Circumcision is the world's oldest planned surgical procedure, suggested by anatomist and hyperdiffusionist historian Grafton Elliot Smith
to be over 15,000 years old, pre-dating recorded history.
There is no
firm consensus as to how it came to be practiced worldwide. One theory
is that it began in one geographic area and spread from there; another
is that several different cultural groups began its practice
independently.
In his 1891 work History of Circumcision, physician Peter Charles Remondino suggested that it began as a less severe form of emasculating a captured enemy: penectomy or castration would likely have been fatal, while some form of circumcision would permanently mark the defeated yet leave him alive to serve as a slave.
The history of the migration and evolution of the practice of circumcision is followed mainly through the cultures and peoples in two separate regions.
In the lands south and east of the Mediterranean, starting with Sudan and Ethiopia, the procedure was practiced by the ancient Egyptians and the Semites, and then by the Jews and Muslims, with whom the practice traveled to and was adopted by the Bantu Africans.
In Oceania, circumcision is practiced by the Australian Aborigines and Polynesians. There is also evidence that circumcision was practiced among the Aztec and Mayan civilizations in the Americas, but little detail is available about its history.
The procedure is not explicitly mentioned in the Quran, however it is a tradition established by Islam's prophet Muhammad directly (following Abraham), and so its practice is considered a sunnah (prophet's tradition) and is very important in Islam.
For Muslims, circumcision is also a matter of cleanliness, purification and control over one's baser self (nafs).
There is no agreement across the many Islamic communities about the age at which circumcision should be performed.
It may be done from soon after birth up to about age 15; most often it is performed at around six to seven years of age.
The timing can correspond with the boy's completion of his recitation of the whole Quran, with a coming-of-age event such as taking on the responsibility of daily prayer or betrothal.
Circumcision may be celebrated with an associated family or community event. Circumcision is recommended for, but is not required of, converts to Islam.[22][83][84]
The Ethiopian Orthodox Church calls for circumcision, with near-universal prevalence among Orthodox men in Ethiopia.
In South Africa, some Christian churches disapprove of the practice, while others require it of their members.
For some of these groups, circumcision appears to be purely cultural, done with no particular religious significance or intention to distinguish members of a group. For others, circumcision might be done for purification, or it may be interpreted as a mark of subjugation.
Among these groups, even when circumcision is done for reasons of tradition, it is often done in hospitals.Male circumcision (from Latin circumcidere, meaning "to cut around") is the surgical removal of the foreskin (prepuce) from the human penis.
In a typical procedure, the foreskin is opened and then separated from the glans after inspection. The circumcision device (if used) is placed, and then the foreskin is removed. Topical or locally injected anesthesia may be used to reduce pain and physiologic stress.
For adults, general anesthesia is an option, and the procedure is often performed without a specialized circumcision device. The procedure is most often elected for religious reasons or personal preferences, but may be indicated for both therapeutic and prophylactic reasons.
It is a treatment option for pathological phimosis, refractory balanoposthitis and chronic urinary tract infections (UTIs); it is contraindicated in cases of certain genital structure abnormalities or poor general health.
The positions of the world's major medical organizations range from considering neonatal circumcision as having no benefit and significant risks to having a modest health benefit that outweighs small risks.
No major medical organization recommends either universal circumcision for all infant males (aside from the recommendations of the World Health Organization for parts of Africa), or banning the procedure.
Ethical and legal questions regarding informed consent and autonomy have been raised over non-therapeutic neonatal circumcision.
Outside the parts of Africa with high prevalence of HIV/AIDS, the positions of the world's major medical organizations on non-therapeutic neonatal circumcision range from considering it as having a modest net health benefit that outweighs small risks to viewing it as having no benefit with significant risks for harm.
No major medical organization recommends non-therapeutic neonatal circumcision, and no major medical organization calls for banning it either.
The Royal Dutch Medical Association, which expresses the strongest opposition to routine neonatal circumcision, does not call for the practice to be made illegal out of their concern that parents who insist on the procedure would turn to poorly trained practitioners instead of medical professionals.
This argument to keep the procedure within the purview of medical professionals is found across all major medical organizations. In addition, the organizations advise medical professionals to yield to some degree to parents' preferences, commonly based in cultural or religious views, in the decision to agree to circumcise.
Owing to the HIV/AIDS epidemic there, sub-Saharan Africa is a special case. The finding that circumcision significantly reduces female-to-male HIV transmission has prompted medical organizations serving the affected communities to promote circumcision as an additional method of controlling the spread of HIV.
The World Health Organization (WHO) and UNAIDS (2007) recommend circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV.
