Circumcision

Un article de Vev.

Modèle:Otheruses4

Circumcision is the removal of some or all of the foreskin (prepuce) from the penis.<ref>Dictionary definitions of circumcision:

• "The act of cutting off the prepuce or foreskin of males, or the internal labia of females." Webster's Revised Unabridged Dictionary (1913) [1]
• "to remove the foreskin of (males) sometimes as a religious rite." The Macquarie Dicitionary (2nd Edition, 1991)
• "Cut off foreskin of (as Jewish or Mohammedan rite, or surgically), Concise Oxford Dictionary, 5th Edition, 1964

Circumcision defined in a medical context:

• "Male circumcision is the surgical removal of all or part of the foreskin of the penis." Information Package on Male Circumcision and HIV Prevention:Insert 1, World Health Organization
• "Circumcision, surgical removal of all or part of the foreskin of the human male...", "Circumcision", Microsoft Encarta, 2007.
• "Male circumcision is an elective surgery to remove the foreskin..." Circumcision, British Columbia Health Guide, June 2, 2006. Retrieved July 18, 2007.
• "Circumcision is surgery..." Pain and Your Infant: Medical Procedures, Circumcision and Teething, University of Michigan Health System, February 2007. Retrieved July 18, 2007.
• " Circumcision is cutting away part of the foreskin... When this surgery is performed..." Newborn Care, Danbury Hospital website. Retrieved July 18, 2007.

</ref> The word "circumcision" comes from Latin circum (meaning "around") and cædere (meaning "to cut").

The earliest pictures are from cave drawings of Ancient Egyptian tombs, though some pictures may be open to interpretation.<ref>http://www.cirp.org/library/history/hodges2 See 'Egyptians'</ref><ref>Modèle:Cite journal as quoted in: Modèle:Cite journal </ref><ref name = "Gollaher">Modèle:Cite book </ref> Male circumcision is a religious commandment in Judaism as well as in Islam,<ref> Circumcision

. American-Israeli Cooperative Enterprise  
 

 

. Retrieved on 2006-10-03.

</ref><ref>Modèle:Cite encyclopedia</ref> and customary in some Oriental Orthodox and other Christian churches in Africa.<ref name=Christian>Customary in some Coptic and other churches:

• "The Coptic Christians in Egypt and the Ethiopian Orthodox Christians— two of the oldest surviving forms of Christianity— retain many of the features of early Christianity, including male circumcision. Circumcision is not prescribed in other forms of Christianity... Some Christian churches in South Africa oppose the practice, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership and participants in focus group discussions in Zambia and Malawi mentioned similar beliefs that Christians should practice circumcision since Jesus was circumcised and the Bible teaches the practice." Male Circumcision: context, criteria and culture (Part 1), Joint United Nations Programme on HIV/AIDS, February 26, 2007.
• "The decision that Christians need not practice circumcision is recorded in Acts 15; there was never, however, a prohibition of circumcision, and it is practiced by Coptic Christians." "circumcision", The Columbia Encyclopedia, Sixth Edition, 2001-05.</ref>

Circumcision is most common in the Middle East, the USA and parts of Africa and Asia. According to WHO 30% of men worldwide have had the procedure, mostly in developing countries where it is common for religious or cultural reasons.<ref name="WHO-Info-2"> Insert 2

. Information Package on Male Circumcision and HIV Prevention
. World Health Organization 
 
   (2007)
     
   
 

. