Circumcision

History of male circumcision

In males, circumcision is the removal of some or all of the prepuce or foreskin though often the frenulum is also excised. Female circumcision is a term applied to a variety of similar procedures performed on the female genitalia; the surgical removal of the clitoral hood is the procedure most comparable to male circumcision. Unless otherwise noted, in this article "circumcision" should be taken to refer specifically to male circumcision.

The word circumcision comes from Latin circum (="around") and caedere (="to cut").

Methods

File:Uncircumsized penis.gif File:Circumsized penis.gif
An uncircumcised penis, a circumcised penis

When performed on infants or young children, circumcision is done either without anesthesia or using a local anesthetic; the use of local anesthetic is increasingly common.

In most infant circumcision procedures, the infant is strapped into a special restraint. Since, in infants, the foreskin is usually connected to the glans penis by one or more bridges of tissue called the synechial membrane or preputial adhesions, prior to circumcision these must be broken or torn by means of a blunt probe, forceps, or scissors. The loosened foreskin is then clamped to crush the foreskin, limiting or eliminating bleeding during the procedure (the clamp also acts as a shield to protect the remainder of the penis from being accidentally cut). Common varieties of clamp include the Gomco clamp, the Plastibell, (a disposable device commonly used in the United States), theMogen clamp (the most common device used in Jewish ritual circumcisions), and the Tara KLamp. The portion of the foreskin held in the clamp is then cut off using a scalpel.

Unless the clamped edges of skin come loose, children's circumcisions are usually dressed in a light bandage without sutures. Some styles of clamp are designed to stay in place for several days, holding the wound closed until it heals.

In adults, where circumcision is performed for medical or personal reasons in a hospital setting it is normally performed under general anaesthesia, but local anesthesia is also commonplace. While some varieties of the clamps used for infant circumcision are also made in adult sizes, adulthood circumcisions are most commonly performed "freehand" using a surgical blade. This requires more skill on the part of the surgeon, but gives the surgeon precise control over how much skin is removed and where it is removed from, the placement and appearance of the resulting scar, and other cosmetic factors. The wound is normally sutured to prevent it from reopening during erection, and then bandaged.

Following circumcision, the pain is controllable using oral analgesics. Normally there is no distress when the penis is flaccid, but erections can cause significant discomfort for several days following the operation. Urination is normal during healing, and sexual functions can usually be resumed after 2-3 weeks. Some men report unpleasant sensitivity of their glans after adult circumcision, but this settles down within the first month as the glans becomes used to being in contact with clothing.

For many disorders, such as phimosis, alternative conservative treatments exist. A dorsal slit or the use of steroid creams often resolve phimosis. Urinary tract infections, while much less common in circumcised boys than in either girls or uncircumcised boys, can often be effectively treated with antibiotics.[1]

Prevalence

Estimates of the worldwide prevalance of male circumcision vary between 20-30%, or approximately one sixth of the male population; except in the United States, where the majority of newborn males are routinely circumcised, worldwide most male circumcisions are performed for religious or cultural reasons.

The majority of males are circumcised in the following countries:

Afghanistan, Albania, Algeria, Azerbaijan, Bahrain, Bangladesh, Benin, Cameroon, Chad, Comoros, Djibouti, Egypt, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Indonesia, Iran, Iraq, Israel, Kazakhstan, Kenya, Kuwait, Lebanon, Libya, Madagascar, Malaysia, Maldives, Mali, Mauritania, Morocco, Nigeria, Niger, Pakistan, Philippines, Qatar, Republic of the Congo, Samoa. Tonga, Saudi Arabia, Sierra Leone, Somalia, South Africa, South Korea, Sudan, Syria, Tajikistan, Togo, Tunisia, Turkey, Turkmenistan, United Arab Emirates, the United States of America, Uzbekistan, Vanuatu and Yemen.

In most of these countries the predominant religion (usually Islam or Judaism) endorses circumcision.

