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Circumcision
Circumcision being performed in central Asia, possibly Turkmenistan c. 1865–1872. Restored albumen print.
ICD-10-PCS	Z41.2
ICD-9-CM	V50.2
MeSH	D002944
MedlinePlus	002998
eMedicine	1015820
[edit on Wikidata]

Male circumcision is the surgical removal of some or all of the foreskin (prepuce) from the penis. Early depictions of circumcision are found in cave paintings and Ancient Egyptian tombs, though some pictures are open to interpretation. Religious male circumcision is considered a commandment from God in Judaism. In Islam, though not discussed in the Qur'an, male circumcision is widely practised and most often considered to be a sunnah. It is also customary in some Christian churches in Africa.

Estimates by the World Health Organization (WHO) suggest that 30 percent of males worldwide are circumcised, of whom 68 percent are Muslim. The prevalence of circumcision varies mostly with religious affiliation, and sometimes culture. In some countries circumcisions are more commonly performed during infancy. Circumcision is also used therapeutically, as one of the treatment options for balanitis xerotica obliterans, phimosis, balanitis, posthitis, balanoposthitis and urinary tract infections.

Strong evidence indicates that circumcision reduces the risk of HIV infection in heterosexual men by 38-66% in populations that are at high risk, and studies have concluded it is cost effective in sub-Saharan Africa. The WHO currently recommends circumcision be recognised as an intervention as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV.

According to the Royal Dutch Medical Association (2010), no professional association of physicians currently recommends routine circumcision. Some bodies have discussed under what circumstances circumcision is ethical.

There is controversy regarding circumcision. Specific controversies have included the health benefits and risks of the procedure, ethical and legal considerations, and the application of human rights principles to the practice.

Modern procedure

If anesthesia is to be used there are several options: local anesthetic cream (EMLA cream) can be applied to the end of the penis 60–90 minutes prior to the procedure; local anesthetic can be injected at the base of the penis to block the dorsal penile nerve; local anesthetic can be injected in a ring around the middle of the penis in what is called a subcutaneous ring block. It is also possible to use general anesthetics in the case of adult surgery, though not the standard practice.

For infant circumcision, devices such as the Gomco clamp, Plastibell, and Mogen clamp are commonly used, together with a restraining device.

With all these devices the same basic procedure is followed. First, the amount of foreskin to be removed is estimated. The foreskin is then opened via the preputial orifice to reveal the glans underneath and ensure it is normal. The inner lining of the foreskin (preputial epithelium) is then bluntly separated from its attachment to the glans. The device is then placed (this sometimes requires a dorsal slit) and remains there until blood flow has stopped. Finally, the foreskin is amputated. Sometimes, the frenulum band may need to be broken or crushed and cut from the corona near the urethra to ensure that the glans can be freely and completely exposed.

• With the Plastibell, once the glans is freed the Plastibell is placed over the glans, and the foreskin is placed over the Plastibell. A ligature is then tied firmly around the foreskin and tightened into a groove in the Plastibell to achieve hemostasis. Foreskin distal to the ligature is excised and the handle is snapped off the Plastibell device. The Plastibell falls from the penis after the wound has healed, typically in four to six days.
• With a Gomco clamp, a section of skin is dorsally crushed with a hemostat and then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is tightened, "crushing the foreskin between the bell and the base plate." The crushed blood vessels provide hemostasis. The flared bottom of the bell fits tightly against the hole of the base plate, so the foreskin may be cut away with a scalpel from above the base plate.
• With a Mogen clamp, the foreskin is pulled dorsally with a straight hemostat, and lifted. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result" to Gomco or Plastibell circumcisions. The clamp is locked, and a scalpel is used to cut the skin from the flat (upper) side of the clamp.

Adult circumcisions are often performed without clamps and require four to six weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal. In some African countries, male circumcision is often performed by non-medical personnel under unsterile conditions. After hospital circumcision, the foreskin may be used in biomedical research, consumer skin-care products, skin grafts, or β-interferon-based drugs. In parts of Africa, the foreskin may be dipped in brandy and eaten by the patient, eaten by the circumciser, or fed to animals. According to Jewish law, the foreskin should be buried after a brit milah.

Medical aspects

Studies comparing healthcare cost to benefits of circumcision have reached varying conclusions. Some found a small net benefit of circumcision, some found a small net decrement, and one found that the benefits and risks balanced each other out and suggested that the decision could "most reasonably be made on nonmedical factors."

Pain

According to the American Academy of Pediatrics' 1999 Circumcision Policy Statement, "There is considerable evidence that newborns who are circumcised without analgesia experience pain and physiologic stress." One of the supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response during vaccination months later. While acknowledging that there may be other factors than circumcision to account for different levels of pain response, they stated that they did not find evidence of such. It therefore recommended to use pain relief for circumcision. Other medical associations also cite evidence that circumcision without anesthetic is painful.

Stang, 1998, found 45% of physicians responding to a survey who circumcise used anaesthesia – most commonly a dorsal penile nerve block – for infant circumcisions. The obstetricians in the sample used anaesthesia less often (25%) than the family practitioners (56%) or pediatricians (71%). Howard et al. (1998) surveyed US medical doctor residency programs and directors, and found that 26% of the programs that taught the circumcision procedure "failed to provide instruction in anesthesia/analgesia for the procedure" and recommended that "residency training in neonatal circumcision should include instruction in pain relief techniques". A 2006 follow-up study revealed that the percentage of programs that taught circumcision and also taught administration of topical or local anesthetic had increased to 97%. However, the authors of the follow-up study also noted that only 84% of these programs used anesthetic "frequently or always" when the procedure was conducted.

Glass, 1999, stated that Jewish ritual circumcision is so quick that "most mohelim do not routinely use any anaesthesia as they feel there is probably no need in the neonate." Glass continued, "However, there is no Talmudic objection and should the parents wish for local anaesthetic cream to be applied there is no reason why this cannot be done." Glass also stated that for older children and adults, a penile block is used. In 2001 the Swedish government passed a law requiring all boys undergoing a bris to be given anaesthetic administered by a medical professional.

Comparisons of the dorsal penile nerve block and EMLA (lidocaine/prilocaine) topical cream methods of pain control have revealed that while both are safe, the dorsal nerve block controls pain more effectively than topical treatments. Neither method eliminates pain completely. The ring block may provide more effective pain control than either of these treatments. The use of sucrose pacifiers and comfortable, padded chairs may also help.

Sexual effects

The effect of circumcision on sexual function is poorly determined with studies reporting mixed effects. The American Academy of Pediatrics points to a survey (self-report) finding circumcised adult men had less sexual dysfunction and more varied sexual practices, but also noted anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males. A 2002 review stated that "the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings—many of which are lost to circumcision, with an inevitable reduction in sexual sensation experienced by circumcised males." The authors concluded, "intercourse is less satisfying for both partners when the man is circumcised".

In January 2007, The American Academy of Family Physicians (AAFP) stated "The effect of circumcision on penile sensation or sexual satisfaction is unknown. Because the epithelium of a circumcised glans becomes cornified, and because some feel nerve over-stimulation leads to desensitization, many believe that the glans of a circumcised penis is less sensitive. No valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction." A 2010 review reported that "despite conflicting results in some of the historical observational studies, most recent articles do not show evidence of adverse effects on sexual function." A review which analysed the data from eight clinical trials concluded that the "evidence suggests that adult circumcision does not affect sexual satisfaction and function."

Complications

Complication rates ranging from 0.06% to 55% have been cited; more specific estimates have included 2–10% and 0.2–0.6%. The authors of a systematic review found a median complication rate of 1.5% among neonates, with a range of 0 to 16%. In older boys, rates varied from 2-14%, with a median of 6%. The median risk of serious complications was 0% in both cases.

According to the American Medical Association (AMA), blood loss and infection are the most common complications, but most bleeding is minor and can be stopped by applying pressure. A survey of circumcision complications by Kaplan in 1983 revealed that the rate of bleeding complications was between 0.1% and 35%.

Meatal stenosis (a narrowing of the urethral opening) may be a longer-term complication of circumcision. It is thought that because the foreskin no longer protects the meatus, ammonia formed from urine in wet diapers irritates and inflames the exposed urethral opening. Meatal stenosis can lead to discomfort with urination, incontinence, bleeding after urination and urinary tract infections.

Circumcisions may remove too much or too little skin. If insufficient skin is removed, the child may still develop phimosis in later life. Other complications include concealed penis, urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias and impotence. Kaplan stated "Virtually all of these complications are preventable with only a modicum of care" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons." Another complication of infant circumcision is skin bridge formation, whereby a remaining part of the foreskin fuses to other parts of the penis (often the glans) upon healing. This can result in pain during erections and minor bleeding can occur if the shaft skin is forcibly retracted.

Although deaths have been reported, the American Academy of Family Physicians states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision. The penis is thought to be lost in 1 in 1,000,000 circumcisions.

Sexually transmitted diseases

There is strong evidence that circumcision reduces the risk of HIV infection in heterosexual men in populations that are at high risk. Evidence among heterosexual men in sub-Saharan Africa shows a decreased risk of between 38 percent and 66 percent over two years and in this population studies rate it cost effective. Whether it is of benefit for women is disputed and whether it is of benefit in developed countries and among men who have sex with men is undetermined.

Human immunodeficiency virus

Over forty observational studies have been conducted to investigate the relationship between circumcision and HIV infection. Reviews of these studies have reached differing conclusions about whether circumcision could be used as a prevention method against HIV.

Experimental evidence was needed to establish a causal relationship between lack of circumcision and HIV, so three randomized controlled trials were commissioned as a means to reduce the effect of any confounding factors. Trials took place in South Africa, Kenya and Uganda. All three trials were stopped early by their monitoring boards on ethical grounds, because those in the circumcised group had a lower rate of HIV contraction than the control group. The results showed that circumcision reduced vaginal-to-penile transmission of HIV by 60%, 53%, and 51%, respectively. A meta-analysis of the African randomised controlled trials found that the risk in circumcised males was 0.44 times that in uncircumcised males, and that 72 circumcisions would need to be performed to prevent one HIV infection. The authors also stated that using circumcision as a means to reduce HIV infection would, on a national level, require consistently safe sexual practices to maintain the protective benefit.

As a result of these findings, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an efficacious intervention for HIV prevention but should be carried out by well trained medical professionals and under conditions of informed consent. Both the WHO and CDC indicate that circumcision may not reduce HIV transmission from men to women, and that data are lacking for the transmission rate of men who engage in anal sex with a female partner. The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should never replace known methods of HIV prevention. The Male Circumcision Clearinghouse website was formed by WHO, UNAIDS, FHI and AVAC to provide current evidence-based guidance, information and resources to support the delivery of safe male circumcision services in countries that choose to scale up male circumcision as one component of comprehensive HIV prevention services.

Circumcision has been judged to be a cost-effective method to reduce the spread of HIV in a population, though not necessarily more cost-effective than condoms. Some have challenged the validity of the African randomized controlled trials, prompting a number of researchers to question the effectiveness of circumcision as an HIV prevention strategy.

In addition to the studies which provided information about female-to-male transmission, some studies have addressed other transmission routes. A randomised controlled trial in Uganda found that male circumcision did not reduce male to female transmission of HIV. The authors could not rule out the possibility of higher risk of transmission from men who did not wait for the wound to fully heal before engaging in intercourse. A meta-analysis of data from fifteen observational studies of men who have sex with men found "insufficient evidence that male circumcision protects against HIV infection or other STIs."

Human papilloma virus

A 2007 meta-analysis of eight observational studies found no protective effect against human papillomavirus (HPV); critics reported that reanalysis of the same data showed a protective effect. A later analysis of 14 studies, by Bosch et al, found a protective effect. In 2011, a meta-analysis of 23 studies (including both randomised controlled trials and observational studies) found reduced risk of prevalent HPV and (though the evidence was less strong) some evidence of reduced risk of new HPV infections. In another analysis, in which 21 studies were included, there was a statistically significant reduction in prevalence of HPV, but no statistically significant association with new acquisitions was observed.

A 2009 meta-analysis of multiple studies found a significant association between genital warts and HPV and the presence of a foreskin, as well as HPV alone. While circumcision was associated with a lesser risk of genital warts alone, the association did not reach statistical significance. However, later analyses found no association between circumcision and penile warts.

Other sexually transmitted infections

Studies evaluating the effect of circumcision on the incidence of other sexually transmitted infections have reached conflicting conclusions. A 2006 meta-analysis of observational data from twenty-six studies found that circumcision was associated with lower rates of syphilis, chancroid and possibly genital herpes. More recently, a 2010 review of clinical trial data found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%. The researchers found mixed results for protection against Trichomonas vaginalis and Chlamydia trachomatis, and no evidence of protection against gonorrhoea or syphilis. Among men who have sex with men, reviews have found insufficient evidence of an effect against sexually transmitted infections other than HIV, with the possible exception of syphilis.

Hygiene, and infectious and chronic conditions

The American Academy of Pediatrics (1999) stated: "Circumcision has been suggested as an effective method of maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene."

An inflammation of the glans penis and foreskin is called balanoposthitis; that affecting the glans alone is called balanitis. Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. Although not as necessary as in the past, circumcision may be considered for recurrent or resistant cases. Most cases of these conditions occur in uncircumcised males, and affect 4 to 11% of uncircumcised boys. The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor. Yeasts, especially Candida albicans, are the most common penile infection, and are rarely identified in samples taken from circumcised males. Escala and Rickwood recommend against a policy of routine infant circumcision to avoid balanitis saying that the condition affects no more than 4% of boys, does not cause pathological phimosis, and in most cases is not serious; in contrast, Morris regards circumcision as "mandated", citing reduced risk of balanitis among other benefits.

Phimosis is the inability to retract the foreskin over the glans penis; authors frequently distinguish between "physiologic" phimosis (or developmental non-retractility) and "pathological" phimosis. The latter is most commonly caused by balanitis xerotica obliterans, for which circumcision is the preferred treatment. The American Medical Association states that circumcision, properly performed, protects against the development of phimosis. Rickwood and other authors have argued that many infant circumcisions are performed unnecessarily for developmental non-retractability of the prepuce rather than for pathological phimosis. Metcalfe et al. stated that "Gairdner and Oster made a strong case for leaving boys uncircumcised, allowing the natural separation of the foreskin from the glans to take place gradually, and instructing boys in proper hygiene. This obviates the need for 'preventive' circumcision." In a study to determine the most cost-effective treatment for phimosis, Van Howe concluded that using cream was 75% more cost-effective than circumcision at treating pathological phimosis.

Urinary tract infections

Circumcision is associated with a reduced risk of urinary tract infections (UTIs) however the magnitude of this benefit is likely to outweigh the risk only in those at high risk of UTIs.

Some UTI studies have been criticized for not taking into account a high rate of UTI's among premature infants, who are usually not circumcised because of their fragile health status. The AMA stated that "depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI," and noted one decision analysis model that concluded that circumcision was not justified as a preventative measure against UTI.

Penile cancer

The American Academy of Pediatrics (1999) stated that studies suggest that neonatal circumcision confers some protection from penile cancer, but circumcision at a later age does not seem to confer the same level of protection. Further, because penile cancer is a rare disease, the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low.

Micali et al describe penile cancer as an "emerging problem", noting that "public health measures, such as prophylactic use of circumcision, have proven successful". A 2011 meta-analysis concluded that childhood or adolescent circumcision substantially reduces the risk of invasive penile cancer. It has been suggested that this may be due, in part, to reduced risk of phimosis, a predisposing factor for penile cancers. While the same study found an association between adult circumcision and an increased risk of invasive penile cancer, the authors suggested this association was possibly due to adult circumcisions being used as a treatment for penile cancer or a condition that is a precursor to cancer, rather than the procedure itself raising the risk of cancer.

The age-adjusted annual incidence of penile cancer is 0.82 per 100,000 in Denmark, 2.9–6.8 per 100,000 in Brazil, 0.9 to 1 per 100,000 in the USA, and 2.0–10.5 per 100,000 in India. Researchers have reported that the risk of penile cancer is greater in never-circumcised men than in men who had been circumcised at birth; estimates of the relative risk include 3 and 22.

The American Cancer Society (2009) stated, "Most experts agree that circumcision should not be recommended solely as a way to prevent penile cancer."

Prevalence

Estimates of the proportion of males that are circumcised worldwide vary from one-sixth to a third. The WHO has estimated that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), with almost 70% of these being Muslim. Circumcision is most prevalent in the Muslim world, parts of Southeast Asia, Africa, the United States, the Philippines, Israel, and South Korea. It is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia and Oceania. Prevalence is near-universal in the Middle East and Central Asia. The WHO states that "there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines". The WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe, and Klavs et al. report findings that "support the notion that the prevalence is low in Europe". In Latin America, prevalence is universally low. Estimates for individual countries include Spain, Colombia and Denmarkless than 2%, Finland 0.006% and 7%, Brazil 7%, Taiwan 9%, Thailand 13% and Australia 58.7%.

The WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively. Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.

History

The origination of male circumcision is not known with certainty. It has been variously proposed that it began as a religious sacrifice, as a rite of passage marking a boy's entrance into adulthood, as a form of sympathetic magic to ensure virility or fertility, as a means of enhancing sexual pleasure, as an aid to hygiene where regular bathing was impractical, as a means of marking those of higher social status, as a means of humiliating enemies and slaves by symbolic castration, as a means of differentiating a circumcising group from their non-circumcising neighbors, as a means of discouraging masturbation or other socially proscribed sexual behaviors, as a means of removing "excess" pleasure, as a means of increasing a man's attractiveness to women, as a demonstration of one's ability to endure pain, or as a male counterpart to menstruation or the breaking of the hymen, or to copy the rare natural occurrence of a missing foreskin of an important leader, and as a display of disgust of the smegma produced by the foreskin. It has been suggested that the custom of circumcision gave advantages to tribes that practiced it and thus led to its spread. Darby describes these theories as "conflicting", and states that "the only point of agreement among proponents of the various theories is that promoting good health had nothing to do with it." Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practising circumcision, leading to its spread. Wilson suggests that circumcision reduces insemination efficiency, reducing a man's capacity for extra-pair fertilizations by impairing sperm competition. Thus, men who display this signal of sexual obedience, may gain social benefits, if married men are selected to offer social trust and investment preferentially to peers who are less threatening to their paternity. It is possible that circumcision arose independently in different cultures for different reasons.

The oldest documentary evidence for circumcision comes from ancient Egypt and Greek historian Herodotus states that "the Egyptians and those who have learned it from them are the only people who practise circumcision". Circumcision was common, although not universal, among ancient Semitic peoples. In the aftermath of the conquests of Alexander the Great, however, Greek dislike of circumcision (they regarded a man as truly "naked" only if his prepuce was retracted) led to a decline in its incidence among many peoples that had previously practiced it.

