Circumcision is the removal of some or all of the prepuce (foreskin). The frenulum is often excised at the same time, in a procedure called frenectomy. The word circumcision comes from Latin circum (="around") and caedere (="to cut"). Female circumcision is a term applied to a variety of procedures performed on the female genitalia, of which only one, the removal of the clitoral hood, is comparable to male circumcision. Except where specified, "circumcision" in this article should be taken as "male circumcision."
An uncircumcised penis, a circumcised penis
Reasons for circumcision
Circumcision is performed for religious, cultural, and medical reasons. Elective adult circumcision may also be chosen as a form of body modification, or for aesthetic or other reasons.
Religious and cultural circumcision
Circumcision is a religious practice traditionally required by Judaism, usually performed in a ceremony 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. See also: 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 Qur'an (and the mutilation of the body is expressly forbidden therein), it is mentioned in some parts of the Hadith, a set of texts explaining Islamic law that most Muslims view as authoritative. Most Muslims believe that Muhammad was born circumcised. Moreover, Hadiths describe that the ritual of circumcision was started by Abraham, who is seen as the founder of Islam. 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. In Egypt, farmers in rural areas celebrate circumcision as a joyous occasion, while in urban populations, as in many industrialized countries such as the USA, the procedure is routinely performed at a hospital.
Circumcision is also customary in the Coptic Christian religious tradition. It is usually performed on the eighth day of life. This practice was condemned by the Council of Florence [(http://www.newadvent.org/cathen/06111a.htm)] 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. 
The United States and South Korea are the only countries that practice circumcision routinely on a majority of 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.
Circumcision may be recommended in cases such as phimosis (a very tight foreskin), or posthitis (an inflamed foreskin), for which it is an effective treatment. It may also be advised in cases of recurrent balanitis and urinary tract infections, balanitis xerotica obliterans, Zoon's balanitis, and penile cancer.
Whether or not circumcision has medical benefits is controversial; some argue that circumcision is an essential public health measure, while others believe that there are no benefits to the procedure. For a detailed discussion, see medical analysis of circumcision.
Most major medical societies and other countries do not recommend routine infant circumcision, though some organisations argue that parents should make an informed decision based upon medical and other benefits and risks, while others discourage the procedure altogether.
Circumcision and body modification
Circumcision may be undertaken voluntarily as a body modification (see also: foreskin restoration). This may be for aesthetic reasons, as part of a Dom/sub relationship, or as part of a Circumcision fetish.
History of circumcision
Main article: History of male circumcision
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, as an aid to hygiene where regular bathing was impractical, as a means of marking those of lower (or higher) social status, as a means of differentiating a circumcising group from their non-circumcising neighbors, as a means of discouraging masturbation or other socially proscribed sexual behaviors, to increase a man's attractiveness to women, as a symbolic castration, as a demonstration of one's ability to endure pain, or as a male counterpart to menstruation or the breaking of the hymen. It is possible that circumcision arose independently in different cultures for different reasons.
Circumcision in the Ancient World
The oldest documentary evidence for circumcision comes from Egypt. Tomb artwork from the Sixth Dynasty (2345 - 2181 BC) 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 both circumcised and uncircumcised men.
Circumcision was common, although not universal, among ancient Semitic peoples. The Book of Jeremiah, written in the sixth century BC, lists the Egyptians, Jews, Edomites, Ammonites, and Moabites as circumcising people. Herodotus, writing in the fifth century BC, would add the Colchians, Ethiopians, Phoenicians, and Syrians to that list.
Circumcision was also practiced by the Jews in a military context. The Biblical account of David's campaigns indicates that he circumcised two hundred fallen enemy warriors, offering the foreskins to King Saul as bride price for one of his daughters.
Except in the portrayal of satyrs, lechers, and barbarians, ancient Greek artwork portrayed penises covered by foreskins. In the aftermath of Alexander the Great's conquests, the Greek dislike of the appearance of the circumcised penis led to a decline in the incidence of circumcision among many peoples that had previously practiced it. The writer of 1 Maccabees wrote that under the Seleucids, many Jewish men attempted to hide or reverse their circumcision so they could exercise in Greek gymnasia. Because of these attempts, and for other reasons, the Pharisees, ca. 100, added two more steps to the Biblical rite of circumcision:
- Brit Peri'ah, which went beyond the relatively simple and Biblical trimming of excess foreskin, and stripped the mucosal lining of the foreskin back to the coronal sulcus.
