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| Current US medical opinion about ] is highly controversial. Many major medical groups now no longer recommend, and some even discourage, routine infant circumcision (see below), because the risks are either perceived greater than the benefits (if any), or the benefits are not believed to have been sufficiently substantiated, or to be too small to justify recommending the procedure. | |||
| == Medical benefits == | |||
| There are a number of circumstances where doctors sometimes recommend circumcision. | |||
| First, a number of conditions of the foreskin only occur in uncircumcised men: ], ], ], ], and ]. These conditions can cause problems in sex, and may cause considerable pain. | |||
| An overtight foreskin (]) can cause problems in sex, as the foreskin may become trapped behind the glans of the penis and restrict blood flow (]). Circumcision is the recommended remedy for this condition, which typically arises in ]s experimenting with sex. It may be treatable by a program of stretching and use of topically applied ] creams, but this is generally considered less effective and risks later ]. As a result, in the ] of the U.K. it is only recommended to patients who wish to retain their foreskin for religious or sexual reasons. A newer, experimental, procedure is minor surgery to make a small slit in the foreskin without removing any tissue. | |||
| Recent studies from Europe demonstrate the prevalence of ] and ] due to the low rate of circumcision. Doctors at Royal Liverpool Children’s Hospital diagnosed over 100 cases (a 4% rate) of balanitis in a 3 ½ year survey of English boys. (Source: Escala JM, Rickwood AMK. Balanitis. Brit J Urol 1989;63:196-197). Doctors from the Children’s Hospital, Sheffield found a prevlance of phimosis among uncircumcised English boys. (Source: Rickwood AMK, Hemalatha V, Batcup G, Spitz L. Phimosis in Boys. Brit J Urol 1980;52:147-150). A study conducted in Denmark examined 9,545 Danish boys between 6 and 17 years of age, and found that 4% had phimosis, (incidence of 8% among 6 year olds), 33% had preputal adhesions (63% among 6 year olds), and 5% had smegma. (Source: Øster J. Further fate of the foreskin. Arch Dis Child 1968; 43:200-203.) | |||
| Phimosis can be difficult to diagnose, and misdiagnoses can lead to unnecessary circumcisions. An author of the two English studies cited above, writes in his 2000 paper "Towards evidence based circumcision of English boys" in the ''British Medical Journal'' : | |||
| :Too many English boys, especially those under 5 years of age, are still being circumcised because of misdiagnosis of phimosis. What is phimosis? At birth, the foreskin is almost invariably non-retractable, but this state is transient and resolves in nearly all boys as they mature. Such normality, with an unscarred and pliant preputial orifice, is clearly distinguishable from pathological phimosis, a condition unambiguously characterised by secondary cicatrisation of the orifice, usually due to balanitis xerotica obliterans. This problem, the only absolute indication for circumcision, affects some 0.6% of boys, peaks in incidence at 11 years of age, and is rarely encountered before the age of 5. (...) Strictly, only some 0.6% of boys with pathological phimosis need to be circumcised, although more relaxed criteria would allow for a similar proportion affected by recurrent balanoposthitis. | |||
| Other studies have linked the uncircumcised penis to other skin disorders of the penis. Researchers from the Imperial College School of Medicine, Chelsea & Westminster Hospital, London, England reported the results of their study of 357 patients referred for genital skin disease: | |||
| : The most common diagnoses were psoriasis (n=94), penile infections (n=58), lichen sclerosus (n=52), lichen planus (n=39), seborrheic dermatitis (n=29), and Zoon balanitis (n=27). Less common diagnoses included squamous cell carcinoma (n=4), bowenoid papulosis (n=3), and Bowen disease (n=3). The age-adjusted odds ratio for all penile skin diseases associated with presence of the foreskin was 3.24 (95% confidence interval, 2.26-4.64). All patients with Zoon balanitis, bowenoid papulosis, and nonspecific balanoposthitis were uncircumcised. Lichen sclerosus was diagnosed in only 1 circumcised patient. Most patients with psoriasis, lichen planus, and seborrheic eczema (72%, 69%, and 72%, respectively) were uncircumcised at presentation. The majority of men with penile infections (84%) were uncircumcised. | |||
| :(Source: Eleanor Mallon, MRCP; David Hawkins, FRCP; Michael Dinneen, FRCS; Nicholas Francis, FRCPath; Louise Fearfield, MRCP; Roger Newson, DPhil; Christopher Bunker, FRCP, Circumcision and Genital Dermatoses, Arch Dermatol. 2000;136:350-354.) | |||
