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This article is about Circumcision. For the practice sometimes referred to as "female circumcision", see Female genital cutting.

Circumcision is the removal of some or all of the foreskin (prepuce) from the penis. The frenulum may also be removed at the same time, in a procedure called frenectomy. The word "circumcision" comes from Latin circum (meaning "around") and caedere (meaning "to cut"). The state of being circumcised is sometimes called acucullophallia, not to be confused with acucullophilia.

The practice of circumcision predates recorded human history, with depictions found in stone-age cave drawings and Egyptian tombs. The origins of the practice are lost in antiquity. Theories include that circumcision is a form of ritual sacrifice or offering, a sign of submission to a deity, a rite of passage to adulthood, a mark of defeat or slavery, or an attempt to alter esthetics or sexuality. Circumcision and frenectomy continue to be performed as cultural rituals on members of the Muslim and Jewish faiths, and also the majority of Americans, South Koreans and Filipinos.

Non-therapeutic infant circumcision has become controversial in recent decades. Medical associations in the US, Australia, and Canada do not recommend routine non-therapeutic circumcision, but in the US and UK, circumcision is often chosen largely because of social or cultural expectations, rather than medical concerns. The genital integrity movement condemns non-therapeutic infant circumcision as a form of male genital mutilation that they consider comparable to female genital cutting. Those who support circumcision often explain their view in terms of what they consider to be the medical benefits of the procedure.

Circumcision may be recommended to treat medical conditions in males, such as phimosis, chronic inflammation of the penis, and penile cancer. However, there are often less invasive treatments that can be tried first.

The procedures of circumcision

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Circumcision removes the foreskin from the penis. For infant circumcision, clamps, such as the Gomco, Plastibell, and Mogen are often used. These clamps are meant to protect the glans while they crush the foreskin and stop any bleeding. With the Plastibell clamp, the foreskin and the clamp come away in three to seven days. Before a Gomco clamp is used, a section of skin is crushed with a hemostat then slit with scissors. Then, the foreskin is drawn over the bell shaped portion of the clamp, which is then inserted through a hole in the base of the clamp, and the clamp is tightened, "crushing the foreskin between the bell and the base plate" (this crushing action provides the hemostasis necessary to limit bleeding). With the flared bottom of the bell fit tightly against the hole of the base plate, the foreskin is cut away with a scalpel from above the base plate, while the bell covers the glans to prevent it being reached by the scalpel.

With a Mogen clamp, used by many physicians and all mohels (Jewish ritual circumcisers), the foreskin is dissected away from the glans with a blunt probe and/or curved hemostat (as with the first part of the Gomco procedure). The foreskin is then grabbed dorsally with a straight hemostat, and tented up as the Mogen clamp is slid between the glans and hemostat. The clamp is then locked shut, and a scalpel used to remove the foreskin from the flat (upper) side of the clamp.

According to a 1998 study, anaesthesia is used by 45% of physicians performing infant circumcisions. Dorsal penile nerve block was the most commonly used form. Obstetricians were notable in the study for a significantly lower rate of anaesthesia use (25%) than pediatricians (71%) or family practitioners (56%) . A 2004 Cochrane review concluded that dorsal penile nerve block is the most effective form of anaesthesia, while EMLA (topical anaesthesia) was less effective. The authors noted that both anaesthetics appear safe, but neither of them completely eliminated pain. Adult circumcisions are often performed without clamps, and require 4 to 6 weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.

Cultures and religions

For information on circumcision in the Bible, see circumcision in the Bible.

Some cultures circumcise their males, either shortly after birth, or around puberty as an initiation rite. The practice is most notable among Jews and Muslims, and is more prevalent in the United States than in other Western nations.

Aesthetics

Circumcision may be undertaken as a body modification of the genitals to change the look of the penis to appeal more to certain aesthetics. In a few cultures, circumcision may be one of other modifications of the penis, such as a split penis or a subincision.

The United States, the Philippines and South Korea are the only countries that circumcise a majority of young males for non-religious reasons. In Canada, the infant circumcision rate was about 48% as of 1970. Routine circumcision practices in South Korea are largely the result of American cultural and military influence following the Korean War. The origin of the practice in the Philippines is uncertain according to one newspaper article . However, Antonio de Morga's "History of the Philippine Islands" (1907) attributes circumcision to Islamic influence .

