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Fitzgerald & Walker As a result, medical doctors performed all manners of invasive, painful procedures on neonates without anesthesia or analgesia, including millions upon millions of painful circumcisions and even open heart surgery. Open heart surgery was performed with curare to paralyze the infant but without any anesthesia. Flechsig's bizarre opinion was not questioned until the 1970s. Several lines of empirical research carried out in the 1970s suggested that infants can in fact feel intense pain.<ref name="vanhowe2008" /> * Anders et al. (20031970) argued showed that extreme measurement of serum cortisol is a useful indicator of pain (such as that caused by circumcision) may alter developing nervous tissue for psychological investigation in the very younginfancy.<refname="anders1970">{{REFbookREFjournal |last=FitzgeraldAnders |firstinit=MariaTF |initfirst=MThomas F.
===History=======Investigating pain * Emde et al. (1971) showed that the "stress" of circumcision==== [[Paul Emil Flechsig]] (1847-1929) was caused an eminent nineteenthincrease in the amount of non-century German neuroanatomist, psychiatrist and neuropathologist. He suggested in 1872 that infants could not feel pain because their nerves are not completely myelinatedREM sleep.<ref name="cope1998emde1971">{{REFjournal |last=CopeEmde |init=DKRN |first=Robert N
As a result* Richards, medical doctors performed all manners of invasive, painful procedures on neonates without anesthesia or analgesia, including millions upon millions of painful circumcisions Bernal & Brackbill (1976) reported behavioral differences between American boys (circumcised) 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. British boys (1970genitally intact) showed that measurement of serum cortisol is a useful indicator of pain for psychological investigation in infancy.<ref name="anders1970richards1976">{{REFjournal |last=AndersRichards |init=TF |first=Thomas F.MPM
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* Gunnar et al. Porter, Miller & Marshall (19811986) recorded serum cortisol and behavior state throughout studied the nature of pain cries during unanesthetized, non-therapeutic circumcision process. Serum cortisol levels and behavioral distress the cries during circumcision were found to be closely related. The authors stated:{{Citation |Text=Neonatal circumcision is performed without anesthesia shorter, with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; and it is clearly stressful for greater variability of the infantfundamental. |Author=Gunnar et alAdult listeners judged these cries to have an unusual degree of urgency. (1981) |ref=<ref name="Gunnar et al 1981porter1986">{{REFjournal |last=GunnarPorter |initfirst=MRFran Lang |firstinit=Megan R.FL
|last4=Donhowe |init4=JM |first4=John M. |author4-link= |etal=no |title=The effects Neonatal pain cries: effect of circumcision on serum cortisol acoustic features and behavior.perceived urgency
}}
So great was Flechsig's influenceSurgical operation on infants without anesthesia continued for well over a century, at least until 1987, when 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 [[circumcisedAmerican Academy of Pediatrics]] boys had more interruptions of feeding in was forced to issue a CYA statement that called for the 24-hour period use of observationanesthesia.<ref name="marshall1982poland1987">{{REFjournal |last=MarshallPoland |initfirst=RERonald L. |firstinit=Richard E.RL
|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 interactionNeonatal anesthesia |trans-title=
Porter, Miller Anand & Marshall Hickey (19861987) studied published a paper in the nature ''New England Journal of Medicine'' that totally demolished Flechsig's ridiculous claims and conclusively proved that newborn infants are capable of feeling intense pain cries during unanesthetized. After publication of this paper, non-therapeutic circumcisionno 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 cries during circumcision were found neurochemical systems now known to be associated with pain transmission and modulation are intact and functional. Physiologic responses to shorterpainful stimuli have been well documented in neonates of various gestational ages and are reflected in hormonal, metabolic, with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; and cardiorespiratory changes similar to but greater variability 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. (1988) examined the fundamentalassociation between behavioral distress and adrenocortical activity. Adult listeners judged these cries It was found that differences in behavioral distress did not reliably the level of adrenocortical activity. Moreover, it was found that while non-nutritive sucking reduces crying it did not reduce the adrenocortical response to have an unusual degree the stressful stimulus of urgencycircumcision pain.<ref name="porter1986gunnar1988">{{REFjournal |last=PorterGunnar |first=Fran LangMegan |init=FLM
