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Friday, January 23, 2009

What is circumcision?

What is circumcision? Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce) of the penis. The first evidence of circumcision comes from early Egyptian wall paintings that are more than 5000 years old.How common is circumcision?About one-fifth of men worldwide have been circumcised, mostly for religious and cultural reasons when the procedure is commonly performed shortly after birth or around puberty. Although adults are occasionally circumcised as an act of religious dedication, adult circumcision is most commonly performed for medical reasons.
At present, around 80 per cent of US males have been circumcised, mostly for non-religious reasons. The frequency of newborn circumcision has fallen in the USA from 90 per cent in the 1950s to around 60 per cent today.
In Korea, more than 90 per cent of men have been circumcised, usually in their teens and twenties.
In the UK in 1948, around 20 per cent of boys were circumcised shortly after birth, more commonly among middle class families and those living in the south of England. Then, 50 per cent of grammar school boys, 84 per cent of public school boys and 60 per cent of graduates were circumcised. By 1975, only 6 per cent of boys born in the UK were circumcised. Why circumcise?Reasons for circumcision fall into three broad groups:
for an immediate medical indication
to prevent future disease
as an act of religious dedication. Circumcision for an immediate medical reason
Non-retractable foreskin in childrenContrary to common belief, the foreskin cannot be pulled back (retracted) in almost all newborn babies. Well-meaning parents do not need to try cleaning under the foreskin until it has become fully retractable of its own accord because attempts to pull back a non-retractable foreskin can result in pain and possibly injury.About 50 per cent of one-year-old boys will have a non-retractable foreskin, 30 per cent of two-year-olds, about 10 per cent of four-year-olds and about 5 per cent of 10-year-olds. The small percentage of adults who have a persistently non-retractable foreskin have a slightly increased chance of developing phimosis (see below), but this persistence is not a reason for circumcision.
PhimosisIn phimosis (foreskin contraction), the opening of the foreskin is narrowed, preventing retraction. Provided that the skin of the foreskin is normal and inability to retract it does not cause problems with intercourse or recurrent infections, no action is necessary.Occasionally, the edge of the foreskin has a white, scarred, inelastic appearance and will not pucker open as it is retracted. Between 1 and 1.5 per cent of boys will develop this condition by the time they are 17 years old. Symptoms can include
irritation or bleeding from the edge of the foreskin
stinging or pain on passing urine (dysuria)
inability to pass urine (acute or, rarely, chronic urinary retention). The changes in the prepuce are known as balanitis xerotica obliterans, which can become cancerous if left untreated. Circumcision is advisable in most cases.
Acute balanoposthitisThis condition involves redness and swelling of the foreskin, together with a discharge of pus from the space between the foreskin and the glans. Sometimes the whole penis may be swollen and inflamed. Between 3 and 10 per cent of boys will develop this condition, depending on how the condition is defined. Balanoposthitis is very occasionally the first sign of diabetes. If there is no underlying cause, simple hygiene measures, mild painkillers and the avoidance of tugging the foreskin are the only necessary treatments. Most cases will recover without further intervention. Circumcision is only done for recurrent and troublesome cases.
ParaphimosisThis condition is caused by forcibly pulling back the foreskin behind the coronal ridge of the glans or head of the penis, without its subsequent replacement. The foreskin then forms a tight tourniquet around the glans, causing severe pain. The condition can sometimes be treated by firmly but gently squeezing the trapped glans until the foreskin can slip over it again.If this is not possible, the paraphimosis needs to be reduced under a general anaesthetic. Circumcision is only very rarely necessary.Circumcision to prevent future disease Prevention of disease is the second most commonly given reason for circumcision after religious reasons, although the evidence that it has any beneficial effect on future health is very poor. The practice is, more likely, rooted in cultural traditions, although western societies may find this an uncomfortable conclusion.
Penile cancerCancer of the penis is an extremely rare disease and, in the early part of the last century, was almost unheard of in circumcised men. However, there is some evidence that circumcision may only offer protection from penile cancer if done in childhood, and adult surgery may not offer any protection. Poor personal hygiene, smoking and exposure to wart virus (human papilloma virus) increase the risk of developing penile cancer at least as much as being uncircumcised. Circumcised men are more at risk from penile warts than uncircumcised men, and the risk of developing penile cancer is now almost equal in the two groups. Therefore, routine circumcision cannot be recommended to prevent penile cancer.
Sexually transmitted diseasesSexually transmitted infections that cause ulcers on the genitals (syphilis, chancroid, herpes simplex) are more common in uncircumcised men. However, urethritis or inflammation of the tube that carries urine through the penis (caused by gonorrhoea and non-gonococcal urethritis) is more common in circumcised men, as are penile warts. Yeast infection (caused by candida or thrush) is equally common in circumcised and uncircumcised men, although circumcised men are less likely to have symptoms with this infection so they are more likely to unknowingly pass on thrush to their sexual partners.Far more effective and reliable methods than circumcision exist to reduce the risk of contracting sexually transmitted diseases, such as the use of condoms and adoption of safer sexual practices. Thus circumcision cannot be recommended to prevent these infections.
Human immunodeficiency virus (HIV) infectionViews conflict on whether circumcision can prevent HIV infection. A recent review in the British Journal of Urology concluded that there is no link between having an intact foreskin and HIV infection, whereas another paper in the British Medical Journal takes exactly the opposite view. Circumcision may be appropriate as a routine preventive measure only in regions that have a high rate of HIV infection, such as sub-Saharan Africa. The existing evidence is inadequate to recommend circumcision as an HIV-preventive measure in the UK.
Cervical cancerA study in 1947 reported that Jewish women rarely developed cervical cancer and the author attributed this finding to the fact that their sexual partners were circumcised. Further studies over the past 50 years have had contradictory conclusions, with experts enthusiastically championing the case for and against circumcision. The evidence is inadequate to recommend it as a preventive measure against cervical cancer.
Urinary tract infection (UTI)Since 1987, several studies have suggested that uncircumcised male infants are up to 10 times more likely to contract a urinary tract infection (UTI). One in 100 uncircumcised infants will develop a UTI, compared with 1 in 1000 circumcised infants.A UTI is not usually a great risk to health, so it does not seem reasonable to perform a surgical procedure on 100 infants to reduce the risk of one developing UTI. Circumcision as an act of religious dedicationThe circumcision of male children is a central feature of both Judaism and Islam. It is also important in many African and New World cultures. An increasing number of committed Jewish and Muslim people reject circumcision on ethical grounds, although they are certainly the minority at present. Attitudes to circumcision may provoke fierce hostility within families and among communities. In the past, wars have been fought, and thousands have died, to preserve the right to circumcise when rulers from other cultures forbade it.
JudaismIn the book of Genesis (17: 10-14), circumcision represents the covenant made by God with Abraham and his descendants.Traditional religious circumcision is performed by a mohel (pronounced mo-hell in Hebrew or moyle in Yiddish). It is usually carried out on the eighth day after birth, unless there is a danger to the child's health, in which case it should be delayed until that danger has passed. In the UK, mohelim attend 40 to 50 circumcisions and have to pass practical and theoretical examinations during their training before performing circumcision alone.
IslamThe divine law or sharia defines every aspect of Muslim life. It is based upon the Holy Koran, the hadith (the sayings of the Prophet Mohammed) and the sunnah (Prophet's tradition). All Muslims agree that these are the three sources of Islamic law, but different groups interpret their application in different ways. Circumcision is not mentioned in the Koran, but has the status of sunnah. Only the Shafiite school of law regards circumcision as obligatory (wajib), while the Hanafite, Jafarite, Malikite, Hanbalite and Zaidite regard it as only recommended, because it is sunnah. Even those who consider circumcision an obligatory duty for themselves do not see it as an essential requirement for others to become a Muslim. However, the procedure is very commonly practised and is certainly seen as an important external symbol of submission to God's will.Should we avoid circumcision?The foreskin is not simply a useless piece of skin, to be disposed of without careful thought. It forms the covering of the head (glans) of the penis in men and the clitoris in women. It is very rich in nerves responsible for touch and the movement of the foreskin backwards and forwards over the glans provides some of the pleasurable sensation experienced during sex.Adult males that were circumcised as infants do not usually report sexual problems linked with their circumcision, perhaps because they have never experienced sexual sensation with a foreskin. However, men circumcised as sexually active adults quite frequently complain of sexual problems arising from either reduced or altered penile sensation.How is circumcision performed?Although religious and cultural circumcision is frequently performed without anaesthetic as part of an important ritual act, it is an intensely painful procedure, even in newborn babies. Adults can testify to the pain for themselves and can give informed consent to the procedure. Infants, however, cannot. Physiological research has repeatedly shown bodily responses that indicate infants experience severe pain during circumcision.It is difficult to justify subjecting infants to this experience when pain could be avoided with a brief general anaesthetic. Anaesthetic injections that numb the penis or the whole genital region are not a reliable substitute for general anaesthesia. If circumcision is important for religious or cultural reasons, then the mohel, or other ritual circumciser, can still perform the procedure and prayers with the assistance of an anaesthetist and surgical team at hand. This practice may not be the traditional family gathering associated with circumcision, but would fulfil religious obligation without causing unnecessary suffering.When circumcision is necessary for an immediate medical reason, the surgeon would be prudent to try to preserve as much of the foreskin as possible, through some form of preputioplasty (a plastic surgery procedure that alters the shape of the foreskin but minimises the amount of skin removed). Preputioplasty may preserve sexual sensation, although its advantage over circumcision is not yet established.Complications of circumcisionHappily, complications of circumcision are relatively rare, although they may be under-reported following religious or cultural circumcision. For this reason, figures on the rate of complications may not be reliable. Complications include:
reduction in penile sensation (an almost universal experience)
damage to the urethra (urine tube in the penis)
amputation of the glans (rare)
infection in the blood or septicaemia (rare).Can circumcision be reversed?Attempts have been made to restore the foreskin following circumcision since ancient times. Unfortunately, no procedure had satisfactory results. Modern surgical procedures may have more success, but they are still experimental and the long-term results are unknown. If foreskin restoration is being considered, a urologist should be consulted.Female circumcision is not required by any religious group and is a traditional practice prevalent in Africa, Southeast Asia and South America. It is far more disfiguring, disabling and potentially dangerous than male circumcision so cannot be viewed in the same light. The author fully supports the World Health Organisation's policy that this procedure should cease throughout the world.ConclusionsCircumcision remains a controversial procedure, as it has been for thousands of years.Male circumcision is vitally important to some religious and cultural groups. Hopefully, the use of general anaesthesia for infant circumcision will increase. Medical and religious authorities should work together to promote this change.Very few absolute medical reasons exist for circumcision, and no reasons exist to justify routine circumcision of infants outside areas with a high rate of HIV infection. Far too many circumcisions are performed without good reason in Europe and the USA. The best advice is 'if it isn't absolutely necessary, don't circumcise'.


Circumcision, once accepted as the norm in the United States, has become controversial. Technically, circumcision is the surgical removal of the skin that normally covers and protects the head, or glans, of the penis. At birth, the penis is covered with a continuous layer of skin extending from the pubis to the tip of the penis where the foreskin (prepuce) folds inward upon itself, creating a double protective layer of skin over the glans penis. The inner lining of the prepuce is mucous membrane and serves to keep the surface of the glans penis (also mucous membrane) soft, moist, and sensitive. The prepuce is often erroneously referred to as ``redundant'' tissue, which allows the medical community and society-at-large to consider the foreskin an optional part of the male sex organ and, therefore, to condone its routine removal in a variety of procedures collectively known as ``circumcision.''
Circumcision, however, was also a part of religious ritual, including Judaism and Islam as well as others. However, 85 percent of the world's male population is not circumcised. Circumcision in 1992 was still the most commonly performed surgical procedure in America, where 59 percent of newborn males underwent this operation. Circumcision reached its peak of 85 to 90 percent during the 1960s and 1970s. The surgery, usually performed on baby boys within the first few days of life, is often considered "routine." The most popular methods, the Gomco clamp and the Plastibell procedures, differ somewhat in technique and instrumentation but the effects on the penis and the baby are basically the same. Most of the American circumcisions are not done for religious reasons, but rather, for hygienic ones.