Christianity

Catholic, Protestant, and Orthodox Christianity do not prescribe circumcision, but welcome all, whether circumcised or not. The first Church Council in Jerusalem decided that circumcision was not a requirement (Acts 15). However, individual Christians and Christian traditions may have different customs.

On 1 January, the Catholic Church celebrates the Solemnity of Mary. This has replaced the Circumcision of Christ, which used to be celebrated on that day and may still be celebrated by some Traditional Catholics.

Coptic Christian

Circumcision is customary in the Coptic Christian, Ethiopian Orthodox, and Eritrean Orthodox religious traditions. It is usually performed on the eighth day of life.

Hinduism

There is no specific reference to male circumcision in the Hindu holy books. It can be assumed on that basis that the decision is left to the individual or the parents (in case of a minor). However, conservative Hindus oppose the practice of male child circumcision on the grounds that it is against the will of God and a barbaric act of cruelty on the child .

Sikhism

"Circumcision holds no relevance to a Sikh." For Sikhs, "acceptance of Nature's beautiful body is an important component of the Sikh value system."

Islam

Islam stresses circumcision as a form of natural hygiene. It is mentioned in some parts of the Hadith, but not in the Qur'an. Fiqh scholars have different opinions about circumcision in Shariah, depending on which Hadith are accepted and how they are interpreted. According to Imam Abu Hanifa, Imam Malik and a majority of others it is a recommended practice (Sunnah), but others, including Imam Shafi, consider it obligatory. The timing of Muslim circumcision varies. Some Muslim communities perform circumcision on the eighth day of life, as with Jews, while others perform the rite later. Turkish, Balkan, rural Egyptians and Central Asian Muslims typically circumcise boys between the ages of six and eleven and the event is viewed communally as a joyous occasion and is celebrated with sweets and feasting. In contrast, Iranian Muslims are typically circumcised in the hospital at birth without much ado. Urban Egyptians, as with many industrialized countries such as the USA, perform the procedure at a hospital. Kamyar et al describe it as an 'obligatory custom', and note that it is not necessary for the circumciser to be a Muslim. Recently, world opinion, including Islamic opinion , has become increasingly critical of the practice of female circumcision, which is also widespread in African cultures.

Judaism

Main article: Brit milah

Circumcision is a religious practice traditionally required by Judaism, usually performed in a ceremony called a Brit milah (or Bris milah, colloquially simply bris) (Hebrew for "Covenant of circumcision"). A mohel performs the ceremony on the eighth day after birth unless health reasons force a delay. According to the Torah (Genesis, chapter 17 verses 9-14), God commanded Abraham to circumcise himself, his offspring and his slaves as part of an everlasting covenant. According to Jewish law, failure to follow the commandment carries the penalty of karet, or being cut off from the community by God. Brit milah is so important that should the eighth day fall on Shabbat, actions that would normally be forbidden because of the sanctity of the day are permitted in order to fulfill the requirement to circumcise. See also Circumcision in the Bible. A less commonly practiced ritual during the circumcision is metzitzah b'peh, oral suction. This is a procedure whereby the mohel will suck out the blood from the wound after removing the foreskin, often using a glass tube.

Tribal traditions

Circumcision is part of the initiation rite in some African, Pacific Islander, and Australian Aboriginal tribal traditions. Among some West African animist groups, such as the Dogon and Dowayo, it is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males. Among Nilotic peoples, such as the Nandi, 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. In the Pacific, ritual circumcision is nearly universal in Vanuatu ; participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised. Circumcision is also commonly practiced in the Pacific Islands of Samoa, Tonga, Niue, and Tikopia; in Samoa, it is accompanied by a celebration. Aboriginal circumcision ceremonies, which also constitute a rite of passage, are noted for their painful nature, including subincision for some tribes in the Western Desert .

Ethical issues

Main article: Bioethics of neonatal circumcision

Circumcising infants as a public health measure is controversial. In cultures such as the United States, lay people may regard infant circumcision as a routine medical practice but medical organizations in Australia, Canada, and the U.S.A. do not recommend routine infant circumcision . While the risks of circumcision-related complications are very low , the complications resulting from a poorly carried out circumcision, of post-operative bleeding or infection can be catastrophic. The American Academy of Pediatrics recommend that parents should be informed about the potential benefits and risks of the procedure. Circumcision advocates assert that circumcision is a significant public health measure, preventing infections, and possibly slowing down the spread of AIDS, while the genital integrity movement asserts that infant circumcision is a human rights violation and a sexual assault, and that the practice of circumcising infants or children should be discouraged or banned.