| In "Medical Department, United States Army, Surgery in World War II, Urology", links observed by clinicians in the field were surveyed and compiled. In it, the author notes that “hospital admissions for paraphimosis, phimosis, balanitis, and ] during 1942-1945 totaled 146,793.” (Source: JF Patton, Medical Department, United States Army, Surgery in World War II, Urology, p. 145). The author also notes the increased seriousness of genital infections in the uncircumcised: | |||
| :A word should be said here about circumcision. Any penile lesion in the presence of a redundant prepuce may present a problem and also invites secondary infection. Phimosis was a common complication of chancroid, and dorsal slits were often necessary, followed by circumcision after the local infection subsided. Phimosis and paraphimosis unrelated to veneral disease were also encountered frequently. Soldiers in combat were seldom able to practice personal hygiene. Higher headquarters sometimes questioned the number of circumcisions performed in the theater, with emphasis on days lost from duty. But all were performed from medical necessity, and none were done electively, to the author’s knowledge. Many circumcisions, performed because of necessity in the active theaters, should have been done prophylactically before the soldier left the zone of interior." | |||
| :(Source: JF Patton, Medical Department, United States Army, Surgery in World War II, Urology , p. 64) | |||
| == Circumcision and cancer == | |||
| Studies finding a reduced risk of ] in circumcised males have a long history. (Sources: Abraham Wolbarst, ''The Lancet'' 1932;1:150-3; AJ Dean, J Urol. 1935; 35:252.) Recent studies appear to confirm that view. Dr. Schoen has reviewed the results of published material relating to penile cancer and circumcision and has quantified the risk of not circumcision a newborn boy: | |||
| :The evidence that circumcision protects against penile cancer is overwhelming. In the US, incidence of penile cancer in circumcised men is essentially zero (about one reported case every five years), but it is 2.2 per 100 000 in uncircumcised men (about 1000 cases are reported annually). On the basis of life table analysis, Kochen and McCurdy estimated that an uncircumcised man in the US has a lifetime risk of penile cancer of one in 600. | |||
| :During the last 50 years in the US, six major series of cancer of the penis encompassing more than 1600 cases have been reported; none of these cancer patients was circumcised in infancy. Human papilloma virus and smegma have been implicated in the aetiology of penile cancer.10 Of the approximately 50 000 cases of cancer of the penis that have occurred in the US since the 1930s (and which resulted in about 10 000 deaths), only 10 were reported in circumcised men. Newborn circumcision virtually eliminates this devastating threat. | |||
| :(Source: Edgar J Schoen, Benefits of newborn circumcision: is Europe ignoring medical evidence?, Arch Dis Child 1997;77:258-260 ( September ); footnotes deleted.) These results are consistent with those of other researchers. (Source: Kochen M, McCurdy S. Circumcision and the risk of cancer of the penis: a life-table analysis. Am J Dis Child 1980;134:484-486.) (see also: Schoen EJ. The relationship between circumcision and cancer of the penis. CA Cancer J Clin 1991;41:306-309). | |||
| Dr. Schoen and colleagues also conclude that newborn circumcision provides protection against penile cancer in situ and a greater protection against invasive penile cancer. (Source: Edgar J. Schoen, Michael Oehrli, Geoffrey Machin, The Highly Protective Effect of Newborn Circumcision Against Invasive Penile Cancer, Pediatrics 2000; 105: e36) | |||
| Opponents of neo-natal circumcision, ] and ] dismiss modern studies, but attack Wolbarst’s 1932 studies, writing in a 1996 opinion letter to the ''British Medical Journal'' in response to a recent paper on circumcision that relied on Wolbarst : | |||
| :Wolbarst invented this myth and was directly responsible for its proliferation; he based it on unverifiable anecdotes, ethnocentric stereotypes, a faulty understanding of human anatomy and physiology, a misunderstanding of the distinction between association and cause, and an unbridled missionary zeal. It was not based on valid scientific and epidemiological research. | |||
| :Epidemiological studies disproved Wolbarst's myth long ago. In North America the rate of penile cancer has been estimated to be 1 in 100000 (...). Maden ''et al.'' reported penile cancer among a fifth of elderly patients from rural areas who had been circumcised neonatally and had been born at a time when the rate of neonatal circumcision was about 20% in rural populations. Their study also shows that the rate of penile cancer among men circumcised neonatally has risen in the United States relative to the rise in the rate of neonatal circumcision. | |||
| This anti-circumcision movement has been gaining ground, and has influenced the ] to issue a statement in 1998: that "the practice of circumcision is strongly associated with socio-ethnic factors, which in turn are associated with lessened risk. The consensus among studies that have taken these other factors into account is circumcision is not of value in preventing cancer of the penis." | |||
| Doctors and researchers on the other side of the debate are active too. Dr. Dagher in an article detailing the high mortality of penile cancer (1/3 of the surveyed patients died), noted: | |||
| :Despite overwhelming evidence from urological surgeons that neoplasm of the penis is a lethal disease that can be prevented by removal of the foreskin, some physicians continue to argue against routine neonatal circumcision in a highly emotional and aggressive fashion. | |||
| :(Source: Dagher, R., et al., Carcinoma of the cervix and the anti-circumcison crusade. J. Urol. 110:79-80, July 1973) | |||
| Women with circumcised sex partners also have lower risk of ]. | |||
| (Dagher, R., et al., Carcinoma of the cervix and the anti-circumcison crusade. J. Urol. 110:79-80, July 1973). Cervical cancer has been related to the presence of ] infection. An international group of researchers from such diverse countries as Spain, Brazil, U.S.A., France, Thailand, Netherlands, Costa Rica, and the Philippines conducted a study published in the New England Journal of Medicine that concluded: | |||
| : Male circumcision is associated with a reduced risk of penile HPV infection and, in the case of men with a history of multiple sexual partners, a reduced risk of cervical cancer in their current female partners. | |||
| :(Source: Xavier Castellsagué, M.D., F. Xavier Bosch, M.D., Nubia Muñoz, M.D., Chris J.L.M. Meijer, Ph.D., Keerti V. Shah, Dr.P.H., Silvia de Sanjosé, M.D., José Eluf-Neto, M.D., Corazon A. Ngelangel, M.D., Saibua Chichareon, M.D., Jennifer S. Smith, Ph.D., Rolando Herrero, M.D., Victor Moreno, M.D., Silvia Franceschi, M.D., Male Circumcision, Penile Human Papillomavirus Infection, and Cervical Cancer in Female Partners, New England Journal of Medicine, Volume 346:1105-1112, April 11, 2002). | |||
| Researchers from the Danish Cancer Registry, Copenhagen, studied women with only one lifetime sexual partner to determine which male factors had an influence on a woman’s risk for contracting cervical cancer and found that her partner’s lack of circumcision was such a factor. (Source: Kjaer SK, de Villiers EM, Dahl C, Engholm G, Bock JE, Vestergaard BF, Lynge E, Jensen OM, Case-control study of risk factors for cervical neoplasia in Denmark. I: Role of the "male factor" in women with one lifetime sexual partner, INTERNATIONAL JOURNAL OF CANCER, Volume 48, Number 1: Pages 39-44, April 22, 1991.) | |||
| == Circumcision and ] (UTI) == | |||
| The American Medical Assocation states: | |||
| :There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI). | |||
| :(Source: American Medical Assocation, Report 10 of the Council on Scientific Affairs on Neonatal Circumcision) | |||
| Infections of the urinary tract (kidneys, ureters, bladder and urethra) can lead to kidney damage if undetected, but can generally be treated effectively with antibiotics. Recent studies find a ten to fifteen times increased risk of uncircumcised UTIs in male infants within the first year of life. (Source: Behrman, Nelson Textbook of Pediatrics, 16th ed. 2000.) | |||
| These studies have been criticized for their methodology. The ] noted in its 1999 circumcision policy statement: | |||
| : Few of the studies that have evaluated the association between UTI in male infants and circumcision status have looked at potential confounders (such as prematurity, breastfeeding, and method of urine collection) in a rigorous way. For example, because premature infants appear to be at increased risk for UTI, the inclusion of hospitalized premature infants in a study population may act as a confounder by suggesting an increased risk of UTI in uncircumcised infants. Premature infants usually are not circumcised because of their fragile health status. In another example, breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status. | |||
| UTI is usually detected through urine tests. Depending on the method of urine collection, there is a varying risk of false positives through contamination. The bacteria detected may in fact come from the foreskin itself, indicating foreskin infection not the urinary tract infection. In spite of this, even anti-circumcision advocates concede that an increased risk of UTI in uncircumcised males is generally considered plausible, a higher likelihood of bacterial colonization being the proposed mechanism. | |||
| On his website, Dr. Schoen states: | |||