Circumcision has ancient roots among several ethnic groups in sub-equatorial Africa, and is still performed on adolescent boys to symbolize their transition to warrior status or adulthood.

Non-religious circumcision

Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada, South Africa, New Zealand and to a lesser extent in the United Kingdom. There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The germ theory of disease elicited an image of the human body as a conveyance for many dangerous germs, making the public "germ phobic" and suspicious of dirt and bodily secretions. The penis became "dirty" by association with its function, and from this premise circumcision was seen as preventative medicine to be practised universally. In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation. Aggleton wrote that John Harvey Kellogg viewed male circumcision in this way, and further "advocated an unashamedly punitive approach." Circumcision was also said to protect against syphilis, phimosis, paraphimosis, balanitis, and "excessive venery" (which was believed to produceparalysis). Gollaher states that physicians advocating circumcision in the late nineteenth century expected public scepticism, and refined their arguments to overcome it.

Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 32% of newborn American boys were being circumcised in 1933. Laumann et al. reported that the prevalence of circumcision among US-born males was approximately 70%, 80%, 85%, and 77% for those born in 1945, 1955, 1965, and 1971 respectively. Xu et al. reported that the prevalence of circumcision among US-born males was 91% for males born in the 1970s and 84% for those born in the 1980s. Between 1981 and 1999, National Hospital Discharge Survey data from the National Center for Health Statistics demonstrated that the infant circumcision rate remained relatively stable within the 60% range, with a minimum of 60.7% in 1988 and a maximum of 67.8% in 1995. A 1987 study found that the most prominent reasons US parents choose circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns. However, a later study speculated that an increased recognition of the potential benefits of neonatal circumcision may have been responsible for the observed increase in the US rate between 1988 and 2000. A report by the Agency for Healthcare Research and Quality placed the 2005 national circumcision rate at 56%.

In 1949, the United Kingdom's newly formed National Health Service removed infant circumcision from its list of covered services, and circumcision has since been an out-of-pocket cost to parents. Among men (aged 15 years or older) who are neither Jews nor Muslims, the overall prevalence of circumcision in the UK is 6% according to the WHO's estimates. When "data from targeted oversampling of black Caribbean, black African, Indian, and Pakistani groups (the Natsal ethnic minority boost) were combined with the main [Natsal II] survey data", it was found that the prevalence of circumcision in the UK is age-graded, with 11.7% of those aged 16–19 years circumcised and 19.6% of those aged 40–44 years. There is a clear ethnic division: "With the exception of black Caribbeans, men from all ethnic minority backgrounds were significantly [(3.02 times)] more likely to report being circumcised compared to men who described their ethnicity as white". These particular findings "confirm that the prevalence of male circumcision among British men appears to be declining. This is despite an increase in the proportion of the British population describing their ethnicity as nonwhite"; indeed, the proportion of newborns circumcised in England and Wales has fallen to less than one percent.

The circumcision rate has declined sharply in Australia since the 1970s, leading to an age-graded fall in prevalence, with a 2000–1 survey finding 32% of those aged 16–19 years circumcised, 50% for 20–29 years and 64% for those aged 30–39 years.

In Canada, Ontario health services delisted circumcision in 1994.

Etymology

The word "circumcision" comes from Latin circumcisione from circum (meaning "around") andcædere (meaning "to cut").

Society and culture

Circumcision has been described as the most controversial surgical procedure of all times.

Ethical issues

Ethical questions have been raised over removing healthy, functioning genital tissue from a minor. Opponents of circumcision state that infant circumcision infringes upon individual autonomy and represents a human rights violation. Rennie et al. note that using circumcision as a way of preventing HIV in high prevalence, low-income countries in sub-Saharan Africa, is controversial, but argue that "it would be unethical to not seriously consider one of the most promising new approaches to HIV-prevention in the 25-year history of the epidemic".

Consent

Views differ on whether limits should be placed on caregivers having a child circumcised.

Some medical associations take the position that the parents should determine what is in the best interest of the infant or child, but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue. The BMA state that in general, "the parents should determine how best to promote their children's interests, and it is for society to decide what limits should be imposed on parental choices." They state that because the parents' interests and the child's interests sometimes differ, there are "limits on parents' rights to choose and parents are not entitled to demand medical procedures contrary to their child's best interests." They state that competent children may decide for themselves. UNAIDS states that "ale circumcision is a voluntary surgical procedure and health care providers must ensure that men and young boys are given all the necessary information to enable them to make free and informed choices either for or against getting circumcised."

Some argue that the medical problems that have their risk reduced by circumcision are already rare, can be avoided, and, if they occur, can usually be treated in less invasive ways than circumcision. Somerville states that the removal of healthy genital tissue from a minor should not be subject to parental discretion and that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient. Denniston states that circumcision is harmful and asserts that in the absence of the individual's consent, non-therapeutic child circumcision violates several ethical principles that govern medicine.

Others believe neonatal circumcision is permissible, if parents should so choose. Viens argues that, in a cultural or religious context, circumcision is of significant enough importance that parental consent is sufficient and that there is "an absence of sufficient evidence or persuasive argumentation" to support changing the present policy. Benatar and Benatar argue that circumcision can be beneficial to a male before he would be able to otherwise provide consent, that "it is far from obvious that circumcision reduces sexual pleasure," and that "it is far from clear that non-circumcision leaves open a future person's options in every regard."

Acknowledgment of pain

Williams (2003) argued that human attitudes toward the pain that animals (including humans) experience may not be based on speciesism, developing an analogy between attitudes toward the pain pigs endure while having their tails docked, and "our culture's indifference to the pain that male human infants experience while being circumcised."

Psychological issues

The British Medical Association (BMA) states that "it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks." Milos and Macris (1992) argue that circumcision encodes the perinatal brain with violence and negatively affects infant-maternal bonding and trust. Goldman discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure. Furthermore, Schultheiss (1998) reports males attempting to undo the effects of circumcision through the practice of foreskin restoration. Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, citing a longitudinal study which did not find a difference "in relation to a number of developmental and behavioural indices." A literature review by Gerharz and Haarmann (2000) reached a similar conclusion. Boyle et al. (2002) state that circumcision may result in psychological harm, including post-traumatic stress disorder (PTSD), citing a study reporting high rates of PTSD among Filipino boys after either ritual or medical circumcision. Hirji et al. (2005) state that "Reports of psychological trauma are not borne out in studies but remain as an anecdotal cause for concern."

Legal issues

In 2001, Sweden passed a law allowing only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anaesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the law, and in 2001, the World Jewish Congress stated that it was "the first legal restriction on Jewish religious practice in Europe since the Nazi era." In 2005, the Swedish National Board of Health and Welfare reviewed the law and recommended that it be maintained. In 2006, the U.S. State Department's report on Sweden stated that most Jewish mohels had been certified under the law and 3000 Muslim and 40–50 Jewish boys were circumcised each year.

In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised was illegal. However, no punishment was assigned by the court, and in 2008 the Finnish Supreme Court ruled that the mother's actions did not constitute a criminal offense and that circumcision of a child for religious reasons, when performed properly, is not a crime. In 2008, the Finnish government was reported to be considering a new law to legalize ritual circumcision if the practitioner is a doctor, "according to the parents' wishes, and with the child's consent", as reported.

In 2007, the Australian states of Victoria, New South Wales, Western Australia, and Tasmania had stopped the practice of non-therapeutic male circumcision in all public hospitals, but did not forbid the procedure from being peformed in private hospitals.

Cultures and religions

In some cultures, males must be circumcised shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is commonly practised in the Jewish and Islamic faiths.

Jewish law states that circumcision is a mitzva aseh ("positive commandment" to perform an act) and is obligatory for Jewish-born males and for non-circumcised Jewish male converts. It is only postponed or abrogated in the case of threat to the life or health of the child. It is usually performed by a mohel on the eighth day after birth in a ceremony called a Brit milah (or Bris milah, colloquially simply bris), which means "Covenant of circumcision" in Hebrew. It is considered of such importance that in Orthodox communities, the body of an uncircumcised Jewish male will sometimes be circumcised before burial. Although 19th centuryReform leaders described it as "barbaric", the practice of circumcision "remained a central rite" and the Union for Reform Judaism has, since 1984, trained and certified over 300 practicing mohels under its "Berit Mila Program".Humanistic Judaism argues that "circumcision is not required for Jewish identity."

In Islam, circumcision is mentioned in some hadith (it is referred as Khitan), but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended (Sunnah); others that it is obligatory. Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant withAbraham. While endorsing circumcision for males, Islamic scholars note that it is not a requirement for converting to Islam.

The Roman Catholic Church formally condemned the ritual observance of circumcision and ordered against its practice in the Ecumenical Council of Basel-Florence in 1442. The Church presently maintains a neutral stance on circumcision as a medical practice.

Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches. Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ. The vast majority of Christians do not practise circumcision as a religious requirement.

Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War. In West Africa infant circumcision may have had tribal significance as a rite of passage or otherwise in the past; today in some non-Muslim Nigerian societies it is medicalised and is simply a cultural norm. Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land, where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago. Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature: subincision is practised amongst some aboriginal peoples in the Western Desert.

In the Pacific, circumcision or superincision is nearly universal among the Melanesians of Fiji and Vanuatu, while participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised. Circumcision or superincision is also commonly practiced in the Polynesian islands of Samoa, Tonga, Niue, and Tikopia, where the custom is recorded as a pre-Christian/colonial practice. In Samoa it is accompanied by a celebration.