- Brit Mezizah, by which the trained rabbi ("mohel") fills his mouth with wine and sucks the wound made by the circumcision, repeating the process a few times
Cultural pressures to circumcise operated throughout the Hellenistic world: when the Judean king John Hyrcanus conquered the Idumeans, he forced them to become circumcised and convert to Judaism, but their ancestors the Edomites had practiced circumcision in pre-Hellenistic times. In Egypt, only the priestly caste retained circumcision, and by the second century, the only circumcising groups in the Roman Empire were Jews, Egyptian priests, and the Nabatean Arabs. Circumcision was sufficiently rare among non-Jews that being circumcised was considered conclusive evidence of Judaism in Roman courts.
Medical circumcision in the 19th century
Until 1870, medical circumcisions were performed to treat conditions local to the penis: phimosis, balanitis, and penile cancer. In that year, Lewis Sayre , a prominent New York orthopedic surgeon and vice president of the newly-formed American Medical Association, examined a five-year-old boy who was unable to straighten his legs, and whose condition had so far defied treatment. Upon noting that the boy's genitals were inflamed, Sayre hypothesized that chronic irritation of the boy's foreskin had paralyzed his knees via reflex neurosis . Sayre circumcised the boy, and within a few weeks, he recovered from his paralysis. After several additional incidents in which circumcision also appeared effective in treating paralyzed joints, Sayre began to promote circumcision as a powerful orthopedic remedy.
Sayre's prominence within the medical profession allowed him to reach a wide audience. He lectured widely in the United States and the United Kingdom, and his ideas influenced physicians throughout the English-speaking world. As more practitioners tried circumcision as a treatment for otherwise intractable medical conditions, sometimes achieving positive results, the list of ailments reputed to be treatable through circumcision grew. By the 1890s, hernia, bladder infections, kidney stones, insomnia, chronic indigestion, rheumatism, epilepsy, asthma, bedwetting, Bright's disease, erectile dysfunction, syphilis, insanity, and skin cancer had all been linked to the foreskin, and many physicians advocated universal circumcision as a preventive health measure.
Specific medical arguments aside, several hypotheses have been raised in explaining the public's acceptance of infant circumcision as preventive medicine. The success of the germ theory of disease had not only enabled physicians to combat many of the postoperative complications of surgery, but had made the wider public deeply suspicious of dirt and bodily secretions. Accordingly, the smegma that collects under the foreskin was viewed as unhealthy, and circumcision readily accepted as good penile hygiene. Secondly, moral sentiment of the day regarded masturbation as not only sinful, but also physically and mentally unhealthy, stimulating the foreskin to produce the host of maladies of which it was suspected. In this climate, circumcision could be employed as a means of discouraging masturbation. All About the Baby, a popular parenting book of the 1890s, recommended infant circumcision for precisely this purpose. Thirdly, with the proliferation of hospitals in urban areas, childbirth, at least among the upper and middle classes, was increasingly undertaken in the care of a physician in a hospital rather than that of a midwife in the home. It has been suggested that once a critical mass of infants were being circumcised in the hospital, circumcision became a class marker of those wealthy enough to afford a hospital birth.
During the same time period, circumcision was becoming easier to perform. William Halstead 's 1885 discovery of hypodermic cocaine as a local anaesthetic made it easier for doctors without expertise in the use of chloroform and other general anaesthetics to perform minor surgeries. Also, several mechanically-aided circumcision techniques, forerunners of modern clamp-based circumcision methods, were first published in the medical literature of the 1890s, allowing surgeons to perform circumcisions more safely and successfully.
By the 1920s, advances in the understanding of disease had undermined much of the original medical basis for preventive circumcision. Doctors continued to promote it, however, as good penile hygeine and as a preventive for a handful of conditions local to the penis: balanitis, phimosis, and penile cancer.
Routine infant circumcision was successfully promoted in the English-speaking parts of Canada, Australia, New Zealand, the United States and the United Kingdom. Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 30% of newborn American boys were being circumcised in 1900, 55% in 1925, and 72% in 1950.
