Circumcision

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News About Circumcision

07-SEPTEMBER-2008 03:17:44 - Circumcision The neutrality of this article's title and/or subject matter is disputed. This is a dispute over the neutrality of viewpoints implied by the title, or the subject matter within its scope, rather than the actual facts stated. Please see the relevant discussion on the talk page.June 2008 This article is about male circumcision. For female circumcision, see Female genital cutting. For Islam's circumcision ritual, see Khitan circumcision. For Judaism's circumcision ritual, see Brit milah. Male circumcision is the removal of some or all of the foreskin prepuce from the penis.1 The word circumcision comes from Latin circum meaning around and cædere meaning to cut. Early depictions of circumcision are found in cave drawings and Ancient Egyptian tombs, though some pictures may be open to interpretation.234 Male circumcision is a commandment from God in Judaism.5 In Islam, though not discussed in the Qur'an, circumcision is widely practiced and most often considered to be a sunnah.6 It is also customary in some Christian churches in Africa, including some Oriental Orthodox Churches.7 According to the World Health Organization WHO, global estimates suggest that 30% of males are circumcised, of whom two thirds are Muslim.8 The prevalence of circumcision varies widely between cultures. For example, circumcision is reported to be nearly universal in the Middle East,9 but under 2% in Scandinavia.10 Advocates of routine neonatal circumcision argue that circumcision provides important health advantages which outweigh the risks, that it has no substantial effects on sexual function, has a complication rate of less than 0.5% when carried out by an experienced physician, and is best performed during the neonatal period.11 Opponents of routine neonatal circumcision argue that circumcision violates the individual's bodily rights, is medically unnecessary, adversely affects sexual pleasure and performance, and is a practice defended through the use of myths.12 The American Medical Association stated in 1999: Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice.13 The World Health Organization WHO; 2007, the Joint United Nations Programme on HIV/AIDS UNAIDS; 2007, and the Centers for Disease Control and Prevention CDC; 2008 state that evidence indicates that male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides partial protection and should not replace other interventions to prevent transmission of HIV.1415 Contents 1 Modern circumcision procedures 2 Cultures and religions 3 Ethical, psychological and legal considerations 3.1 Ethical issues 3.1.1 Consent 3.2 Psychological and emotional consequences 3.3 Legality 4 Medical analysis 4.1 Pain and pain relief during circumcision 4.2 Sexual effects of circumcision 4.3 Complications from circumcision 4.4 HIV and other sexually transmitted diseases 4.5 Hygiene, and infectious and chronic conditions 4.5.1 Improper care of the intact penis 4.6 Penile cancer 5 Policies of various national medical associations 5.1 United States 5.2 Canada 5.3 United Kingdom 5.4 Australasia 6 History of circumcision 6.1 Circumcision in the English-speaking world 7 Prevalence of circumcision 8 Foreskin-based medical and consumer products 9 See also 10 Further reading 11 Notes and references 12 External links 12.1 Circumcision opposition 12.2 Circumcision promotion 12.3 Circumcision techniques Modern circumcision procedures For infant circumcision, clamps, such as the Gomco clamp, Plastibell, and Mogen are often used.16 Clamps cut off blood supply to the foreskin, limiting bleeding and protecting the glans from being cut. Before using a clamp, synechia which adheres foreskin to the glans is torn with a blunt probe and/or curved hemostat. With the Plastibell, the adhesions between glans and foreskin are torn with a probe. The foreskin is cut longitudinally, the Plastibell is placed over the glans, and the foreskin is draped over the Plastibell. A ligature is then tied firmly around the foreskin and tightened into a groove in the Plastibell to crush the blood vessels. The parts of the foreskin protruding beyond the ligature are circumcised. The clamp is removed in three to seven days after the wound has sealed.17 With a Gomco clamp, a section of skin is first crushed with a hemostat then slit dorsally with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is tightened, crushing the foreskin between the bell and the base plate. The crushed blood vessels provide hemostasis. The flared bottom of the bell fits tightly against the hole of the base plate, so the foreskin may be cut away with a scalpel from above the base plate. 18 With a Mogen clamp, the foreskin is pulled dorsally with a straight hemostat, and lifted. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to avoid removing excess skin ventrally and to obtain a superior cosmetic result to Gomco or Plastibell circumcisions. The clamp is locked, and a scalpel is used to cut the skin from the flat upper side of the clamp.1920 In poor countries, male circumcision is often performed by non-medical personnel in unsterile conditions.21 Cultures and religions Jewish ritual circumcision Jewish ritual circumcision See also: Circumcision in cultures and religions See also: Brit milah See also: Khitan circumcision Circumcising cultures may circumcise their males either shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is most prevalent in the Muslim world, parts of South East Asia, Africa, the United States, The Philippines, Israel, and South Korea. It is also a growing trend among young men in Japan, and it is estimated that around 25% of young men in China's major cities have been circumcised. It is also commonly practised in the Jewish and Islamic faiths. Under Jewish law circumcision is a mitzva aseh positive commandment to perform an act and is obligatory for Jewish-born males, and some Jewish male converts. It is only postponed or abrogated in the case of threat to the life or health of the child.22 It is usually performed by a mohel on the eighth day after birth in a ceremony called a Brit milah or Bris milah, colloquially simply bris, which means Covenant of circumcision in Hebrew. It is considered of such religious importance that the body of an uncircumcised Jewish male will sometimes be circumcised before burial.23 In Islam, circumcision is mentioned in some hadith, but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended Sunnah; others that it is obligatory.24 Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham.25 While endorsing circumcision for males, scholars note that it is not a requirement for converting to Islam.26 Illustrated account of the circumcision ceremony of Sultan Ahmed III's three sons. Illustrated account of the circumcision ceremony of Sultan Ahmed III's three sons. Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches.7 Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya,727 require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ.2829 Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War. In West Africa infant circumcision may have had tribal significance as a rite of passage or otherwise in the past; today in some non-Muslim Nigerian societies it is medicalised and is simply a cultural norm.30 Circumcision of Jesus. Illumination from a missal, ca 1460. Circumcision of Jesus. Illumination from a missal, ca 1460. 31 Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land,32 where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.33 Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature: subincision is practised amongst some aboriginal peoples in the Western Desert.34 In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu;35 participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.36 Circumcision is also commonly practiced in the Polynesian islands of Samoa, Tonga, Niue, and Tikopia. In Samoa it is accompanied by a celebration. Among some West African animist groups, such as the Dogon and Dowayo, circumcision is taken to represent a removal of feminine aspects of the male, turning boys into fully masculine males.37 Among the Urhobo of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te Oshare the boy is now man, constitutes a rite of passage from one age set to another.38 For Nilotic peoples, such as the Kalenjin and Maasai, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set.39 Ethical, psychological and legal considerations Ethical issues A protest against routine infant circumcision A protest against routine infant circumcision Main article: Bioethics of neonatal circumcision The American Medical Association defines non-therapeutic circumcision as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. It states that medical associations in the US, Australia, and Canada do not recommend the routine non-therapeutic circumcision of newborns.40 UNAIDS state 2007: Male circumcision is a voluntary surgical procedure and health care providers must ensure that men and young boys are given all the necessary information to enable them to make free and informed choices either for or against getting circumcised.41 Circumcision advocates argue that circumcision prevents infections and slows down the spread of AIDS.42 Opponents of circumcision question the ethical validity of removing healthy, functioning genital tissue from a minor, arguing that infant circumcision infringes upon individual autonomy and represents a human rights violation.4344 Consent Views differ on whether limits should be placed on caregivers having a child circumcised. Some medical associations take the position that the parents should determine what is in the best interest of the infant or child,454046 but the Royal Australasian College of Physicians RACP and the British Medical Association BMA observe that controversy exists on this issue.4748 The BMA state that in general, the parents should determine how best to promote their children's interests, and it is for society to decide what limits should be imposed on parental choices. They state that because the parents' interests and the child's interests sometimes differ, there are limits on parents' rights to choose and parents are not entitled to demand medical procedures contrary to their child's best interests. They state that competent children may decide for themselves.48 Some argue that the medical problems that have their risk reduced by circumcision are already rare, can be