Circumcision

Circumcision is the surgical removal of some or all of the prepuce or foreskin, including the highly innervated ridged band, of the penis of male humans. Female circumcision is a term applied to a variety of mutilations performed on female genitalia, only one of which, the removal of the clitoral hood, is comparable to male circumcision. However, only the operation on males is discussed in the remainder of this article as "circumcision". Another form of surgery practiced on the penis in a few cultures is subincision.

Circumcision may be considered necessary for medical reasons in a small number of cases, such as phimosis. However, the majority of circumcisions are performed for religious or cultural reasons, and when medical benefits are claimed, these are of a preventive rather than therapeutic nature, that is, the procedure is supposed to reduce certain risks later in life. The practice is therefore the source of considerable controversy.

Table of contents

1 Prevalence 2 How circumcision is performed 3 Origins of circumcision 4 Circumcision in the 18th Century 5 Circumcision in the 19th Century and beyond 6 Anti-masturbation panic and circumcision 7 Circumcision for religious purposes 8 The movement against routine neonatal circumcision 9 See also 10 References 11 External links 11.1 Against circumcision 11.2 In favor of circumcision 11.3 General

Prevalence

Approximately one-sixth of males are circumcised [1]; the vast majority for religious or cultural reasons. The United States is the only country that still practices circumcision routinely on a majority of infants for non-religious reasons.

The majority of males are circumcised in the following countries:

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

It should be noted that the vast majority of these countries have a religion that endorses circumcision such as Islam or Judaism.

Historically, routine neonatal circumcision was promoted during late Victorian times in the English-speaking parts of Canada, Australia, New Zealand, the United States and the United Kingdom and was widely practiced during the first part of the 20th century in these countries. However, the practice declined sharply in the United Kingdom after the Second World War, and somewhat later in Canada, Australia and New Zealand. It has been argued (e.g., Goldman 1997) that the practice did not spread to other European countries because others considered the arguments for it fallacious. In South Korea, circumcision was largely unknown before the establishment of the United States trusteeship in 1945. More than 90% of South Korean high school boys are now circumcised, but the average age of circumcision is 12 years, which makes South Korea a unique case [1].

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

Routine infant circumcision has been abandoned in New Zealand and Britain, and is now much less common in Australia and in Canada (see table 1). The decline in circumcision in the United Kingdom followed the decision by the National Health Service (NHS) in 1948 not to cover the procedure following an influential article by Douglas Gardiner which claimed that circumcision resulted in the deaths of about 16 children under 5 each year in the United Kingdom. [1]. In most of the rest of the world, circumcision is done either as a religious or cultural practice, less frequently as a therapeutic procedure, as a lifestyle choice, or as a mark of societal elite status.

Routine neonatal circumcision in the United States grew out of a widespread fear that masturbation caused various diseases, a view now universally rejected by the medical community. Circumcision was thought to reduce masturbation and other sexual behavior considered undesirable. Circumcision, depending on how it is practiced, can have a significant impact on masturbation; see masturbation for a detailed discussion.

Circumcision is now also dwindling in the United States. The rate has been steadily decreasing from near universality in the 1960s to approximately 55% today. Thirty-eight states pay for the procedure under Medicaid; twelve states have now dropped this coverage.

Many medical claims have been made to justify circumcision. These included the prevention of epilepsy, penile cancer and phimosis. Circumcision advocates today claim that it reduces urinary tract infections and HIV infection, but these claims are strongly disputed. (See medical analysis of circumcision.)

The major medical societies in Great Britain, Canada, Australia and New Zealand oppose routine infant circumcision. All major medical organizations in the United States now judge the benefits of the procedure to be too small to justify the risks associated with performing it routinely. Neonatal circumcision nonetheless remains the most common pediatric operation carried out in the U.S. today.