Consent

Debate often focuses on what limits, if any, should be placed on a caregiver's ability to have a child circumcised. The procedure is irreversible, the immediate medical value is disputed and the result may not be in accordance with the child's wishes when he is an adult. Some question the apparent inconsistency of allowing male circumcision but prohibiting female genital cutting . Some assert that circumcision causes sexual harm and emotional scarring later in life, or urge that the procedure should be left until a man is mature enough to make the choice for himself. Others assert that circumcision is less traumatic when performed in infancy and point out that it may disturb some religious communities and interfere with the traditional right of parents to make this decision on behalf of their child.

The American Academy of Pediatrics (1999) said the medical benefits of circumcision are not sufficient to recommend routine neonatal circumcision, but that it should be the decision of informed parents. The British Medical Association states "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.”

Deferral of discussion until after birth, combined with the fact that many parents' decisions about circumcision are preconceived, contribute to the high rate of elective circumcision. Two studies in the United States found that strong parental cultural expectations clash with deliberate informed consent, and “a significant number of parents expressed animosity toward the care provider.” Discord arises from the implication that parental desire to circumcise involves “undue risks” and provides “limited medical benefit” to their child.

Emotional consequences

Much attention has been given to the emotional impact of female genital cutting but the emotional impact of male circumcision is mostly ignored. Issues about the rights of the child are often overlooked, and so is the possibility that circumcision may cause emotional and physical harm to males. There are some organizations that have been created as support groups for circumcised men who are upset with their status.

In the USA, the majority of neonatal circumcisions are performed without anaesthesia. Several studies suggest that circumcised infants do not forget the pain during circumcision easily, as a correlation between circumcision with ineffective anaesthesia and intensity of pain response during vaccination months later has been noted.

Legality

Main article: Circumcision and law

The mainstream medical organizations do not consider circumcision to be a legal issue as long as the decision for circumcision was made by the legal guardians, and that they have given their informed consent.

Religious circumcision of minors

Main article: Religious circumcision

In Islam and Judaism, it is customary or obligatory for boys to be circumcised for religious reasons. Many believe that this practice is protected by the principle of freedom of religion. Others argue that the right of a child to bodily integrity takes precedence over parental preference or religious custom or that freedom of religion only applies to personal belief, and circumcision should not be imposed on minors. Female genital cutting is prohibited in most western countries, and has come under criticism in the parts of the world where it is customary. Sweden has restricted male infant circumcision.

Medical aspects

Main article: Medical analysis of circumcision

Neonatal circumcision has been studied using cost-benefit analyses. Largely these have computed the average net lifetime health and financial results of circumcision. The complications morbidity is compared to the potential gain in expected longevity, and the medical costs of circumcision are compared to the expected reduction in lifetime health costs. The results have mostly shown neither cost savings nor improved longevity to the practice of neonatal circumcision.

File:Skin bridge 2.jpg

Example of a "skin bridge", one of the possible negative side effects of circumcision.

Risks of circumcision

Circumcision is a surgical procedure, and there is a risk of complications. Bleeding and infection are the most common complications of the procedure, according to the AMA. Longer term complications include infections, urinary fistulas, meatal stenosis, ulceration of the glans, removal of too much tissue, and secondary phimosis.

The American Academy of Pediatrics recommend that parents should be informed about the potential benefits and risks of the procedure. The British Medical Association states " is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks."

The AAP, AMA, and AAFP state that the rate is between 0.2% and 0.6%, based upon large series. The CPS acknowledge these series, but additionally cite a review which suggested that a rate of 2% to 10% would be more realistic. The Royal Australasian College of Physicians states the rate of complications of infant circumcision as "between 0.2% and 0.6% to 2%-10%" in one section, and "1% to 5%" in another. They suggest that the variation in reported rates depends upon how the circumcision is performed and what definition of complication is used.

While the risks of circumcision procedure-related complications are very low in a hospital setting, complications resulting from a poorly carried out circumcision, involving post-operative bleeding or infection can be catastrophic. Infant circumcision may cause problems such as skin bridges, when the cut skin does not heal neatly but attaches to the glans penis instead. Loss of the penis itself has been documented. The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.

Fatal complications have been reported. The American Academy of Family Physicians states that death is rare, and cites an estimated death rate with circumcisions of infants of 1 in 500,000 . Gairdner's 1949 study reported that 16 children per year died following circumcision in the UK during the 1940s, a rate of 18 in 100,000 . At that time, deaths attributed to phimosis and circumcision were grouped together, but Gairdner stated that the deaths were probably due to circumcision. Gairdner stated that most deaths had occurred suddenly under anaesthesia, and couldn't be explained further, but haemorrhage and infection had also proven fatal. The Jewish practice of metzitzah b'peh has also been implicated in the transfer of HSV carried by the mohel to be passed to the child. In either 2003 and 2004, there were a few infants upon whom this procedure was performed in New York City who contracted herpes, one of which died. However, there remains no conclusive medical evidence as to whether it was caused by the mohel performing the procedure or not.

Meatal stenosis may be the most common longer-term complication from circumcision, and is variously reported to occur in .9%,9% - 10%, and 7.29% of circumcised boys. . The AAFP states “One author(10) reports that meatitis, meatal ulcer and consequent stenosis occur in an estimated 8 to 31 percent of circumcised infants, while another(11) states there are no well-controlled cohort related studies to document their relation.”

The Royal Australasian College of Physicians and the American Medical Association criticise neonatal circumcision without anaesthetics . The American Academy of Pediatrics explicitly recommends that if the procedure is to be performed, anaesthesia should be used .

HIV

The possibility that circumcision reduces HIV transmission remains the subject of ongoing research and debate in the medical community.

The March 2005 Cochrane review of the medical evidence concluded that, despite widely observed correlation between circumcision and low rates of HIV infection, a causal relationship between circumcision and reduced risk of HIV transmission had not been established . Initial population based studies suggesting that circumcision might play a protective role were criticised because confounding factors such as religion may have skewed the results; the reviewers therefore commented that the results of randomised controlled trials now underway will be critical.

The results of the first randomised controlled trials were published in November 2005, reporting a 60% reduction in the rate of new HIV infection in the circumcised group.. Results of two further randomised trials to investigate the protective effect of circumcision against HIV infections will become available in 2007.

There are fears that some may mistakenly believe they will be protected against HIV through circumcision and see circumcision as a safe alternative to other forms of protection, such as condoms. The World Health Organization stresses that the protective effect offered by male circumcision in Africa has to be confirmed by further studies, and is not reliable enough to replace sex education and safer sex practice as a means to combat AIDS.

If circumcision does protect against HIV transmission, the mechanism by which it does so is unclear. Langerhans cells, a part of the human immune system, can be infected by the HIV virus.. Szabo and Short (2000) suggested that Langerhans cells in the foreskin may provide an entry point for viral infection. Three studies, Patterson et al. (2002) , Donoval et al. (2006) and Hussain et al. (1995) identified high concentrations of Langerhans and other HIV target cells in the human prepuce. Additionally, McCoombe and Short (2002) found that the keratin is thinnest on the foreskin and frenulum. Conversely, some authors believe that the prepuce has an important immunological function, and that its removal increases the chances of infections. This hypothesis has been criticised on technical grounds.

HPV

Several studies have shown that non-circumcised men are at greater risk of human papilloma virus (HPV) infection. While most genital HPV strains are considered harmless, some can cause genital warts or cancer. One study found no statistically significant difference between men with foreskins for HPV infection than those who are circumcised, but did note a significantly higher incidence of HPV lesions and urethritis.

Hygiene

Circumcision reduces the amount of smegma produced by the male. Smegma is a combination of exfoliated (shed) epithelial cells, transudated skin oils and moisture that can accumulate under the foreskin of males and within the female vulva area, with a characteristic strong odor and taste, and is common to all mammals, male and female. While smegma is generally not believed to be harmful to health, the strong odour may be considered to be a nuisance or give the impression of a lack of hygiene. In rare cases, accumulating smegma may help cause balanitis.

The Royal Australasian College of Physicians and the Canadian Pediatric Society emphasize that a non-circumcised infant's penis requires no special care and should be left alone. Attempts to forcibly retract the foreskin, e.g. to clean it, are painful, often injure the foreskin, and can lead to scarring, infections and pathologic phimosis. It is recommended that, while there is no special age where the foreskin should be retractable, once the foreskin becomes retractible, the child should gently wash it with soap and water. It has been suggested, however, that excessive washing of the foreskin and the glans will make infections such as balanitis more likely.