Surgical operation on Although by 1989 it was totally clear that infants without anesthesia continued for well over a centurycan feel intense pain, at least until 1987, when the [[American_Academy_of_Pediatrics#Third_policy_.281989.29 1989| American Academy of PediatricsCircumcision Task Force]], under the leadership of the infamous [[Edgar J. Schoen]] was forced , {{MD}}, declined to issue a CYA statement that called for recommend the use of anesthesiaanalgesics for non-therapeutic neonatal [[circumcision]], thereby condemning millions of newborn baby boys to a painful, stressful, traumatizing circumcision.<ref name="poland1987">{{REFjournal |last=Poland Schoen |first=Ronald LEdgar J. |init=RLEJ |author-link=Edgar J. Schoen |last2=Roberts Anderson |first2=Ronald JGlen |init2=RJG
Anand & Hickey (1987) published The financially and psychologically vested circumcision industry suddenly found itself in a paper in the ''New England Journal predicament. It was now suddenly proven beyond any shadow of Medicine'' that totally demolished Flechsig's ridiculous claims and conclusively proved a doubt that newborn infants are capable of feeling baby boys can feel 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, Medical ethics and the neurochemical systems standard of care now known to be associated with necessitated 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 hormonalrelief, metabolic, and cardiorespiratory changes similar however it is dangerous to but greater than those observed in adult subjects. Other responses in newborn infants are suggestive of integrated emotional and behavioral responses give general anesthesia to pain and are retained in memory long enough to modify subsequent behavior patternsneonates. |Author=Anand & Hickey [[Edward Wallerstein]] (19871985) had proposed that [[Routine Infant Circumcision|ref=<ref name="anand1987"/><ref name="vanhowe2008"/>}} Gunnar et al. routine]] (1988non-therapeutic) examined the association between behavioral distress circumcision of baby boys be eliminated just as routine tonsillectomy and adrenocortical activity. It was found that differences in behavioral distress did not reliably the level of adrenocortical activity. Moreoveradenoidectomy previously had been eliminated, it was found that while non-nutritive sucking reduces crying it did not reduce the adrenocortical response to the stressful stimulus of circumcision pain.<ref name="gunnar1988wallerstein1985">{{REFjournal |last=GunnarWallerstein |first=MeganEdward |init=ME |author-link= |last2=Connors |first2=Joan |init2=J |author2-link= |last3=Isensee |first3=Jill |init3=J |author3-link= |last4=Wall |first4=Lee |init4=L |author4-link=Edward Wallerstein |etal=yesno |title=Adrenocortical activity and behavioral distress in human newbornsCircumcision: the uniquely American medical enigma |trans-title= |language=English |journal=Dev PsychobiolUrol Clin North Am |location= |date=1988-051985 |volume=2112 |issue=41 |pages=297123-31032 |url=http://www.cirp.org/library/paingeneral/gunnar1988wallerstein/
|pubmedID=2664697 |pubmedCID= |DOI= |accessdate=2020-11-18}}</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.
====Finding an ethical way to do painful non-therapeutic circumcision====Three methods were proposed:
The financially and psychologically vested circumcision industry suddenly found itself in * Application of [[EMLA]] Cream topical anesthetic. [[EMLA]] is a predicament. It was now suddenly proven beyond any shadow eutectic mixture of a doubt that newborn baby boys can feel intense painlidocaine 2. Medical ethics 5% and the standard of care now necessitated pain relief, however it is dangerous to give general anesthesia to neonatesprilocaine 2.5%. [[Edward WallersteinEMLA]] Cream (1985lidocaine 2.5% and prilocaine 2.5%) had proposed that , applied to intact [[Routine Infant Circumcision| routineskin]] 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]] (non-therapeutic) circumcision and by the accumulation of lidocaine and prilocaine in the vicinity of baby boys be eliminated just as routine tonsillectomy dermal pain receptors and adenoidectomy previously had been eliminated,nerve endings.<ref name="wallerstein1985">{{REFjournalREFweb |lasturl=Wallerstein |first=Edward |init=E |authorhttps://www.drugs.com/pro/emla.html#s-34069-link=Edward Wallerstein5 |etalarchived=no |title=Circumcision: the uniquely American medical enigmaEMLA
|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 BollingerDorsal penile nerve block| Dorsal Penile Nerve Block]] (2012DPNB) as proposed by Kirya & Werthman (1978) estimated that the total annual cost of non-therapeutic circumcision to Americans is $3,647,000,000.<refname="kirya1978">{{REFwebREFjournal |last=Kirya |first=Christopher |init=C |author-link= |last2=Werthman Jr |urlfirst2=https://wwwMilton W.academia.edu/6442587/High_Cost_of_Circumcision_3_6_Billion_Annually |archivedinit2=MW |author2-link= |etal=no |title=High cost of Neonatal circumcisionand penile dorsal nerve block—a painless procedure.
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|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?