Table 1 International circumcision rates
Country	Year	Routine neonatal circumcisions (%)
United States	2001	55.1% [1]
Canada	FY 1996/97	17% [1]
Australia	1995-96	10.6% [1]
New Zealand	1995	0.35%* [1]
United Kingdom	1998	0.4% [1]
*Samoans, Tongans and Niueans in New Zealand continue to practice circumcision, but not in public hospitals, which this data refers to

How circumcision is performed

In infants, a variety of methods are used. In the great majority of cases, there is either no anaesthetic or a local anaesthetic. All methods have in common the tearing away of the skin covering the glans penis (these are still attached in infants), and the removal of a varying amount of skin. The extent of the removal, the precise location of the removal, and the cosmetic result all vary a great deal: some circumcised males retain a significant proportion of their nerve-rich penile skin, others do not; some circumcised males have an amount of mobile skin remaining on the erect penis, others do not; in some cases the scar is small and neat, in others it is large, jagged and obvious.

In adults, circumcision is sometimes performed under general anaesthetic. The foreskin is partly removed with a sharp-bladed instrument of some kind. The remaining foreskin is then stitched back using dissolvable stitches. The penis is then wrapped in protective bandages and a jockstrap style harness to keep it in place.

The skin that was previously underneath the foreskin is very sensitive; some people are prone to bleeding. After the circumcision, the pain is controllable and goes away quickly during the day. Normally there is no distress when the penis is flaccid, but the penis becomes partially or fully erect one or more times each night. Thus, for the first week or two after an adult circumcision, the patient can experience a significant amount of pain during the erection. Some patients stay in a hospital for 1-2 nights after the operation. The skin slowly becomes desensitized during the following month.

Origins of circumcision

The origin of circumcision is hidden in the mists of pre-history. It is possible that it arose as a religious ritual, as a form of sympathetic magic, as a health control measure, as a way to control the sexuality of children and adults, or as a way to prevent masturbation. It is almost certain that it independently developed in different cultures for different reasons.

Documentary evidence shows the first references to circumcision in Egypt no later than 2300 B.C. Artwork showing the rite being performed on a standing adult male adorns tombs of this period. Moreover, the hieroglyphic sign for "penis" in the Egyptian Book of the Dead is a circumcised organ. (Source: Gerald Weiss, MD, A Perspective on Controversies Over Neonatal Circumcision, Clinical Pediatrics, Vol 33 No 12, December 1994).

Herodotus wrote that Colchians, Ethiopians, Phoenicians, Syrians, and Macroni practiced circumcision. In reference specifically to the Egyptians, and reflecting the prevalent Greek view that an uncircumcised penis was more attractive than a circumcised one, mused that "They practice circumcision for the sake of cleanliness, considering it better to be clean than comely." (Herodotus, Book 2, 37:2).

Some philosophers, including the Jewish philosophers Maimonides and Philo believed that the reason circumcision was commanded was to control the male's sexual impulses. Other Jewish philosophers hold that the reason is to seal in one's flesh a symbol of the covenant between God and the Jewish people.

Many, possibly hundreds, of explanations have been offered. For example, Desmond Morris offers this speculation: "The Egyptians believed that when the snake shed its skin, and emerged shiny and new again, it was undergoing rebirth. They reasoned that if, by shedding skin, the snake could become apparently immortal, then humans should follow suit. They made the simple equation: snakeskin = foreskin, and the operation began."

Dunsmuir and Gordon write "Nineteenth century historians suggested that the ritual is an ancient form of social control. They conceive that the slitting of a man's penis to cause bleeding and pain is to remind him of the power of the Church, i.e., 'We have control over your distinction to be a man, your pleasure and your right to reproduce'. The ritual is a warning and the timing dictates who is warned; for the newborn it is the parents who accede to the Church: 'We mark your son, who belongs to us, not to you'. For the young adolescent, the warning accompanies the aggrandizement of puberty; the time when growing strength give independence, and the rebellion of youth."

Other theories advanced include that circumcision was instituted to mark slaves or captured prisoners, to distinguish the people practicing circumcision from other groups as means of preventing dilution of the bloodline or intermarriage, to be attractive to the opposite sex, for hygienic purposes, for the symbolic freedom from motherly care, for increased sexual feelings, as a test of bravery, as entry into adulthood, as self-sacrifice to promote longevity or rebirth, as symbolic castration, and as simulated menstruation. [1]

Some believe that in some cultures, circumcision was developed, and is still used, to control a child's sexuality, that this is the core motive behind circumcision, and that any other explanation is secondary or a pretext.