The World Health Organization promotes circumcision as a preventive measure for sexually active men in populations at high risk for HIV.
Circumcision is contraindicated in premature infants and those who are not clinically stable and in good health.
If an individual, child or adult, is known to have or has a family history of serious bleeding disorders (hemophilia), it is recommended that the blood be checked for normal coagulation properties before the procedure is attempted.
Evidence among heterosexual men in sub-Saharan Africa shows an absolute decrease in risk of 1.8% which is a relative decrease of between 38 percent and 66 percent over two years, and in this population studies rate it cost effective. Whether it is of benefit in developed countries is undetermined.
There are plausible explanations based on human biology for how circumcision can decrease the likelihood of female-to-male HIV transmission.
The superficial skin layers of the penis contain Langerhans cells, which are targeted by HIV; removing the foreskin reduces the number of these cells.
When an uncircumcised penis is erect during intercourse, any small tears on the inner surface of the foreskin come into direct contact with the vaginal walls, providing a pathway for transmission.
When an uncircumcised penis is flaccid, the pocket between the inside of the foreskin and the head of the penis provides an environment conducive to pathogen survival; circumcision eliminates this pocket. Some experimental evidence has been provided to support these theories.
The WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) state that male circumcision is an efficacious intervention for HIV prevention, but should be carried out by well-trained medical professionals and under conditions of informed consent (parents' consent for their infant boys).
The WHO has judged circumcision to be a cost-effective public health intervention against the spread of HIV in Africa, although not necessarily more cost-effective than condoms.
The Centers for Disease Control and Prevention (CDC) has calculated that newborn circumcision is cost-effective against HIV in the US.
The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should not replace known methods of HIV prevention.
The available evidence does not indicate that circumcision provides HIV protection for heterosexual women.
Data is lacking regarding the effect circumcision may have on the transmission rate of men who engage in anal sex with a female partner. It is undetermined whether circumcision benefits men who have sex with men.
A 2010 review of clinical trial data found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%. The researchers found mixed results for protection against trichomonas vaginalis and chlamydia trachomatis and no evidence of protection against gonorrhea or syphilis.
Among men who have sex with men, reviews have found poor evidence for protection against sexually transmitted infections other than HIV, with the possible exception of syphilis.
There is good but not ideal evidence that circumcision reduces the incidence of UTIs in boys under two years of age, and there is fair evidence that the reduction in incidence is by a factor of 3–10 times, but prevention of UTIs does not justify routine use of the procedure.
Circumcision is most likely to benefit boys who have a high risk of UTIs due to anatomical defects, and may be used to treat recurrent UTIs.
There is a plausible biological explanation for the reduction in UTI risk after circumcision. The orifice through which urine passes at the tip of the penis (the urinary meatus) hosts more urinary system disease-causing bacteria in uncircumcised boys than in circumcised boys, especially in those under six months of age.
As these bacteria are a risk factor for UTIs, circumcision may reduce the risk of UTIs through a decrease in the bacteria population.
Penile cancer is rare, with about 1 new case per 100,000 people per year in developed countries, and higher incidence rates per 100,000 in sub-Saharan Africa (for example, 1.6 in Zimbabwe, 2.7 in Uganda and 3.2 in Swaziland).
Penile cancer development can be detected in the carcinoma in situ (CIS) cancerous precursor stage and at the more advanced invasive squamous cell carcinoma stage.
Childhood or adolescent circumcision is associated with a reduced risk of invasive squamous cell carcinoma in particular.
There is an association between adult circumcision and an increased risk of invasive penile cancer; this is believed to be from men being circumcised as a treatment for penile cancer or a condition that is a precursor to cancer rather than a consequence of circumcision itself.
Penile cancer has been observed to be nearly eliminated in populations of males circumcised neonatally.
Important risk factors for penile cancer include phimosis and HPV infection, both of which are mitigated by circumcision.
The mitigating effect circumcision has on the risk factor introduced by the possibility of phimosis is secondary, in that the removal of the foreskin eliminates the possibility of phimosis.
This can be inferred from study results that show uncircumcised men with no history of phimosis are equally likely to have penile cancer as circumcised men.
Circumcision is also associated with a reduced prevalence of cancer-causing types of HPV in men and a reduced risk of cervical cancer (which is caused by a type of HPV) in female partners of men.
Because penile cancer is rare (and may get more rare with increasing HPV vaccination rates), and circumcision has risks, the practice is not considered to be valuable solely as a prophylactic measure against penile cancer in the United States.
These complications occur in less than 1% of procedures, and constitute the vast majority of all acute circumcision complications in the United States.