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=== Infant circumcision procedure ===This is a video of an actual infant circumcision. It has a sound tract so one can hear Pain researcher Maria Fitzgerald (1998) reported the comments sensitivity of the doctor and the sounds made by the infant. The doctor gives an injection of local anesthetic that apparently does not stop any nervous system to extreme 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:
* <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>{{REFwebREFjournal |last=Fitzgerald |first= |urlinit=M |author-link=https://www.reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ |archivedetal=no |title=Trained medical professionals restrain infant to amputate part The Birth of its body while baby kicks and screams in painPain
*Several later researchers suggested that extreme pain in the newborn could cause neurological injury. [https://www[Kanwaljeet J.reddit.com/r/Intactivism/comments/qbpzqr/trained_medical_professionals_restrain_infant_to/ Circumcision videoSingh Anand| Anand]]& Scalzo (2000) concluded:
* There is, of course, post-surgical Fitzgerald & Walker (2003) argued that extreme pain, which may be relieved (such as that caused by a potent oral analgesic. One should have a two-week supply of analgesic medicine. * The recovery period for adolescent and adult circumcision is usually placed at six weeks. During that period of time, many patients experience pain when they they have involuntary nocturnal [[erectioncircumcision]]s and ) may alter developing nervous tissue in the [[erection]] tightens the residual [[skin]] and pulls at the incision and suturevery young.<ref>{{REFjournalREFbook |last=DaiFitzgerald |initfirst=Maria |firstinit=A-JuanM
* That <blockquote>Thus, while there is literature that addresses the ways in which pain experienced by neonates not the only source of pain. [[Circumcision]] amputates the protective [[foreskin]]. In cases of [[phimosis]]has negative short- and long term psychological consequences, policy making documents on neonatal circumcision do not address the [[glans penis]] may never have been exposed before, so there frequently is severe pain when the [[glans penis]] touches anything. Many men complain fact that they are unable to wear trousers for an extended period of time. Only time and [[keratinization]] can ease this such 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 adequately nor regularly controlled for 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]]procedure, which would cause additional pain. * Neuromas may form at the [[circumcision scar]]. Cold & Taylor (1999) reported and that they are "notorious failure to control for generating pain."can have lasting effects on the child, possibly into adulthood.<ref name="cold-taylor1999tye2022">{{ColdCJ TaylorJR 1999}}</ref>REFjournal |last=Tye{{SEEALSO}} |first=* [[Circumstraint]] |init=NC* [[Does Cosmetic Surgery Harm Babies?]]* [[Post |author-traumatic stress disorder]]link=* [[Psychological issues of male circumcision]] |last2=Sardi* [[Shock]] |first2=* [[Sudden Infant Death Syndrome]] |init2=LM* [[Trauma]] {{LINKS}}* {{REFjournal |author2-link=
}}
* {{REFweb
|url=http://www.cirp.org/library/pain/
|archived=
|title=Pain of circumcision and pain control
|trans-title=
|language=English
|last=Hill
|first=George
|author-link=
|publisher=Circumcision Reference Library
|website=
|date=2006-09-11
|accessdate=2020-11-08
|format=
|quote=Circumcision is the most stressful surgical procedure commonly performed on newborns.
Pain
,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
|url=http://adversechildhoodexperiences.net/CGC_as_an_ACE.pdf
|archived=
}}</ref>
}}
==Infant circumcision==
# 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
===Traumatic effect of infant circumcision===
When an infant boy is to be [[circumcised]], it is the usual practice to immobilize the infant for the painful surgery by securely tying his limbs to a molded plastic board, called the [[Circumstraint]], specially made for that purpose. The infant thus is preventing from fighting or fleeing, which is the [[trauma]]-producing situation of ''inescapable [[shock]]'', described as a "physical condition in which the organism cannot do anything to affect the inevitable."<ref name="vanderkolk2014">{{REFbook
|last=van der Kolk
Taddio et al. (1997) concluded:
{{Citation
|Text=Although postsurgical central sensitisation (allodynia and hyperalgesia) can extend to sites of the body distal from the wound, suggesting a supraspinal effect, the long-term consequences of surgery done without anaesthesia are likely to include post-traumatic stress as well as pain. It is, therefore, possible that the greater vaccination response in the infants circumcised without anaesthesia may represent an <u>infant analogue of a post-traumatic stress disorder</u> triggered by a traumatic and painful event and re-experienced under similar circumstances of pain during vaccination.
}}</ref>
===Effect History=== ====Investigating pain of extreme pain on developing nervous systemcircumcision====Several researchers have suggested that extreme pain in the newborn could cause neurological injury. [[Kanwaljeet J. Singh Anand| AnandPaul Emil Flechsig]] & Scalzo (20001847-1929) concluded:was an eminent nineteenth-century German neuroanatomist, psychiatrist and neuropathologist. He suggested in 1872 that infants could not feel pain because their nerves are not completely myelinated.<ref name="cope1998">{{CitationREFjournal |last=Cope |init=DK |Textauthor-link= |title=Neonatal pain: the evolution of an idea. |journal=The public health importance American Association of abnormal stimulation during the neonatal period cannot be overemphasized. While programs for formulating appropriate health policies and public education campaigns must disseminate this message, it is also important for these effects to be investigated, particularly with a view to developing effective therapeutic strategies for the growing childen and adolescents who were exposed to abnormal conditions during the neonatal period.Anesthesiologists Newsletter |date=1998-09 |volume= |issue= |pages= |Authorurl=Anand & Scalzo (2000) |accessdate=2020-11-12}}</ref=> Incredible as it may seem today, his idea was accepted without question and without being tested.<ref name="anand2000vanhowe2008">{{REFjournal |last=AnandVan Howe |first=Robert S. |init=KJSRS |author-link=Kanwaljeet JRobert S. Singh AnandVan Howe |last2=ScalzoSvoboda |first2=J. Steven |init2=FMJS |author2-link=J. Steven Svoboda |etal=no |title=Can adverse neonatal experiences alter brain development Neonatal pain relief and subsequent behavior? |trans-title= |language=the Helsinki Declaration |journal=Biol NeonateJournal of Law, Medicine, and Ethics |location= |date=20002008-0212 |volume=7736 |issue=24
|article=
|page=
|pages=69803-8223 |url=httphttps://www.cirpacademia.orgedu/librarydownload/pain/anand433981944/27_Van_Howe.pdf
|archived=
|quote=
|pubmedID=1065768219094008
|pubmedCID=
|DOI=10.11591111/000014197j.1748-720X.2008.00339.x |accessdate=2021-0810-0931
}}</ref>
|author-link=
|last2=WalkerSachar |first2init2=SuellenEJ |init2first2=SEdward J.
|author2-link=
|yearlast3=2003Kream |titleinit3=The role of activity in developing pain pathways |url=http://www.cirp.org/library/pain/fitzgerald2/ |work=Proceedings of the 10th World Congress on PainJ |editorfirst3=Dostovsky JO, Carr DB, Koltzenburg M (eds)Jacob |edition= |volume=24 |chapter= |pages=185author3-96 |locationlink=Seattle |publisherlast4=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.Roffwarg |accessdateinit4=2020-11-18HP |notefirst4=}}</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 adulthoodHoward P.<ref name="tye2022">{{REFjournal |last=Tye |first= |init=NC |authorauthor4-link= |last2last5=SardiHellman |first2init5=L |init2first5=LMLeon |author2author5-link= |etal=no |title=Psychological, psychosocial, Behavioral state and psychosexual aspects ofpenile circumcision |trans-title= |language=plasma cortisol response in the human neonate |journal=Int J Impot ResPediatrics |location= |date=2022-031970-2810 |volume=46 |issue= |article= |page=4 |pages=532-7 |url=httpshttp://www.naturecirp.comorg/library/pain/articlesanders1/s41443-022-00553-9
|archived=
|quote=
|pubmedID=353473024323242
|pubmedCID=
|DOI=10.1038/s41443-022-00553-9 |accessdate=20222020-0411-2913}}</ref></blockquote>
|author-link=
|titlelast2=Neonatal pain: the evolution of an idea.Harmon |journalinit2=The American Association of Anesthesiologists NewsletterRJ |datefirst2=1998-09Robert J. |volumeauthor2-link= |issuelast3=Metcalf |pagesinit3=D |urlfirst3=David |accessdate=2020author3-11-12}}</ref> Incredible as it may seem today, his idea was accepted without question and without being tested.<ref namelink="vanhowe2008">{{REFjournal |lastlast4=Van HoweKoenig |firstinit4=Robert S.KL |initfirst4=RSKenneth L. |authorauthor4-link=Robert S. Van Howe |last2last5=SvobodaWagonfeld |first2init5=J. StevenS |init2first5=JSSamuel |author2author5-link=J. Steven Svoboda
|etal=no
|title=Neonatal pain relief Stress and the Helsinki Declarationneonatal sleep |journal=Journal of Law, Medicine, and EthicsPsychosom Med
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|date=2008-121971 |volume=3633 |issue=4 |article= |page=6 |pages=803491-237 |url=httpshttp://www.academiacirp.eduorg/downloadlibrary/33981944birth/emde/27_Van_Howe.pdf
|archived=
|quote=
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}}</ref>
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|last3=KreamBrackbill |init3=JY |first3=JacobYvonne
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|etal=no
|title=Behavioral state and plasma cortisol response in the human neonateEarly behavioral differences: gender or circumcision? |journal=PediatricsDev Psychobiol
|location=
|date=19701976-1001 |volume=469 |issue=41 |pages=53289-795 |url=http://www.cirp.org/library/painpsych/anders1brackbill/
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}}</ref>
* Emde et al. Luther, Kraybill & Potter (19711976) showed that 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 caused an increase in the amount of non-REM sleep.<ref name="emde1971">{{REFjournal |last=EmdeTalbert |init=RNLM |first=Robert NLuther M.
|author-link=
|last2=HarmonKraybill |init2=RJEN |first2=Robert JErnest N.
|author2-link=
|last3=MetcalfPotter |init3=D |first3=DavidHD
|author3-link=
|last4etal=Koenigno |init4=KL |first4title=Kenneth LAdrenal cortical response to circumcision in the neonate. |author4trans-link= |last5=Wagonfeld |init5=S |first5=Samuel |author5-link= |etaltitle=no |titlelanguage=Stress and neonatal sleepEnglish |journal=Psychosom Med Obstet Gynecol
|location=
|date=19711976-08 |volume=3346 |issue=62 |pages=491208-710 |url=http://www.cirp.org/library/birthpain/emdetalbert/
|archived=
|quote=
|pubmedID=940653
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|accessdate=2020-11-13
}}</ref>
* RichardsRawlings, Bernal Miller & Brackbill Engel (1976) reported behavioral differences between American boys (circumcised) and British boys (genitally intact1980)showed that as the pain of circumcision increased, oxygenation of the [[skin]] decreased.<ref name="richards1976rawlings1980">{{REFjournal |last=RichardsRawlings |init=MPMDJ |first=David J.