Among some West African groups, such as the Dogon and Dowayo, circumcision is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males. Among the Urhobo of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te Oshare ("the boy is now man"), constitutes a rite of passage from one age set to another. For Nilotic peoples, such as the Kalenjin and Maasai, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set.

Positions of medical associations

The World Health Organization (WHO; 2007), the Joint United Nations Programme on HIV/AIDS (UNAIDS; 2007), and the US Centers for Disease Control and Prevention (CDC; 2008) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides partial protection and should be considered only in conjunction with other proven prevention measures. (The CDC have not yet made any final recommendations regarding circumcision.)

Australasia

As of 2010, the Royal Australasian College of Physicians state: "After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. However it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons."

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Neonatal circumcision revisited" in 1996 and "Circumcision: Information for Parents" in November 2004. The 1996 position statement says that "circumcision of newborns should not be routinely performed", and the 2004 information to parents says: 'Circumcision is a "non-therapeutic" procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social, or cultural reasons. After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.'

Netherlands

In the Netherlands, the Royal Dutch Medical Association (KNMG) stated in 2010 that non-therapeutic male circumcision "conflicts with the child's right to autonomy and physical integrity." They called on doctors to inform caregivers seeking the intervention of the (in their assessment) medical and psychological risks and lack of convincing medical benefits. They stated that there are as good reasons for legal prohibition of male circumcision as exist for female genital mutilation (FGM).

United Kingdom

The British Medical Association states that "Male circumcision that is performed for any reason other than physical clinical need is termed non-therapeutic (or sometimes "ritual") circumcision. Some people ask for non-therapeutic circumcision for religious reasons, some to incorporate a child into a community, and some want their sons to be like their fathers. Circumcision is a defining feature of some faiths".

The BMA provides that "male circumcision is generally assumed to be lawful provided that it is performed competently; it is believed to be in the child's best interests; and there is valid consent" from both parents and the child, if possible".

The BMA stipulates that "competent children may decide for themselves; the wishes that children express must be taken into account; if parents disagree, non-therapeutic circumcision must not be carried out without the leave of a court; consent should be confirmed in writing".

"In the past, circumcision of boys has been considered to be either medically or socially beneficial or, at least, neutral. The general perception has been that no significant harm was caused to the child and therefore with appropriate consent it could be carried out. The medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks. It is essential that doctors perform male circumcision only where this is demonstrably in the best interests of the child. The responsibility to demonstrate that non-therapeutic circumcision is in a particular child's best interests falls to his parents. The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it."

United States

The American Academy of Pediatrics (1999) stated: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, 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." The AAP recommends that if parents choose to circumcise, analgesia should be used to reduce pain associated with circumcision. It states that circumcision should only be performed on newborns who are stable and healthy.

The American Medical Association supports the AAP's 1999 circumcision policy statement with regard to non-therapeutic circumcision, which they define as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. They state that "policy statements issued by professional societies representing Australian, Canadian, and American pediatricians do not recommend routine circumcision of male newborns."

The American Academy of Family Physicians (2007) recognizes the controversy surrounding circumcision and recommends that physicians "discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son."

The American Urological Association (2007) stated that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks, recommending that "circumcision should be presented as an option for health benefits".

See also

• Circumcision scar
• Frenectomy
• Genital modification and mutilation
• Holy Prepuce
• Preputioplasty

Notes

1. Dictionary definitions of circumcision:
   • "The act of cutting off the prepuce or foreskin of males, or the internal labia of females." Webster's Revised Unabridged Dictionary (1913)
   • "to remove the foreskin of (males) sometimes as a religious rite." The Macquarie Dictionary (2nd Edition, 1991)
   • "Cut off foreskin of (as Jewish or Mohammedan rite, or surgically), Concise Oxford Dictionary, 5th Edition, 1964
   Circumcision defined in a medical context:
   • "Male circumcision is the surgical removal of all or part of the foreskin of the penis." Information Package on Male Circumcision and HIV Prevention:Insert 1, World Health Organization
   • "Circumcision, surgical removal of all or part of the foreskin of the human male. . .", "Circumcision", Microsoft Encarta, 2007.
   • "Male circumcision is an elective surgery to remove the foreskin. . ." Circumcision, British Columbia Health Guide, June 2, 2006. Retrieved July 18, 2007.
   • "Circumcision is surgery. . ." Pain and Your Infant: Medical Procedures, Circumcision and Teething, University of Michigan Health System, February 2007. Retrieved July 18, 2007.
   • " Circumcision is cutting away part of the foreskin. . . When this surgery is performed. . ." Newborn Care, Danbury Hospital website. Retrieved July 18, 2007.
2. Hodges, F.M. (2001). "The ideal prepuce in ancient Greece and Rome: male genital aesthetics and their relation to lipodermos, circumcision, foreskin restoration, and the kynodesme". The Bulletin of the History of Medicine. 75 (3): 375–405. doi:10.1353/bhm.2001.0119. PMID 11568485. {{cite journal}}: Cite has empty unknown parameter: |coauthors= (help); Unknown parameter |month= ignored (help)
3. Wrana, P. (1939). "Historical review: Circumcision". Archives of Pediatrics. 56: 385–392. as quoted in: Zoske, Joseph (1998). "Male Circumcision: A Gender Perspective". The Journal of Men's Studies. 6 (2): 189–208. Retrieved 2006-06-14. {{cite journal}}: Unknown parameter |month= ignored (help)
4. Gollaher, David L. (2000). Circumcision: A History of the World's Most Controversial Surgery. New York, NY: Basic Books. pp. 53–72. ISBN 978-0-465-04397-2. {{cite book}}: Cite has empty unknown parameter: |chapterurl= (help); Unknown parameter |month= ignored (help)
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6. "Genesis 17:9–14 (New International Version)"
7. Rizvi, S.A.H.; A Naqvi, S.A.; Hussain, M.; Hasan, A.S. (1999). "Religious circumcision: a Muslim view". BJU International. 83: 13–6. doi:10.1046/j.1464-410x.1999.0830s1013.x. PMID 10349409.
8. ^ Customary in some Coptic and other churches:
   • "The Coptic Christians in Egypt and the Ethiopian Orthodox Christians —two of the oldest surviving forms of Christianity— retain many of the features of early Christianity, including male circumcision. Circumcision is not prescribed in other forms of Christianity.…Some Christian churches in South Africa oppose the practice, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership and participants in focus group discussions in Zambia and Malawi mentioned similar beliefs that Christians should practice circumcision since Jesus was circumcised and the Bible teaches the practice." Male Circumcision: context, criteria and culture (Part 1), Joint United Nations Programme on HIV/AIDS, February 26, 2007.
   • "The decision that Christians need not practice circumcision is recorded in Acts 15; there was never, however, a prohibition of circumcision, and it is practiced by Coptic Christians." "circumcision", The Columbia Encyclopedia, Sixth Edition, 2001–5.
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70. Eaton, L (2009 Nov). "Behavioral aspects of male circumcision for the prevention of HIV infection". Current HIV/AIDS reports. 6 (4): 187–93. doi:10.1007/s11904-009-0025-9. PMID 19849961. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
71. Kim, HH (2010 Nov). "Male circumcision: Africa and beyond?". Current opinion in urology. 20 (6): 515–9. doi:10.1097/MOU.0b013e32833f1b21. PMID 20844437. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
72. Templeton, DJ (2010 Feb). "Male circumcision to reduce the risk of HIV and sexually transmitted infections among men who have sex with men". Current opinion in infectious diseases. 23 (1): 45–52. doi:10.1097/QCO.0b013e328334e54d. PMID 19935420. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
73. Wiysonge, CS.; Kongnyuy, EJ.; Shey, M.; Muula, AS.; Navti, OB.; Akl, EA.; Lo, YR. (2011). Wiysonge, Charles Shey (ed.). "Male circumcision for prevention of homosexual acquisition of HIV in men". Cochrane Database Syst Rev (6): CD007496. doi:10.1002/14651858.CD007496.pub2. PMID 21678366. {{cite journal}}: Cite has empty unknown parameter: |month= (help)
74. Szabo, R. (2000). "How does male circumcision protect against HIV infection?". BMJ. 320 (7249): 1592–1594. doi:10.1136/bmj.320.7249.1592. PMC 1127372. PMID 10845974. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
75. Van Howe, R.S. (1999). "Circumcision and HIV infection: review of the literature and meta-analysis". International Journal of STD's and AIDS. 10: 8–16. doi:10.1258/0956462991913015. Retrieved 2008-09-23. Thirty-five articles and a number of abstracts have been published in the medical literature looking at the relationship between male circumcision and HIV infection. Study designs have included geographical analysis, studies of high-risk patients, partner studies and random population surveys. Most of the studies have been conducted in Africa. A meta-analysis was performed on the 29 published articles where data were available. When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis (odds ratio (OR) = 1.06, 95% confidence interval (CI) = 1.01–1.12). Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded. {{cite journal}}: Cite has empty unknown parameter: |coauthors= (help); Unknown parameter |month= ignored (help)
76. O'Farrell N, Egger M (2000). "Circumcision in men and the prevention of HIV infection: a 'meta-analysis' revisited". International Journal of STD & AIDS. 11 (3): 137–42. doi:10.1258/0956462001915480. PMID 10726934. The results from this re-analysis thus support the contention that male circumcision may offer protection against HIV infection, particularly in high-risk groups where genital ulcers and other STDs 'drive' the HIV epidemic. A systematic review is required to clarify this issue. Such a review should be based on an extensive search for relevant studies, published and unpublished, and should include a careful assessment of the design and methodological quality of studies. Much emphasis should be given to the exploration of possible sources of heterogeneity. In view of the continued high prevalence and incidence of HIV in many countries in sub-Saharan Africa, the question of whether circumcision could contribute to prevent infections is of great importance, and a sound systematic review of the available evidence should be performed without delay. {{cite journal}}: Unknown parameter |month= ignored (help)
77. Weiss HA, Quigley MA, Hayes RJ (2000). "Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis". AIDS. 14 (15): 2361–70. doi:10.1097/00002030-200010200-00018. PMID 11089625. Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
78. ^ Siegfried, N (2003). Siegfried, Nandi (ed.). "Male circumcision for prevention of heterosexual acquisition of HIV in men". Cochrane Database of Systematic Reviews (3): CD003362. doi:10.1002/14651858.CD003362. PMID 12917962. Retrieved 2009-07-25. We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
79. Mills E, Cooper C, Anema A, Guyatt G (2008). "Male circumcision for the prevention of heterosexually acquired HIV infection: a meta-analysis of randomized trials involving 11,050 men". HIV Medicine. 9 (6): 332–5. doi:10.1111/j.1468-1293.2008.00596.x. PMID 18705758. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
80. ^ <Please add first missing authors to populate metadata.> (March 28, 2007). "New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications" (PDF). World Health Organization. Retrieved 2007-08-13. {{cite journal}}: Cite journal requires |journal= (help)
81. ^ "Male Circumcision and Risk for HIV Transmission and Other Health Conditions: Implications for the United States". Centers for Disease Control and Prevention. 7 February 2008. Retrieved 15 July 2011.
82. McNeil, Jr., Donald G. (March 3, 2009). "AIDS: New Web Site Seeks to Fight Myths About Circumcision and H.I.V." New York Times. p. D6. Retrieved February 1, 2012.
83. AVAC About male circumcision
84. Sansom, L. (2010). Kissinger, Patricia (ed.). "Cost-Effectiveness of Newborn Circumcision in Reducing Lifetime HIV Risk among U.S. Males". PLoS ONE. 5 (1): e8723. doi:10.1371/journal.pone.0008723. PMC 2807456. PMID 20090910. Our results show that newborn circumcision is usually cost saving in the United States because of the low cost of the procedure, current lifetime risk of HIV among U.S. males and the high cost of treating HIV. {{cite journal}}: Check date values in: |year= / |date= mismatch (help); Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: unflagged free DOI (link)
85. Mcallister RG, Travis JW, Bollinger D, Rutiser C, Sundar V (Fall 2008). "The cost to circumcise Africa". International Journal of Men's Health. 7 (3). Men's Studies Press: 307–316. doi:10.3149/jmh.0703.307. ISBN 1532-6306 (Print) 1933-0278 (Online). {{cite journal}}: Check |isbn= value: invalid character (help)CS1 maint: multiple names: authors list (link) CS1 maint: year (link)
86. Mills, J. (2006). "Cautious optimism for new HIV/AIDS prevention strategies". Lancet. 368 (9543): 1236. doi:10.1016/S0140-6736(06)69513-5. PMID 17027724. "The inferences drawn from the only completed randomised controlled trial (RCT) of circumcision could be weak because the trial stopped early. In a systematic review of RCTs stopped early for benefit, such RCTs were found to overestimate treatment effects. When trials with events fewer than the median number (n=66) were compared with those with event numbers above the median, the odds ratio for a magnitude of effect greater than the median was 28 (95% CI 11–73). The circumcision trial recorded 69 events, and is therefore at risk of serious effect overestimation. We therefore advocate an impartial meta-analysis of individual patients' data from this and other trials underway before further feasibility studies are done. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
87. Dowsett, G.W. (2007). "Male circumcision and HIV prevention: is there really enough of the right kind of evidence?" (PDF). Reproductive Health Matters. 15 (29): 33–44. doi:10.1016/S0968-8080(07)29302-4. PMID 17512372. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
88. Wawer, Maria; et al. (18 July 2009). "Randomized Trial of Male Circumcision in HIV-infected Men: Effects on HIV Transmission to Female Partners, Rakai, Uganda". Lancet. 374 (9685): 229–237. doi:10.1016/S0140-6736(09)60998-3. PMC 2905212. PMID 19616720.
89. Millett GA; Flores SA; Marks G; et al. (2008). "Circumcision Status and Risk of HIV and Sexually Transmitted Infections Among Men Who Have Sex With Men". JAMA. 300 (14): 1674–1684. doi:10.1001/jama.300.14.1674. PMID 18840841. {{cite journal}}: Unknown parameter |author-separator= ignored (help)
90. Van Howe, Robert S. (2007). "Human papillomavirus and circumcision: A meta-analysis". Journal of Infection. 54 (5): 490–496. doi:10.1016/j.jinf.2006.08.005. PMID 16997378. Retrieved 2008-09-18. {{cite journal}}: Unknown parameter |month= ignored (help)
91. Castellsagué X, Albero G, Clèries R, Bosch FX (2007). "HPV and circumcision: a biased, inaccurate and misleading meta-analysis". J. Infect. 55 (1): 91–3, author reply 93–6. doi:10.1016/j.jinf.2007.02.009. PMID 17433445. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
92. ^ Bosch FX, Albero G, Castellsagué X (2009). (PDF). J Fam Plann Reprod Health Care. 35 (1): 5–7. doi:10.1783/147118909787072270. PMID 19126309. {{cite journal}}: Check |url= value (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
93. ^ Larke N, Thomas SL, Dos Santos Silva I, Weiss HA (2011). "Male circumcision and human papillomavirus infection in men: a systematic review and meta-analysis". J. Infect. Dis. 204 (9): 1375–90. doi:10.1093/infdis/jir523. PMID 21965090. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
94. ^ Albero G, Castellsagué X, Giuliano AR, Bosch FX (2012). "Male Circumcision and Genital Human Papillomavirus: A Systematic Review and Meta-Analysis". Sex Transm Dis. 39 (2): 104–113. doi:10.1097/OLQ.0b013e3182387abd. PMID 22249298. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
95. Weiss HA, Thomas SL, Munabi SK, Hayes RJ (2006). "Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta‐analysis". Sexually Transmitted Infections. 82 (2): 101–9, discussion 110. doi:10.1136/sti.2005.017442. PMC 2653870. PMID 16581731. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