Minor complications are reported to occur in 3% of procedures. A specific complication rate is difficult to determine due to scant data on complications and inconsistencies in their classification.
Complication rates are greater when the procedure is performed by an inexperienced operator, in unsterile conditions, or when the child is at an older age.
Significant acute complications happen rarely, occurring in about 1 in 500 newborn procedures in the United States.
Severe to catastrophic complications are sufficiently rare that they are reported only as individual case reports.
The death rate due to circumcision is estimated at 1 in every 500,000 neonatal procedures conducted within the United States.
Other possible complications include concealed penis, skin bridges, urethral fistulas, and meatal stenosis. These complications may be avoided with proper technique, and are most often treatable without requiring a hospital visit.
Circumcision does not appear to decrease the sensitivity of the penis, harm sexual function or reduce sexual satisfaction.
A 2013 systematic review and meta-analysis found the circumcision did not appear to affect sexual desire, pain with intercourse, premature ejaculation, time to ejaculation, erectile dysfunction or difficulties with orgasm.
The Royal Dutch Medical Association's 2010 Viewpoint mentions that "complications in the area of sexuality" have been reported.
Additionally, the procedure may carry the risks of heightened pain response for newborns and dissatisfaction with the result.
In his 1891 work History of Circumcision, physician Peter Charles Remondino suggested that it began as a less severe form of emasculating a captured enemy: penectomy or castration would likely have been fatal, while some form of circumcision would permanently mark the defeated yet leave him alive to serve as a slave.
The history of the migration and evolution of the practice of circumcision is followed mainly through the cultures and peoples in two separate regions.
In the lands south and east of the Mediterranean, starting with Sudan and Ethiopia, the procedure was practiced by the ancient Egyptians and the Semites, and then by the Jews and Muslims, with whom the practice traveled to and was adopted by the Bantu Africans.
In Oceania, circumcision is practiced by the Australian Aborigines and Polynesians. There is also evidence that circumcision was practiced among the Aztec and Mayan civilizations in the Americas, but little detail is available about its history.
Cultures and religions
In some cultures, males must be circumcised shortly after birth, during childhood or around puberty as part of a rite of passage. Circumcision is commonly practiced in the Jewish and Islamic faiths.Islam
Although there is some debate within Islam over whether it is a religious requirement, circumcision (called khitan) is practiced nearly universally by Muslim males. Islam bases its practice of circumcision on the Genesis 17 narrative, the same Biblical chapter referred to by Jews.The procedure is not explicitly mentioned in the Quran, however it is a tradition established by Islam's prophet Muhammad directly (following Abraham), and so its practice is considered a sunnah (prophet's tradition) and is very important in Islam.
For Muslims, circumcision is also a matter of cleanliness, purification and control over one's baser self (nafs).
There is no agreement across the many Islamic communities about the age at which circumcision should be performed.
It may be done from soon after birth up to about age 15; most often it is performed at around six to seven years of age.
The timing can correspond with the boy's completion of his recitation of the whole Quran, with a coming-of-age event such as taking on the responsibility of daily prayer or betrothal.
Circumcision may be celebrated with an associated family or community event. Circumcision is recommended for, but is not required of, converts to Islam.[22][83][84]
Christianity
The New Testament chapter Acts 15 records that Christianity does not require circumcision; Christianity does not forbid it either. In 1442, the leadership of the Catholic Church declared that circumcision was not necessary. Coptic Christians practice circumcision as a rite of passage.\The Ethiopian Orthodox Church calls for circumcision, with near-universal prevalence among Orthodox men in Ethiopia.
In South Africa, some Christian churches disapprove of the practice, while others require it of their members.
African cultures
Certain African cultural groups, such as the Yoruba and Igbo of Nigeria, customarily circumcise their infant sons. The procedure is also practiced by some cultural groups or individual family lines in the Sudan, Zaire, Uganda and in southern Africa.For some of these groups, circumcision appears to be purely cultural, done with no particular religious significance or intention to distinguish members of a group. For others, circumcision might be done for purification, or it may be interpreted as a mark of subjugation.
Among these groups, even when circumcision is done for reasons of tradition, it is often done in hospitals.Male circumcision (from Latin circumcidere, meaning "to cut around") is the surgical removal of the foreskin (prepuce) from the human penis.
In a typical procedure, the foreskin is opened and then separated from the glans after inspection. The circumcision device (if used) is placed, and then the foreskin is removed. Topical or locally injected anesthesia may be used to reduce pain and physiologic stress.
For adults, general anesthesia is an option, and the procedure is often performed without a specialized circumcision device. The procedure is most often elected for religious reasons or personal preferences, but may be indicated for both therapeutic and prophylactic reasons.
It is a treatment option for pathological phimosis, refractory balanoposthitis and chronic urinary tract infections (UTIs); it is contraindicated in cases of certain genital structure abnormalities or poor general health.
The positions of the world's major medical organizations range from considering neonatal circumcision as having no benefit and significant risks to having a modest health benefit that outweighs small risks.
No major medical organization recommends either universal circumcision for all infant males (aside from the recommendations of the World Health Organization for parts of Africa), or banning the procedure.
Ethical and legal questions regarding informed consent and autonomy have been raised over non-therapeutic neonatal circumcision.
Indications and contraindications
Routine or elective
Neonatal circumcision is often elected for non-medical reasons, such as for religious beliefs or for personal preferences possibly driven by societal norms.Outside the parts of Africa with high prevalence of HIV/AIDS, the positions of the world's major medical organizations on non-therapeutic neonatal circumcision range from considering it as having a modest net health benefit that outweighs small risks to viewing it as having no benefit with significant risks for harm.
No major medical organization recommends non-therapeutic neonatal circumcision, and no major medical organization calls for banning it either.
The Royal Dutch Medical Association, which expresses the strongest opposition to routine neonatal circumcision, does not call for the practice to be made illegal out of their concern that parents who insist on the procedure would turn to poorly trained practitioners instead of medical professionals.
This argument to keep the procedure within the purview of medical professionals is found across all major medical organizations. In addition, the organizations advise medical professionals to yield to some degree to parents' preferences, commonly based in cultural or religious views, in the decision to agree to circumcise.
Owing to the HIV/AIDS epidemic there, sub-Saharan Africa is a special case. The finding that circumcision significantly reduces female-to-male HIV transmission has prompted medical organizations serving the affected communities to promote circumcision as an additional method of controlling the spread of HIV.
The World Health Organization (WHO) and UNAIDS (2007) recommend circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV.
Medical indications
Circumcision may be medically indicated in children for pathological phimosis, refractory balanoposthitis and chronic, recurrent urinary tract infections (UTIs) in males who are chronically susceptible to them.The World Health Organization promotes circumcision as a preventive measure for sexually active men in populations at high risk for HIV.
Contraindications
Circumcision is contraindicated in infants with certain genital structure abnormalities, such as a misplaced urethral opening (as in hypospadias and epispadias), curvature of the head of the penis (chordee), or ambiguous genitalia, because the foreskin may be needed for reconstructive surgery.Circumcision is contraindicated in premature infants and those who are not clinically stable and in good health.
If an individual, child or adult, is known to have or has a family history of serious bleeding disorders (hemophilia), it is recommended that the blood be checked for normal coagulation properties before the procedure is attempted.
Effects
Sexually transmitted diseases
Human immunodeficiency virus
There is strong evidence that circumcision reduces the risk of HIV infection in heterosexual men in high-risk populations.Evidence among heterosexual men in sub-Saharan Africa shows an absolute decrease in risk of 1.8% which is a relative decrease of between 38 percent and 66 percent over two years, and in this population studies rate it cost effective. Whether it is of benefit in developed countries is undetermined.
There are plausible explanations based on human biology for how circumcision can decrease the likelihood of female-to-male HIV transmission.
The superficial skin layers of the penis contain Langerhans cells, which are targeted by HIV; removing the foreskin reduces the number of these cells.
When an uncircumcised penis is erect during intercourse, any small tears on the inner surface of the foreskin come into direct contact with the vaginal walls, providing a pathway for transmission.
When an uncircumcised penis is flaccid, the pocket between the inside of the foreskin and the head of the penis provides an environment conducive to pathogen survival; circumcision eliminates this pocket. Some experimental evidence has been provided to support these theories.
The WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) state that male circumcision is an efficacious intervention for HIV prevention, but should be carried out by well-trained medical professionals and under conditions of informed consent (parents' consent for their infant boys).
The WHO has judged circumcision to be a cost-effective public health intervention against the spread of HIV in Africa, although not necessarily more cost-effective than condoms.
The Centers for Disease Control and Prevention (CDC) has calculated that newborn circumcision is cost-effective against HIV in the US.
The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should not replace known methods of HIV prevention.
The available evidence does not indicate that circumcision provides HIV protection for heterosexual women.
Data is lacking regarding the effect circumcision may have on the transmission rate of men who engage in anal sex with a female partner. It is undetermined whether circumcision benefits men who have sex with men.