|author-link=
|last2=BernalMiller |init2=JFPA |first2=Patricia Anne
|author2-link=
|last3=BrackbillEngel |init3=YRR |first3=YvonneRolf R.
|author3-link=
|etal=no
|title=Early behavioral differences: gender or The effect of circumcision?on transcutaneous PO2 in term infants |trans-title= |language=English |journal=Dev PsychobiolAm J Dis Child
|location=
|date=19761980-0107 |volume=9134 |issue=17 |pages=89676-958 |url=http://www.cirp.org/library/psychpain/brackbillrawlings1/
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|accessdate=2020-11-13
}}</ref>
* Luther, Kraybill & Potter Gunnar et al. (19761981) compared the level of recorded serum cortisol in infants before and after behavior state throughout the unanesthetized, non-therapeutic circumcisionprocess. They found a substantial rise in the Serum cortisol levels in the infants, which they said was due 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 "stress" of circumcisioninfant. |Author=Gunnar et al.(1981) |ref=<refname="Gunnar et al 1981">{{REFjournal |last=TalbertGunnar |init=LMMR |first=Luther MMegan R.
|author-link=
|last2=KraybillFisch |init2=ENRO |first2=Ernest NRobert O.
|author2-link=
|last3=PotterKorsvick |init3=HDS |first3=Sherry
|author3-link=
|last4=Donhowe
|init4=JM
|first4=John M.
|author4-link=
|etal=no
|title=Adrenal cortical response to The effects of circumcision in the neonateon serum cortisol and behavior.
|trans-title=
|language=English
|journal=Obstet Gynecol Psychoneuroendocrinology
|location=
|date=1976-081981 |volume=466 |issue=23 |pages=208260-1075 |url=http://www.cirp.org/library/pain/talbertgunnar/
|archived=
|quote=
|pubmedID=9406537291435
|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"/> * Rawlings, Miller & Engel Marshall et al. (19801982) showed studied mother-child interaction with regard to feeding behavior after circumcision without anesthesia. They found that as the pain of circumcision increased, oxygenation of the [[skincircumcised]] decreasedboys had more interruptions of feeding in the 24-hour period of observation.<ref name="rawlings1980marshall1982">{{REFjournal |last=RawlingsMarshall |init=DJRE |first=David JRichard E.
|author-link=
|last2=MillerPorter |init2=PAFL |first2=Patricia AnneFran L.
|author2-link=
|last3=EngelRogers |init3=RRAG |first3=Rolf RAnn 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=The effect of circumcision on transcutaneous PO2 in term infantsCircumcision: II: Effects upon mother-infant interaction |trans-title=
|language=English
|journal=Am J Dis ChildEarly Hum Dev
|location=
|date=1980-071982 |volume=1347 |issue=74 |pages=676367-874 |url=http://www.cirp.org/library/painbirth/rawlings1marshall2/
|archived=
|quote=
|pubmedID=73958297169032
|pubmedCID=
|DOI=10.10011016/archpedi.1980.021301900440110378-3782(82)90038-x |accessdate=2020-11-1314
}}</ref>
|author-link=
|last2=FischMiller |init2first2=RORichard H. |first2init2=Robert O.RH
|author2-link=
|last3=KorsvickMarshal |init3first3=SRichard E |first3init3=SherryRE
|author3-link=
|trans-title=
|language=English
|journal=PsychoneuroendocrinologyChild Dev
|location=
|date=19811986-06 |volume=657
|issue=3
|pages=260790-75802 |url=httphttps://www.cirpjstor.org/library/pain/gunnarstable/1130355?seq=1
|archived=
|quote=
|pubmedID=72914353720404
|pubmedCID=
|DOI=10.10162307/0306-4530(81)90037-81130355 |accessdate=2020-11-1315
}}</ref>
|author-link=
|last2=PorterRoberts |init2first2=FLRonald J |first2init2=Fran L.RJ
|author2-link=
|last3=RogersGutierrez-Mazorra |init3first3=AGJuan F. |first3init3=Ann G.JF
|author3-link=
|last4=MooreFonkalsrud |init4first4=JEric W. |first4init4=JoAnnEW
|author4-link=
|language=English
|journal=Early Hum DevPediatrics
|location=
|date=19821987-09 |volume=780 |issue=43 |pages=367-74446 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/birth80/marshall23/446
|archived=
|quote=
|pubmedID=7169032
|pubmedCID=
|DOI=10.1016/0378-3782(82)90038-x |accessdate=2020-11-1412}}</ref><ref name="vanhowe2008"/>
|author-link=
|last2=MillerConnors |first2=Richard H.Joan |init2=RHJ
|author2-link=
|last3=MarshalIsensee |first3=Richard EJill |init3=REJ
|author3-link=
|last4=Wall |first4=Lee |init4=L |author4-link= |etal=noyes |title=Neonatal pain cries: effect of circumcision on acoustic features Adrenocortical activity and perceived urgencybehavioral distress in human newborns
|trans-title=
|language=English
|journal=Child DevPsychobiol
|location=
|date=19861988-0605 |volume=5721 |issue=34 |pages=790297-802310 |url=httpshttp://www.jstorcirp.org/stablelibrary/pain/gunnar1988/1130355?seq=1
|archived=
|quote=