96. Wetmore CM, Manhart LE, Wasserheit JN (2010). "Randomized controlled trials of interventions to prevent sexually transmitted infections: learning from the past to plan for the future". Epidemiol Rev. 32 (1): 121–36. doi:10.1093/epirev/mxq010. PMC 2912604. PMID 20519264. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
97. Millett GA, Flores SA, Marks G, Reed JB, Herbst JH (2008). "Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis". JAMA. 300 (14): 1674–84. doi:10.1001/jama.300.14.1674. PMID 18840841. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
98. ^ Templeton DJ, Millett GA, Grulich AE (2010). "Male circumcision to reduce the risk of HIV and sexually transmitted infections among men who have sex with men". Curr. Opin. Infect. Dis. 23 (1): 45–52. doi:10.1097/QCO.0b013e328334e54d. PMID 19935420. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
99. Leber, Mark J. (June 8, 2006). "Balanitis". EMedicine. Retrieved 2008-10-14. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
100. Osipov, Vladimir O. (November 14, 2006). "Balanoposthitis". Reactive and Inflammatory Dermatoses. EMedicine. Retrieved 2006-11-20. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
101. Edwards S (1996). "Balanitis and balanoposthitis: a review". Genitourin Med. 72 (3): 155–9. PMC 1195642. PMID 8707315. {{cite journal}}: Unknown parameter |month= ignored (help)
102. ^ Aridogan IA, Izol V, Ilkit M (2011). "Superficial fungal infections of the male genitalia: a review". Crit. Rev. Microbiol. 37 (3): 237–44. doi:10.3109/1040841X.2011.572862. PMID 21668404. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
103. ^ Hayashi Y, Kojima Y, Mizuno K, Kohri K (2011). "Prepuce: phimosis, paraphimosis, and circumcision". ScientificWorldJournal. 11: 289–301. doi:10.1100/tsw.2011.31. PMID 21298220.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
104. Escala, JM (1988). "Balanitis". British journal of urology. 63 (2): 196–197. doi:10.1111/j.1464-410X.1989.tb05164.x. PMID 2702407. Retrieved 2008-10-14. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
105. Morris BJ (2007). "Why circumcision is a biomedical imperative for the 21(st) century". Bioessays. 29 (11): 1147–58. doi:10.1002/bies.20654. PMID 17935209. {{cite journal}}: Unknown parameter |month= ignored (help)
106. Becker K (2011). "Lichen sclerosus in boys". Dtsch Arztebl Int. 108 (4): 53–8. doi:10.3238/arztebl.2011.053. PMC 3036008. PMID 21307992. {{cite journal}}: Unknown parameter |month= ignored (help)
107. Rickwood AM, Walker J (1989). "Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence?". Annals of the Royal College of Surgeons of England. 71 (5): 275–7. PMC 2499015. PMID 2802472. {{cite journal}}: Unknown parameter |month= ignored (help)
108. Shankar KR, Rickwood AM (1999). "The incidence of phimosis in boys". BJU International. 84 (1): 101–2. doi:10.1046/j.1464-410x.1999.00147.x. PMID 10444134. {{cite journal}}: Unknown parameter |month= ignored (help)
109. Metcalfe, Thomas J. (1983). "Circumcision: A Study of Current Practices". Clinical Pediatrics. 22 (8): 575–579. doi:10.1177/000992288302200811. PMID 6861426. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
110. Van Howe RS (1998). "Cost-effective treatment of phimosis". Pediatrics. 102 (4): E43. doi:10.1542/peds.102.4.e43. PMID 9755280. The argument that circumcision is a minor surgical procedure without complications is not only erroneous, but also irrelevant. It is ethically as well as economically questionable to operate on a child to treat a physiological process {{cite journal}}: Unknown parameter |month= ignored (help)
111. Singh-Grewal D, Macdessi J, Craig J (2005). "Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies". Archives of Disease in Childhood. 90 (8): 853–8. doi:10.1136/adc.2004.049353. PMC 1720543. PMID 15890696. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
112. Micali G, Nasca MR, Innocenzi D, Schwartz RA (2006). "Penile cancer". J. Am. Acad. Dermatol. 54 (3): 369–91, quiz 391–4. doi:10.1016/j.jaad.2005.05.007. PMID 16488287. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
113. ^ Larke NL, Thomas SL, Dos Santos Silva I, Weiss HA (2011). "Male circumcision and penile cancer: a systematic review and meta-analysis". Cancer Causes Control. 22 (8): 1097–110. doi:10.1007/s10552-011-9785-9. PMC 3139859. PMID 21695385. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
114. Maden, C; et al. (1993). "History of circumcision, medical conditions, and sexual activity and risk of penile cancer". J Natl Cancer Inst. 85 (1): 19–24. doi:10.1093/jnci/85.1.19. PMID 8380060. {{cite journal}}: Unknown parameter |month= ignored (help)
115. Schoen, EJ (2000). "The highly protective effect of newborn circumcision against invasive penile cancer". Pediatrics. 105 (3): e36. doi:10.1542/peds.105.3.e36. PMID 10699138. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
116. "Can Penile Cancer be Prevented?".
117. Crawford, DA (2002). "Circumcision: a consideration of some of the controversy". J Child Health Care. 6 (4): 259–270. doi:10.1177/136749350200600403. PMID 12503896. {{cite journal}}: Unknown parameter |month= ignored (help)
118. Klavs I, Hamers FF (2008). "Male circumcision in Slovenia: results from a national probability sample survey". Sexually Transmitted Infections. 84 (1): 49–50. doi:10.1136/sti.2007.027524. PMID 17881413. {{cite journal}}: Unknown parameter |month= ignored (help)
119. ^ Drain PK, Halperin DT, Hughes JP, Klausner JD, Bailey RC (2006). "Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries". BMC Infectious Diseases. 6: 172. doi:10.1186/1471-2334-6-172. PMC 1764746. PMID 17137513.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
120. ^ Castellsagué X; Bosch FX; Muñoz N; et al. (2002). "Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners". The New England Journal of Medicine. 346 (15): 1105–12. doi:10.1056/NEJMoa011688. PMID 11948269. {{cite journal}}: Unknown parameter |author-separator= ignored (help); Unknown parameter |month= ignored (help)
121. Frisch M, Friis S, Kjaer SK, Melbye M (1995). "Falling incidence of penis cancer in an uncircumcised population (Denmark 1943–90)". BMJ. 311 (7018): 1471. doi:10.1136/bmj.311.7018.1471. PMC 2543732. PMID 8520335. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
122. Denniston, G (1996). "Circumcision and the Code of Ethics". Humane Health Care International. 12: 78–80. {{cite journal}}: Unknown parameter |month= ignored (help)
123. Schoen EJ, Colby CJ, To TT (2006). "Cost analysis of neonatal circumcision in a large health maintenance organization". The Journal of Urology. 175 (3 Pt 1): 1111–5. doi:10.1016/S0022-5347(05)00399-X. PMID 16469634. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
124. Ko MC, Liu CK, Lee WK, Jeng HS, Chiang HS, Li CY (2007). "Age-specific prevalence rates of phimosis and circumcision in Taiwanese boys". Journal of the Formosan Medical Association = Taiwan Yi Zhi. 106 (4): 302–7. doi:10.1016/S0929-6646(09)60256-4. PMID 17475607. …the prevalence of circumcision slightly increased with age from 7.2% (95% CI, 5.3–10.8%) for boys aged 7 years to 8.7% (95% CI, 6.5–13.3%) for boys aged 13 years. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
125. ^ Richters, J; et al. (2006). "Circumcision in Australia: prevalence and effects on sexual health". Int J STD AIDS. 17 (8): 547–554. doi:10.1258/095646206778145730. PMID 16925903. Neonatal circumcision was routine in Australia until the 1970s … In the last generation, Australia has changed from a country where most newborn boys are circumcised to one where circumcision is the minority experience.
126. Ronald Immerman and Wade Mackey (1997). "A Biocultural Analysis of Circumcision". Social Biology. 44 (3–4): 265–275. doi:10.1111/j.1467-9744.1976.tb00285.x. PMID 9446966.
127. ^ Robert Darby (2003). "Medical history and medical practice: persistent myths about the foreskin". Medical Journal of Australia. 178 (4): 178–9. PMID 12580747.
128. Immerman, R.S. (1997). "A biocultural analysis of circumcision". Social Biology. 44 (3–4): 265–275. doi:10.1111/j.1467-9744.1976.tb00285.x. PMID 9446966. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
129. Wilson, Christopher G. (2008). "Male genital mutilation: an adaptation to sexual conflict" (PDF). Evolution and Human Behavior. 29 (3): 149–164. doi:10.1016/j.evolhumbehav.2007.11.008.
130. Tomb artwork from the Sixth Dynasty (2345–2181 BCE) shows men with circumcised penises, and one relief from this period shows the rite being performed on a standing adult male. TheEgyptian hieroglyph for "penis" depicts either a circumcised or an erect organ. The examination of Egyptian mummies has found some with foreskins and others who were circumcised.
131. Herodotus, The Histories, 2.36, on Perseus
132. The book of Genesis records circumcision as God's covenant/command to Abraham. It was to be performed by the male child's eighth day after birth. Herodotus, writing in the fifth century BCE, lists theColchians, Ethiopians, Phoenicians, and Syrians as a circumcising cultures.
133. The writer of the 1 Maccabees wrote that under the Seleucids, many Jewish men attempted to hide or reverse their circumcision so they could exercise in Greek gymnasia, where nudity was the norm. First Maccabees also relates that the Seleucids forbade the practice of brit milah (Jewish circumcision), and punished those who performed it–as well as the infants who underwent it–with death.
134. Marck, J (1997). "Aspects of male circumcision in sub-equatorial African culture history". Health Transit Review. 7 (supplement): 337–360. PMID 10173099. {{cite journal}}: Cite has empty unknown parameter: |month= (help)
135. ^ Gollaher, David (1994). "From ritual to science: the medical transformation of circumcision in America". Journal of Social History. 28 (1): 5–36. doi:10.1353/jsh/28.1.5. Retrieved 2007-12-06. {{cite journal}}: Cite has empty unknown parameter: |coauthors= (help); Unknown parameter |month= ignored (help)
136. Aggleton, P. (2007). "Roundtable: "Just a Snip"?: A Social History of Male Circumcision" (PDF). Reproductive Health Matters. 15 (29): 15–21. doi:10.1016/S0968-8080(07)29303-6. PMID 17512370. Retrieved 2008-12-17.
137. <Please add first missing authors to populate metadata.> (1855). "On the influence of circumcision in preventing syphilis". Medical Times and Gazette. NS Vol II: 542–3. {{cite journal}}: Unknown parameter |unused_data= ignored (help)
138. ^ Laumann, E. (1997). "Circumcision in the United States. Prevalence, prophylactic effects, and sexual practice". JAMA. 277 (13): 1052–1057. doi:10.1001/jama.277.13.1052. PMID 9091693. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
139. Xu F, Markowitz LE, Sternberg MR, Aral SO (2007). "Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999–2004". Sex Transm Dis. 34 (7): 479–84. doi:10.1097/01.olq.0000253335.41841.04. PMID 17413536. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
140. "Trends in circumcisions among newborns". National Hospital Discharge Survey. National Center for Health Statistics. January 11, 2007. Retrieved 2008-08-19.
141. Brown, M.S. (1987). "Circumcision decision: prominence of social concerns". Pediatrics. 80 (2): 215–219. PMID 3615091. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
142. Nelson, C.P. (2005). "The increasing incidence of newborn circumcision: data from the nationwide inpatient sample". Journal of Urology. 173 (3): 978–981. doi:10.1097/01.ju.0000145758.80937.7d. PMID 15711354. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
143. "U.S. circumcision rates vary by region" (PDF). Agency for Healthcare Research and Quality. January, 2008. Retrieved 2008-08-19. {{cite news}}: Check date values in: |date= (help)
144. Dave SS, Fenton KA, Mercer CH, Erens B, Wellings K, Johnson AM (2003). "Male circumcision in Britain: findings from a national probability sample survey". Sexually Transmitted Infections. 79 (6): 499–500. doi:10.1136/sti.79.6.499. PMC 1744763. PMID 14663134. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
145. "In Australia and New Zealand, the circumcision rate has fallen considerably in recent years and it is estimated that currently only 10%–20% of male infants are routinely circumcised." (RACP: 2004)
146. Walton RE, Ostbye T, Campbell MK (1997). "Neonatal male circumcision after delisting in Ontario. Survey of new parents". Can Fam Physician. 43: 1241–7. PMC 2255121. PMID 9241462.{{cite journal}}: CS1 maint: multiple names: authors list (link)
147. Kim, HH (2010 Nov). "Male circumcision: Africa and beyond?". Current opinion in urology. 20 (6): 515–9. doi:10.1097/MOU.0b013e32833f1b21. PMID 20844437. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
148. ^ Somerville, Margaret (2000). "Altering Baby Boys' Bodies: The Ethics of Infant Male Circumcision". The ethical canary: science, society, and the human spirit. New York, NY: Viking Penguin Canada. pp. 202–219. ISBN 0670893021. LCCN 2001369341. {{cite book}}: External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help); Unknown parameter |month= ignored (help)