Other infections
Studies evaluating the effect of circumcision on the incidence of other sexually transmitted infections have reached conflicting conclusions. A 2006 meta-analysis found that circumcision was associated with lower rates of syphilis, chancroid and possibly genital herpes.A 2010 review of clinical trial data found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%. The researchers found mixed results for protection against trichomonas vaginalis and chlamydia trachomatis and no evidence of protection against gonorrhea or syphilis.
Among men who have sex with men, reviews have found poor evidence for protection against sexually transmitted infections other than HIV, with the possible exception of syphilis.
Urinary tract infections
A UTI affects parts of the urinary system including the urethra, bladder, and kidneys. There is about a 1% risk of UTIs in boys under two years of age, and the majority of incidents occur in the first year of life.There is good but not ideal evidence that circumcision reduces the incidence of UTIs in boys under two years of age, and there is fair evidence that the reduction in incidence is by a factor of 3–10 times, but prevention of UTIs does not justify routine use of the procedure.
Circumcision is most likely to benefit boys who have a high risk of UTIs due to anatomical defects, and may be used to treat recurrent UTIs.
There is a plausible biological explanation for the reduction in UTI risk after circumcision. The orifice through which urine passes at the tip of the penis (the urinary meatus) hosts more urinary system disease-causing bacteria in uncircumcised boys than in circumcised boys, especially in those under six months of age.
As these bacteria are a risk factor for UTIs, circumcision may reduce the risk of UTIs through a decrease in the bacteria population.
Cancers
Circumcision has a protective effect against the risks of penile cancer in men, and cervical cancer in the female sexual partners of heterosexual men.Penile cancer is rare, with about 1 new case per 100,000 people per year in developed countries, and higher incidence rates per 100,000 in sub-Saharan Africa (for example, 1.6 in Zimbabwe, 2.7 in Uganda and 3.2 in Swaziland).
Penile cancer development can be detected in the carcinoma in situ (CIS) cancerous precursor stage and at the more advanced invasive squamous cell carcinoma stage.
Childhood or adolescent circumcision is associated with a reduced risk of invasive squamous cell carcinoma in particular.
There is an association between adult circumcision and an increased risk of invasive penile cancer; this is believed to be from men being circumcised as a treatment for penile cancer or a condition that is a precursor to cancer rather than a consequence of circumcision itself.
Penile cancer has been observed to be nearly eliminated in populations of males circumcised neonatally.
Important risk factors for penile cancer include phimosis and HPV infection, both of which are mitigated by circumcision.
The mitigating effect circumcision has on the risk factor introduced by the possibility of phimosis is secondary, in that the removal of the foreskin eliminates the possibility of phimosis.
This can be inferred from study results that show uncircumcised men with no history of phimosis are equally likely to have penile cancer as circumcised men.
Circumcision is also associated with a reduced prevalence of cancer-causing types of HPV in men and a reduced risk of cervical cancer (which is caused by a type of HPV) in female partners of men.
Because penile cancer is rare (and may get more rare with increasing HPV vaccination rates), and circumcision has risks, the practice is not considered to be valuable solely as a prophylactic measure against penile cancer in the United States.
Adverse effects
Neonatal circumcision is generally safe when done by an experienced practitioner. The most common acute complications are bleeding, infection and the removal of either too much or too little foreskin.These complications occur in less than 1% of procedures, and constitute the vast majority of all acute circumcision complications in the United States.
Minor complications are reported to occur in 3% of procedures. A specific complication rate is difficult to determine due to scant data on complications and inconsistencies in their classification.
Complication rates are greater when the procedure is performed by an inexperienced operator, in unsterile conditions, or when the child is at an older age.
Significant acute complications happen rarely, occurring in about 1 in 500 newborn procedures in the United States.
Severe to catastrophic complications are sufficiently rare that they are reported only as individual case reports.
The death rate due to circumcision is estimated at 1 in every 500,000 neonatal procedures conducted within the United States.
Other possible complications include concealed penis, skin bridges, urethral fistulas, and meatal stenosis. These complications may be avoided with proper technique, and are most often treatable without requiring a hospital visit.
Circumcision does not appear to decrease the sensitivity of the penis, harm sexual function or reduce sexual satisfaction.
A 2013 systematic review and meta-analysis found the circumcision did not appear to affect sexual desire, pain with intercourse, premature ejaculation, time to ejaculation, erectile dysfunction or difficulties with orgasm.
The Royal Dutch Medical Association's 2010 Viewpoint mentions that "complications in the area of sexuality" have been reported.
Additionally, the procedure may carry the risks of heightened pain response for newborns and dissatisfaction with the result.