Historically, routine infant circumcision was promoted during late Victorian times in the English-speaking parts of Canada, Australia, New Zealand, the United States and the United Kingdom and was widely practiced during the first part of the 20th century in these countries. However, the practice declined sharply in the United Kingdom after the Second World War, and somewhat later in Canada, Australia and New Zealand. It has been argued that the practice did not spread to other European countries because others considered the arguments for it fallacious. In South Korea, circumcision was largely unknown before the establishment of the United States trusteeship in 1945 and the spread of Chrisitanity. More than 90% of South Korean high school boys are now circumcised, but the average age of circumcision is 12 years, which makes South Korea a unique case [2].

From the late Victorian era, circumcision became more common in the higher classes in the United Kingdom. Queen Victoria had the notion that her family was descended from King David of Israel, and mandated that her sons, including the future King Edward VII be circumcised. King Edward continued the practice, and among the English royal family, the practice is still widespread: Prince Charles, Prince Andrew and Prince Edward were all circumcised. Reportedly, the late Diana, Princess of Wales rebelled against the royal tradition and refused to allow her sons, Prince William and Prince Harry, to be circumcised.

Routine infant circumcision has been abandoned in New Zealand and Britain, and is now much less common in Australia and in Canada (see table 1). The decline in circumcision in the United Kingdom followed the decision by the National Health Service (NHS) in 1948 not to cover the procedure following an influential article by Douglas Gardiner which claimed that circumcision resulted in the deaths of about 16 children under the age of five every year in the United Kingdom [3].

Before the 1870s, circumcision in the United States was performed to treat phimosis and cancerous lesions. During the last few decades of the nineteenth century, in accord with the accepted reflex neurosis theory of the time, circumcision came to be used to treat diseases that were not localized to the penis, especially those that affected the nervous system. In addition, circumcision was performed to prevent masturbation, which was believed to cause various diseases. Social considerations helped make the procedure widespread. During the Victorian era a great emphasis was placed on cleanliness and secretions such as smegma were treated with suspicion. In the end, however, routine neonatal circumcision eventually came to be practiced on a majority of males around the turn of the century because of the supposed hygienic and preventive benefits of the procedure, the same justification that is still used today.

In the United States, statistics collected by the National Center for Health Statistics show that the overall rate of neonatal circumcision has remained near 65% since data collection began in 1979 [4]. However, strong regional differences in the circumcision rates have developed during this time. While more than 80% of newborn boys are circumcised in the Midwest and South, circumcision rates have declined to about 37% in the West [5]. This has been attributed in part to increasing births among Latin Americans, who usually do not circumcise [6]. Thirteen states no longer pay for the procedure under Medicaid; the other 37 still do.

The medical benefits of circumcision, or the lack thereof, are a controversial topic. Some argue that circumcision is an essential public health measure, while others believe that there are no benefits to the procedure (see medical analysis of circumcision).

The major medical societies in Britain, Canada, Australia and New Zealand no longer support routine infant circumcision. All major medical organizations in the United States now judge the benefits of the procedure to be too small to justify the risks associated with performing it routinely. Neonatal circumcision nonetheless still remains the most common pediatric operation carried out in the U.S. today.

Table 1 International circumcision rates
Country	Year	Routine neonatal circumcisions (%)
United States	1999	65.4% [7]
Canada	FY 1996/97	17% [8]
Australia	1995-96	10.6% [9]
New Zealand	1995	0.35%* [10]
United Kingdom	1972	0.41% [11]
*Samoans, Tongans and Niueans in New Zealand continue to practice circumcision, but not in public hospitals, which these data refer to

Circumcision and religion

Circumcision is a religious practice traditionally required by Judaism and Islam. The Jewish ceremony of circumcision is called a Brit milah or Bris Milah (Hebrew for "Covenant of circumcision"). The ceremony is to be performed on the eighth day of life of the newborn boy unless health reasons force a delay. See also Circumcision in the Bible.

According to nearly all Muslim religious leaders, circumcision is an important element of Islam. Although circumcision is not mentioned in the Quran (and the mutilation of the body is expressly forbidden therein), it is mentioned in some parts of the Hadith, a set of texts explaining Islamic law that most Muslims view as authoritative. Most Muslims believe that Mohammed was born circumcised. Moreover, Hadiths describe that the ritual of circumcision was started by Abraham, who is seen as the founder of Islam.