|pubmedID= 37204043378676
|pubmedCID=
|DOI=10.23071002/1130355 dev.420210402
|accessdate=2020-11-15
}}</ref>
|author2-link=
|last3=Gutierrez-MazorraBohon |first3=Juan F.Constance |init3=JFC
|author3-link=
|last4=FonkalsrudHinman Jr |first4=Eric W.Frank |init4=EWF
|author4-link=
|last5=Poland |first5=Ronald L. |init5=RL |author5-link= |last6=Wakeman |first6=Maurice |init6=ME |author6-link= |etal=no |title=Neonatal anesthesiaReport of the Task Force of Circumcision |trans-title=
|language=English
|journal=Pediatrics
|location=
|date=19871989-0910 |volume=8089 |issue=34 |pages=446388-91 |url=httpshttp://pediatricswww.aappublicationscirp.org/contentlibrary/80statements/3aap/446#a1989
|archived=
|quote=
|pubmedID=2664697
|pubmedCID=
|DOI=
|accessdate=2020-11-1218}}</ref><ref name ====Finding an ethical way to do painful non-therapeutic circumcision===="vanhowe2008" />
|archived=
|quote=
|pubmedID=33786763883617
|pubmedCID=
|DOI=10.1002/dev.420210402
|accessdate=2020-11-15
}}</ref> Although by 1989 it was totally clear that infants can feel intense pain, however this clearly would not do for the 1989 American Academy of Pediatrics Circumcision Task Force, under the leadership of the infamous 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. [[Edgar J. SchoenDan Bollinger]], {{MD}}, declined to recommend (2012) estimated that the use total annual cost of analgesics for non-therapeutic neonatal [[circumcision]]to Americans is $3,647, thereby condemning millions of newborn baby boys to a painful000, stressful' traumatizing circumcision000.<ref>{{REFjournalREFweb |lasturl=Schoen |first=Edgar Jhttps://www. |init=EJ |author-link=Edgar Jacademia. Schoen |last2=Anderson |first2=Glen |init2=Gedu/6442587/High_Cost_of_Circumcision_3_6_Billion_Annually |author2-linkarchived= |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 High cost of the Task Force of Circumcisioncircumcision
|trans-title=
|language=English
|journallast=PediatricsBollinger |locationfirst=Dan |dateauthor-link=1989-10Dan Bollinger |volumepublisher=89Academia |issuewebsite=4 |pagesdate=388-912012 |urlaccessdate=http://www.cirp.org/library/statements/aap/#a19892020-11-15 |archivedformat=PDF
|quote=
|trans-title=
|language=English
|journallast=Urol Clin North Am |locationfirst= |dateauthor-link=1985 |volumepublisher=12Drugs.com |issuewebsite=1 |pagesdate=1232020-3204-21 |urlaccessdate=http://www.cirp.org/library/general/wallerstein/2020-11-21 |archivedformat=
|quote=
|trans-title=
|language=English
|lastjournal=BollingerJ Pediatr |first=Dan |author-link=Dan Bollinger |publisher=Academia |websitelocation= |date=20121978-06 |accessdatevolume=2020-11-1592 |formatissue=PDF6 |quotepages=}}</ref> The avaricious American [[circumcision industry]] is simply not willing to give that lucrative income up, so a way to make non998-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>{{REFweb1000 |url=httpshttp://www.drugscirp.comorg/prolibrary/pain/kirya1/emla.html#s-34069-5
|archived=
|quote=
|pubmedID=660375
|pubmedCID=
|DOI=10.1016/s0022-3476(78)80386-2
|accessdate=2020-11-16
}}</ref>
* [[Dorsal penile nerve Ring block| Dorsal Penile Nerve Ring Block]] . Broadman et al. (DPNB1987) as proposed by Kirya & Werthman (1978)ring block for neonatal non-therapeutic circumcision.<ref name="kirya1978broadman1987">{{REFjournal |last=Kirya |first=ChristopherBroadman |init=CLM
|author-link=
|last2=Werthman Jr |first2=Milton W.Hannallah |init2=MWRS
|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= Neonatal Post-circumcision and penile dorsal nerve block—a painless procedure. |trans-title= |language=Englishanalgesia—a prospective evaluation of subcutaneous ring block of the penis |journal=J PediatrAnesthesiology
|location=
|date=19781987-0608-31 |volume=9267 |issue=63 |pages=998399-1000402 |url=http://www.cirp.org/library/pain/kirya1/
|archived=
|quote=
|pubmedID=6603753307533
|pubmedCID=
|DOI=10.10161097/s002200000542-3476(78)80386198709000-2 00019 |accessdate=2020-11-1618}}</ref> * [[Ring block| Ring Block]]. Broadman et al. (1987) proposed 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="broadman1987lander1997"/><ref name="stang1997">{{REFjournal |last=BroadmanStang |first=Howard J. |init=LMHJ
|author-link=
|last2=HannallahSnellman |first2=Leonard W. |init2=RSLW
|author2-link=
|last3=BelmanCondon |first3=Lawrence M |init3=ABLM
|author3-link=
|last4=ElderConroy |first4=Mary Margaret |init4=PTMM
|author4-link=
|last5=RuttimanLiebo |first5=Rhoda |init5=UR
|author5-link=
|last6=EpsteinBrodersen |first6=Laurie |init6=BSL
|author6-link=
|last7=Gunnar
|first7=Megan R.