avoided, and, if they occur, can usually be treated in less invasive ways than circumcision. Medical Ethicist Professor Margaret Somerville states that the removal of healthy genital tissue from a minor should not be subject to parental discretion and that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient.43 Dr. George Denniston contends that circumcision is harmful and asserts that in the absence of the individual's consent, non-therapeutic child circumcision violates several ethical principles that govern medicine.49 Others believe neonatal circumcision is permissible, if parents should so choose. Dr. Adrian Viens argues that, in a cultural or religious context, circumcision is of significant enough importance that parental consent is sufficient and that there is an absence of sufficient evidence or persuasive argumentation to support changing the present policy.50 Benatar and Benatar argue that circumcision can be beneficial to a male before he would be able to otherwise provide consent, that it is far from obvious that circumcision reduces sexual pleasure, and that it is far from clear that non-circumcision leaves open a future person's options in every regard.51 Psychological and emotional consequences The British Medical Association 2006 state that it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks.48 Goldman 1999 discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure.52 Milos asserts the existence of excruciating pain, perinatal encoding of the brain with violence, interruption of maternal-infant bonding, betrayal of infant trust... among other consequences, and points to support groups providing information to Jewish parents who are grappling with this difficult issue as well as men who perceive themselves as victims of a sexual assault.12 Moses et al. 1998 state that scientific evidence is lacking for psychological and emotional harm, and cite a longitudinal study finding no difference in developmental and behavioural indices.53 Legality Main article: Circumcision and law In 2001, Sweden allowed only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anaesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the law,54 and in 2001, the World Jewish Congress stated that it was the first legal restriction on Jewish religious practice in Europe since the Nazi era.55 In 2005, the Swedish National Board of Health and Welfare reviewed the law and recommended that it be maintained. In 2006, the U.S. State Department's report on Sweden stated that most Jewish mohels had been certified under the law and 3000 Muslim and 40-50 Jewish boys were circumcised each year.56 In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised were illegal. The prosecutor argued that, part of healthy genitalia is removed without medical foundation, or competent consent. No punishment was assigned by the court.57 In 2008, the Finnish government was reported to be considering a new law to legalize circumcision if the practitioner is a doctor and if the child or parents consents.58 Medical analysis Main article: Medical analysis of circumcision Pain and pain relief during circumcision According to the American Academy of Pediatrics' 1999 Circumcision Policy Statement, There is considerable evidence that newborns who are circumcised without analgesia experience pain and psychologic stress.45 It therefore recommended using pain relief for circumcision.45 One of the supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response during vaccination months later. While acknowledging that there may be other factors besides circumcision to account for different levels of pain response, they stated that they did not find evidence of such. They concluded pretreatment and postoperative management of neonatal circumcision pain is recommended based on these results.59 Other medical associations also cite evidence that circumcision without anesthetic is painful.6061 Stang, 1998, found 45% of physicians used anaesthesia - most commonly a dorsal penile nerve block - for infant circumcisions. Obstetricians used anaesthesia significantly less often 25% than family practitioners 56% or pediatricians 71%.62 Howard et. al 1998 studied US medical doctor residency programs, and stated that 26% of the programs that taught the circumcision procedure failed to provide instruction in anesthesia/analgesia for the procedure. They concluded: Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques.63 J.M. Glass, 1999, stated that Jewish ritual circumcision is so quick that most mohelim do not routinely use any anaesthesia as they feel there is probably no need in the neonate. However, there is no Talmudic objection and should the parents wish for local anaesthetic cream to be applied there is no reason why this cannot be done.22 Tannenbaum and Shechet, 2000, stated that an authentic, traditional bris performed by a mohel does not use clamps, so there is no pain associated with crushing tissue.64 They also asserted that due to the speed of the procedure and rarity of complication, it is more humane not to subject the infant to a local anesthetic.64 Lander et al., found that babies circumcised without pain relief exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the circumcision and following. Two newborns ... became ill following circumcision choking and apnea.4 A 2004 Cochrane review, which compared the dorsal penile nerve block and EMLA topical anaesthesia found both anaesthetics appear safe, but neither of them completely eliminated pain.65 Razmus et al. reported that newborns circumcised with the dorsal block and the ring block in combination with the concentrated oral sucrose had the lowest pain scores.66 Ng et al. found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.67 Williams 2003 argued that human attitudes toward the pain that animals including humans experience may not be based on speciesism; developing an analogy between attitudes toward the pain pigs endure while having their tails docked, and our culture's indifference to the pain that male human infants experience while being circumcised.68 Sexual effects of circumcision Main article: Sexual effects of circumcision The sexual effects of circumcision are the subject of much debate. The American Academy of Pediatrics 1999 stated There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males, however they also stated that a survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men. They continued, Masters and Johnson noted no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men.45 In January 2007, The American Academy of Family Physicians AAFP stated The effect of circumcision on penile sensation or sexual satisfaction is unknown. Because the epithelium of a circumcised glans becomes cornified, and because some feel nerve over-stimulation leads to desensitization, many believe that the glans of a circumcised penis is less sensitive. ... No valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction.60 Payne et al. reported that direct measurement of penile sensation during sexual arousal failed to support the hypothesised sensory differences associated with circumcision status.69 Conversely, Boyle et al. stated that the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings-many of which are lost to circumcision, with an inevitable reduction in sexual sensation experienced by circumcised males. They concluded, Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well.70 Sorrells et al., using monofilament touch-test mapping, found that the foreskin contains the most sensitive parts of the penis, noting that these parts are lost to circumcision. They also found that the glans of the circumcised penis is less sensitive to fine-touch than the glans of the uncircumcised penis.71 Schoen also argues that circumcision may play a role in sexual attraction.72 Some studies have shown that women, by a margin of about 3 to 1, prefer the circumcised penis, mainly because of cleanliness which is of particular importance in oral sex. There is a minimal difference in the sexual act itself - circumcised men take slightly longer to reach orgasm after vaginal insertion, an effect considered to be advantageous. The exact effect of circumcision on sexual attraction and performance remain controversial. Reports detailing the effect of circumcision on erectile dysfunction have been mixed. Studies have shown that circumcision can result in a statistically significant increase,7374 or decrease,75 in erectile dysfunction among circumcised men, while other studies have shown little to no effect.767778 Complications from circumcision Complication rates ranging from 0.06% to 55% have been cited, though a 1993 survey of circumcision complications by Williams and Kapilla79 put a realistic rate at 2-10 percent. One study looking at 354,297 births in Washington State from 1987-1996 found that immediate post-birth complications occurred at a rate of 0.2% in the circumcised babies and at a rate of 0.01% in the intact babies. The study warned though that this was a conservative estimate because it did not capture the very rare but serious delayed complications associated with circumcisions eg, necrotizing fasciitis, cellulitis and the less serious but more common complications such as the circumcision scar or a less than ideal cosmetic result. It also warned that the risks of circumcision do not seem to be mitigated by the hands of more experienced physicians.80 A 1999 study of 48 boys seen between January 1981 and December 1995 found that haemorrhage occured in 52% of boys, infection in 21% and one child had his penis amputated.81 According to the American Medical Association AMA, blood loss and infection are the most common complications, but most bleeding is minor and can be stopped by applying pressure.40 A meta-analysis confirmed that haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%.82 A penis that has been circumcised a skin bridge is present in this example. A penis that has been circumcised a skin bridge is present in this example. A penis that has not been circumcised. A penis that has not been circumcised. In 1983 G.W Kaplan83 looked at the complications of circumcision using previous studies done. He found one study that showed 9.5 per cent of patients had repeated circumcisions for inadequately performed initial operations. Another study noted the rate of bleeding complications to be between 0.1 percent and 35 percent. Other complications were too much skin or not enough skin being cut off. If insufficient skin is removed true