Medical ProcedureUsually, the procedure for circumcision in America involves the baby being strapped spread-eagle to a plastic board, with his arms and legs immobilized by Velcro straps. A nurse scrubs his genitals with an antiseptic solution and places a surgical drape - with a hole in it to expose his penis - across his body. The doctor grasps the tip of the foreskin with one hemostat and inserts another hemostat between the foreskin and the glans. (In 96 percent of newborns, these two structures are attached to one another by a continuous layer of epithelium, which protects the sensitive glans from urine and feces in infancy and childhood.) The foreskin is then torn from the glans. The hemostat is used to crush an area of the foreskin lengthwise, which prevents bleeding when the doctor cuts through the tissue to enlarge the foreskin opening. This allows insertion of the circumcision instrument. The foreskin is crushed against this device circumferentially and amputated.
Anesthesia was not used to alleviate infant suffering until recently because it was believed that babies do not feel pain. Additionally, it was recognized that anesthesia was risky for the newborn, thus contributing to the medical reluctance to use it for painful procedures on infants, such as circumcision. Currently, some doctors use a dorsal penile nerve block to numb the penis during infant circumcision. While not always effective, this anesthesia may afford some pain relief during the surgery, although it offers no pain relief during the recovery period (which can last up to 14 days) when the baby urinates and defecates into the raw wound.
Function of the ForeskinTo understand the function of the prepuce, it is necessary to understand the function of the penis. While it is commonly recognized that the penis has two functions - urination and procreation - in reality, it is essential only for procreation, since it is not required for urination.
For procreation to occur, the normally flaccid penis must become erect. As it changes from flaccidity to rigidity, the penis increases in length about 50 percent. As it elongates, the double fold of skin (foreskin) provides the skin necessary for full expansion of the penile shaft. But microscopic examination reveals that the foreskin is more than just penile skin necessary for a natural erection; it is specialized tissue, richly supplied with blood vessels, highly innervated, and uniquely endowed with stretch receptors. These attributes of the foreskin contribute significantly to the sexual response of the intact male. The complex tissue of the foreskin responds to stimulation during sexual activity. Stretching of the foreskin over the glans penis activates preputial nerve endings, enhances sexual excitability, and contributes to the male ejaculatory reflex. Besides the neurological role of the preputial tissue, the mucosal surface of the inner lining of the foreskin has a specific function during masturbation or sexual relations.
During masturbation, the mucosal surface of the foreskin rolls back and forth across the mucosal surface of the glans penis, providing nontraumatic sexual stimulation. During heterosexual activity, the mucosal surfaces of the glans penis and foreskin move back and forth across the mucosal surfaces of the labia and vagina, providing nontraumatic sexual stimulation of both male and female. This mucous-membrane-to-mucous-membrane contact provides the natural lubrication necessary for sexual relations and prevents both the dryness responsible for painful intercourse and the chafing and abrasions which allow entry of sexually transmitted diseases, both viral and bacterial.
When normal, sexually functioning tissue is removed, sexual functioning is also altered. Changes of the penis that occur with circumcision have been documented. These may vary according to the procedure used and the age at which the circumcision was performed, nevertheless penile changes will inevitably occur following circumcision.
Circumcision performed in the newborn period traumatically interrupts the natural separation of the foreskin from the glans that normally occurs somewhere between birth and age 18. The raw, exposed glans penis heals in a process that measurably thickens the surface of the glans and results in desensitization of the head of the penis.
When circumcision is performed after the normal separation of the foreskin from the glans, the damage done by forcible separation of these two parts of the penis is avoided, but the glans must still thicken in order to protect itself from constant chafing and abrasion by clothing.
The thickened, drier tissue covering the glans of the circumcised penis may necessitate the use of synthetic lubricants to facilitate nontraumatic sexual intercourse. Often, it is erroneously considered the woman's lack of lubrication that makes intercourse painful rather than the lack of natural male lubrication, which is more likely the cause. During masturbation, the circumcised male must use his hands for direct stimulation of the glans, and this may require synthetic lubrication as well.