| :Uncircumcised boys are about 10 times as likely to get serious kidney infections in the first year of life as are circumcised infants; uncircumcised older boys and men are more likely to get UTIs as well. These kidney infections are most dangerous in the first 3 months, during which time they often lead to hospitalization and can result in overwhelming blood infection and other serious infections. Kidney scarring has been shown to occur later. There is concern that future kidney failure and high blood pressure may follow infantile UTIs. Abnormal kidney function and hormonal secretion can occur with infant UTIs. Fecal contamination of the moist inner foreskin layer with bacterial attachment leads to these kidney infections. | |||
| :(Source: http://www.medicirc.org/meditopics/uti/more_info_uti.html) | |||
| Researchers from the University of Texas and Southwestern Medical School surveyed the incidence of UTIs in young children. They found that 95% of boys with UTIs were uncircumcised among a predominantly circumcised populace (Dallas, Texas in 1982). (Source: Ginsberg CM, and McCracken GH: Urinary tract infections in young infants. Pediatrics 69:409, 1982) | |||
| Other researchers have reported similar results. (Source: Wiswell TE, Prepuce presence portends prevalence of potentially perilous periurethral pathogens, The Journal of Urology, 1992; 148: 739-42) One textbook notes: | |||
| :It has become apparent that uncircumcised newborns are predisposed to urinary tract infections (UTIs) in the neonatal period. For example, in a study of 100 neonates with UTIs, Ginsburg and McCracken (1982) found that only 3 of the 62 males (5%) who developed a UTI were circumcised. Subsequently, Wiswell and colleagues (1985) studied more than 2500 male infants and found that 41 had symptomatic UTIs; of these 88% were uncircumcised. In that study, uncircumcised males were nearly 20 times more likely to develop UTIs than circumcised neonates. Other studies of larger groups of infants have corroborated these reports (Wiswell, 1992) | |||
| :(Source: Walsh, Campbell's Urology, 7th ed. 1998) (Accord: Behrman, Nelson Textbook of Pediatrics, 16th ed. 2000: “UTIs are 10 to 15 times more common in uncircumcised infants than in circumcised infants”) | |||
| == Circumcision and ]/] == | |||
| The American Medical Assocation states: | |||
| :The data on circumcision status and susceptibility to HIV infection and other sexually transmissible diseases have been recently reviewed. Five of 7 prospective studies involving heterosexual transmission of HIV-1 found a statistically significant association between lack of circumcision and elevated risk for acquisition of HIV... At least 16 studies have examined the relationship between circumcision and sexually transmissible diseases other than HIV. In general, circumcised individuals appear to have somewhat lower susceptibility to acquiring chancroid and syphilis, possibly genital herpes, and gonorrhea compared to individuals in whom the foreskin is intact. | |||
| :(Source: American Medical Assocation, Report 10 of the Council on Scientific Affairs on Neonatal Circumcision) | |||
| Comprehensive studies of the benefits of circumcision in preventing HIV/AIDS have mostly focused on the female-to-male heterosexual transmission. It is axiomatic that possession (or not) of a foreskin does not influence transmission rates associated with the non-insertional partner’s acquisition of HIV/AIDS through anal, vaginal, or oral sex, or any partner through pregnancy, nursing, blood transfusions, needle sticks or sharing needles. | |||
| Uncircumcised men were first shown to be more likely to acquire heterosexual HIV infection over a decade ago, in articles in the leading medical journals "Lancet" and "New England Journal of Medicine". Since then over 40 separate studies have shown that uncircumcised men are more likely to become infected with HIV on heterosexual exposure. The ease with which the foreskin tears during intercourse, leaving mini-abrasions through which the virus enters, can lead to the infections. It has recently been shown that certain specialized cells in the foreskin, Langerhans cells, can trap the HIV virus and promote infection. | |||
| In 1986 Dr. ], a noted medical expert, proposed that circumcision might prevent the distribution of ]. He hypothesized that the keratinization of the circumcised penis might prevent HIV infection. Other researchers soon investigated the question whether there is a link between circumcision and HIV infection rates. | |||
| In a study published in the ], researchers studied patients appearing at a Nairobi, Kenya, STD clinic. The researchers, JN Simonsen, DW Cameron, MN Gakinya, JO Ndinya-Achola, LJ D'Costa, P Karasira, M Cheang, AR Ronald, P Piot, and FA Plummer, found “en who were uncircumcised were more likely to have HIV infection (odds ratio, 2.7; P = 0.003).” | |||
| :(Source: Human immunodeficiency virus infection among men with sexually transmitted diseases. Experience from a center in Africa, JN Simonsen et al., The New England Journal of Medicine, Volume 319:274-278, August 4, 1988) | |||