It has been suggested that circumcision arose in peoples living in arid and sandy regions as a public health measure intended to prevent recurring irritation and infection caused by sand accumulating under the foreskin . Darby, after checking the official war histories of Britain, Australia and New Zealand and other records, and finding no mention of 'balanitis' or 'foreskin' or 'circumcision' dismissed this idea as a "medical urban myth", concluding that "sand under the foreskin," balanitis and circumcision were not significant problems during either of the World Wars.' .

Infectious and chronic conditions

Non-circumcised boys and men tend to have higher rates of various infections and inflammations of the penis, and of the foreskin, than circumcised men. The reasons are unclear, but several hypotheses have been suggested:

The foreskin may harbor bacteria and infect if it is not cleaned enough.
The foreskin may become inflamed if it is cleaned too often with soap.
The forcible retraction of the foreskin in boys can lead to infections.

There are less invasive treatments than circumcision for posthitis (an inflamed foreskin) and balanitis (inflammation of the glans) . However, these are not as successful in treating balanitis xerotica obliterans (BXO) , which is harder to treat .

Lichen sclerosus et atrophicus (LSA) produces a whitish-yellowish patch on the skin, and is not believed to be always harmful or painful, and may sometimes disappear without intervention. Some consider balanitis xerotica obliterans to be a form of LSA that happens to be on the foreskin, where it may cause pathological phimosis. Circumcision is believed to reliably reduce the threat of BXO.

Penile cancer

Penile cancer is cancer of the penis, i.e. on the glans or the foreskin. 80% of the cases have been found to be in men over the age of 70. . One researcher estimated the lifetime risk to be 0.17% for a non-circumcised male, .

In 1998, the American Cancer Society labelled some claims about a relationship of circumcision with penile cancer misleading. It said:

However, the penile cancer risk is low in some non-circumcised populations, and the practice of circumcision is strongly associated with socio-ethnic factors, which in turn are associated with lessened risk. The consensus among studies that have taken these other factors into account is circumcision is not of value in preventing cancer of the penis. (1998, )

However, in 2005, the society said:

Recent studies have found that circumcised men are less likely to be infected with HPV, even after this risk is adjusted for differences in sexual behavior. Other studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer. However, it is important that the issue of circumcision not distract the public's attention from avoiding known penile cancer risk factors – poor hygiene, having unprotected sex with multiple partners (increasing the likelihood of human papillomavirus infection), and cigarette smoking. (2005, )

In another 2005 statement, they state:

In the past, circumcision has been suggested as a way to prevent penile cancer. This suggestion was based on studies that reported much lower penile cancer rates among circumcised men than among non-circumcised men. However, most researchers now believe those studies were flawed because they failed to consider other factors that are now known to affect penile cancer risk. (2005, )

Phimosis and paraphimosis

Pathological phimosis is a condition of a very tight foreskin that makes retraction over the glans painful or impossible. Rickwood suggested that the term 'phimosis' should be restricted to cases in which the prepuce loses suppleness and becomes scarred. Paraphimosis is an acute condition where the tight foreskin is stuck behind the glans and cannot be moved back, curbs the blood flow from the glans. In children, it is sometimes caused by a caregiver trying to forcibly retract the infant foreskin.

The AAP state that the true frequency of such problems is unknown. Fergusson et al found phimosis in 16% of non-circumcised boys, while Herzog and Alvarez found it in 2.6%. Rickwood and Walker raised concern that phimosis is frequently misdiagnosed by physicians confusing it with the developmentally non-retractible foreskin.

Several studies have identified phimosis as a risk factor for penile cancer, leading Willcourt to state that it would be irresponsible to expose a patient to risk for longer than necessary.

Urinary tract infections

Twelve studies have indicated that neonatal circumcision reduces the occurrence rate of Urinary tract infections in male infants by a factor of about 10. Some of these studies have been criticised in not taking other factors (especially for non-circumcision) into account. A Swedish study found that the cumulative incidence of UTIs in boys under 2 years of age was 2.2%.

The Canadian Pediatric Society poses the question of whether increased UTI and balanitis rates in non-circumcised male infants may be caused by forced premature retraction. According to the Lerman and Liao, aside from its effects on UTI infection rates, "Most of the other medical benefits of circumcision probably can be realized without circumcision as long as access to clean water and proper penile hygiene are achieved."