In addition to the predictable physical changes that occur with circumcision, there are inherent risks and potential complications from the surgery. These include, but are not limited to, hemorrhage, infection, surgical damage and, while rare, death. Surgical damage and healing complications can result in extensive scarring, skin bridging, curvature of the penis, and deformities of the glans penis and urethral meatus (urinary opening). Extreme mutilations have resulted from inappropriate electrocautery use in circumcision, causing loss of the entire penis. Sex-change operations have been used as a ``remedy'' for this iatrogenic condition.
While circumcision has potential risks and alters normal, sexual functioning of the penis, proponents of the practice consider it to confer many "prophylactic" benefits on the recipient. This rationale was initiated in the English-speaking countries during the 19th century when the etiology of diseases was unknown. At that time, circumcision evolved from a religious ritual or puberty rite into routine surgery for "health" reasons.
Within the miasma of myth and ignorance, a theory emerged that masturbation caused many and varied ills, so some physicians thought it logical to perform genital surgery on both sexes to stop masturbation. In 1891, P.C. Remondino advocated circumcision to prevent or to cure alcoholism, epilepsy, asthma, hernia, gout, rheumatism, curvature of the spine, and headaches. As scientific research uncovered legitimate pathological etiology for diseases previously thought to be prevented or cured by circumcision, new rationales were postulated to validate the practice. Prophylactic circumcision of females fell out of vogue in English-speaking countries, but the incidence of male circumcision steadily rose. In the early 20th century, circumcision was advocated as a hygienic measure. Though criticism of the practice mounted, it was not until 1975 that the American Academy of Pediatrics came out in opposition, arguing that good personal hygiene would offer all the advantages of routine circumcision without the attendant surgical risk. The advent of antibiotics negated the rationale that circumcision was needed to prevent venereal disease.
As a religious ritual, circumcision is practiced by Jews and Moslems in accordance with the biblical account of Abraham's covenant with God. Even so, the ``purpose'' of the Jewish ritual of circumcision has been argued by Jews throughout history. Noted Rabbi Moses Maimonides, in the Guide of the Perplexed, explains a rationale for circumcision that merits attention when circumcision is considered relative to human sexuality.
As regards circumcision... [s]ome people believe that circumcision is to remove a defect in man's formation; but every one can easily reply: How can products of nature be deficient so as to require external completion, especially as the use of the foreskin to that organ is evident. This commandment has not been enjoined as a complement to a deficient physical creation, but as a means for perfecting man's moral shortcomings. The bodily injury caused to that organ is exactly that which is desired; it does not interrupt any vital function, nor does it destroy the power of generation. Circumcision simply counteracts excessive lust; for there is no doubt that circumcision weakens the power of sexual excitement, and sometimes lessens the natural enjoyment; the organ necessarily becomes weak when it loses blood and is deprived of its covering from the beginning.
The Moslems, who also circumcise in accordance with the biblical covenant between Abraham and God, traditionally circumcised their males at age 13. More recently, however, Moslem boys are circumcised at varying ages from birth to puberty.
In the United States, the religious rights of parents are being questioned in regard to the constitutional rights of infants and children. Freedom of religion became a legal issue when it was introduced in a circumcision lawsuit claiming a male had been denied his right to freedom of religion when his body was marked by circumcision in accordance with his parents' religion.
The inalienable body ownership rights of infants and children continue to be addressed within the U.S. legal system in lawsuits asserting that the only person who can legally consent to a circumcision is a person making this personal decision for himself. The reports of dissatisfaction with parental circumcision decisions by circumcised men help to illustrate this point. Performed on their penises without their consent, thousands are now undergoing foreskin restoration, either medical or surgical, to reconstruct what they consider was violently taken from their bodies early in their lives. The Declaration of the First International Symposium on Circumcision acknowledges the unrecognized victims of circumcision and, in support of genital ownership rights of infants and children, states: ``We recognize the inherent right of every human being to an intact body. Without religious or racial prejudice, we affirm this basic human right.'' Due to the lifelong consequences of the permanent surgical alteration of children's genitals, it becomes imperative that children have the right to own their own reproductive organs and to preserve their natural sexual function.

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