phimosis can result. A concealed penis was another complication. This is where an excess of skin is removed from the penile shaft while not enough of the inner preputial epithelium has been removed. The new preputial orifice is distal to the tip of the penis and it fibroses so that as healing occurs, the penile shaft is forced into the suprapubic fat and the stenotic preputial ring that results lies at, or just above, the abdominal skin level. Other complications looked at were urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias and impotence. He stated Virtually all of these complications are preventable with only a modicum of care and most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons. Infant circumcision may result in skin bridges, whereby the end of the severed part of the foreskin fuses to other parts of the penis normally the glans on repair.84 Meatal stenosis a narrowing of the urethra may be a common longer-term complication of circumcision. This can lead to discomfort with urination, incontinence, bleeding after urination and urinary tract infections8586 Although deaths have been reported8387, the American Academy of Family Physicians states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision.60 Gairdner's 1949 study88 reported that an average of 16 children per year out of about 90,000 died following circumcision in the UK. He found that most deaths had occurred suddenly under anaesthesia and could not be explained further, but hemorrhage and infection had also proven fatal. Deaths attributed to phimosis and circumcision were grouped together, but Gairdner argued that such deaths were probably due to the circumcision operation. The penis is thought to be lost in 1 in a 1,000,000 circumcisions.89 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.citation needed HIV and other sexually transmitted diseases According to Valiere Alcena 5, it was he who first hypothesised that low rates of circumcision in Africa were partly responsible for the continent's high rate of HIV infection.90 He did this via a letter to the New York State Journal of Medicine in August 1986.91 He also alleges that the late Aaron J. Fink stole his idea when Fink published a letter to the New England Journal of Medicine entitled A possible explanation for heterosexual male infection with AIDS, in October 1986.92 Three randomised control trials were carried out in Africa to test the hypothesis93 that circumcision reduces female to male HIV transmission.94 All three trials were stopped early by their monitoring boards on ethical grounds, because those in the circumcised group had a lower rate of HIV contraction than the intact group.95 In March 2007, WHO and the Joint United Nations Programme on HIV/AIDS UNAIDS stated that male circumcision is an efficacious intervention for HIV prevention, providing about a 60% reduction in HIV transmission from female to male when done by well trained medical professionals.14 The Centers for Disease Control and Prevention CDC state that several types of research have documented that male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex. Both the WHO and CDC indicate that it may not reduce HIV transmission from men to women, and that data is lacking for the transmission rate of men who engage in anal sex with either a female or male partner, as either the insertive or receptive partner.1415 WHO and UNAIDS have stated that scientific findings regarding the role of male circumcision in preventing heterosexual HIV infection are particularly relevant in regions where the incidence of heterosexually acquired HIV infection is high, such as Sub-Saharan Africa, and stressed that the procedure must be carried out safely and under conditions of informed consent.9697 Before there were any results from randomized controlled trials, reviews of observational data differed as to whether there was sufficient evidence for an intervention effect of circumcision against HIV.9899 The joint WHO/UNAIDS recommendation on male circumcision notes that it is not a magic bullet: it only provides partial protection from HIV and should never replace known methods of HIV prevention, such as the delayed onset of sexual relations, abstinence from penetrative sex, reduction in the number of sexual partners, increased male and female condom distribution and compliance, access to HIV testing and counselling, and promotion of treatment for sexually transmitted disease.96 A meta-analysis of the African randomised controlled trials and other observational studies confirmed that using circumcision as a means to reduce HIV infection would, on a national level, require consistently safe sexual practices to maintain the protective benefit. According to this particular meta-analysis, 72 circumcisions would need to be performed to prevent 1 HIV infection.100 McCoombe et al. stated that a layer of keratin could provide protection from viral entry, and found that the keratin is thinner on the foreskin than the glans penis, and thinnest on the inner surface of the foreskin.101 Other reports have indicated that circumcision has little to no effect on HIV transmission.102103104 Furthermore, some have challenged the validity of the African randomized controlled trials, prompting a number of researchers to question the effectiveness of circumcision as an HIV prevention strategy.105106 A meta-analysis found that circumcision is associated with lower rates of syphilis, chancroid and possibly genital herpes.107 Hygiene, and infectious and chronic conditions The American Academy of Pediatrics 1999 stated: Circumcision has been suggested as an effective method of maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene. 45 Some studies found that boys with foreskins had higher rates of various infections and inflammations of the penis than those who were circumcised.108109110 One study looked at 150 intact men and 75 circumcised men at a sexually transmitted infections STI clinic at Ealing Hospital, London. It found that the intact men did not wash as often as the circumcised men.111 The usual treatment for balanoposthitis is to use topical antibiotics metronidazole cream and antifungals clotrimazole cream or low-potency steroid creams, but circumcision is another option.112 In several studies, uncircumcised men were found to have a greater incidence of human papilloma virus HPV infection than circumcised men.113114115 One study found no statistically significant difference in the incidence of HPV infection between circumcised and uncircumcised men, but did note a higher prevalence of urethritis in the uncircumcised.116 Results of the 1999 to 2004 United States National Health and Nutrition Examination Survey demonstrated that more circumcised men reported having been diagnosed with genital warts compared with uncircumcised men 4.5% and 2.4%, respectively.117 Another study also found that circumcised men were more likely to have genital warts than uncircumcised men.118 A meta-analysis of 12 studies one randomised controlled trial, four cohort studies and seven case-control studies representing 402,908 children determined that circumcision was associated with a significantly reduced risk of urinary tract infection UTI. Given that the risk of UTI in normal boys was about 1%, it determined that the number-needed-to treat number of circumcisions necessary to prevent one urinary tract infection was 111. Because haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%, assuming equal utility of benefits and harms, the authors concluded that the net clinical benefit of circumcision is only likely in boys at high risk of urinary tract infection such as those with high grade vesicoureteral reflux or a history of recurrent UTIs, where the number needed to treat declined to 11 and 4, respectively.82 Some UTI studies have been criticized for not taking into account a high rate of UTI's among premature infants, who are usually not circumcised because of their fragile health status.45 The AMA stated that depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI, and noted one decision analysis model that concluded that circumcision was not justified as a preventative measure against UTI.40 Improper care of the intact penis Many doctors and parents inadvertently cause harm by forcible retraction of the foreskin. After birth the foreskin naturally separates from the glans and should never be forced. The majority of boys can retract their foreskin by age 18. The only person to retract the foreskin should be the owner of the penis. Forcible retraction of the foreskin is not only painful but tends to produce tears in the preputial orifice resulting in inelastic scar tissue that may lead to pathologic phimosis. According to one study, a lot of unnecessary circumcisions are performed due to falsely diagnosed phimosis.119 Adhesions after forcible retraction, especially in infants, can fuse the foreskin with itself or the glans, leading to skin bridges. Soap can cause inflammation so water alone is thought to be preferable to clean the foreskin.120 Penile cancer The American Cancer Society 2006 stated, The current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer.121 The American Academy of Pediatrics 1999 stated that studies suggest that neonatal circumcision confers some protection from penile cancer, but circumcision at a later age does not seem to confer the same level of protection. Further, because penile cancer is a rare disease, the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low.45 National circumcision rate statistics show no correlation between circumcision status and penile cancer. Penile cancer affects 0.82 per 100,000 in Denmark and 0.3 per 100,000 in Japan, where almost all men are intact. In the USA, where the majority of men are circumcised the rate is 0.9 to 1 per 100,000. In parts of India the rate is 10.5 per 100,000 men per year.45 Two other studies have reported a rate of penile cancer from 3 to 22 times higher in uncircumcised than circumcised men.122123 Policies of various national medical associations The American Medical Association stated in 1999: Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice.124 The British Medical Association, states there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.48 Cost-benefit analyses have varied. Some found a small net benefit of circumcision,125126verification needed some found a small net decrement,127128 and one found that the benefits and risks balanced each other out and suggested that the decision could most reasonably be made on nonmedical factors.129 Most guidelines make a distinction between therapeutic and non-therapeutic circumcision. Therapeutic circumcision where there is a medical need to circumcise is rarely controversial. Neonatal circumcision is not considered medically necessary and is therefore categorised as non-therapeutic. The medical harms or benefits have not been unequivocally proven but there are clear risks of harm if the procedure is done inexpertly. Reasons for non-therapeutic circumcision include religious beliefs as well as cultural and family conformity.48 United States The American Academy of Pediatrics 1999 does not recommend routine neonatal circumcision.45 If parents choose to circumcise, the AAP also recommends using analgesia to reduce pain associated with circumcision, and that circumcision only be performed on newborns who are stable and healthy.130 The American Medical Association echoes the 1999 Circumcision Policy Statement of the American Academy of Pediatrics.40 The American Academy of Family Physicians 2007 recognizes the controversy surrounding circumcision and recommends that physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering circumcision for newborn boys.131 The American Urological Association 2007 believes that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. 