Muslim custom on circumcision varies. Some Muslim communities perform circumcision on the eighth day of life, as the Jews do, while others perform the rite at a different time. Turkish, Balkan, and Central Asian Muslims typically circumcise boys at between six and eleven years of age, and the event is viewed communally as a joyous occasion and celebrated with sweets and feasting. In contrast, Iranian Muslims are typically circumcised in the hospital at birth without much ado. In Egypt, rural populations celebrate circumcision as a joyous occasion, while urban populations have it done in the hospital.

Circumcision is also customary in the Coptic Christian religious tradition. It is also usually performed on the eighth day of life. This practice was condemned by the Council of Florence[12] in 1442, held by leading theologians of the Roman Catholic Church, which said in part:

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 [13].

A number non-Western peoples practice circumcision as part of their belief systems, such as the Machapunga tribe of Native North Americans, some Australian Aborigines, some tribes in New Guinea, Tongans, Niueans, Samoans and widley across Africa. Circumcision practices among these societies vary, including at what age the procedure is done, whether women may be present, what celebrations are attendant on the procedure, and whether the procedure is viewed as an initiation.

Contemporary attitudes toward circumcision

Just as circumcision rates vary widely between circumcising countries, and even between different regions in countries, so attitudes toward circumcision vary widely.

Besides cultural or religious motivations for circumcision, some people believe that circumcised penises are more attractive. A 1988 study of new mothers found that 71% preferred a circumcised partner for sexual intercourse, and 83% for giving fellatio. When asked why, 92% cited cleanliness and 90% appearance. Although 78% of the women had not had direct contact with an uncircumcised penis, those who did expressed the same preference.[14]

Most men, whether circumcised or not, are content with their circumcision status. Others resent having been circumcised, citing lack of consent, loss of sensitivity, a desire to appear natural, and so on. Claims of increased keratinization of the glans and reduced sensitivity in circumcised penises are disputed. Some men seek to regain their foreskin through surgical or non-surgical foreskin restoration. Such procedures only produce the appearance of a natural foreskin; the specialised nerves and other parts of the foreskin that are removed during circumcision cannot be regrown or surgically recreated. Some men who undergo foreskin restoration proceudres claim that the procedure improves glans sensitivity.

Growing numbers of people are beginning to speak out or campaign against circumcision, and there has been a growing movement against both male and female circumcision in the last twenty years. The goal of this movement is to end, and possibly even criminalize, the forced circumcision of males and females.

History of circumcision

Many, possibly hundreds, of hypotheses have been advanced as to the origin of the practice of circumcision. Some propose 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) male 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 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 probable that circumcision arose independently in different cultures for different reasons.

The oldest documentary evidence for circumcision comes from Egypt. Tomb artwork from the Sixth Dynasty (2345 - 2181 BC) 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 both circumcised and uncircumcised men.

Circumcision in the Ancient World

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

The ancient Greeks, however, considered an unmodified penis far more aesthetic than a circumcised one. Ancient Greek artwork portrayed penises as covered by the foreskin (sometimes in exquisite detail), except in the portrayal of satyrs, lechers, and barbarians.[15] The Greek preference for the uncircumcised penis is reflected in Herodotus' comment on the Egyptians: "They practice circumcision for the sake of cleanliness, considering it better to be clean than comely." (Herodotus, Book 2, 37:2).

In the aftermath of Alexander the Great's conquests, the Greek prejudice against the appearance of the circumcised penis led to a decline in the incidence of circumcision among many peoples that had previously practiced it. The writer of 1 Maccabees wrote that under the Seleucids, many Jewish men attempted to hide or reverse their circumcision so they could exercise in Greek gymnasia (see foreskin restoration). Similar cultural pressures operated throughout the Hellenistic world: when the Judean king John Hyrcanus conquered the Idumeans, he forced them to become circumcised and convert to Judaism, but their ancestors the Edomites had practiced circumcision in pre-Hellenistic times. In Egypt, only the priestly caste retained circumcision, and by the second century, the only circumcising groups in the Roman Empire were Jews, Egyptian priests, and the Nabatean Arabs. Circumcision was sufficiently rare among non-Jews that being circumcised was considered conclusive evidence of Judaism in Roman courts—Suetonius described a court proceeding in which a ninety-year-old man was stripped naked before the court to determine whether he was evading the head tax placed on Jews.