|init7=MR
|author7-link=
|etal=no
|title=PostBeyond dorsal penile nerve block: A more humane circumcision |trans-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penistitle= |language= |journal=AnesthesiologyPediatrics
|location=
|date=19871997-08-31 |volume=67100 |issue=32 |pages=399-402e3 |url=https://pediatrics.aappublications.org/content/100/2/e3
|archived=
|quote=
|pubmedID=33075339233974
|pubmedCID=
|DOI=10.10971542/00000542-198709000-00019 peds.100.2.e3
|accessdate=2020-11-18
}}</ref> Ring block is considered {{Box|Boxtext=<big><b>However, none of the most effective above three procedures totally eliminate pain. A baby boy will still experience some pain and [[trauma]] despite any of those analgesic procedure for procedures.<ref name="bellini2022 /> Prevention of pain requires protecting a boy from elective neonatal non-therapeutic circumcision. Infant Only boys feel less who are protected from the medically unnecessary circumcision surgery experience no pain and suffer less or [[trauma than with the other two pain reduction procedures]].<ref name="lander1997"/b></big>}} Wallerstein (1985)<ref name="stang1997">{{REFjournal |last=StangWallerstein |first=Howard J.Edward |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=Edward Wallerstein
|etal=no
|trans-title=
|language=
}}</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
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.
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.
|init=
|author-link=
|etal=yes
|title=Circumcision policy statement
|journal=Pediatrics
|date=1999-03
|volume=103
===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
|etal=no
|title=Neonatal circumcision revisited
|journal=CMAJ
|location=
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 infant circumcision, but recognized that it would be performed for religious, cultural, or family reasons, in which case, the non-therapeutic [[circumcision]] should be deferred for six months, so that general anesthesia may be used. The AAPS stated:
<blockquote>
In this event the procedure should be performed electively after six months of age. When performed, it should be carried out by a surgeon performing circumcisions on children on a regular basis with an anaesthetist using appropriate techniques. This would imply that the anaesthetist is fully trained in the art of paediatric anaesthesia, including the ability to perform caudal and penile regional or local anaesthesia. The operation should be carried out in a paediatrically orientated environment, designed to reduce the risk to the child and providing support to the parents or caregivers.<ref>{{REFdocument
The practice of non-therapeutic circumcision of boys has nearly died out in [[Australia]].
==VideosPain's injury to the infant nervous system == Anand & Hickey (1985) conclusively demonstrated that infants feel pain and feel it more intensely than adults.<ref name="anand1987"/>
|trans-title=
|language=
|lastjournal=MRC News |firstlocation= |author-linkdate=1998 |season=Summer |volume= |publisherissue= |websitearticle= |datepage= |accessdatepages=202220-03-1123 |url=https://www.cirp.org/library/pain/fitzgerald/ |formatarchived=
|quote=
|accessdate=2024-01-31}}</ref></blockquote>
{{Citation<youtube>SLhEoOQhsVw</youtube> Here is an infant circumcision video |Text=The public health importance of an Islamic circumcision from abnormal stimulation during the Russian Federationneonatal period cannot be overemphasized. The surgical technique is different but the pain is no less: <vimeo>259674034</vimeo><br>Here 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 video of Dr. Paul Fleiss speaking about view to developing effective therapeutic strategies for the harm of circumcision, including pain growing children and traumaadolescents who were exposed to abnormal conditions during the neonatal period.<youtube>ouHSz-OmOH8</youtube><br> ===Ronald Goldman== |Author=Anand & Scalzo (2000)[[Ronald Goldman]] discussed pain and trauma in a video by [[Brendon Marotta]]: <youtube>lNItNHs9PR8</youtube> ==Adolescent and adult circumcision= |ref= [[Adolescent and adult circumcision]] is usually carried out under total anesthesia, either by local or regional nerve block or by general anesthesia,<refname="anand2000">{{REFjournal |last=HolmanAnand |initfirst= |firstinit=John R.KJS |author-link=Kanwaljeet J. Singh Anand |last2=StuessiScalzo |init2first2= |first2init2=Keith A.FM |author2-link= |etal=no |title=Adult circumcisionCan adverse neonatal experiences alter brain development and subsequent behavior? |trans-title= |language=English |journal=American Family PhysicianBiol Neonate
|location=
|date=19992000-03-1502 |volume=5977 |issue=62 |article= |page= |pages=151469-882 |url=httpshttp://www.aafpcirp.org/afplibrary/1999pain/0315anand4/p1514.html
|archived=
|quote=
|pubmedID=10193593 10657682
|pubmedCID=
|DOI=10.1159/000014197 |accessdate=20202021-1108-1909}}</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 />}}