Circumcision since 1950
In 1949, a lack of consensus in the medical community as to whether circumcision carried with it any notable health benefit motivated the United Kingdom's newly-formed National Health Service to remove routine infant circumcision from its list of covered services. Since then, circumcision has been an out-of-pocket cost to parents, and the fraction of newborns circumcised in the hospital has fallen to less than one percent.
The practice was quickly dropped in the United Kingdom shortly after World War II, partially owing to the nation's massive post-war depression and devastation of much of its cities. Families during this time barely had the resources to get food and water, let alone money to spend on an operation whose necessity was already being called into question.
Trends similar to Britain's National Health Service have operated in Canada. Individual provincial heath services began delisting circumcision in the 1980s; at present, only Manitoba pays for the procedure. The infant circumcision rate in Canada has fallen from roughly half in the 1970s to its present value of 13%, albeit with strong regional variations.
In South Korea, circumcision was largely unknown before the establishment of the United States trusteeship in 1945 and the spread of Christianity. More than 90% of South Korean high school boys are now circumcised, but the average age of circumcision is 12 years .
In South Africa circumcision has roots in several belief systems and is performed much of the time to teen aged males : "...The young men in the eastern Cape belong to the Xhosa ethnic group for whom circumcision is considered part of the passage into manhood... A law was recently introduced requiring initiation schools to be licensed and only allowing circumcisions to be performed on youths aged 18 and older. But Eastern Cape provincial Health Department spokesman Sizwe Kupelo told Reuters news agency that boys as young as 11 had died. Each year thousands of young men go into the bush alone, without water, to attend initiation schools. Many do not survive the ordeal..." .
In the United States, statistics collected by the National Center for Health Statistics show that the overall rate of neonatal circumcision has remained near 65% since data collection began in 1979 . However, strong regional differences in the circumcision rates have developed during this time. While more than 80% of newborn boys are circumcised in the Midwest and South, circumcision rates have declined to about 37% in the West . This has been attributed in part to increasing births among Latin Americans, who usually do not circumcise . Thirteen states no longer pay for the procedure under Medicaid; the other 37 still do.
The major medical societies in Britain, Canada, Australia and New Zealand do not support routine non-therapeutic infant circumcision. Major medical organizations in the United States state that parents should decide what is in their child's best interests, declining to make a recommendation one way or another. Neonatal circumcision nonetheless still remains the most common pediatric operation carried out in the U.S. today.
International circumcision rates
||Neonatal circumcisions (%)
|*Samoans, Tongans and Niueans in New Zealand continue to practice circumcision, but not in public hospitals, which these data refer to
Emotional impact of circumcision and non-circumcision
Much attention has been given to the emotional impact of the female form of circumcision, but some argue that male circumcision has just as much impact in this area. Emotional impact will vary from person to person and depend on cultural context and other factors. Issues about the rights of the child are often overlooked, as is the possibility that circumcision causes emotional harm to some males.
Two large-scale internet surveys have found that the percentages of circumcised and uncircumcised males dissatisfied with their status are approximately equal, with about 10-15% dissatisfied in each group.  The only formal study in the literature, by Schlossberger et al., found that circumcised boys scored higher on satisfaction items.
There are an increasing number of support groups for circumcised males that feel violated by their circumcision which, they often feel, was forced on them and had little or no medical value. These groups often advocate foreskin restoration. There are also support groups for men dissatisfied with being uncircumcised , and considering adult circumcision.
The issue of consent is of particular relevance to circumcision since its often done to infants, the segment of the population most unable to understand or communicate wishes about the procedure. The decision therefore must ride entirely on the child's caregiver.
In particular, debate focuses on what limits if any should be placed on the caregiver's ability to make a decision for their child about a procedure with disputed immediate medical value which causes pain and, some argue, mutilation, that may be unwanted later in life. Some suggest that circumcision may cause emotional scarring later on.