Circumcision in the 18th Century

Circumcision was not practiced amongst Christians in Europe in the 18th Century. It was regarded with repulsion.

Edward Gibbon had referred to it as a "singular mutilation" practised only by Jews and Turks and as "a painful and often dangerous rite" ...(R. Darby) [1]

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

"the best of Your property" and guard their threatened foreskins. It was an extraordinary outpouring of popular beliefs about sex, fears about masculinity and misconceptions about Jews, but also a striking indication of how central to their sexual identity men considered their foreskins at that time. (R.Darby) [1]

Circumcision in the 19th Century and beyond

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

Richard Burton observed that "Christendom practically holds circumcision in horror". This attitude is reflected in the ninth edition of the Encyclopaedia Britannica (1876) which discusses the practice as a religious rite among Jews, Moslems, the ancient Egyptians and tribal peoples in various parts of the world. The author of the entry rejected sanitary explanations of the procedure in favour of a religious one: "like other body mutilations ... [it is] of the nature of a representative sacrifice". (R. Darby) [1]

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

By 1910 the entry had been turned on its head: "This surgical operation, which is commonly prescribed for purely medical reasons, is also an initiation or religious ceremony among Jews and Mahommedans": now it was primarily a medical procedure and only after that a religious ritual. The entry explained that "in recent years the medical profession has been responsible for its considerable extension among other than Jewish children ... for reasons of health" (11th edition, Vol. 6). By 1929 the entry is much reduced in size and consists merely of a brief description of the operation, which is "done as a preventive measure in the infant" and "performed chiefly for purposes of cleanliness". Ironically, readers are then referred to the entries for "Mutilation" and "Deformation" for a discussion of circumcision in its religious context (14th edition, 1929, Vol. 5). (R. Darby) [1]

Anti-masturbation panic and circumcision

The movement of the skin layers of the foreskin provides a built-in form of lubrication, usually making it easy to masturbate without additional lubrication if a foreskin is present. Depending on its degree, this normal lubricating function can be absent after circumcision.

Non-religious circumcision in English-speaking countries arose in a climate of sexual fear, especially concerning masturbation. In her 1978 article The Ritual of Circumcision,[1] Karen Erickson Paige writes: "In the United States, the current medical rationale for circumcision developed after the operation was in wide practice. The original reason for the surgical removal of the foreskin, or prepuce, was to control 'masturbatory insanity' - the range of mental disorders that people believed were caused by the 'polluting' practice of 'self-abuse.'"

"Self-abuse" was a term commonly used to describe masturbation in the 19th century. According to Paige, "treatments ranged from diet, moral exhortations, hydrotherapy, and marriage, to such drastic measures as surgery, physical restraints, frights, and punishment. Some doctors recommended covering the penis with plaster of Paris, leather, or rubber; cauterization; making boys wear chastity belts or spiked rings; and in extreme cases, castration." Paige details how circumcision became popular as a masturbation remedy:

"In the 1890s, it became a popular technique to prevent, or cure, masturbatory insanity. In 1891 the president of the Royal College of Surgeons in Great Britain published On Circumcision as Preventive of Masturbation, and two years later another British doctor wrote Circumcision: Its Advantages and How to Perform It, which listed the reasons for removing the 'vestigial' prepuce. Evidently the foreskin could cause 'nocturnal incontinence,' hysteria, epilepsy, and irritation that might 'give rise to erotic stimulation and, consequently, masturbation.' Another physician, P.C. Remondino, added that 'circumcision is like a substantial and well-secured life annuity...it insures better health, greater capacity for labor, longer life, less nervousness, sickness, loss of time, and less doctor bills.' No wonder it became a popular remedy." [1]

At the same time circumcisions were advocated on men, clitoridectomies (removal of the clitoris) were also performed for the same reason (to treat female masturbators). The US "Orificial Surgery Society" for female "circumcision" operated until 1925, and clitoridectomies and infibulations would continue to be advocated by some through the 1930s.