149. Van Howe, R. S.; Svoboda, J. S.; Dwyer, J. G.; Price, C. P. (1999). "Involuntary circumcision: the legal issues" (PDF). BJU International. 83 (Supp1): 63–73. doi:10.1046/j.1464-410x.1999.0830s1063.x. PMID 10349416. {{cite journal}}: Unknown parameter |month= ignored (help)
150. Tanne, Janice Hopkins (2005). "US group lobbies UN to outlaw male circumcision". British Medical Journal. 331 (7514): 422. doi:10.1136/bmj.331.7514.422-b. PMC 1188135. {{cite journal}}: Unknown parameter |month= ignored (help)
151. Rennie S, Muula AS, Westreich D (2007). "Male circumcision and HIV prevention: ethical, medical and public health tradeoffs in low‐income countries". Journal of Medical Ethics. 33 (6): 357–61. doi:10.1136/jme.2006.019901. PMC 2598273. PMID 17526688. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
152. ^ Fetus and Newborn Committee (1996). "Neonatal circumcision revisited". Canadian Medical Association Journal. 154 (6): 769–780. PMC 1487803. PMID 8634956. Retrieved 2006-07-02. {{cite journal}}: Unknown parameter |month= ignored (help) "We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors."
153. ^ Paediatrics & Child Health Division, The Royal Australasian College of Physicians (2010). "Circumcision of Infant Males" (PDF). Retrieved January 31, 2012. The Paediatrics & Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on circumcision of infant boys for doctors and to assist parents who are considering having this procedure undertaken on their male children. Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years and it remains an important ritual in some religious and cultural groups. In Australia and New Zealand, the circumcision rate has fallen in recent years and it is estimated that currently 10-20% of newborn male infants are circumcised. Recently there has been renewed debate regarding both the potential health benefits and the ethical and human rights issues relating to infant male circumcision. Circumcision is generally a safe procedure but there are risks of minor complications and some rare but serious complications. The most important conditions where benefits may result from circumcision are recurrent urinary tract infections in children; and Human Immunodeficiency Virus (HIV) plus some other sexually transmitted infections in adults from populations with a high prevalence of these conditions; cancer of the penis in men with a history of phimosis, and cancer of the cervix in women whose partners engage in sexual practices known to increase the risk of Human Papilloma Virus (HPV) infection. The protection against Sexually Transmitted Infections (STIs) and HIV is less clear-cut in Australia and New Zealand than in high prevalence countries. Ethical and human rights concerns have been raised regarding elective infant male circumcision because it is recognised that the foreskin has a functional role, the operation is non-therapeutic and the infant is unable to consent.
     After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. However it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons. When parents request a circumcision for their child the medical attendant is obliged to provide accurate unbiased and up to date information on the risks and benefits of the procedure. Parental choice should be respected. When the operation is to be performed it should be undertaken in a safe, child-friendly environment by an appropriately trained competent practitioner, capable of dealing with the complications, and using appropriate analgesia. {{cite journal}}: Cite journal requires |journal= (help); Unknown parameter |month= ignored (help)
154. ^ Medical Ethics Committee (2006). "The law and ethics of male circumcision – guidance for doctors" (PDF). British Medical Association. Retrieved 2006-07-01. {{cite web}}: Unknown parameter |month= ignored (help)
155. "Information Package on Male Circumcision and HIV Prevention" (PDF).
156. "Circumcision and the Code of Ethics, George C. Denniston, Humane Health Care Volume 12, Number 2".
157. Viens AM (2004). "Value judgment, harm, and religious liberty". J Med Ethics. 30 (3): 241–7. doi:10.1136/jme.2003.003921. PMC 1733861. PMID 15173355.
158. Benatar, David (2003). "How not to argue about circumcision" (PDF). American Journal of Bioethics. 3 (2): W1–W9. doi:10.1162/152651603102387820. PMID 14635630. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
159. Williams, R. M. (2003-01). "On the Tail-Docking of Pigs, Human Circumcision, and their Implications for Prevailing Opinion Regarding Pain". Journal of Applied Philosophy. 20 (1): 89–93. doi:10.1111/1468-5930.00237. Retrieved 2008-06-24. {{cite journal}}: Check date values in: |date= (help); Cite has empty unknown parameter: |coauthors= (help)
160. Milos MF, Macris D (1992). "Circumcision. A medical or a human rights issue?". J Nurse Midwifery. 37 (2 Suppl): 87S–96S. doi:10.1016/0091-2182(92)90012-R. PMID 1573462.
161. Goldman, R. (1999). "The psychological impact of circumcision" (PDF). BJU International. 83 (S1): 93–102. doi:10.1046/j.1464-410x.1999.0830s1093.x. Retrieved 2006-07-02. {{cite journal}}: Unknown parameter |month= ignored (help)
162. Schultheiss D, Truss MC, Stief CG, Jonas U (1998). "Uncircumcision: A Historical Review of Preputial Restoration". Plast Reconstr Surg. 101 (7): 1990–8. doi:10.1097/00006534-199806000-00037. PMID 9623850.{{cite journal}}: CS1 maint: multiple names: authors list (link)
163. Moses, S (1998). "Male circumcision: assessment of health benefits and risks". Sex Transm Infect. 74 (5): 368–73. doi:10.1136/sti.74.5.368. PMC 1758146. PMID 10195035. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
164. Gerharz EW, Haarmann C (2000). "The first cut is the deepest? Medicolegal aspects of male circumcision". BJU Int. 86 (3): 332–8. doi:10.1046/j.1464-410x.2000.00103.x. PMID 10930942. {{cite journal}}: Unknown parameter |month= ignored (help)
165. Boyle, G (2002). "Male Circumcision: Pain, Trauma and Psychosexual Sequelae". Journal of Health Psychology. 7 (3): 329–343. doi:10.1177/1359105302007003225. PMID 22114254. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
166. Hirji, H (2005). "Male circumcision: a review of the evidence". Journal of men's health. 2 (1): 21–30. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
167. "Sweden restricts circumcisions". BBC Europe. October 1, 2001. Retrieved 2006-10-18. Swedish Jews and Muslims object to the new law, saying it violates their religious rights.
168. "Jews protest Swedish circumcision restriction". Reuters. 2001-06-07. A WJC spokesman said, "This is the first legal restriction placed on a Jewish rite in Europe since the Nazi era. This new legislation is totally unacceptable to the Swedish Jewish community."
169. Bureau of Democracy, Human Rights, and Labor (September 15, 2006). "Sweden". International Religious Freedom Report 2006. U.S. Department of State. Retrieved 2007-07-04.{{cite web}}: CS1 maint: multiple names: authors list (link)
170. "Court rules circumcision of four-year-old boy illegal". HELSINGIN SANOMAT, INTERNATIONAL EDITION. 2006-08-07. Retrieved 2007-09-17.
171. "Supreme Court: Properly performed religious based male circumcision no crime". Helsingin Sanomat. October 17, 2008. Retrieved 2008-10-17. {{cite news}}: Cite has empty unknown parameter: |coauthors= (help)
172. "Finland Considers Legalising Male Circumcision". Ylesiradio. 2008-07-31. Retrieved 2008-08-05.
173. "Circumcision debate on Mornings". ABC Tasmania. August 15, 2007. Retrieved January 31, 2012. Victoria is following the lead of New South Wales, Western Australia and Tasmania, where non-medical circumcisions are not performed in public hospitals unless there is a medical reason to do so. However, male circumcision is not totally banned, as parents can elect to pay for the procedure in a private hospital.
174. Lamm, Maurice (2000) . "6: Special Situations". The Jewish way in death and mourning. Middle Village, NY: Jonathan David Publishers, Inc. pp. 215–216. ISBN 0-8246-0423-7. LCCN 99-088942. The custom is to circumcise male infants who have not undergone circumcision until then, usually during taharah.
175. adapted from Shamash (2007). "The Origins of Reform Judaism". Jewish Virtual Library. Retrieved 2007-11-03.
176. Berit Mila Program of Reform Judaism, Union for Reform Judaism website. Retrieved January 23, 2010.
177. Hilary Leila Kreiger (21 November 2002). "A cut above the rest". Jerusalem Post.
178. Al-Munajjid, Muhammed Salih. "Question #9412: Circumcision: how it is done and the rulings on it". Islam Q&A. Retrieved 2006-07-01.
179. Al-Munajjid, Muhammed Salih. "Question #7073: The health and religious benefits of circumcision". Islam Q&A. Retrieved 2006-07-01.
180. al-Sabbagh, Muhammad Lutfi (1996). Islamic ruling on male and female circumcision. Alexandria: World Health Organization. p. 16.
181. "Session 11—4 February 1442 (Bull of union with the Copts)". Eccumenical Council of Florence (1438–1445). Eternal Word Television Network. Retrieved 2009-05-11. Therefore it strictly orders all who glory in the name of Christian, not to practise circumcision either before or after baptism, since whether or not they place their hope in it, it cannot possibly be observed without loss of eternal salvation.
182. Slosar, J.P. (2003). "The Ethics of Neonatal Male Circumcision: A Catholic Perspective". American Journal of Bioethics. 3 (2): 62–64. doi:10.1162/152651603766436306. PMID 12859824. {{cite journal}}: Cite has empty unknown parameter: |month= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
183. Mattson CL, Bailey RC, Muga R, Poulussen R, Onyango T (2005). "Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya". AIDS Care. 17 (2): 182–94. doi:10.1080/09540120512331325671. PMID 15763713. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
184. "Greek Orthodox Archdiocese calendar of Holy Days".
185. "Russian Orthodox Church, Patriarchate of Moscow".
186. Ajuwon et al., "Indigenous surgical practices in rural southwestern Nigeria: Implications for disease," Health Educ. Res..1995; 10: 379–384 Health Educ. Res..1995; 10: 379–384 Retrieved 3 October 2006
187. Aaron David Samuel Corn (2001). "Ngukurr Crying: Male Youth in a Remote Indigenous Community" (PDF). Working Paper Series No. 2. University of Wollongong. Archived from the original (PDF) on 2006-08-28. Retrieved 2006-10-18. {{cite journal}}: Cite journal requires |journal= (help)
188. "Migration and Trade". Green Turtle Dreaming. Retrieved 2006-10-18. In exchange for turtles and trepang the Makassans introduced tobacco, the practice of circumcision and knowledge to build sea-going canoes.
189. Jones IH (1969). "Subincision among Australian western desert Aborigines". The British Journal of Medical Psychology. 42 (2): 183–90. doi:10.1111/j.2044-8341.1969.tb02069.x. PMID 5783777. {{cite journal}}: Unknown parameter |month= ignored (help)
190. "RECENT GUEST SPEAKER". Australian AIDS Fund Incorporated. 2006. Retrieved 2006-07-01.
191. "Weird & Wonderful". United Travel. Retrieved 2006-07-01.
192. "Circumcision amongst the Dogon". The Non-European Components of European Patrimony (NECEP) Database. 2006. Retrieved 2006-09-03.
193. Agberia, J. T. (2006). "Aesthetics and Rituals of the Opha Ceremony among the Urhobo People". Journal of Asian and African Studies. 41 (3): 249. doi:10.1177/0021909606063880.
194. "Masai of Kenya". Retrieved 2007-04-06. Authority derives from the age-group and the age-set. Prior to circumcision a natural leader or olaiguenani is selected; he leads his age-group through a series of rituals until old age, sharing responsibility with a select few, of whom the ritual expert (oloiboni) is the ultimate authority. Masai youths are not circumcised until they are mature, and a new age-set is initiated together at regular intervals of twelve to fifteen years. The young warriors (ilmurran) remain initiates for some time, using blunt arrows to hunt small birds which are stuffed and tied to a frame to form a head-dress.
195. "Status of CDC Male Circumcision Recommendations". Centers for Disease Control and Prevention. 27 August 2009. Retrieved 15 July 2011.
196. "Circumcision: Position Paper on Neonatal Circumcision". American Academy of Family Physicians. 2007. Archived from the original on 2006-09-25. Retrieved 2007-01-30. Considerable controversy surrounds neonatal circumcision. Putative indications for neonatal circumcision have included preventing UTIs and their sequelae, preventing the contraction of STDs including HIV, and preventing penile cancer as well as other reasons for adult circumcision. Circumcision is not without risks. Bleeding, infection, and failure to remove enough foreskin occur in less than 1% of circumcisions. Evidence-based complications from circumcision include pain, bruising, and meatitis. More serious complications have also occurred. Although numerous studies have been conducted to evaluate these postulates, only a few used the quality of methodology necessary to consider the results as high level evidence.
     