Sexual

Main article: Sexual effects of circumcision

The effects of neonatal circumcision on sexuality have not been studied. Excision of penile mucosa and skin desensitizes the penis. The prepuce is considered a specific erogenous zone. Specifically, according to Hass and Crooks the frenulum is "particularly responsive to stimulation," and "very reactive," thus contributing to erogenous pleasure during sexual activity.. Loss of erogenous sensation will relate to the amount and location of preputial mucosa removed.

The American Academy of Pediatrics states "a survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men. There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males." The American Academy of Family Physicians states "no valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction." Research on adult circumcision and erogenous sensitivity are discussed in the main article.

History of circumcision

Main article: History of male circumcision

It has been variously proposed that circumcision 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, as a means of suppressing (or enhancing) sexual pleasure, as an aid to hygiene where regular bathing was impractical, as a means of marking those of lower (or higher) social status, 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, to remove "excess" pleasure, to increase a man's attractiveness to women, as a symbolic castration, as a demonstration of one's ability to endure pain, or as a male counterpart to menstruation or the breaking of the hymen. It is possible that circumcision arose independently in different cultures for different reasons.

Circumcision in the ancient world

The oldest documentary evidence for circumcision comes from ancient Egypt. 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. The Egyptian 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.

Circumcision was common, although not universal, among ancient Semitic peoples. The Book of Jeremiah, written in the sixth century BCE, lists the Egyptians, Jews, Edomites, Ammonites, and Moabites as circumcising cultures. Herodotus, writing in the fifth century BCE, would add the Colchians, Ethiopians, Phoenicians, and Syrians to that list.

In the aftermath of the conquests of Alexander the Great, Greek dislike of circumcision led to a decline in its incidence among many peoples that had previously practiced it. 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.

Medical circumcision in the 19th century and early 20th century

Several hypotheses have been raised in explaining the American public's acceptance of infant circumcision as preventive medicine. The success of the germ theory of disease had not only enabled physicians to combat many of the postoperative complications of surgery, but had made the wider public deeply suspicious of dirt and bodily secretions. Accordingly, the smegma that collects under the foreskin was viewed as unhealthy, and circumcision readily accepted as good penile hygiene. Second, moral sentiment of the day regarded masturbation as not only sinful, but also physically and mentally unhealthy, stimulating the foreskin to produce the host of maladies of which it was suspected. In this climate, circumcision could be employed as a means of discouraging masturbation. All About the Baby, a popular parenting book of the 1890s, recommended infant circumcision for precisely this purpose. Interestingly, a 1410-man survey in the United States in 1992, Laumann found that circumcised men were more likely to report masturbating at least once a month.

With the proliferation of hospitals in urban areas, childbirth, at least among the upper and middle classes, was increasingly undertaken in the care of a physician in a hospital rather than that of a midwife in the home. It has been suggested that once a critical mass of infants were being circumcised in the hospital, circumcision became a class marker of those wealthy enough to afford a hospital birth.

By the 1920s, advances in the understanding of disease had undermined much of the original medical basis for preventive circumcision. Doctors continued to promote it, however, as good penile hygiene and as a preventive for a handful of conditions local to the penis: balanitis, phimosis, and penile cancer.

Routine infant circumcision was taken up in the English-speaking parts of Canada, the United States and Australia, and to a lesser extent in New Zealand and the United Kingdom. Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 30% of newborn American boys were being circumcised in 1900, 55% in 1925, and 72% in 1950.

Circumcision since 1950

In 1949, a lack of consensus in the medical community as to whether circumcision carried with it any notable health benefit motivated the United Kingdom's newly-formed National Health Service to remove routine infant circumcision from its list of covered services. One factor in this rejection of circumcision may have been Douglas Gardiner's famous paper, The fate of the foreskin, which revealed that for the years 1942–1947, about 16 children per year had died because of circumcision in England and Wales, a rate of about 1 per 6000 performed circumcisions. Since then, circumcision has been an out-of-pocket cost to parents, and the proportion of newborns circumcised in England and Wales has fallen to less than one percent.

In Canada, individual provincial health services began delisting circumcision in the 1980s. At present, only Manitoba pays for the procedure.