Circumcision in the 18th Century

Circumcision was not practiced amongst Christians in Europe in the 18th Century. It was regarded with repulsion. Edward Gibbon, for example, referred to it as a "singular mutilation" practised only by Jews and Turks and as "a painful and often dangerous rite" [16].

In 1753 in London there was a proposal for Jewish emancipation. It was furiously opposed by the pamphleteers of the time, who spread the fear that Jewish emancipation meant universal circumcision. Men were urged to protect:

"the best of Your property" and guard their threatened foreskins. It was an extraordinary outpouring of popular beliefs about sex, fears about masculinity and misconceptions about Jews, but also a striking indication of how central to their sexual identity men considered their foreskins at that time. (R.Darby) [17]

Circumcision in the 19th Century and beyond

Until well into the Nineteenth Century, the same sentiments prevailed.

Richard Burton observed that "Christendom practically holds circumcision in horror". This attitude is reflected in the ninth edition of the Encyclopaedia Britannica (1876) which discusses the practice as a religious rite among Jews, Moslems, the ancient Egyptians and tribal peoples in various parts of the world. The author of the entry rejected sanitary explanations of the procedure in favour of a religious one: "like other body mutilations ... [it is] of the nature of a representative sacrifice". (R. Darby) [18]

Then, a change of attitude began, something that was reflected in successive editions of the Encyclopaedia Britannica:

By 1910 the entry had been turned on its head: "This surgical operation, which is commonly prescribed for purely medical reasons, is also an initiation or religious ceremony among Jews and Mahommedans": now it was primarily a medical procedure and only after that a religious ritual. The entry explained that "in recent years the medical profession has been responsible for its considerable extension among other than Jewish children ... for reasons of health" (11th edition, Vol. 6). By 1929 the entry is much reduced in size and consists merely of a brief description of the operation, which is "done as a preventive measure in the infant" and "performed chiefly for purposes of cleanliness". Ironically, readers are then referred to the entries for "Mutilation" and "Deformation" for a discussion of circumcision in its religious context (14th edition, 1929, Vol. 5). (R. Darby) [19]

Anti-masturbation panic and circumcision

The movement of the skin layers of the foreskin provides a built-in form of lubrication, usually making it easy to masturbate without additional lubrication if a foreskin is present. This lubricating function is often lost after circumcision.

Non-religious circumcision in English-speaking countries arose in a climate of sexual fear, especially concerning masturbation. In her 1978 article "The Ritual of Circumcision", Karen Erickson Paige writes that in the 1890s circumcision became a popular technique to prevent, or cure, masturbatory insanity. Among other things, the foreskin was thought to cause "nocturnal incontinence," hysteria, and epilepsy, and that, in the United States, the current medical rationale for circumcision developed after the operation was in wide practice. The original reason for the surgical removal of the foreskin, or prepuce, was to control 'masturbatory insanity' - the range of mental disorders that people believed were caused by the 'polluting' practice of 'self-abuse.'" At the same time circumcisions were advocated on men, clitoridectomies (removal of the clitoris) were also performed for the same reason (to treat female masturbators). The US "Orificial Surgery Society" for female "circumcision" operated until 1925, and clitoridectomies and infibulations would continue to be advocated by some through the 1930s.

One of the leading advocates of circumcision was John Harvey Kellogg, who is well known for his pseudoscientific views on human sexuality. He advocated the consumption of Kellogg's corn flakes to prevent masturbation, and he believed that circumcision would be an effective way to eliminate masturbation in males.

Robert Darby, writing in the Australian Medical Journal, noted that 19th Century circumcision advocates—and their opponents—were both well aware of the sexual sensitivity of the foreskin:

In the 19th century the role of the foreskin in erotic sensation was well understood by physicians who wanted to cut it off precisely because they considered it the major factor leading boys to masturbation. The Victorian physician and venereologist William Acton (1814–1875) damned it as "a source of serious mischief", and most of his contemporaries concurred. Both opponents and supporters of circumcision agreed that the significant role the foreskin played in sexual response was the main reason why it should be either left in place or removed. William Hammond, a Professor of Mind in New York in the late 19th century, commented that "circumcision, when performed in early life, generally lessens the voluptuous sensations of sexual intercourse", and both he and Acton considered the foreskin necessary for optimal sexual function, especially in old age. Jonathan Hutchinson, English surgeon and pathologist (1828–1913), and many others, thought this was the main reason why it should be excised. [20]

Forced Circumcisions

Forcible circumcisions occasionally happen in circumcising cultures. In one case a young Rastafarian South African was captured by his Xhosa relatives and forcibly circumcised against his will [21] . The outcry that followed this alarmed the Jewish and Muslim communities in case all circumcisions were made illegal [22].