     The evidence indicates that neonatal circumcision prevents UTIs in the first year of life with an absolute risk reduction of about 1% and prevents the development of penile cancer with an absolute risk reduction of less than 0.2%. The evidence suggests that circumcision reduces the rate of acquiring an STD, but careful sexual practices and hygiene may be as effective. Circumcision appears to decrease the transmission of HIV in underdeveloped areas where the virus is highly prevalent. No study has systematically evaluated the utility of routine neonatal circumcision for preventing all medically-indicated circumcisions in later life. Evidence regarding the association between cervical cancer and a woman's partner being circumcised or uncircumcised, and evidence regarding the effect of circumcision on sexual functioning is inconclusive. If the decision is made to circumcise, anesthesia should be used.
     
     The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son.
197. American Urological Association. "Circumcision". Retrieved 2008-11-02.

Further reading

• Billy Ray Boyd. Circumcision Exposed: Rethinking a Medical and Cultural Tradition. Freedom, CA: The Crossing Press, 1998. (ISBN 978-0-89594-939-4)
• Anne Briggs. Circumcision: What Every Parent Should Know. Charlottesville, VA: Birth & Parenting Publications, 1985. (ISBN 978-0-9615484-0-7)
• Robert Darby. A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain. Chicago: University of Chicago Press, 2005. (ISBN 978-0-226-13645-5)
• Aaron J. Fink, M.D. Circumcision: A Parent's Decision for Life. Kavanah Publishing Company, Inc., 1988. (ISBN 978-0-9621347-0-8)
• Paul M. Fleiss, M.D. and Frederick Hodges, D. Phil. What Your Doctor May Not Tell You About Circumcision. New York: Warner Books, 2002. (ISBN 978-0-446-67880-3)
• Leonard B. Glick. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. New York: Oxford University Press, 2005. (ISBN 978-0-19-517674-2)
• Ronald Goldman, Ph.D. Circumcision: The Hidden Trauma. Boston: Vanguard, 1996. (ISBN 978-0-9644895-3-0)
• Paysach J. Krohn, Rabbi. Bris Milah. Circumcision—The Covenant Of Abraham/A Compendium of Laws, Rituals, And Customs From Birth To Bris, Anthologized From Talmudic, And Traditional Sources. New York: Mesorah Publications, 1985, 2005.
• Brian J. Morris, Ph.D., D.Sc. In Favour of Circumcision. Sydney: UNSW Press, 1999. (ISBN 978-0-86840-537-7)
• Peter Charles Remondino. History of Circumcision from the Earliest Times to the Present. Philadelphia and London; F. A. Davis; 1891.
• Holm Putzke, Ph.D. Die strafrechtliche Relevanz der Beschneidung von Knaben. Zugleich ein Beitrag über die Grenzen der Einwilligung in Fällen der Personensorge, in: H. Putzke u.a. (Hrsg.), Strafrecht zwischen System und Telos, Festschrift für Rolf Dietrich Herzberg zum siebzigsten Geburtstag am 14. Februar 2008 , Mohr Siebeck: Tübingen 2008, p. 669–709 (ISBN 978-3161495700)
• Holm Putzke, Ph.D., Maximilian Stehr, Ph.D., and Hans-Georg Dietz, Ph.D. Liability to penalty for circumcision in boys. Medico-legal aspects of a controversial medical intervention, in: Monatsschrift Kinderheilkunde 8/2008, p. 783–788
• Rosemary Romberg. Circumcision: The Painful Dilemma. South Hadley, MA Bergan & Garvey, 1985. (ISBN 978-0-89789-073-1)
• Edgar J Schoen, M.D. Ed Schoen, MD on Circumcision. Berkeley, CA: RDR Books, 2005. (ISBN 978-1-57143-123-3)
• Edward Wallerstein. Circumcision: An American Health Fallacy. New York: Springer, 1980 (ISBN 978-0-8261-3240-6)
• Gerald N. Weiss M.D. and Andrea W Harter. Circumcision: Frankly Speaking. Wiser Publications, 1998. (ISBN 978-0-9667219-0-4)
• Yosef David Weisberg, Rabbi. Otzar Habris. Encyclopedia of the laws and customs of Bris Milah and Pidyon Haben. Jerusalem: Hamoer, 2002.
• George C. Denniston; Frederick M. Hodges; Marilyn Fayre Milos (2009). Circumcision and Human Rights. Springer. ISBN 9781402091667.

External links

Opposition

• Intact America: Say No to Circumcision by Georganne Chapin.
• National Organization of Circumcision Information Resource Centers by Marilyn Milos, RN.
• The Circumcision Information and Resource Pages by Geoffrey T. Falk.
• Doctors Opposing Circumcision Presided by George C. Denniston, MD, MPH.

Promotion

• Malecircumcision.org – Clearinghouse on Male Circumcision for HIV Prevention by WHO, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the AIDS Vaccine Advocacy Coalition (AVAC), and Family Health International (FHI)
• Circinfo.net – Male Circumcision Guide for Doctors, Parents, Adults, & Teens by Professor Brian Morris
• Medicirc.org – Circumcision: a lifetime of medical benefits by Edgar Schoen, BSc., M.D.
• Circs.org maintained by Jake Waskett.

Techniques and videos

• Description of an adult circumcision from the American Academy of Family Physicians.
• Videos of infant circumcision: using a Plastibell, a Gomco clamp and a Mogen clamp (all from Stanford Medical School.)
• Video of the circumcision procedure from the US Medical Videos Journal
• A video of dorsal penile and ring block and the Plastibell Circumcision

• Misplaced Pages neutral point of view disputes from February 2012
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