| In a study published in ] in 1989, researchers studied possible risk factors in female-to-male HIV transmission. The researchers found that uncircumcised men (29.0%) were ten times more likely to acquire HIV from a single sexual encounter than circumcised men (2.5%). Uncircumcised men with genital ulcers (52.6%) were four times more likely to become infected than circumcised men with genital ulcers (13.4%). | |||
| :(Source: Cameron DW, Simonsen JN, D’Costa LJ, Ronald AR, Maitha GM, Gakinya MN, et al. Female to Male Transmission of Human Immunodeficiency Virus Type 1: Risk Factors for Seroconversion in Men. Lancet 1989; 2:403-27.) | |||
| Another set of researchers concluded that “In the AIDS belt, lack of male circumcision in combination with risky behavior, such as having multiple sex partners, engaging in sex with prostitutes and leaving chanchroid untreated has led to rampant HIV transmission.” | |||
| :(Source: "The African AIDS Epidemic," by J. C. Caldwell and Pat Caldwell, | |||
| Scientific American, March 1996, p. 62) | |||
| Researchers from the University of Manitoba also studied heterosexual HIV transmission in Africa. The researchers concluded that: “There is substantial evidence that circumcision protects males from HIV infection, penile carcinoma, urinary tract infections, and ulcerative sexually transmitted diseases. We could find little scientific evidence of adverse effects on sexual, psychological, or emotional health.” | |||
| :(Source: S Moses, RC Bailey and AR Ronald, Male circumcision: assessment of health benefits and risks, Sexually Transmitted Infections, Vol. 74, Issue 5, p. 368-373) | |||
| Another publication in the New England Journal of Medicine found that “Male circumcision consistently shows a protective effect against HIV infection” and noted that HIV prevalence was 1.7 to 8.2 times higher among uncircumcised heterosexual men than among circumcised heterosexual men. The study faulted the Langerhans cells in the foreskin and a “receptive HIV environment between foreskin and glans” for the increased risk. | |||
| :(Source: Rachel A. Royce, Ph.D., M.P.H., Arlene Seña, M.D., Willard Cates, M.D., M.P.H., and Myron S. Cohen, M.D, Sexual Transmission of HIV, The New England Journal of Medicine, Volume 336:1072-1078, April 10, 1997) | |||
| A group of researchers from the University of Washington studied truckers in Kenya who used the services of prostitutes. They found that a trucker’s uncircumcised status was associated with a four-fold increased risk of contracting HIV even after eliminating behavior, religion, or other factors. | |||
| :(Source: Lavreys L; Rakwar JP; Thompson ML; Jackson DJ; Mandaliya K; Chohan BH; Bwayo JJ; Ndinya-Achola JO; Kreiss JK; Effect of circumcision on incidence of human immunodeficiency virus type 1 and other sexually transmitted diseases: a prospective cohort study of trucking company employees in Kenya, J Infect Dis. 1999 Aug;180(2):330-6) | |||
| In the Lancet, researchers at the University of California, San Francisco (“UCSF”) and the University of Illinois, Chicago, published the results of their review of over 30 studies on the association between circumcision and HIV. The researchers concluded that circumcision “could potentially save millions of men and their partners” and were sufficiently motivated to cause UCSF to issue a press release announcing the discovery. The report contains tables showing the significantly higher HIV infection rate among countries with non-circumcised majorities. | |||
| :(Source: Daniel T Halperin, Robert C Bailey, Viewpoint: Male Circumcision and HIV Infection: 10 Years and Counting, The Lancet, 354 (9192): pp. 1813-15.) | |||
| Tying AIDS/HIV rates to circumcision status in the abstract has been eschewed by careful scientists and statisticians. One must correct base data that may tend to favor societies that practice other behavior regardless of circumcision or whose behavior in transmission of HIV has less to do with heterosexual sex, wherein the vulnerability of men with foreskins to female-to-male transmission may be demonstrated to anal or oral homosexual sex wherein the mode of transmission of tears in the colon or gums are the primary vectors of spread of the virus. | |||
| Anti-circumcision advocates show that HIV/AIDS prevalence is higher in industrial societies that practice circumcision. | |||
| <table border=1 align="center"> | |||
| <tr bgcolor="#eeeeee"><td colspan=2> | |||
| <center>'''Table 2<br>] data of AIDS rates for 1995'''</centeR> | |||
| </td></tr> | |||
| <tr bgcolor="#f2f2f2"><td>Nation</td> | |||
| <td>AIDS cases per 100,000 pop.</td> | |||
| </tr> | |||
| <tr> | |||
| <td>USA</td><td>16.0</td></tr> | |||
| <tr><td>Australia</td><td>4.5</td></tr> | |||
| <tr><td>Canada</td><td>3.8</td></tr> | |||
| <tr><td>France</td><td>3.5</td></tr> | |||
| <tr><td>Netherlands</td><td>3.1</td></tr> | |||
| <tr><td>United Kingdom</td><td>2.4</td></tr> | |||
| <tr><td>Germany</td><td>2.2</td></tr> | |||
| <tr><td>Sweden</td><td>2.0</td></tr> | |||