In South Korea, circumcision was largely unknown before the establishment of the United States trusteeship in 1945 and the spread of American influence. More than 90% of South Korean high school boys are now circumcised, but the average age of circumcision is 12 years .

In some South African ethnic groups, circumcision has roots in several belief systems, and is performed most of the time on teenage boys:

"...The young men in the eastern Cape belong to the Xhosa ethnic group for whom circumcision is considered part of the passage into manhood... A law was recently introduced requiring initiation schools to be licensed and only allowing circumcisions to be performed on youths aged 18 and older. But Eastern Cape provincial Health Department spokesman Sizwe Kupelo told Reuters news agency that boys as young as 11 had died. Each year thousands of young men go into the bush alone, without water, to attend initiation schools. Many do not survive the ordeal..." .

Prior to 1989, the American Academy of Pediatrics had a long-standing opinion that medical indications for routine circumcision were lacking. This stance, according to the AMA, was reversed in 1989, following new evidence of reduction in risk of urinary tract infection. A study in 1987 found that the prominent reasons for parents choosing circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns. A 1999 study reported that reasons for circumcision included "ease of hygiene (67 percent), ease of infant circumcision compared with adult circumcision (63 percent), medical benefit (41 percent), and father circumcised (37 percent)." The authors commented that "Medical benefits were cited more frequently in this study than in past studies, although medical issues remain secondary to hygience and convenience." A 2001 study reported that "The most important reason to circumcise or not circumcise the child was health reasons."A 2005 study suggested that increased recognition of the potential benefits may be responsible for an observed increase in the rate of neonatal circumcision in the USA. In two studies conducted in the 1980s, strong parental cultural expectations clashed with deliberate informed consent, and “a significant number of parents in the studies mentioned expressed animosity toward the care provider.” In a 2001 study, however, 86.6% of parents felt respected by their medical provider, and parents who did not circumcise "felt less respected by their medical provider".

The major medical societies in Britain, Canada, Australia and New Zealand do not support routine non-therapeutic infant circumcision. Major medical organizations in the United States state that parents should decide what is in their child's best interests, explicitly not recommending the procedure for medical reasons. Neonatal circumcision remains the most common pediatric operation carried out in the U.S. today.

**Table 1: International circumcision rates**
Country	Year	Neonatal circumcisions (%)
United States	2003	55.9%*
Canada	2003	11.5%
Australia	2004	12.7%
New Zealand	1995	0.35%**
United Kingdom	1972	0.41%
*The percentage refers to infants born in non-Federal hospitals; see p 52, Table 44 of the reference.
**Samoans, Tongans and Niueans in New Zealand continue to practice circumcision, but not in public hospitals, to which these data refer.

Prevalence of circumcision worldwide

Main article: Circumcision worldwide

Estimates of the proportion of males that are circumcised worldwide vary from one sixth to one third.

United States

Statistics from different sources give different pictures of infant circumcision rates in the United States.

The National Center for Health Statistics stated that the overall rate of neonatal circumcision was 64.3% in 1979 and 65.3% in 1999. However, the rate for white infants was 0.3% lower in 1999 than 1979 and the circumcision rate for black infants increased by 6.5% over this time . Also, strong regional differences developed. In the West, circumcision declined from 63.9% to 36.7%, but this was counterbalanced by rises in the Midwest and South. The decline in the West has been partly attributed to increasing births among Latin Americans, who usually do not circumcise .

A recent study, which used data from the Nationwide Inpatient Sample (a sample of 5-7 million of the nation's total inpatient stays, and representing a 20% sample taken from 8 states in 1988 and 28 in 2000), stated that circumcisions rose from 48.3% in 1988 to 61.1% in 1997.

Figures from the Nationwide Hospital Discharge Survey (for the 2003 survey based on a sample of 320,000 inpatient stays in 426 non-Federal short-stay hospitals; cf Abstract on p. 1 of ), state that circumcision rates declined from 64.7% in 1980 to 59.0% in 1990, then rose to 64.1% in 1995, and fell again to 55.9% in 2003. Overall, the West saw the most significant change, declining from 61.8% in 1980 to 31.4% in 2003 (see Table 44, page 52 of the National Hospital Discharge Survey 2003) .

Sixteen states no longer pay for the procedure under Medicaid . One study in the Midwest of the US found that this had no effect on the newborn circumcision rate but it did affect the demand for circumcision at a later time.

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