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

"Covering the organs with a cage has been practiced with entire success. A remedy which is almost always successful in small boys is circumcision, especially when there is any degree of phimosis. The operation should be performed by a surgeon without administering an anaesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. The soreness which continues for several weeks interrupts the practice, and if it had not previously become too firmly fixed, it may be forgotten and not resumed. If any attempt is made to watch the child, he should be so carefully surrounded by vigilance that he cannot possibly transgress without detection. If he is only partially watched, he soon learns to elude observation, and thus the effect is only to make him cunning in his vice."

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

In the 19th century the role of the foreskin in erotic sensation was well understood by physicians who wanted to cut it off precisely because they considered it the major factor leading boys to masturbation. The Victorian physician and venereologist William Acton (1814–1875) damned it as "a source of serious mischief", and most of his contemporaries concurred. Both opponents and supporters of circumcision agreed that the significant role the foreskin played in sexual response was the main reason why it should be either left in place or removed. William Hammond, a Professor of Mind in New York in the late 19th century, commented that "circumcision, when performed in early life, generally lessens the voluptuous sensations of sexual intercourse", and both he and Acton considered the foreskin necessary for optimal sexual function, especially in old age. Jonathan Hutchinson, English surgeon and pathologist (1828–1913), and many others, thought this was the main reason why it should be excised. [1]

Circumcision for religious purposes

Circumcision of males is a religious practice traditionally required by Judaism. The Jewish ceremony of circumcision is called a Brit milah or Bris Milah (Hebrew for "Covenant of circumcision"). The ceremony is to be performed on the eighth day of life of the newborn boy unless health reasons force a delay. A separate article exists for a more detailed treatment of Circumcision in the Bible.

According to nearly all Muslim religious leaders, circumcision is an important element of Islam. Although circumcision is not mentioned in the Quran, it is mentioned in some parts of the Hadith, a set of texts explaining Islamic law that most Muslims outside of Libya view as authoritative. Most Muslims believe that Mohammed was born circumcised. Muslim custom on circumcision varies. Some Muslim communities perform circumcision on the eighth day of life, as the Jews do, while others perform the rite at a different time. Turkish, Balkan, and Central Asian Muslims typically circumcise boys at between six and eleven years of age, and the event is viewed communally as a joyous occasion and celebrated with sweets and feasting. In contrast, Iranian Muslims are typically circumcised in the hospital at birth without much ado.

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

Therefore it strictly orders all who glory in the name of Christian, not to practise circumcision either before or after baptism, since whether or not they place their hope in it, it cannot possibly be observed without loss of eternal salvation. [1]

The Council of Florence is also viewed by many, including the Catholic Encyclopedia as cementing the rupture between Roman Catholicism and other Christian denominations, including Greek Catholics and Hussites. [1]

Circumcision also has been or continues to be an important part of religious and cultural practices for other ethnic and religious groups, including the ancient Egyptians and many African, Australian Aboriginal, and Polynesian societies. Circumcision practices among these societies vary, including at what age the procedure is done, whether women may be present, what celebrations are attendant on the procedure, and whether the procedure is viewed as an initiation into the "secrets" of the society.

Many non-Western cultures practice circumcision, including the Machapunga tribe of Native North Americans, some Australian Aborigines, some tribes in New Guinea, Tongans, Niueans, and Samoans.

The movement against routine neonatal circumcision

Many groups have developed in the past twenty years to oppose circumcision. Most of the groups are not opposed to adults choosing circumcision but regard neonatal circumcision as a sexual mutilation, and consider it barbaric, primitive, unnecessary, and dangerous. Most oppose infant circumcision in all cases but many are particularly concerned when the procedure is done without pain relief, still a common practice. Many of these groups try to avoid vocabulary like "anti-circumcision" in order to avoid confusion with the adult circumcision issue; the critics of the movement, however, often use such vocabulary.

An umbrella organization, the International Coalition for Genital Integrity [1], is unilaterally opposed to any forced genital cutting, whether on males, females or the intersexed. Many of the pro-intact organizations are members.