|author-link=
|last2=LiWalker |init2first2=Suellen |first2init2=MiaoS
|author2-link=
|last3year=Wang2003 |init3title=The role of activity in developing pain pathways |first3url=Li-Li |author3-link= |last4=Wang |init4= |first4=Xiao-Huahttp://www.cirp.org/library/pain/fitzgerald2/ |author4-linkwork= |last5=Huang |init5= |first5=Yu-Hua |author5-link= |etal=no |title=Improvement Proceedings of erection related incision pain in circumcision patients using interrupted rapid eye movement sleep: A randomized controlled study the 10th World Congress on Pain |journaleditor=Urol JDostovsky JO, Carr DB, Koltzenburg M (eds) |locationedition= |date=2018 |volume=1524 |issuechapter=3 |pages=126185-3196 |urllocation=https://journals.sbmu.ac.ir/urolj/index.php/uj/article/view/3981Seattle |archivedpublisher=ASP Press |quoteisbn= |pubmedIDquote=29308579 |pubmedCID= |DOI=10In common with other areas of the central nervous system, synaptic development of spinal sensory connections is experience or activity dependent.22037/ujEvidence 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.v0i0While these studies are incomplete and more investigation is needed in this area, the potential clinical importance of neonatal plasticity in pain development is clear.3981 |accessdate=2020-11-2818 |note=}}</ref> In a few cases, the [[erection]]s may cause [[wound dehiscence]] which requires additional surgery to re-close the surgical wound. Tye & Sardi advised:
|etal=no
|lasttitle=American Academy Psychological, psychosocial, and psychosexual aspects of Pediatricspenile circumcision |authortrans-linktitle=American Academy of Pediatrics |titlelanguage=The assessment and management of acute pain in infants, children, and adolescents |journal=PediatricsInt 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] <youtube>SLhEoOQhsVw</youtube> Here is an infant circumcision video of an Islamic circumcision from the Russian Federation. The surgical technique is different but the pain is no less: <vimeo>259674034</vimeo> Here is a video of Dr. Paul Fleiss speaking about the harm of circumcision, including pain and trauma. <youtube>ouHSz-OmOH8</youtube> ===Ronald Goldman=== [[Ronald Goldman]] discussed pain and trauma in a video by [[Brendon Marotta]]: <youtube>lNItNHs9PR8</youtube> ==Adolescent and adult circumcision== [[Adolescent and adult circumcision]] is usually carried out under total anesthesia, either by local or regional nerve block or by general anesthesia,<ref>{{REFjournal |last=Holman |init= |first=John R. |author-link= |last2=Stuessi |init2= |first2=Keith A. |author2-link= |etal=no |title=Adult circumcision |trans-title= |language=English |journal=American Family Physician |location= |date=1999-03-15 |volume=59 |issue=6 |pages=1514-8 |url=https://www.aafp.org/afp/1999/0315/p1514.html |archived= |quote= |pubmedID=10193593 |pubmedCID= |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. * The recovery period for adolescent and adult circumcision is usually placed at six weeks. During that period of time, many patients experience pain when they they have involuntary nocturnal [[erection]]s and the [[erection]] tightens the residual [[skin]] and pulls at the incision and suture.<ref>{{REFjournal |last=Dai |init= |first=A-Juan |author-link= |last2=Li |init2= |first2=Miao |author2-link= |last3=Wang |init3= |first3=Li-Li |author3-link= |last4=Wang |init4= |first4=Xiao-Hua |author4-link= |last5=Huang |init5= |first5=Yu-Hua |author5-link= |etal=no |title=Improvement of erection related incision pain in circumcision patients using interrupted rapid eye movement sleep: A randomized controlled study |journal=Urol J |location= |date=2018 |volume=15 |issue=3 |pages=126-31 |url=https://journals.sbmu.ac.ir/urolj/index.php/uj/article/view/3981 |archived= |quote= |pubmedID=29308579 |pubmedCID= |DOI=10.22037/uj.v0i0.3981 |accessdate=2020-11-28}}</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> {{SEEALSO}}* [[Circumstraint]]* [[Does Cosmetic Surgery Harm Babies?]]* [[Post-traumatic stress disorder]]* [[Psychological issues of male circumcision]]* [[Shock]]* [[Sudden Infant Death Syndrome]]* [[Trauma]] {{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 |last=American Academy of Pediatrics |author-link=American Academy of Pediatrics |title=The assessment and management of acute pain in infants, children, and adolescents |journal=Pediatrics |location= |date=2001-09 |volume=108 |issue=3 |pages=793-7 |url=http://www.cirp.org/library/pain/re9933/ |archived= |quote= |pubmedID=11533354 |pubmedCID= |DOI=10.1542/peds.108.3.793. |accessdate=2020-11-17}}* {{REFjournal |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
|format=PDF
|accessdate=2023-10-09
}}
* {{REFweb
|accessdate=2023-08-18
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* {{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
}}
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