| <tr><td>Norway</td><td>1.6</td></tr> | |||
| <tr><td>New Zealand</td><td>1.2</td></tr> | |||
| <tr><td>Finland</td><td>0.9</td></tr> | |||
| <tr><td>Japan</td><td>0.2</td></tr> | |||
| </table> | |||
| However, the data are misleading because most transmission in industrial societies involves homosexual sex, needle sharing, and blood transfusions. | |||
| In the developing world, however, most HIV/AIDS is heterosexually transmitted. | |||
| :(Source: June 1998 UNAIDS/WHO report) | |||
| <table border=1 align="center"> | |||
| <tr bgcolor="#eeeeee"><td colspan=2> | |||
| <center>'''Table 2<br>] data of HIV infection rates for 1998'''</centeR> | |||
| </td></tr> | |||
| <tr bgcolor="#f2f2f2"><td>Nation</td> | |||
| <td>HIV infections per 100,000 pop. in African countries with under 20% circumcision rate</td> | |||
| </tr> | |||
| <tr> | |||
| <td>Zimbabwe</td><td>25,840</td></tr> | |||
| <tr><td>Botswana</td><td>25,100</td></tr> | |||
| <tr><td>Namibia</td><td>19,940</td></tr> | |||
| <tr><td>Zambia</td><td>19,070</td></tr> | |||
| <tr><td>Swaziland</td><td>18,500</td></tr> | |||
| <tr><td>Malawi</td><td>14,920</td></tr> | |||
| <tr><td>Mozambique</td><td>14,170</td></tr> | |||
| <tr><td>Rwanda</td><td>12,750</td></tr> | |||
| </table> | |||
| <table border=1 align="center"> | |||
| <tr bgcolor="#eeeeee"><td colspan=2> | |||
| <center>'''Table 2<br>] data of HIV infection rates for 1998'''</centeR> | |||
| </td></tr> | |||
| <tr bgcolor="#f2f2f2"><td>Nation</td> | |||
| <td>HIV infections per 100,000 pop. in Asian countries with under 20% circumcision rate</td> | |||
| </tr> | |||
| <tr> | |||
| <td>Cambodia</td><td>2,400</td></tr> | |||
| <tr><td>Thailand </td><td>2,230</td></tr> | |||
| <tr><td>Myanmar</td><td>1,790</td></tr> | |||
| <tr><td>India</td><td>820</td></tr> | |||
| <tr><td>Nepal</td><td>240</td></tr> | |||
| </table> | |||
| <table border=1 align="center"> | |||
| <tr bgcolor="#eeeeee"><td colspan=2> | |||
| <center>'''Table 2<br>] data of HIV infection rates for 1998'''</centeR> | |||
| </td></tr> | |||
| <tr bgcolor="#f2f2f2"><td>Nation</td> | |||
| <td>HIV infections per 100,000 pop. in African countries with over 80% circumcision rate</td> | |||
| </tr> | |||
| <tr> | |||
| <td>Kenya</td><td>11,640</td></tr> | |||
| <tr><td>Congo (Brazzaville)</td><td>7,640</td></tr> | |||
| <tr><td>Cameroon</td><td>4,890</td></tr> | |||
| <tr><td>Nigeria</td><td>4,120</td></tr> | |||
| <tr><td>Gabon</td><td>4,250</td></tr> | |||
| <tr><td>Liberia</td><td>3,650</td></tr> | |||
| <tr><td>Sierra Leone</td><td>3,170</td></tr> | |||
| <tr><td>Ghana</td><td>2,380</td></tr> | |||
| <tr><td>Gambia</td><td>2,240</td></tr> | |||
| <tr><td>Guinea</td><td>2,090</td></tr> | |||
| <tr><td>Benin</td><td>2,060</td></tr> | |||
| </table> | |||
| <table border=1 align="center"> | |||
| <tr bgcolor="#eeeeee"><td colspan=2> | |||
| <center>'''Table 2<br>] data of HIV infection rates for 1998'''</centeR> | |||
| </td></tr> | |||
| <tr bgcolor="#f2f2f2"><td>Nation</td> | |||
| <td>HIV infections per 100,000 pop. in Asian countries with over 80% circumcision rate</td> | |||
| </tr> | |||
| <tr> | |||
| <td>Pakistan</td><td>90</td></tr> | |||
| <tr><td>Philippines </td><td>60</td></tr> | |||
| <tr><td>Indonesia</td><td>50</td></tr> | |||
| <tr><td>Bangladesh</td><td>30</td></tr> | |||
| </table> | |||
| == Medical complications of circumcision == | |||
| While all benefits associated with circumcision are controversial, the procedure has risks. Complications of circumcision are rare and generally mild. | |||
| :In general, neonatal circumcision is safe, although there is a complication rate of 0.2% to 3% (Ross, 1995). Dorsal penile nerve block with either lidocaine or bupivacaine significantly reduces the pain associated with the procedure (Ryan et al, 1994) | |||
| :(Source: Walsh, Campbell's Urology, 7th ed. 1998) | |||
| Anti-circumcision advocates claim that about 200 deaths per year in the United States are attributable to neo-natal circumcision ,; this would equate with approximately 1 per 4,500 circumcisions. If this were the case, one would expect a large outcry; its absence tends to negate the contention by the anti-circumcision claim. The opponents also claim that in countries with lower medical standards, complication rates are much higher, and historically, circumcision has been a risky procedure. Again, the lack of a large number of actual victims disproves the claim. The Talmud grants an exemption from circumcision if the first three sons died from it . | |||
| A few (obviously rare) extreme cases of circumcision complications have been documented in the scientific literature. Perhaps best known is the case of "Bruce/Brenda/David", an infant whose genitalia were amputated after a botched non-neonatal circumcision and who was then raised as a girl, with traumatic consequences. The case has been documented by ] in the book ''As Nature Made Him'' | |||