Medical circumcision of a minor
There is some question whether or not most parents without medical training have the understanding to grant informed consent on behalf of their child for medical circumcision since circumcision is a taboo subject in many cultures. Little or no information about it appears in the media, and given circumcision's religious and cultural importance, the impartiality of information about circumcision may be drawn into question. Individuals and organizations from cultures where circumcision is common may lean too much towards ideals of circumcision being painless, beneficial or harmless, while the opposite might be true for cultures where circumcision is uncommon. Scientific and medical data may be set aside and ignored in favour of a more culturally palatable view of the procedure.
Religious circumcision of a minor
It is not uncommon in some parts of the world to circumcise minors for medicinal, religious or cultural reasons. Many people believe that this practice is protected fundamentally under the principal of freedom of religion and conscience. Other people disagree, arguing that no right has precedence over the rights of the child. Still others contend that freedom of religion only applies to belief and not action involving others.
Circumcision of an adult
Although the right to consent on behalf of a minor is widely debated, the right for an adult to consent to relgious or cultural circumcision is less controversial. In most cases doing so is legal at one's own volition. This view is often true for female circumcision too, although female circumcision is often viewed as more distasteful in Western cultures.
Prevalence of circumcision
Estimates of the proportion of males that are circumcised worldwide vary from one sixth to one third.
The majority of males are circumcised in the following countries:
Afghanistan, Albania, Algeria, Azerbaijan, Bahrain, Bangladesh, Benin, Cameroon, Chad, Comoros, Djibouti, Egypt, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Indonesia, Iran, Iraq, Israel, Kazakhstan, Kenya, Kuwait, Lebanon, Libya, Madagascar, Malaysia, Maldives, Mali, Mauritania, Morocco, Nigeria, Niger, Pakistan, Philippines, Qatar, Republic of the Congo, Samoa. Tonga, Saudi Arabia, Sierra Leone, Somalia, "Somaliland", South Africa, South Korea, Sudan, Syria, Tajikistan, Togo, Tunisia, Turkey, "Turkish Republic of Northern Cyprus", Turkmenistan, United Arab Emirates, the United States of America, Uzbekistan, Vanuatu and Yemen.
In most of these countries the predominant religion (usually Islam or Judaism) endorses circumcision.
In the United States, statistics collected by the National Center for Health Statistics show that the overall rate of neonatal circumcision has remained near 65% since data collection began in 1979 . However, strong regional differences in the circumcision rates have developed during this time. While more than 80% of newborn boys are circumcised in the Midwest and South, circumcision rates have declined to about 37% in the West . This has been attributed in part to increasing births among Latin Americans, who usually do not circumcise . A recent study used data from the Nationwide Inpatient Sample (a 20% sample of the nation's total inpatients), and found a significant rise in circumcisions between 1988 and 2000. Thirteen states no longer pay for the procedure under Medicaid, causing some parents to request the procedure at a later time.
- Billy Ray Boyd. Circumcision Exposed: Rethinking a Medical and Cultural Tradition. Freedom, CA: The Crossing Press, 1998. (ISBN 0-89594-939-3)
- Anne Briggs. Circumcision: What Every Parent Should Know. Charlottesville, VA: Birth & Parenting Publications, 1985. (ISBN 0-9615484-0-1)
- Aaron J. Fink, M.D. Circumcision: A Parent's Decision for Life. Kavanah Publishing Company, Inc., 1988. (ISBN 0-962-13470-8)
- 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 0-446-67880-5)
- David L. Gollaher. Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000. (ISBN 0-456-04397-6)
- Ronald Goldman, Ph.D. Circumcision: The Hidden Trauma. Boston: Vanguard, 1996. (ISBN 0-964-44895-3-8)
- Brian J. Morris, Ph.D., D.Sc. In Favour of Circumcision. Sydney: UNSW Press, 1999. (ISBN 0-86840-537-X)
- Rosemary Romberg. Circumcision: The Painful Dilemma. South Hadley, MA Bergan & Garvey, 1985. (ISBN 0-897-89073-6)
- Edward Wallerstein. Circumcision: An American Heath Fallacy. New York: Springer, 1980 (ISBN 0-826-13240-5)
- Gerald N. Weiss M.D. and Andrea W Harter. Circumcision: Frankly Speaking. Wiser Publications, 1998. (ISBN 0-966-72190-X)
Last updated: 06-02-2005 13:03:31
Last updated: 09-12-2005 02:39:13