Circumcision

Circumcision is the removal of some or all of the foreskin (prepuce) from the penis. The frenulum may also be removed at the same time, in a procedure called frenectomy. The word "circumcision" comes from Latin circum (meaning "around") and caedere (meaning "to cut"). Female circumcision is a term applied to a variety of procedures performed on the female genitalia. Except where specified, "circumcision" in this article should be regarded as "male circumcision".

Circumcision as a therapeutic medical procedure may be recommended to treat a variety of conditions, such as pathological phimosis, chronic inflammations of the penis and penile cancer. The frequent use of circumcision is often criticised since the indicators for circumcision are regularly misdiagnosed, e.g. confusing normal, congenital infant phimosis with pathological phimosis,[1] and circumcision is often used where less invasive treatments are available and effective. [2]

Routine, non-therapeutic infant circumcision is controversial. National medical associations in America, Canada, and Australia do not recommend routine infant circumcision, and several recommend that doctors discuss the benefits and risks with prospective parents.[3] [4] [5] The genital integrity movement condemns non-therapeutic infant circumcision as a human rights violation that they consider comparable to female genital cutting,[6] while circumcision advocates stress the medical benefits of the procedure.[7]

Contents
1 The procedures of circumcision
2 Cultures and Religions
2.1 Aesthetics
2.2 Coptic Christian
2.3 Islam
2.4 Judaism
2.5 Tribal traditions
3 Ethical Issues
3.1 Consent
3.2 Emotional consequences
3.3 Legality
3.4 Religious circumcision of minors
4 Medical Aspects 
 
The procedures of circumcision
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Circumcision is the removal of the foreskin from the penis. Clamps, such as the Gomco, Plastibell, and Mogen are commonly used for infant circumcision.[8] These are intended to protect the glans from harm, and crush the foreskin to achieve hemostasis. When the Gomco or Mogen clamp is used, a dorsal slit must be made before application of the clamp. In the case of the Mogen and Plastibell, the foreskin is then surgically removed, while when the Plastibell is used, the foreskin sloughs away along with the clamp in three to seven days.

According to a 1998 study, anaesthesia is used by 45% of physicians performing infant circumcision.[9] Dorsal penile nerve block is the most commonly used form. Obstetricians were notable in the study for a significantly lower rate of anaesthesia use (25%) than pediatricians or family practitioners. Adult circumcisions are often performed without clamps, and require the following 4 to 6 weeks of abstinence from masturbation or intercourse to allow wound healing. [10]

Cultures and Religions
For information on circumcision in the Bible, see Circumcision in the Bible.
Some cultures circumcise their males, either shortly after birth, or around puberty as an initiation rite. The practice is most notable among Muslims, Jews, and Americans.

Aesthetics
Circumcision may be undertaken as a body modification of the genitals to change the looks of the penis to appeal more to certain aesthetics. Where infant or childhood circumcision is the norm, people may consider non-circumcised penises to be less preferable sexually, visually or otherwise. In a few cultures, circumcision may be one of other modifications of the penis, such as a split penis or a subincision.

The United States, the Philippines and South Korea are the only countries that circumcise a majority of young males for non-religious reasons. Routine circumcision practices in South Korea are largely the result of American cultural and military influence following the Korean War. The origin of the practice in the Philippines is uncertain according to one newspaper article [11]. However, Antonio de Morga's "History of the Philippine Islands" (1907) attributes circumcision to Islamic influence [12].

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

Islam
Islam stresses cleanliness and considers circumcision a form of natural hygiene. Although circumcision is not mentioned in the Qur'an, it is mentioned in some parts of the Hadith. Fiqh scholars have different opinions about circumcision in Shariah, depending on which Hadith are accepted and how they are interpreted. According to Imam Abu Hanifa, Imam Malik and a majority of others it is a recommended practice (Sunnah), but others, including Imam Shafi, consider it obligatory. The timing of Muslim circumcision varies. Some Muslim communities perform circumcision on the eighth day of life, as with Jews, while others perform the rite later. Turkish, Balkan, rural Egyptians and Central Asian Muslims typically circumcise boys between the ages of six and eleven and the event is viewed communally as a joyous occasion and is celebrated with sweets and feasting. In contrast, Iranian Muslims are typically circumcised in the hospital at birth without much ado. Urban Egyptians, as with many industrialized countries such as the USA, perform the procedure at a hospital. Kamyar et al describe it as an 'obligatory custom', and note that it is not necessary for the circumciser to be a Muslim. Recently, world opinion, including Islamic opinion [13], has become increasingly critical of the practice of female circumcision, which is also widespread in Islamic cultures. [14]

Judaism
Main articles: Brit milah, and [[]], and [[]], and [[]], and [[]]
Circumcision is a religious practice traditionally required by Judaism, usually performed in a ceremony called a Brit (or Bris) milah (Hebrew for "Covenant of circumcision"). A mohel performs the ceremony on the eighth day after birth unless health reasons force a delay. According to the Torah (Genesis, chapter 17 verses 9-14), God commanded Abraham to circumcise himself, his offspring and his slaves as part of an everlasting covenant. According to Jewish law, failure to follow the commandment carries the penalty of karet, or being cut off from the community by God. Brit milah is so important that should the eighth day fall on Shabbat, actions that would normally be forbidden because of the sanctity of the day are permitted in order to fulfill the requirement to circumcise. See also Circumcision in the Bible.

Tribal traditions
Circumcision is part of the initiation rite in a number of African and Australian Aboriginal tribal traditions. Among some West African animist groups, such as the Dogon and Dowayo, it is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males. Among Nilotic peoples, such as the Nandi, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set. Aboriginal circumcision ceremonies, which also constitute a rite of passage, are noted for their painful nature, including subincision for some tribes.

Ethical Issues
Main articles: Bioethics of neonatal circumcision, and [[]], and [[]], and [[]], and [[]]
Circumcising infants as a public health measure is controversial. In cultures such as the USA, lay people may regard infant circumcision as a routine medical practice but medical organizations in Australia, Canada, and America do not recommend routine infant circumcision [15]. While the risks of circumcision-related complications are very low [16], the possible catastrophic complications of a poorly carried out circumcision, or of post-operative bleeding or infection, are not to be taken lightly. The American Association of Physicians recommend that parents should be informed about the benefits and risks of the procedure.[17] Circumcision advocates argue that circumcision is a significant public health measure, preventing infections, and possibly slowing down the spread of AIDS, while the genital integrity movement asserts that infant circumcision is a human rights violation and a sexual assault, and the practice of circumcising infants or children should be discouraged or banned.

Consent
The issue of consent is of particular relevance to circumcision because it is often done to infants, who, naturally are unable to consent to this, or indeed any other, medical procedure. The decision, therefore, must fall to the child's caregiver(s). If a grown man wants to be circumcised, he can give meaningful consent to the procedure. However, if a man is not happy at having been circumcised, there is no way to replace his foreskin, and foreskin restoration, which extends the remaining skin, will not replace the missing nerve endings of the original foreskin.

Therefore, debate often focuses on what limits, if any, should be placed on a caregiver's ability to make a decision for a boy about a painful (and, some argue, mutilating) procedure with disputed immediate medical value and that may be unwanted later in life. Some question the apparent inconsistency of allowing male circumcision but prohibiting female genital cutting [18]. Many suggest that circumcision may cause emotional scarring later in life, and claim that the procedure should be left until a man is mature enough to make the choice for himself. Those in favour believe that the procedure is less traumatic when performed in infancy and do not wish to disturb the traditional and religious rights of parents to make decisions on behalf of their child.

Emotional consequences
Much attention has been given to the emotional impact of female genital cutting. For no clear reasoning the emotional impact of circumcision has traditionally been ignored. Issues about the rights of the child are often overlooked, as is the possibility that circumcision causes emotional and physical harm to some males.

In the USA, most neonatal circumcisions are performed without anaesthesia.[19] It is now known, that circumcised infants do not forget the pain during circumcision easily, as a correlation between circumcision and intensity of pain response during vaccination months later could be established.

There are a number of support groups for circumcised males that are dissatisfied with their circumcised state. These groups often advocate foreskin restoration.

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

Religious circumcision of minors
Main articles: Religious circumcision, and [[]], and [[]], and [[]], and [[]]
In some parts and cultures of the world, it is customary or obligatory for minors of both sexes to be circumcised for religious reasons. Many believe that this practice is protected by the principle of freedom of religion. Others disagree, arguing that no right has precedence over the rights of bodily integrity of a child. Still others contend that freedom of religion only applies to belief, not action involving others. Female circumcision is prohibited in most western countries, and Sweden has restricted religious male infant circumcision. [20]

Medical Aspects
Main articles: Medical analysis of circumcision, and [[]], and [[]], and [[]], and [[]]

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

Bleeding and infection are the most common complications, according to the AMA. Other complications are known, including infections, urinary fistulas, meatal stenosis, ulceration of the glans, removal of too much tissue, and secondary phimosis.

The Royal Australasian College of Physicians and the American Medical Association criticise neonatal circumcision without anaesthetics because of the pain involved in the procedure.[21] [22] The American Academy of Pediatrics explicitly recommends that if the procedure is to be performed, anaesthetics are to be used. [23]

Infant circumcision may cause problems such as skin bridges, when the foreskin does not just heal back together but instead attaches to the glans penis.[24]

Loss of the penis itself has been documented. The RACP states that the penis is lost only in 1 in 1,000,000 circumcisions.

Gairdner's 1949 study [25] reported that 16 children per year died in the UK during the 1940s, a rate of 1.8 in 10,000.[26] Gairder stated that most deaths had occurred suddenly under anaesthesia, and couldn't be explained further, but haemorrhage and infection had also proven fatal. (disputed — see talk page)

Accurate figures of death rates in the United States are unknown, but reports range from 1:50,000 to 1:25,000,000. The American Academy of Family Physicians states that death is rare, and cites an estimated death rate with circumcisions of infants of 1 in 500,000.[27] By comparison, cosmetic surgery in healthy adults has a lethality of 1:57'000, a rate the American Society for Aesthetic Plastic Surgery considers "extremely low".