| == Effects of circumcision == | |||
| Medical authorities are generally in accord that possession or absence of a foreskin does not affect sexual pleasure in the male. Recent studies published in the Journal of Urology studied men who were circumcised as adults, and found the majority reported no significant difference in sex drive, erection, ejaculation, or sexual satisfaction. | |||
| :(Source: Collins, S, et al., Circumcision and Male Sexual Function, Journal of Urology 2002;167:2111-2116) | |||
| However, circumcisions done to correct ] and ], conditions that only occur in uncircumcised men, tend to enable sexual functioning that was previously painful or impossible. Neo-natal circumcision absolutely prevents ] and ]. | |||
| == Circumcision as an indication of elite status == | |||
| Due to pressures brought to bear by the anti-circumcision movements, health care systems have been refusing to pay for neo-natal circumcision. Circumcision is fast becoming a mark of the elite – a status it enjoyed prior to the 19th Century. | |||
| Famous circumcised men include virtually a who’s who of thinkers: ], ], ] of Nazereth, ], ], ], ], ], ], ], ], ], ], the authors of the ], ], ], ], ] and ]. | |||
| Famous circumcised men also comprise a varied cross-section of important persons in history, culture, or simply, modern celebrities, including: | |||
| ], Canadian singer | |||
| ], African-American boxer | |||
| ], American film impresario | |||
| The ], American singers | |||
| ], English royal | |||
| ], UN secretary general | |||
| ], Palestinian leader | |||
| ], Costa Rican president | |||
| ], American actor | |||
| ], Syrian president | |||
| ], American singer | |||
| ], American comedian | |||
| ], American television pioneer | |||
| ], American baseball figure | |||
| ], French prime minister | |||
| ], Irish politician | |||
| ], American newsman | |||
| ], German singer | |||
| ], American humorist | |||
| ], American actor | |||
| ], Panamanian baseball star | |||
| ], American president | |||
| ], Russian-French artist | |||
| ], English royal | |||
| ], American actor | |||
| ], Panamanian president | |||
| ], American singer | |||
| ], American cartoonist | |||
| ], English prime minister | |||
| ], American movie star | |||
| ], English king | |||
| ], English king | |||
| ], Russian movie maker | |||
| ], Tasmanian movie star | |||
| ], American movie star | |||
| ], American president | |||
| ], Libyan leader | |||
| ], UN secretary general | |||
| ], American singer/songwriter | |||
| ], English king | |||
| ], English king | |||
| ], American movie star | |||
| ], Australian movie star | |||
| ], English movie star | |||
| ], American economist | |||
| ], Canadian hockey star | |||
| ], American actor | |||
| ], Israeli musician | |||
| ], New Zealander mountain climber | |||
| ], American actor | |||
| ], Russian pianist | |||
| ], Indian singer | |||
| ], Jordanian king | |||
| ], Australian governor general | |||
| ], American basketball star | |||
| ], American singer | |||
| ], English singer | |||
| ], Cuban-American singer | |||
| ], American actor | |||
| ], American president | |||
| ], Austrian-American diplomat | |||
| ], Austrian prime minister | |||
| ], Mexican-American actor | |||
| ], American diver | |||
| ], French king | |||
| ], American actor | |||
| ], South African president | |||
| ], French actor | |||
| ], American actor | |||
| ], English singer/song-writer | |||
| ], French prime minister | |||
| ], American football star | |||
| ], French actor | |||
| ], Indian viceroy | |||
| ], Egyptian president | |||
| ], Pakistani president | |||
| ], American politician | |||
| ], American football star | |||
| ], American actor | |||
| ], American president | |||
| ], French tennis star | |||
| ], American boxer | |||
| ], American actor | |||
| ], Israeli violinist | |||
| ], Russian czar | |||
| ], English royal | |||
| ], American actor | |||
| ], Polish movie director | |||
| ], Italian actor | |||
| ], Russian prime minister | |||
| ], American movie star | |||
| ], American actor | |||
| ], American admiral | |||
| ], Puerto Rican newsman | |||
| ], New Zealander diplomat | |||
| ], Russian pianist | |||
| ], American astronomer | |||
| ], Portuguese president | |||
| ], Austrian actor | |||
| ], English actor | |||
| ], Egyptian actor | |||
| ], Canadian actor | |||
| ], American playwright | |||
| ], American singer/song-writer | |||
| ], American actor | |||
| ], American movie maker | |||
| ], American swimmer | |||
| ], Australian singer | |||
| ], American singer | |||
| ], American actor | |||
| ], English singer | |||
| ], English singer | |||
| ], Canadian television pioneer | |||
| ], American actor | |||
| ], Russian revolutionary | |||
| ], American mathematician | |||
| ], Egyptian pharaoh | |||
| ], Russian-English actor | |||
| ], American author | |||
| ], American newsman | |||
| ], American artist | |||
