefits. This argument has to be viewed in the context of the environment the person in question grows up in. It is commonly known that bad hygienic circumstances, especially insufficient access to clean drinking water, pose a serious problem. The situation in disaster areas or refugee camps in the so-called third world keep reminding us of that.
In western industrial nations, however, this problem does not exist, in view of the availability of clean water for daily personal hygiene. If the cleaning of the genitals is performed on a daily basis - — and that may be assumed - — no pathogens can accumulate under the [[foreskin]]. Cleaning of the [[Glans penis|glans]] and the area [[preputial sac]] underneath the [[foreskin]] is easy - — they are simply [[Preputial_sac#Washing| washed with warm water along with the rest of the body]], just like the areas between the toes.
In small boys, where the [[foreskin]] cannot be retracted yet, cleaning is not necessary, since the [[Synechia| membrane]] that fuses the [[foreskin]] to the [[Glans penis|glans]] prevents the accumulation of micro-organisms. The so-called "[[Ballooning of the foreskin| ballooning]]", where the [[foreskin]] inflates during urination, is not a serious problemconcern.
The opening of the [[foreskin]] in small boys is often quite narrow and serves as a one-way valve, allowing the [[urine]] to flow out, but preventing entry of microbes, for example from a dirty diaper. As long as the child is able to pass water, everything works as nature intended.
But even in areas where there are poorer hygienic conditions and an insufficient access to medical care, the benefits of easier cleaning of a [[circumcised ]] [[penis]] are to be viewed with a critical eye. Although even longer periods without personal hygiene will not result in an accumulation of germs under the [[foreskin]], circumcision itself is not without risk of complications. If the operation is carried out without proper sterility, there is a high risk of an [[infection]] of the wound. This also applies to the treatment of common complications like post-operative [[bleeding]].
The benefit of easier cleaning must be balanced against the risk of promoting serious infections - — among others [[HIV]] - — during the operation. In parts of Africa, several dozen of one tribe's boys die each year as a result of their circumcision.
== Circumcision methods ==
The [[Circumcision methods]] are discussed in a separate article.
== Pain ==
In the past, advocates of circumcision claimed that a newborn child's nerve system was not yet fully developed, and that as a result, the child felt no [[pain]] during the circumcision procedure. [[Kanwaljeet J. Singh Anand | Anand]] & Hickey (1987) have shown that newborn children do in fact feel [[pain]], and more acutely than adults.<ref name="anand-hickey1987">{{REFjournal
|last=Anand
|first=KJS
|author-link=Kanwaljeet J. Singh Anand
|last2=Hickey
|first2=PR
|author2-link=
|etal=no
|pages=1321-9
|url=https://www.cirp.org/library/pain/anand/
|quote=However, in decisions about the use of these techniques, current knowledge suggests that humane considerations should apply as forcefully to the care of neonates and young, nonverbal infants as they do to children and adults in similar painful and stressful situations.
|pubmedID=3317037
|pubmedCID=
|DOI=10.1056/NEJM198711193172105
|accessdate=2019-11-08
}}</ref> This has led American health associations to recommend doctors take measures to reduce the [[pain ]] of circumcision in infants.
The [https://www.cirp.org/library/statements/aap1999/|AAP Circumcision Policy Statement] (1999) states quite clearly that ''"There is considerable evidence that newborns who are [[circumcised]] without analgesia experience pain and physiologic stress"''. Furthermore, the pain is quite severe, and requires injections for proper pain management. Sucrose and Acetaminophen ''"cannot be recommended as the sole method of analgesia"''. Topical cream is no longer thought sufficient as ''"the analgesic effect is limited during the phases associated with extensive tissue trauma such as...tightening of the clamp"''.<ref>{{REFjournal
}}</ref> This is not a debatable fact, and yet, it is not widely accepted, even by some doctors. It might be hard for some doctors to accept, as they may have been taught that the infant does not feel [[pain]], and may have performed countless circumcisions with this idea. Usage of anesthesia for infant circumcision is still by no means the rule.
Penile injections of local anesthetic are now recommended by all of the major medical institutionsif a circumcision is to be performed. In their [http://www.ama-assn.org/ama/no-index/about-ama/13585.shtml Report 10 of the Council on Scientific Affairs], the AMA states ''"When the decision is made to proceed with circumcision, local anesthesia should be provided for the procedure. [[Ring block ]] or [[dorsal penile blocks nerve block]] [injections] are most effective. [[EMLA]] cream has limited utility"''. Alarmingly, ''"Despite the clear evidence that newborn males generate brisk pain responses during circumcision, a recent survey of residency training programs found that 26% of programs that taught circumcision provided no instruction on the use of local anesthesia". The AMA reports that "Of physicians performing circumcision, 45% use anesthesia, 71% of pediatricians, 56% of family practitioners, and 25% of obstetricians"''.<ref>{{REFweb
|title=Report 10 of the Council on Scientific Affairs (I-99): Neonatal Circumcision
|website=American Medical Association Official Website
}}</ref> Be that as it may, few forms of analgesia are recommended. There are basically two types of injections to choose from, and the website does not go into the difference between a 'dorsal nerve block' and a 'ring block' injection.
Given what is known from aforementioned official documents, the AAP website may be more informative and effective if it would say ''"Make sure your doctor knows of the ineffectiveness of anything short of local anesthesia, and make sure your baby is given an injection. This is your responsibility, because your doctor may or may not be up to date on the latest understandings of infant sensitivity to [[pain ]] during circumcision."'' The AAP may be holding back, however, perhaps because this would upset the doctor/parent power relationship, and may cause too much questioning of doctors in general. One may not expect to find this kind of advice on such a website, and yet, anything less than this is a dangerously weak statement.
To control [[pain]], some physicians that circumcise use Tylenol, sugar,<ref>{{REFweb
=== Physical effects ===
* [[Bodily harm]]
* [[Circumcision scar]] is an invariable effect.
* An unavoidable effect of any circumcision is the permanent loss of sexual sensitivity. This is partly due to the removal of sensory tissue. The [[foreskin]] contains very many nerve endings and touch receptors, which account for the major part of male sexual sensation. If the [[foreskin]] is removed, they can no longer provide sexual stimulation. It is also partly due to the fact that the surface of the [[Glans penis|glans]] reacts to the missing protection from friction and drying out by developing a callus layer. This reduces the sensitivity of the remaining nerves in the [[Glans penis|glans]] gradually over the years. The study conducted by Sorrells et al.<ref>{{Sorrells etal 2007}}</ref> found a significant reduction of sensitivity to touch for [[circumcised]] compared to [[intact]] [[penis]]es in adult males. Other studies revealed that [[circumcised]] men use condoms significantly less often than [[intact]] men, since they further limit the sexual sensitivity (see above).
}}</ref>
}}
=== Sexual effects ===
Cepeda-Emiliani et al (2023) cited six reports in the literature of detrimental effects of circumcision, including erectile function, sensation, masturbatory pleasure, orgasm, and sexual satisfaction. The authors also cited three studies of severe distress in [[circumcised]] men, due to their infant circumcision, with complaints of [[glans]] insensitivity, delayed [[ejaculation]], and unpleasant sensation.<ref name="cepeda2023">{{REFjournal
|accessdate=2019-10-12
}}</ref>
* If the [[circumcised]] male feels incomplete, or due to the missing [[foreskin]] disadvantaged compared to [[intact]] males, an inferiority complex and [[depression ]] may occur. This can be accompanied by conscious recognition of his own incompleteness, or the deficiency may remain completely subconscious<ref>{{REFjournal
|last=Rhinehart
|init=J
* Fear of doctors, clinics and also closed rooms.<ref name="Levy1945"/>
* Relapse into the state of bed-wetting, even if the child was already dry before.<ref name="Levy1945"/>
* [[Circumcised ]] males who become fathers frequently manifest [[adamant father syndrome]].
[[Intact America]] (2019) called circumcision an [[Adverse Childhood Experiences (ACEs)| adverse childhood experience]],<ref name-"bollinger2019">{{REFdocument
|accessdate=2021-11-02
}}</ref>
== Complications ==
=== Possible operative and postoperative complications ===
}}</ref>
=== Death ===
A study in 2010 estimated approximately 117 neonatal circumcision-related [[Death| deaths ]] occur annually in the [[United States]], about one out of every 77 male neonatal deaths, more than suffocation, auto accidents, or even [[SIDS]].<ref name="Bollinger 2010">{{REFjournal
|last=Bollinger
|first=Dan
|accessdate=
}}</ref> See also the list of [[fatalities]].
== Forced circumcision ==
<!--=== United States military ===
{{SEEALSO}}
* [[Adolescent and adult circumcision]]
* [[Bodily harm]]
* [[Breastfeeding]]
* [[Case Histories]]
|accessdate=2023-04-30
}}
* {{REFweb
|url=https://intactamerica.org/pros-and-cons-of-circumcision/
|title=Pros and Cons of Circumcision (Spoiler: You’ve Been Lied to)
|last=Garrett
|first=
|init=CJ
|publisher=Intact America
|date=2023-11-10
|accessdate=2024-03-22
}}
* {{REFweb
|url=https://intactamerica.org/groups-who-pressure-you-to-circumcise/
|title=The 4 Authority Figures and Groups Who Will Pressure You to Circumcise (and What You Can Do)
|last=Anonymous
|first=
|init=
|publisher=Intact America
|date=2024-01-24
|accessdate=2024-01-27
}}
* {{REFweb
|url=https://intactamerica.org/keeping-your-sons-penis-intact/
|title=Keeping Your Son’s Penis Intact: A Guide for Parents
|last=Anonymous
|first=
|init=
|publisher=Intact America
|date=2024-01-24
|accessdate=2024-01-29
}}
* {{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
}}
{{REF}}
[[Category:Circumcision]]
[[Category:Male circumcision]]
[[Category:Parental information]]
[[Category:Penile surgery]]
[[Category:Medical term]]
[[Category:Male genital mutilation]]