The goal of most of these groups is to end, and possibly even criminalize, the forced circumcision of male and female individuals. Anti-circumcision groups take a varying approach toward Judaism and Islam. Some make no distinction between differently motivated types of circumcision, others ask for reform instead of criminalization. [1] Most Jewish and Muslim groups oppose the anti-circumcision movement, as they fear that it could stigmatize or criminalize a key practice of their religions.

Some of the anti-circumcision groups include: NOCIRC (National Organization of Circumcision Information Resource Centers), ARC (Attorneys for the Rights of the Child), NOHARMM (the National Organization to Halt the Abuse and Routine Mutilation of Males), D.O.C. (Doctors Opposing Circumcision), and NRC (Nurses for the Rights of the Child). One of the positions held by opponents of circumcision is that a significant part of the infant's body is unnecessarily and permanently removed without the subject's consent, the same argument used by opponents of female genital mutilation. Some have tried to challenge the legal status of circumcision.

Some men resent having been circumcised without their consent. Some campaign against circumcision. A few seek to regain their foreskin through medical procedures while others use non-medical methods such as stretching the skin covering the distal penile shaft down over the glans penis through techniques such as wearing weights on it, or taping the skin over a small cap worn over the glans.

This process is known as epispasm or foreskin restoration and is mentioned as far back as the Maccabees, over 2000 years ago (1 Macc 1:15). Those attempting to restore their foreskins have reported some success, although a great deal of patience and consistency is required to have any permanent effect. Cosmetic surgical procedures to repair the foreskin also exist. None of these methods can restore the sexually sensitive tissue that is removed by circumcision.

Some Jews oppose circumcision. Ronald Goldman has collected arguments against circumcision in his book Questioning Circumcision: A Jewish Perspective. Based on many of the above arguments, he argues that circumcision is unnecessary and dangerous, and claims that foregoing the practice would be consistent with traditional and reform Jewish ethics, while continuing it would not. The book has been strongly condemned by the Jewish community. Several Reconstructionist and Reform rabbis, who no longer follow Jewish law, have given it favorable reviews. A small number of Jews have joined a group called Jews Against Circumcision [1]. People in this group and some other Jews opposed to the Brit Milah practice an alternative ritual called Brit Shalom that does not involve circumcision [1]. Such alternative rituals are rejected by the mainstream Jewish community.

See also

• Decircumcision
• Medical analysis of circumcision
• Circumcision in the Bible
• Association for Genital Integrity

References

• Goldman, Ronald Circumcision: The Hidden Trauma Boston 1997.
• Goldman, Ronald Questioning Circumcision: A Jewish Perspective Boston 1998.
• Wallerstein, E. Circumcision: The Uniquely American Medical Enigma, Urological Clinics of North America 12 (February 1985): 123-32.
• John Harvey Kellogg Treatment for Self-Abuse and its Effects in Plain Fact for Old and Young, Burlington, Iowa: F. Segner & Co. (1888). P. 295
• Walsh, Campbell's Urology, 7th ed. 1998

External links

Against circumcision

• Circumcision Information and Resource Pages, an anti-circumcision website that hosts and comments on articles and studies on various aspects of circumcision. It is endorsed by the British Medical Journal.
  • Circumcision FAQ by Geoffrey T. Falk
  • What Happens During Circumcision? - describes the medical procedure itself in detail
  • Circumcision Status, HIV Infection and AIDS - summarizes existing research into a possible link
• International Coalition for Genital Integrity An alliance of genital integrity groups.
• Intactivism, a site which is strongly opposed to circumcision and collects arguments on the subject
• The Case for Labectomy by Jason Rohrer, a satirical anti-circumcision text.

In favor of circumcision

• Benefits of Circumcision, a pro-circumcision information website
• Circlist, a pro-circumcision website and discussion group. It is noted for the sexual involvement of many of its contributors in circumcision. It is not a medical site and takes no stand on infant circumcision.
• Medicirc by circumcision advocate Dr. Edgar Schoen promotes circumcision because of its alleged health benefits
• ACT inc., "Advocating Circumcision Today", a Jewish group that refers mohels for circumcisions

General

• Foreskin.org, a collection of photographic images and related material about the male foreskin