| ], Romanian author | |||
| ], American actor | |||
| ], American playwright | |||
| ], American singer | |||
| == The anti-circumcision advocates’ arguments == | |||
| The anti-circumcision movement claims that the process of keratinization after circumcision is well known and negatively affects the sexual sensitivity of the glans to stimulation. This effect of the procedure is sometimes presented as an advantage (prolonging the sexual act) or as a disadvantage (decrease in sensation). In a study of adult males who became circumcised (in 84% cases due to medical conditions), 38% reported negative outcomes such as decreased sensitivity and erectile dysfunction . | |||
| According to the anti-cirucmcision movement: Because the foreskin acts as a natural lubricant, uncircumcised men and boys can usually masturbate without any external aids by simply sliding the foreskin back and forth over the glans. Circumcised men frequently have to resort to using a lubricant and other techniques. With total foreskin amputation, which is no longer common, erection can become painful or even impossible as the remaining skin is stretched to its limits. This effect on masturbation and sexual behavior was alluded to in early circumcision advocacy (see below). | |||
| O'Hara and O'Hara have conducted a survey among women who had sex with both circumcised and uncircumcised males, and found that 85.5% preferred intact partners. Women reported having had more single and multiple orgasms with uncircumcised men, and less vaginal discomfort. Specifically regarding the loss of vaginal secretion in partners of circumcised men, the authors write : | |||
| : When the anatomically complete penis thrusts in the vagina, it does not slide, but rather glides on its own 'bedding' of movable skin, in much the same way that a turtle's neck glides in and out of the folder layers of skin surrounding it. The underlying corpus cavernosa and corpus spongiosum slide within the penile skin, while the skin juxtaposed against the vaginal wall moves very little. This sheath-within-a-sheath alignment allows penile movement, and vaginal and penile stimulation, with minimal friction or loss of secretions. | |||
| Circumcision without anaesthesia is believed by many child psychologists and neurologists to have severe long term traumatic effects. However, circumcision is usually practiced today with local anaesthesia. | |||
| == Statements by health groups == | |||
| The American Academy of Pediatrics created a Task Force on Circumcision, which issued an official policy statement. The abstract of their statement reads: | |||
| :"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided." | |||
| The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists issued a statement in 1997 that "newborn circumcision is an elective procedure to be performed at the request of the parents on baby boys who are physiologically and clinical stable." | |||
| The American Academy of Family Physicians Reference Manual states: "Current medical literature regarding neonatal circumcision is controversial and conflicting. The decision to perform neonatal circumcision should be based on the informed consent of the parents, and requires objective, factual counseling of parents by the family physician." | |||
| In recent years the ] has issued a neutral position statement on circumcision. "We would like to discourage the ] from promoting routine circumcision as a preventive measure for penile or cervical ]." The American Academy of Pediatrics no longer promotes routine circumcision. | |||
| The American Medical Assocation states: | |||
| :There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI), although the magnitude of this risk is debatable... Despite the increased relative risk in uncircumcised infants, the absolute incidence of UTI is small in this population... One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition. | |||
| :The data on circumcision status and susceptibility to HIV infection and other sexually transmissible diseases have been recently reviewed. Five of 7 prospective studies involving heterosexual transmission of HIV-1 found a statistically significant association between lack of circumcision and elevated risk for acquisition of HIV... At least 16 studies have examined the relationship between circumcision and sexually transmissible diseases other than HIV. In general, circumcised individuals appear to have somewhat lower susceptibility to acquiring chancroid and syphilis, possibly genital herpes, and gonorrhea compared to individuals in whom the foreskin is intact... Regardless of these findings, behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision status. | |||
| :(Source: American Medical Assocation, Report 10 of the Council on Scientific Affairs on Neonatal Circumcision) | |||
Latest revision as of 18:31, 5 September 2012
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