There are also cases where men have responded violently to being circumcised against their will [23] or because of being taunted because of their circumcision status. [24]

Forced circumcisions and conversions are not supported by moderate Muslim leaders. However, Muslim extremists forcibly circumcised men, women and children in the Moluccas Islands (Indonesia) in January 2001. Forced circumcisions and forced conversions to Islam have also occurred in the Sudan and in Pakistan.

Circumcision as an identifying mark

In non-circumcising cultures, circumcision can be seen as evidence of being Muslim or Jewish. Nazis used this to determine which men were Jewish in a massacre at Pushkin, near St Petersburg, in 1941 [25]. This also occurred in India on several occasions, such as in 1992 following the destruction of the Babri mosque in Ayodhya, Hindu mobs would undress men in the street and kill any circumcised people they found, assuming they were Muslim. In the Moscow theatre hostage crisis in 2003, the Russian forces undressed the corpses to identify the Muslims. Similarly, following the massacre of children at Beslan, enraged people turned on any men with a foreign accent, undressed them to see if they were circumcised and if they were, they were determined to be Muslim. One man was torn apart by the angry mob and police were barely able to rescue four others [26].

See also

• Foreskin
• Foreskin restoration
• Medical analysis of circumcision
• Circumcision in the Bible (Mohel)
• Association for Genital Integrity

References

• John Harvey Kellogg Treatment for Self-Abuse and its Effects in Plain Fact for Old and Young, Burlington, Iowa: F. Segner & Co. (1888). P. 295.
• Goldman, Ronald Circumcision: The Hidden Trauma Boston 1997.
• Goldman, Ronald Questioning Circumcision: A Jewish Perspective Boston 1998.
• Wallerstein, E. Circumcision: The Uniquely American Medical Enigma, Urological Clinics of North America 12 (February 1985): 123-32.
• Walsh, Campbell's Urology, 7th ed. 1998
• Gollaher, David A., Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000. 253 pages. (ISBN 0-465-04397-6)
• [27]

External links

Pro-circumcision

• Benefits of Circumcision - Informational website
• Circlist- Pro-circumcision website and discussion group. It is not a medical site.
• Medicirc - Website by circumcision advocate Dr. Edgar Schoen, who promotes circumcision because of its alleged health benefits
• ACT inc. - "Advocating Circumcision Today", a Jewish circumcision advocacy organization and mohel referral service.
• ICIRC - "International Circumcision Information Reference Center" - discussion and information about circumcision from The Gilgal Society. It is strongly in favor of circumcision
• Circumcision information pages - Pro-circumcision website.
• The First Cut - An Australian website about circumcision.
• Circumcision Independent Reference and Commentary Service

Neutral

• Adhesions, Phimosis and Frenulum Breve - Medical information on potential penile conditions.

Anti-circumcision

• Circumcision Information and Resource Pages, a vast library website that hosts and comments on hundreds of articles and studies on various aspects of circumcision.
• International Coalition for Genital Integrity - An alliance of genital integrity groups.
• Intactivism - A site which is strongly opposed to circumcision and collects arguments on the subject
• The Case for Labectomy by Jason Rohrer, a satirical anti-circumcision text.
• Doctors Opposing Circumcision - An organization of physicians and others who are opposed to routine neonatal circumcision.
• Circumcision Resource Center - Includes some perspectives on the religious aspects of circumcision, and the mothers' feelings following the procedure.
• NOHARMM - National Organization to Halt the Abuse and Routine Mutilation of Males.
• NORM - National Organization of Restoring Men - non-profit support group for men who have concerns about being circumcised, are considering foreskin restoration, or are in the process of restoring their foreskins.
• Reports on forced circumcisions:[28] [29] [30] [31] [32] [33]

[34] [35] [36]