132 Canada The Fetus and Newborn Committee of the Canadian Paediatric Society posted Circumcision: Information for Parents in November 2004,61 and Neonatal circumcision revisited in 1996. The 1996 position statement says that circumcision of newborns should not be routinely performed, a statement with which the Royal Australasian College of Physicians concurs, and the 2004 advice to parents says it does not recommend circumcision for newborn boys. Many pediatricians no longer perform circumcisions.46 United Kingdom There is a spectrum of views within the British Medical Association's BMA membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. As a general rule, the BMA believe that parents should be entitled to make choices about how best to promote their children's interests, and it is for society to decide what limits should be imposed on parental choices. They also state that both parents...must give consent for non-therapeutic circumcision, and that parents and children should be provided with up-to-date written information about the risks involved.48 According to the BMA, circumcision for medical purposes should only be used where less invasive procedures are either unavailable or not as effective. They state that to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. Furthermore, the BMA believe that children who are capable of expressing a view should be involved in the decision making process with regard to their own circumcision, and their views should be taken into account. The BMA state that they cannot envisage a situation in which it is ethically acceptable to circumcise a competent, informed young person who consistently refuses the procedure.48 The BMA state that parents should be informed about the lack of concensus within the medical profession with regard to the potential health benefits of non-therapeutic circumcision, adding that they consider the evidence for such benefits to be insufficient as the sole reason for carrying out a circumcision.48 Australasia The Royal Australasian College of Physicians RACP state that after extensive review of the literature they reaffirm that there is no medical indication for routine neonatal circumcision. They also state that if the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment. Additionally, the RACP state that there is an obligation to provide parents who request a circumcision for their child with accurate, up-to-date and unbiased information about the risks and benefits of circumcision, adding that there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate.47 The Tasmanian President of the Australian Medical Association AMA, Haydn Walters, has stated that the AMA would support a call to ban circumcision for non-medical, non-religious reasons.133 History of circumcision Main article: History of male circumcision Ancient Egyptian carved scene of circumcision, from the inner northern wall of the Temple of Khonspekhrod at the Precinct of Mut, Luxor, Egypt. Eighteenth dynasty, Amenhotep III, c. 1360 BC. Ancient Egyptian carved scene of circumcision, from the inner northern wall of the Temple of Khonspekhrod at the Precinct of Mut, Luxor, Egypt. Eighteenth dynasty, Amenhotep III, c. 1360 BC. 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 or to increase a man's attractiveness to women, or as an aid to hygiene where regular bathing was impractical, among other possibilities. Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practicing circumcision, leading to its spread regardless of whether the people understood this.134 It is possible that circumcision arose independently in different cultures for different reasons. Family circumcision set and trunk, ca. eighteenth century Wooden box covered in cow hide with silver implements: silver trays, clip, pointer, silver flask, spice vessel. Family circumcision set and trunk, ca. eighteenth century Wooden box covered in cow hide with silver implements: silver trays, clip, pointer, silver flask, spice vessel. The oldest documentary evidence for circumcision comes from ancient Egypt.135 Circumcision was common, although not universal, among ancient Semitic peoples.136 In the aftermath of the conquests of Alexander the Great, however, Greek dislike of circumcision they regarded a man as truly naked only if his prepuce was retracted led to a decline in its incidence among many peoples that had previously practiced it.137 Circumcision has ancient roots among several ethnic groups in sub-equitorial Africa, and is still performed on adolescent boys to symbolize their transition to warrior status or adulthood.138 Circumcision in the English-speaking world Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada, South Africa and to a lesser extent in the United Kingdom and New Zealand. There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The germ theory of disease elicited an image of the human body as a conveyance for many dangerous germs, making the public germ phobic and suspicious of dirt and bodily secretions. Because of its function, the penis became dirty by association, and from this premise circumcision was seen as preventative medicine to be practiced universally.139 In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation.139 It was also said to protect against syphilis,140 phimosis, paraphimosis, balanitis, and excessive venery which was believed to produce paralysis.139 Gollaher states that physicians advocating circumcision in the late nineteenth century expected public skepticism, and refined their arguments to overcome it.139 Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 32% of newborn American boys were being circumcised in 1933.75 According to Laumann, Masi and Zuckerman, US circumcision rates were approximately 70% in 1945, 80% in 1955, 85% in 1965, and 77% in 1971.75 Between 1981 and 1999, National Hospital Discharge Survey data from the National Center for Health Statistics demonstrated that the US circumcision rate remained relatively stable within the 60% range, with a minimum rate of 60.7% in 1988 and a maximum rate of 67.8% in 1995.141 A 1987 study found that the most prominent reasons US parents choose circumcision were concerns about the attitudes of peers and their sons' self concept in the future, rather than medical concerns.142 However, a later study speculated that an increased recognition of the potential benefits of neonatal circumcision may have been responsible for the observed increase in the US rate between 1988 and 2000.143 A report by the Agency for Healthcare Research and Quality placed the 2005 national circumcision rate at 56%.144 Circumcision grew in popularity in South Korea following 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, and the average age of circumcision is 12 years.145 In 1949, the United Kingdom's newly-formed National Health Service removed infant circumcision from its list of covered services, and circumcision has since been an out-of-pocket cost to parents. As a result, prevalence in the UK is age-graded, with 12% of those aged 16-19 years circumcised and 20% of those aged 40-44 years,146 and the proportion of newborns circumcised in England and Wales has fallen to less than one percent. The circumcision rate has declined sharply in Australia since the 1970s, leading to an age-graded fall in prevalence, with a 2000-01 survey finding 32% of those aged 16-19 years circumcised, 50% for 20-29 years and 64% for those aged 30-39 years.147148 In Canada, individual provincial health services began delisting circumcision in the 1980s.citation needed Prevalence of circumcision Main article: Prevalence of circumcision Map published by the United Nations WHO/UNAIDS showing percentage of males who have been circumcised, at a country level. Data was provided by MEASURE DHS 2 and other sources. 3 Map published by the United Nations WHO/UNAIDS showing percentage of males who have been circumcised, at a country level. Data was provided by MEASURE DHS 2 and other sources. 3 Estimates of the proportion of males that are circumcised worldwide vary from one-sixth79 to a third.149 WHO has estimated that 664,500,000 males aged 15 and over are circumcised 30% global prevalence, with almost 70% of these being Muslim.96 Prevalence is near universal in the Middle East and Central Asia.96 WHO states that there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines.96 WHO presents a map of estimated prevalence in which the level is generally low 20% across Europe,96 and Klavs et al. report findings that support the notion that the prevalence is low in Europe.150 In Latin America, prevalence is universally low.151 Estimates for individual countries include Spain152, Colombia152 and Denmark153 less than 2%, Finland154 and Brazil152 7%, Taiwan155 9%, Thailand152 13%, New Zealand9 less than 20% and Australia148 58.7%. WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively.96 Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.151 Foreskin-based medical and consumer products Foreskins from circumcised babies are used to make a commercial anti-wrinkle skin cream. A six-week supply costs US$130.156 Foreskins of babies are also used for skin graft tissue,157158159 and for β-interferon-based drugs.160 Foreskin fibroblasts have been used in biomedical research.161 See also Brit milah Circumcision scar Foreskin restoration Genital integrity Genital modification and mutilation Holy Prepuce Preputioplasty, alternative to circumcision in the treatment for phimosis Further reading Billy Ray Boyd. Circumcision Exposed: Rethinking a Medical and Cultural Tradition. Freedom, CA: The Crossing Press, 1998. ISBN 978-0-89594-939-4 Anne Briggs. Circumcision: What Every Parent Should Know. Charlottesville, VA: Birth Parenting Publications, 1985. ISBN 978-0-9615484-0-7 Robert Darby. A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain. Chicago: University of Chicago Press, 2005. ISBN 978-0-226-13645-5 Aaron J. Fink, M.D. Circumcision: A Parent's Decision for Life. Kavanah Publishing Company, Inc., 1988. ISBN 978-0-9621347-0-8 Paul M. Fleiss, M.D. and Frederick Hodges, D. Phil. What Your Doctor May Not Tell You About Circumcision. New York: Warner Books, 2002. ISBN 978-0-446-67880-3 Leonard B. Glick. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. New York: Oxford University Press, 2005. ISBN 978-0-19-517674-2 David Gollaher. Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000. ISBN 0465026532 Ronald Goldman, Ph.D. Circumcision: The Hidden Trauma. Boston: Vanguard, 1996. ISBN 978-0-9644895-3-0 Paysach J. Krohn, Rabbi. Bris Milah. Circumcision-The Covenant Of Abraham/A Compendium of Laws, Rituals, And Customs From Birth To Bris, Anthologized From Talmudic, And Traditional Sources. New York: Mesorah Publications, 1985, 2005. Brian J. Morris, Ph.D., D.Sc. In Favour of Circumcision. Sydney: UNSW Press, 1999. ISBN 978-0-86840-537-7 Peter Charles Remondino. History of Circumcision from the Earliest Times to the Present. Philadelphia and London; F. A. Davis; 1891. Holm Putzke, Ph.D. Die strafrechtliche Relevanz der Beschneidung von Knaben. Zugleich ein Beitrag über die Grenzen der Einwilligung in Fällen der Personensorge, in: H. Putzke u.a. Hrsg., Strafrecht zwischen System und Telos, Festschrift für Rolf Dietrich Herzberg zum siebzigsten Geburtstag am 14. Februar 2008 , Mohr Siebeck: Tübingen 2008, p. 669-709 ISBN 978-3161495700 Holm Putzke, Ph.D., Maximilian Stehr, Ph.D., and Hans-Georg Dietz, Ph.D. Strafbarkeit der Zirkumzision von Jungen. Medizinrechtliche Aspekte eines umstrittenen ärztlichen Eingriffs Liability to penalty for circumcision in boys. Medico-legal aspects of a controversial medical intervention, in: Monatsschrift Kinderheilkunde 8/2008, p. 783-788 Rosemary Romberg. Circumcision: The Painful Dilemma. South Hadley, MA Bergan Garvey, 1985. ISBN 978-0-89789-073-1 Edgar J Schoen, M.D. Ed Schoen, MD on Circumcision. Berkeley, CA: RDR Books, 2005. ISBN 978-1-57143-123-3 Edward Wallerstein. Circumcision: An American Health Fallacy. New York: Springer, 1980 ISBN 978-0-8261-3240-6 Gerald N. Weiss M.D. and Andrea W Harter. Circumcision: Frankly Speaking. Wiser Publications, 1998. ISBN 978-0-9667219-0-4 Yosef David Weisberg, Rabbi. Otzar Habris. Encyclopedia of the laws and customs of Bris Milah and Pidyon Haben. Jerusalem: Hamoer, 2002. Notes and references Some referenced articles are available on-line only in the Circumcision Information and Resource Page's CIRP library or in The Circumcision Reference Library CIRCS. CIRP articles are chosen from an anti-circumcision point of view, and text in support of this position is often highlighted on-screen using HTML. CIRCS articles are chosen from a pro-circumcision point of view. If documents are not freely available on-line elsewhere, links to articles in one or other of these two websites may be provided. ^ Dictionary definitions of circumcision: The act of cutting off the prepuce or foreskin of males, or the internal labia of females. Webster's Revised Unabridged Dictionary 1913 1 to remove the foreskin of males sometimes as a religious rite. The Macquarie Dictionary 2nd ion, 1991 Cut off foreskin of as Jewish or Mohammedan rite, or surgically, Concise Oxford Dictionary, 5th ion, 1964 Circumcision defined in a medical context: Male circumcision is the surgical removal of all or part of the foreskin of the penis. Information Package on Male Circumcision and HIV Prevention:Insert 1, World Health Organization Circumcision, surgical removal of all or part of the foreskin of the human male..., Circumcision, Microsoft Encarta, 2007. Male circumcision is an elective surgery to remove the foreskin... Circumcision, British Columbia Health Guide, June 2, 2006. Retrieved July 18, 2007. Circumcision is surgery... Pain and Your Infant: Medical Procedures, Circumcision and Teething, University of Michigan Health System, February 2007. Retrieved July 18, 2007. Circumcision is cutting away part of the foreskin... When this surgery is performed... Newborn Care, Danbury Hospital website. Retrieved July 18, 2007. ^ Hodges, F.M. Fall 2001. The ideal prepuce in ancient Greece and Rome: male genital aesthetics and their relation to lipodermos, circumcision, foreskin restoration, and the kynodesme.. The Bulletin of the History of Medicine 75 3: 375-405. doi:10.1353/bhm.2001.0119. PMID 11568485. ^ Wrana, P. 1939. Historical review: Circumcision. Archives of Pediatrics 56: 385-392. as quoted in: Zoske, Joseph Winter 1998. Male Circumcision: A Gender Perspective. The Journal of Men's Studies 6 2: 189-208. Retrieved on 2006-06-14. ^ Gollaher, David L. February 2000. Circumcision: a history of the world's most controversial surgery. New York, NY: Basic Books, 53-72. ISBN 978-0-465-04397-2 LCCN 99-40015. ^ Circumcision. American-Israeli Cooperative Enterprise. Retrieved on 2006-10-03. ^ S.A.H Rizvi, S.A A Naqvi, M Hussain, A.S Hasan 1999. Religious circumcision: a Muslim view PDF. BJU International 83 s1: 13-16. doi:10.1046/j.1464-410x.1999.0830s1013.x. ^ a b c Customary in some Coptic and other churches: The Coptic Christians in Egypt and the Ethiopian Orthodox Christians- two of the oldest surviving forms of Christianity- retain many of the features of early Christianity, including male circumcision. Circumcision is not prescribed in other forms of Christianity... Some Christian churches in South Africa oppose the practice, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership and participants in focus group discussions in Zambia and Malawi mentioned similar beliefs that Christians should practice circumcision since Jesus was circumcised and the Bible teaches the practice. Male Circumcision: context, criteria and culture Part 1, Joint United Nations Programme on HIV/AIDS, February 26, 2007. The decision that Christians need not practice circumcision is recorded in Acts 15; there was never, however, a prohibition of circumcision, and it is practiced by Coptic Christians. circumcision, The Columbia Encyclopedia, Sixth ion, 2001-05. ^ Male circumcision: Global trends and determinants of prevalence, safety and acceptability PDF. World Health Organization 2007. Retrieved on 2008-08-20. ^ a b Insert 2. Information Package on Male Circumcision and HIV Prevention. World Health Organization 2007. Retrieved on 2007-08-15. ^ A M K Rickwood, S E Kenny, S C Donnell 2000. Towards evidence based circumcision of English boys: survey of trends in practice PDF. BMJ 321 7264: 792-793. doi:10.1136/bmj.321.7264.792. ^ Schoen, Edgar J 2007. Should newborns be circumcised? Yes. Can Fam Physician 53 12: 2096-8, 2100-2. PMID 18077736. Retrieved on 2008-05-02. ^ a b Milos, Marilyn Fayre; Donna Macris March-April 1992. Circumcision: A medical or a human rights issue?. Journal of Nurse-Midwifery 37 2 S1: S87-S96. doi:10.1016/0091-21829290012-R. PMID 1573462. Retrieved on 2007-04-06. ^ Neonatal Circumcision. Retrieved on 2008-04-20. ^ a b c March 28, 2007. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications PDF. World Health Organization. Retrieved on 2007-08-13. ^ a b Male Circumcision and Risk for HIV Transmission and Other Health Conditions: Implications for the United States. Centers for Disease Control and Prevention 2008. ^ Holman, John R.; Evelyn L. Lewis, Robert L. Ringler August 1995. Neonatal circumcision techniques - includes patient information sheet. American Family Physician 52 2: 511-520. ISSN 0002-838X PMID 7625325. Retrieved on 2006-06-29. ^ Herbert, Barrie; et al 1965. The Plastibell Technique for Circumcision. Br Med J 2 5456: 273-275. PMID 14310205. ^ Peleg, David; Ann Steiner September 15, 1998. The Gomco Circumcision: Common Problems and Solutions. American Family Physician 58 4: 891-898. ISSN 0002-838X PMID 9767725. Retrieved on 2006-06-29. ^ Pfenninger, John L.; Grant C. Fowler 1994 July 21, 2003. Procedures for primary care, 2nd, Mosby. ISBN 978-0-323-00506-7 LCCN 2003-56227. ^ Reynolds, RD July 1996. Use of the Mogen clamp for neonatal circumcision Abstract. American Family Physician 54 1: 177-182. PMID 8677833. Retrieved on 2006-07-18. ^ In Africa, a problem with circumcision and AIDS. ^ a b Glass, J.M. January 1999. Religious circumcision: a Jewish view PDF. BJU International 83 Supplement 1: 17-21. doi:10.1046/j.1464-410x.1999.0830s1017.x. PMID 10766529. Retrieved on 2006-10-18. ^ Lamm, Maurice 1969. The Jewish Way in Death and Mourning. New York: Jonathan David, 239-240. ^ Al-Munajjid, Muhammed Salih. Question #9412: Circumcision: how it is done and the rulings on it. Islam QA. Retrieved on 2006-07-01. ^ Al-Munajjid, Muhammed Salih. Question #7073: The health and religious benefits of circumcision. Islam QA. Retrieved on 2006-07-01. ^ al-Sabbagh, Muhammad Lutfi 1996. Islamic ruling on male and female circumcision. Alexandria: World Health Organization, 16. ^ Mattson, C.L.; R.C. Bailey, R. Muga, R. Poulussen, T. Onyango February 2005. Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya. AIDS Care 17 2: 182-194. doi:10.1080/09540120512331325671. PMID 15763713. ^ Greek Orthodox Archdiocese calendar of Holy Days. ^ Russian Orthodox Church, Patriarchate of Moscow. ^ Ajuwon et al., Indigenous surgical practices in rural southwestern Nigeria: Implications for disease, Health Educ. Res..1995; 10: 379-384 Health Educ. Res..1995; 10: 379-384 Retrieved 3 October 2006 ^ Municipal Library of Clermont-Ferrand, France ^ Aaron David Samuel Corn. Ngukurr Crying: Male Youth in a Remote Indigenous Community PDF. Working Paper Series No. 2. University of Wollongong. Retrieved on 2006-10-18. ^ Migration and Trade. Green Turtle Dreaming. Retrieved on 2006-10-18. In exchange for turtles and trepang the Makassans introduced tobacco, the practice of circumcision and knowledge to build sea-going canoes. ^ Jones, IH June 1969. Subincision among Australian western desert Aborigines. British Journal of Medical Psychology 42 2: 183-190. ISSN 0007-1129 PMID 5783777. ^ RECENT GUEST SPEAKER. Australian AIDS Fund Incorporated 2006. Retrieved on 2006-07-01. ^ Weird Wonderful. United Travel. Retrieved on 2006-07-01. ^ Circumcision amongst the Dogon. The Non-European Components of European Patrimony NECEP Database 2006. Retrieved on 2006-09-03. ^ Agberia, John Tokpabere 2006. Aesthetics and Rituals of the Opha Ceremony among the Urhobo People PDF. Journal of Asian and African Studies 41 3: 249-260. doi:10.1177/0021909606063880. Retrieved on 2006-10-18. ^ Masai of Kenya. Retrieved on 2007-04-06. Authority derives from the age-group and the age-set. Prior to circumcision a natural leader or olaiguenani is selected; he leads his age-group through a series of rituals until old age, sharing responsibility with a select few, of whom the ritual expert oloiboni is the ultimate authority. Masai youths are not circumcised until they are mature, and a new age-set is initiated together at regular intervals of twelve to fifteen years. The young warriors ilmurran remain initiates for some time, using blunt arrows to hunt small birds which are stuffed and tied to a frame to form a head-dress. ^ a b c d e Report 10 of the Council on Scientific Affairs I-99:Neonatal Circumcision. 1999 AMA Interim Meeting: Summaries and Recommendations of Council on Scientific Affairs Reports 17. American Medical Association December 1999. Retrieved on 2006-06-13. ^ Information Package on Male Circumcision and HIV Prevention. ^ Auvert, Bertran; Dirk Taljaard, Emmanuel Lagarde, Joëlle Sobngwi-Tambekou, Rémi Sitta, Adrian Puren November 2005. Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial PDF. PLoS Medicine 2 11: 1112-1122. doi:10.1371/journal.pmed.0020298. PMID 16231970. Retrieved on 2006-07-09. ^ a b Somerville, Margaret November 2000. Altering Baby Boys' Bodies: The Ethics of Infant Male Circumcision, The ethical canary: science, society, and the human spirit. New York, NY: Viking Penguin Canada, 202-219. LCCN 2001-369341. ISBN 0670893021. Retrieved on 2007-02-12. ^ Van Howe, R.S.; J.S. Svoboda, J.G. Dwyer, and C.P. Price January 1999. Involuntary circumcision: the legal issues PDF. BJU International 83 Supp1: 63-73. doi:10.1046/j.1464-410x.1999.0830s1063.x. PMID 10349416. Retrieved on 2007-02-12. ^ a b c d e f g h i American Academy of Pediatrics Task Force on Circumcision March 1, 1999. Circumcision Policy Statement PDF. Pediatrics 103 3: 686-693. doi:10.1542/peds.103.3.686. ISSN 0031-4005 PMID 10049981. Retrieved on 2006-07-01. ^ a b Fetus and Newborn Committee March 1996. Neonatal circumcision revisited. Canadian Medical Association Journal 154 6: 769-780. Retrieved on 2006-07-02. We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors. ^ a b Policy Statement On Circumcision PDF. Royal Australasian College of Physicians September 2004. Retrieved on 2007-02-28. The Paediatrics and Child Health Division, The Royal Australasian College of Physicians RACP has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision. Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It remains an important ritual in some religious and cultural groups....In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis....The complication rate of neonatal circumcision is reported to be around 1% to 5% and includes local infection, bleeding and damage to the penis. Serious complications such as bleeding, septicaemia and meningitis may occasionally cause death. The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law. If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate. ^ a b c d e f g h Medical Ethics Committee June 2006. The law and ethics of male circumcision - guidance for doctors. British Medical Association. Retrieved on 2006-07-01. ^ Circumcision and the Code of Ethics, George C. Denniston, Humane Health Care Volume 12, Number 2. ^ Viens AM 2004. Value judgment, harm, and religious liberty. J Med Ethics 30: 241-7. doi:10.1136/jme.2003.003921. ^ Benatar, David; Benatar, Michael 2003. How not to argue about circumcision PDF. American Journal of Bioethics 3 2: W1-W9. doi:10.1162/152651603102387820. ^ Goldman, R. January 1999. The psychological impact of circumcision PDF. BJU International 83 S1: 93-102. doi:10.1046/j.1464-410x.1999.0830s1093.x. Retrieved on 2006-07-02. ^ Moses, S; Bailey, RC; Ronald AR 1998. Male circumcision: assessment of health benefits and risks. Sex Transm Infect 74: 368-73. ^ Sweden restricts circumcisions. BBC Europe October 1, 2001. Retrieved on 2006-10-18. Swedish Jews and Muslims object to the new law, saying it violates their religious rights. ^ Reuters June 7, 2001. Jews protest Swedish circumcision restriction. Canadian Children's Rights Council. Retrieved on 2006-10-18. A WJC spokesman said, 'This is the first legal restriction placed on a Jewish rite in Europe since the Nazi era. This new legislation is totally unacceptable to the Swedish Jewish community.' ^ Bureau of Democracy, Human Rights, and Labor September 15, 2006. Sweden. International Religious Freedom Report 2006. US Department of State. Retrieved on 2007-07-04. ^ Court rules circumcision of four-year-old boy illegal. HELSINGIN SANOMAT, INTERNATIONAL ION 2006-08-07. Retrieved on 2007-09-17. ^ Finland Considers Legalising Male Circumcision. Ylesiradio 2008-07-31. Retrieved on 2008-08-05. ^ Taddio, Anna; Joel Katz, A Lane Ilersich, Gideon Koren March 1997. Effect of neonatal circumcision on pain response during subsequent routine vaccination PDF - free registration required. The Lancet 349 9052: 599-603. doi:10.1016/S0140-67369610316-0. Retrieved on 2007-08-08. ^ a b c Circumcision: Position Paper on Neonatal Circumcision. American Academy of Family Physicians 2007. Retrieved on 2007-01-30. ^ a b Circumcision: Information for parents. Caring for kids. Canadian Paediatric Society November 2004. Retrieved on 2006-10-24. Circumcision is a non-therapeutic procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social or cultural reasons. To help make the decision about circumcision, parents should have information about risks and benefits. It is helpful to speak with your baby's doctor. After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions. ^ Stang, Howard J.; Leonard W. Snellman June 1998. Circumcision Practice Patterns in the United States PDF. Pediatrics 101 6: e5-. doi:10.1542/peds.101.6.e5. ISSN 1098-4275. Retrieved on 2006-06-29. ^ Howard, Cynthia R.; Fred M. Howard, Lynn C. Garfunkel, Elisabeth A. de Blieck, Michael Weitzman 1998-03. Neonatal Circumcision and Pain Relief: Current Training Practices. Pediatrics 101 3: 423-428. Retrieved on 2008-06-19. ^ a b Shechet, Jacob; Barton Tanenbaum 2000. Circumcision-The Debates Goes On PDF. Pediatrics 105 3: 682-683. doi:10.1542/peds.105.3.681. PMID 10733391. Retrieved on 2007-04-06. ^ Brady-Fryer, B; Wiebe N, Lander JA July 2004. Pain relief for neonatal circumcision. The Cochrane Database of Systematic Reviews 3: Art. No.: CD004217. doi:10.1002/14651858.CD004217.pub2. PMID 15495086. Retrieved on 2006-06-29. ^ Razmus I, Dalton M, Wilson D. Pain management for newborn circumcision. Pediatr Nurs 30 5: 414-7, 427. PMID 15587537. ^ Ng, WT; et al. 2001. The use of topical lidocaine/prilocaine cream prior to childhood circumcision under local anesthesia. Ambul Surg 9 1: 9-12. doi:10.1016/S0966-65320000061-5. PMID 11179706. ^ Williams, R. M. 2003-01. On the Tail-Docking of Pigs, Human Circumcision, and their Implications for Prevailing Opinion Regarding Pain. Journal of Applied Philosophy 20 1: 89-93. doi:10.1111/1468-5930.00237. Retrieved on 2008-06-24. ^ Payne, Kimberley; Thaler, Lea; Kukkonen, Tuuli; Carrier, Serge; and Binik, Yitzchak. Sensation and Sexual Arousal in Circumcised and Uncircumcised Men. Journal of Sexual Medicine, May, 2007. ^ Boyle, Gregory J; Svoboda, J Steven; Goldman, Ronald; Fernandez, Ephrem 2002. Male circumcision: pain, trauma, and psychosexual sequelae. Bond University Faculty of Humanities and Social Sciences. ^ Sorrells, M.L.; J.L. Snyder, M.D. Reiss, C. Eden, M.F. Milos, N. Wilcox and R.S. Van Howe May 2007. Fine-touch pressure thresholds in the adult penis. BJU International 99 4: 864-869. PMID 17378847. ^ Dr. Edgar Schoen. Circumcision and Sexual Activity. Opposing Views, August, 2008. ^ Fink, K.S.; C.C. Carson, R.S. DeVellis May 2002. Adult Circumcision Outcomes Study: Effect on Erectile Dysfunction, Penile Sensitivity, Sexual Activity and Satisfation. Journal of Urology 167 5: 2113-2116. PMID 11956453. Retrieved on 2008-06-28. ^ Shen, Z.; S. Chen, C. Zhu, Q. Wan and Z. Chen 2004. Erectile function evaluation after adult circumcision in Chinese. Zhonghua Nan Ke Xue 10 1: 18-19. PMID 14979200. ^ a b c Laumann, E.; C. Masi and F. Zuckerman 1997. Circumcision in the United States. Prevalence, prophylactic effects, and sexual practice. JAMA 277 13: 1052-1057. PMID 9091693. ^ Senkul, T.; C. IşerI, B. şen, K. KarademIr, F. Saraçoğlu and D. Erden 2004. Circumcision in adults: effect on sexual function. Urology 63 1: 155-8. PMID 14751371. ^ Collins S, Upshaw J, Rutchik S, Ohannessian C, Ortenberg J, Albertsen P 2002. Effects of circumcision on male sexual function: debunking a myth?. J Urol 167 5: 2111-2. PMID 11956452. ^ Masood S, Patel H, Himpson R, Palmer J, Mufti G, Sheriff M 2005. Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly?. Urol Int 75 1: 62-6. PMID 16037710. ^ a b Williams, N; L. Kapila October 1993. Complications of circumcision. British Journal of Surgery 80 10: 1231-1236. doi:10.1002/bjs.1800801005. Retrieved on 2006-07-11. ^ Christakis, Dmitry A.; Eric Harvey, Danielle M. Zerr, Chris Feudtner, Jeffrey A. Wright, and Frederick A. Connell January 2000. A Trade-off Analysis of Routine Newborn Circumcision. Pediatrics 105 1: 246-249. doi:10.1542/peds.105.1.S2.246 inactive 2008-06-26. PMID 10617731. Retrieved on 2006-07-01. ^ Ahmed A,, A; Mbibi NH, Dawam D, Kalayi GD March 1999. Complications of traditional male circumcision. Annals of Tropical Paediatrics 19 1: 113-117. PMID 10605531 ISSN 0272-4936. Retrieved on 2006-07-01. ^ a b Singh-Grewal, D.; J. Macdessi, and J. Craig August 1, 2005. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies PDF. Archives of Disease in Childhood 90 8: 853-858. doi:10.1136/adc.2004.049353. PMID 15890696. Retrieved on 2006-09-21. Circumcision was associated with a significantly reduced risk of UTI OR = 0.13; 95% CI, 0.08 to 0.20; p0.001 with the same odds ratio 0.13 for all three types of study design. ^ a b Kaplan, G.W. August 1983. Complications of Circumcision HTML. Urologic Clinics of North America 10 3: 543-549. PMID 6623741. Retrieved on 2006-09-29. ^ Naimer, Sody A.; Roni Peleg, Yevgeni Meidvidovski, Alex Zvulunov, Arnon Dov Cohen, and Daniel Vardy November 2002. Office Management of Penile Skin Bridges with Electrocautery PDF. Journal of the American Board of Family Practice 15 6: 485-488. PMID 10605531. Retrieved on 2006-07-01. ^ Yegane, Rooh-Allah; Abdol-Reza Kheirollahi, Nour-Allah Salehi, Mohammad Bashashati, Jamal-Aldin Khoshdel, and Mina Ahmadi May 2006. Late complications of circumcision in Iran Abstract. Pediatric Surgery International 22 5: 442-445. doi:10.1007/s00383-006-1672-1. PMID 16649052. Retrieved on 2006-07-02. ^ Angel, Carlos A. June 12, 2006. Meatal Stenosis. eMedicine. WebMD. Retrieved on 2006-07-02. ^ Paediatric Death Review Committee: Office of the Chief Coroner of Ontario April 2007. Coroner's Corner Circumcision: A minor procedure? PDF. Paediatric Child Health Vol 12 No 4, April 2007 pages 311-312. Pulsus Group Inc.. Retrieved on 2007-06-17. ^ Gairdner, Douglas December 1949. The Fate of the Foreskin. British Medical Journal 2 4642: 1433-1437. PMID 15408299. Retrieved on 2006-07-01. ^ Complications Of Circumcision. Paediatric Policy - Circumcision. The Royal Australasian College of Physicians October 2004. Retrieved on 2006-07-11. ^ Alcena, Valiere 2006-10-16. AIDS in Third World countries letter. response to Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLos Medicine. Retrieved on 2008-08-24. ^ Alcena, Valiere August 1986. AIDS in Third World countries letter. New York State Journal of Medicine 86 8: 446. Retrieved on 2008-08-24. . ^ Fink, Aaron J. October 1986. A possible explanation for heterosexual male infection with AIDS.. New England Journal of Medicine 315 18: 1167. PMID 3762636. Retrieved on 2008-08-24. ^ Szabo, R.; R.V. Short June 2000. How does male circumcision protect against HIV infection?. BMJ 320: 1592-1594. ^ WHO and UNAIDS Secretariat welcome corroborating findings of trials assessing impact of male circumcision on HIV risk. World Health Organization February 23, 2007. Retrieved on 2007-02-23. ^ Bailey, R.C.; S. Moses, C.B. Parker, K. Agot, I. Maclean, J.N. Krieger, C.F.M. Williams, R.T. Campbell, J.O. Ndinya-Achola February 24, 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial PDF. The Lancet 369 9562: 643-656. doi:10.1016/S0140-67360760312-2. PMID 17321310. Retrieved on 2007-04-01. ^ a b c d e f g WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention. World Health Organisation March 2007. ^ Male circumcision: Global trends and determinants of prevalence, safety and acceptability. World Health Organisation/UNAIDS February 2007. ^ Weiss, HA; Quigley MA, Hayes RJ. Oct 20 2000. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis.. AIDS. 2000 14 15: 2361-70. Retrieved on 2007-12-27. Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised. ^ Siegfried, N; M Muller, J Volmink, J Deeks, M Egger, N Low, H Weiss, S Walker, P Williamson 2003. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD003362. CD003362. Retrieved on 2007-12-27. We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV. ^ Male circumcision for the prevention of heterosexually acquired HIV infection: a meta-analysis of randomized trials involving 11050 men July 2008. HIV Medicine 9 6: 332-3354. doi:10.1111/j.1468-1293.2008.00596.x. Retrieved on 2008-08-24. ^ McCoombe SG, Cameron PU, Short RV July 7, 2002. The distribution of HIV-1 target cells and keratin in the human penis. Abstract. International AIDS Society. Retrieved on 2006-07-09. ^ Carael, M.; P.H. Van de Perre, P.H. Lepage, S. Allen, F. Nsengumuremyi, C. Van Goethem, M. Ntahorutaba, D. Nzaramba, N. Clumeck June 1988. Human immunodeficiency virus transmission among heterosexual couples in Central Africa.. AIDS 2 3: 201-205. PMID 3134914. ^ Grosskurth, H.; F. Mosha, J. Todd, K. Senkoro, J. Newell, A. Klokke, J. Changalucha, B. West, P. Mayaud, A. Gavyole A, et al. August 1995. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results.. AIDS 9 8: 927-934. PMID 7576329. ^ Barongo, L.R.; M.W. Borgdorff, F.F. Mosha, A. Nicoll, H. Grosskurth, K.P. Senkoro, J.N. Newell, J. Changalucha, A.H. Klokke, J.Z. Killewo JZ, et al. December 1992. The epidemiology of HIV-1 infection in urban areas, roadside settlements and rural villages in Mwanza Region, Tanzania.. AIDS 6 12: 1521-1528. PMID 1492935. ^ Mills, J.; N. Siegfried October 2006. Cautious optimism for new HIV/AIDS prevention strategies.. Lancet 368 9543: 1236. PMID 17027724. The inferences drawn from the only completed randomised controlled trial RCT of circumcision could be weak because the trial stopped early. In a systematic review of RCTs stopped early for benefit, such RCTs were found to overestimate treatment effects. When trials with events fewer than the median number n=66 were compared with those with event numbers above the median, the odds ratio for a magnitude of effect greater than the median was 28 95% CI 11--73. The circumcision trial recorded 69 events, and is therefore at risk of serious effect overestimation. We therefore advocate an impartial meta-analysis of individual patients' data from this and other trials underway before further feasibility studies are done. ^ Dowsett, G.W.; M. Couch May 2007. Male circumcision and HIV prevention: is there really enough of the right kind of evidence?. Reproductive Health Matters 15 29: 33-44. PMID 17512372. ^ Weiss, HA; Thomas, SL; Munabi SK; Hayes RJ Apr 2006. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect 82 2: 101-9. doi:10.1136/sti.2005.017442. PMID 16581731. ^ Fergusson, DM; JM Lawton and FT Shannon April 1988. Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics 81 4: 537-541. PMID 3353186. Retrieved on 2007-07-18. ^ Fakjian, N; S Hunter, GW Cole and J Miller August 1990. An argument for circumcision. Prevention of balanitis in the adult. Arch Dermatol 126 8: 1046-7. doi:10.1001/archderm.126.8.1046. PMID 2383029. ^ Herzog, LW; SR Alvarez March 1986. The frequency of foreskin problems in uncircumcised children. Am J Dis Child 140 3: 254-6. PMID 3946358. ^ O'Farrel, Nigel; Maria Quigley and Paul Fox August 2005. Association between the intact foreskin and inferior standards of male genital hygiene behaviour: a cross-sectional study Abstract. International Journal of STD AIDS 16 8: 556-5884. doi:10.1258/0956462054679151. PMID 16105191. Retrieved on 2006-08-20. ^ Osipov, Vladimir O.; Scott M. Acker November 14, 2006. Balanoposthitis. Reactive and Inflammatory Dermatoses. EMedicine. Retrieved on 2006-11-20. ^ Castellsagué, Xavier; et al. April 11, 2002. Male circumcision, penile human papillomavirus infection, and cervical cancer PDF - free registration required. The New England Journal of Medicine 346 15: 1105-1112. doi:10.1056/NEJMoa011688. PMID 11948269. Retrieved on 2006-07-09. ^ Lajous, Martín; Nancy Mueller, Aurelio Cruz-Valdéz, Luis Victor Aguilar, Silvia Franceschi, Mauricio Hernández-�?vila, and Eduardo Lazcano-Ponce July 2005. Determinants of Prevalence, Acquisition, and Persistence of Human Papillomavirus in Healthy Mexican Military Men PDF. Cancer Epidemiology Biomarkers and Prevention 14 7: 1710-1716. doi:10.1158/1055-9965.EPI-04-0926. PMID 16030106. Retrieved on 2006-07-09. ^ Hernandez, B.Y.; L.R. Wilkens, X. Zhu, K. McDuffie, P. Thompson, Y.B. Shvetsov, L. Ning and M.T. Goodman March. Circumcision and Human Papillomavirus Infection in Men: A Site-Specific Comparison. The Journal of Infectious Diseases 197 6: 787-794. doi:10.1086/528379. PMID 18284369. ^ Aynaud, O.; D. Piron, G. Bijaoui, and JM Casanova July. Developmental factors of urethral human papillomavirus lesions: correlation with circumcision PDF. BJU International 84 1: 57-60. doi:10.1046/j.1464-410x.1999.00104.x. PMID 10444125. Retrieved on 2006-07-09. ^ Dinh, T.H.; M. Sternberg, E.F. Dunne and L.E. Markowitz April 2008. Genital Warts Among 18- to 59-Year-Olds in the United States, National Health and Nutrition Examination Survey, 1999-2004. Sexually Transmitted Diseases 35 4: 357-360. doi:10.1097/OLQ.0b013e3181632d61. PMID 18360316. The percentage of circumcised men reporting a diagnosis of genital warts was significantly higher than uncircumcised men, 4.5% 95% CI, 3.6%-5.6% versus 2.4% 95% CI, 1.5%-4.0% ^ Cook, L.S; L A Koutsky, K K Holmes August 1993. Clinical Presentation of Genital Warts Among Circumcised and Uncircumcised Heterosexual Men Attending an Urban STD Clinic. Genitourinary medicine 69 4: 262-264. PMID 1195083. ^ Rickwood September 1989. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence?. Annals of the royal college of surgery 71 5: 275-277. ^ Birley October 1993. Clinical Features and management of recurrent balanitis; association with atopy and genital washing. Genitourinary Medicine 69 5: 400-403. doi:10.1136/jme.2002.001313. PMID 8244363. Retrieved on 2008-04-12. ^ Can Penile Cancer be Prevented?. ^ Maden, C; et al Jan 1993. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst 85 1: 19-24. doi:10.1093/jnci/85.1.19. PMID 8380060. ^ Schoen, EJ; Oehrli, M; Colby, C; Machin, G Mar 2000. The highly protective effect of newborn circumcision against invasive penile cancer. Pediatrics 105 3: e36. doi:10.1542/peds.105.3.e36. ^ Neonatal Circumcision. Retrieved on 2008-04-20. ^ Schoen, Edgar J.; Christopher J. Colby, Trinh T. To March 2006. Cost Analysis of Neonatal Circumcision in a Large Health Maintenance Organization Abstract. The Journal of Urology 175 3: 1111-1115. doi:10.1016/S0022-53470500399-X. PMID 16469634. Retrieved on 2006-07-01. ^ Alanis, Mark C.; Richard S. Lucidi May 2004. Neonatal Circumcision: A Review of the World's Oldest and Most Controversial Operation Abstract. Obstetrical Gynecological Survey 59 5: 379-395. PMID 15097799. Retrieved on 2006-09-27. ^ Van Howe, Robert S. November 2004. A Cost-Utility Analysis of Neonatal Circumcision Abstract. Medical Decision Making 24 6: 584-601. doi:10.1177/0272989X04271039. PMID 15534340. Retrieved on 2006-07-01. ^ Ganiats, TG; Humphrey JB, Taras HL, Kaplan RM. Oct-Dec 1991. Routine neonatal circumcision: a cost-utility analysis. Medical Decision Making 11 4: 282-293. PMID 1766331. Retrieved on 2006-07-01. ^ Lawler, FH; Bisonni RS, Holtgrave DR. Nov-Dec 1991. Circumcision: a decision analysis of its medical value.. Family Medicine 23 8: 587-593. PMID 1794670. Retrieved on 2006-07-01. ^ Task Force on Circumcision March 1, 1999. Circumcision Policy Statement PDF. Pediatrics 103 3: 686-693. doi:10.1542/peds.103.3.686. ISSN 0031-4005 PMID 10049981. Retrieved on 2006-07-01. Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. It is legitimate for parents to take into account cultural, religious, and ethnic traditions, in addition to the medical factors, when making this decision. Analgesia is safe and effective in reducing the procedural pain associated with circumcision; therefore, if a decision for circumcision is made, procedural analgesia should be provided. If circumcision is performed in the newborn period, it should only be done on infants who are stable and healthy. ^ Circumcision: Position Paper on Neonatal Circumcision. American Academy of Family Physicians 2007. Retrieved on 2007-01-30. Considerable controversy surrounds neonatal circumcision. Putative indications for neonatal circumcision have included preventing UTIs and their sequelae, preventing the contraction of STDs including HIV, and preventing penile cancer as well as other reasons for adult circumcision. Circumcision is not without risks. Bleeding, infection, and failure to remove enough foreskin occur in less than 1% of circumcisions. Evidence-based complications from circumcision include pain, bruising, and meatitis. More serious complications have also occurred. Although numerous studies have been conducted to evaluate these postulates, only a few used the quality of methodology necessary to consider the results as high level evidence. The evidence indicates that neonatal circumcision prevents UTIs in the first year of life with an absolute risk reduction of about 1% and prevents the development of penile cancer with an absolute risk reduction of less than 0.2%. The evidence suggests that circumcision reduces the rate of acquiring an STD, but careful sexual practices and hygiene may be as effective. Circumcision appears to decrease the transmission of HIV in underdeveloped areas where the virus is highly prevalent. No study has systematically evaluated the utility of routine neonatal circumcision for preventing all medically-indicated circumcisions in later life. Evidence regarding the association between cervical cancer and a woman's partner being circumcised or uncircumcised, and evidence regarding the effect of circumcision on sexual functioning is inconclusive. If the decision is made to circumcise, anesthesia should be used. The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son. ^ American Urological Association. Circumcision. Retrieved on 2007-08-26. ^ Doctors back call for circumcision ban, ABC News 2007-12-09. ^ Immerman, R.S.; W.C. Mackey Fall-Winter 1997. A biocultural analysis of circumcision. Social Biology 44 3-4: 265-275. doi:10.1111/j.1467-9744.1976.tb00285.x. PMID 9446966. ^ 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. ^ 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. ^ 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. ^ Marck, J 1997. Aspects of male circumcision in sub-equatorial African culture history. Health Transit Review 7 supplement: 337-360. PMID 10173099. ^ a b c d Gollaher, David Fall 1994. From ritual to science: the medical transformation of circumcision in America. Journal of Social History 28 1: 5-36. Retrieved on 2007-12-06. ^ On the influence of circumcision in preventing syphilis 1855. Medical Times and Gazette NS Vol II: 542-3. ^ Trends in circumcisions among newborns. National Hospital Discharge Survey. National Center for Health Statistics January 11, 2007. Retrieved on 2008-08-19. ^ Brown, M.S.; C.A. Brown August 1987. Circumcision decision: prominence of social concerns. Pediatrics 80 2: 215-219. PMID 3615091. ^ Nelson, C.P.; R. Dunn, J. Wan, J.T. Wei March 2005. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. Journal of Urology 173 3: 978-981. PMID 15711354. ^ U.S. circumcision rates vary by region, UPI January 21, 2008. Retrieved on 2008-08-19. ^ Pang, MG; Kim DS 2002. Extraordinarily high rates of male circumcision in South Korea: history and underlying causes. BJU Int 89 1: 48-54. doi:10.1046/j.1464-410X.2002.02545.x. ^ Dave, SS; et al 2003. Male circumcision in Britain: findings from a national probability sample survey. Sex Transm Infect 79: 499-500. doi:10.1136/sti.79.6.499. ^ In Australia and New Zealand, the circumcision rate has fallen considerably in recent years and it is estimated that currently only 10%-20% of male infants are routinely circumcised. RACP: 2004 ^ a b Richters, J; et al. 2006. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 17: 547-554. doi:10.1258/095646206778145730. PMID 16925903. Neonatal circumcision was routine in Australia until the 1970s ... In the last generation, Australia has changed from a country where most newborn boys are circumcised to one where circumcision is the minority experience. ^ Crawford DA. Circumcision: a consideration of some of the controversy. J Child Health Care. 2002 December;64:259-70. PMID 12503896 ^ Klavs I, Hamers FF February 2008. Male circumcision in Slovenia: results from a national probability sample survey. Sex Transm Infect 84 1: 49-50. doi:10.1136/sti.2007.027524. PMID 17881413. ^ a b Drain, PK; et al November 2006. Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries. BMC Infect Dis 30 6: 172. doi:10.1186/1471-2334-6-172. PMID 17137513. Retrieved on 2008-04-25. ^ a b c d Castellsagué, X; et al 2002. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med 346 15: 1105-12. doi:10.1056/NEJMoa011688. PMID 11948269. ^ Frisch, M; et al 1995. Falling incidence of penis cancer in an uncircumcised population Denmark 1943-90. BMJ 311: 1471. PMID 8520335. ^ Schoen, E J; Colby, C J; Trinh, T To 2006. Cost analysis of neonatal circumcision in a large health maintenance organization. J Urol 175: 1111-1115. doi:10.1016/S0022-53470500399-X. ^ Ko, MC; et al April 2007. Age-specific prevalence rates of phimosis and circumcision in Taiwanese boys. J Formos Med Assoc 106 4: 302-7. PMID 17475607. ... the prevalence of circumcision slightly increased with age from 7.2% 95% CI, 5.3-10.8% for boys aged 7 years to 8.7% 95% CI, 6.5-13.3% for boys aged 13 years. ^ The Skinny On 'Miracle' Wrinkle Cream. NBC10.com. NBC Universal, Inc November 2002. Retrieved on 2008-08-20. ^ High-Tech Skinny on Skin Grafts. www.wired.com:science:discoveries. CondéNet, Inc 02.16.99. Retrieved on 2008-08-20. ^ Skin Grafting. www.emedicine.com. WebMD. Retrieved on 2008-08-20. ^ Amst, Catherine; Carey, John July 27, '98. Biotech Bodies. www.businessweek.com. The McGraw-Hill Companies Inc. Retrieved on 2008-08-20. ^ Cowan, Alison Leigh April 19, 1992. Wall Street; A Swiss Firm Makes Babies Its Bet. New York Times:Business. New York Times. Retrieved on 2008-08-20. ^ Hovatta, O.; M. Mikkola1, K. Gertow, A.-M. Strömberg, J. Inzunza1, J. Hreinsson1, B. Rozell, E. Elisabeth Blennow, M. Andäng, L. Ährlund-Richter July 2003. A culture system using human foreskin fibroblasts as feeder cells allows production of human embryonic stem cells. Human Reproduction 18 7: 1404-1409. PMID 12832363. External links Wikimedia Commons has media related to: Circumcision Circumcision opposition The Circumcision Information and Resource Pages by Geoffrey T. Falk Doctors Opposing Circumcision presided by George C. Denniston, MD, MPH National Organization of Circumcision Information Resource Centers by Marilyn Milos, RN Sex as Nature Intended It by Kristen O'Hara. Circumcision promotion Jewish Circumcision - Brit Milah Chabad.org Benefits of circumcision: medical, health and sexual by Professor Brian Morris Circumcision: a lifetime of medical benefits by Edgar Schoen, BSc., M.D. Circumcision techniques Description of an adult circumcision from the American Academy of Family Physicians. Visualisation of amount of skin removed, showing 'styles' of circumcision. Video demonstration of infant circumcision using a Gomco clamp. v d e Urogenital surgical and other procedures ICD-9-CM V3 55-71 Urinary system kidney: Nephrostomy - Nephrectomy - Kidney transplantation - Nephropexy ureter: Ureteroscopy - Ureterostomy - Urinary diversion - Ureterosigmoidostomy urinary bladder: Cystectomy Suprapubic cystostomy - Cystoscopy Reproductive system - male prostate: Prostatectomy Transurethral resection of the prostate vas deferens: Vasectomy - Vasovasostomy penis: Circumcision - Penectomy - Penile prosthesis testes: orchiectomy Inguinal orchiectomy Reproductive system - female gynecological surgery ovary: Oophorectomy fallopian tubes: Tubal ligation - Salpingectomy uterus: Hysterotomy - Hysteroscopy - Pelvic exenteration - Hysterectomy - Vacuum aspiration vagina: Colposcopy - Culdocentesis - Hymenotomy - Vaginectomy vulva: Female genital cutting - Vulvectomy Retrieved from http://en..org/wiki/Circumcision Categories: Circumcision | Body modification | Penis | Sexuality | Surgical removal proceduresHidden categories: Pages with DOIs broken since 2008 | NPOV disputes from June 2008 | Articles containing Latin language text | All articles with statements | Articles with statements since February 2008 | All pages needing cleanup | articles needing factual verification since November 2007 | All pages needing factual verification | Articles with statements since August 2008 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages العربية Bamanankan Brezhoneg Българ�?ки Català Česky Dansk Deutsch Eesti Ελληνικά Español Esperanto �?ارسی Français 한국어 हिन�?दी Hrvatski Bahasa Indonesia Italiano עברית Қазақша Latina Lietuvių Magyar Македон�?ки മലയാളം Bahasa Melayu Nederlands 日本語 ‪Norsk nynorsk‬ Polski Português Română Ру�?�?кий Simple English Sloven�?ina Slovenš�?ina Suomi Svenska Tagalog Tagalog ไทย Türkçe Україн�?ька 中文 This page was last modified on 29 August 2008, at 17:1

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Why Drink MonaVie?

So many of us do not eat a balanced diet, get enough sleep, have too much stress, or are impacted with toxins and pollutants. Drinking 2 ounces of MonaVie twice a day will help your body detoxify as well as build your immune system. Its the smartest thing you can do for yourself, so start today. Buying MonaVie through our company guarantees you support 7 days a week and, if you would like to share MonaVie with your family and friends we will guide you from start to finish.

The Best Way to Buy MonaVie is Wholesale

1. Click on Enroll Now (30 - 55% off retail price)
2. Pay $39 for your Wholesale ID number.
3. NO minimum order required.
4. MonaVie is delivered to your door in 3 to 5 days.

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Why Drink MonaVie?

The Best Way to Buy MonaVie is Wholesale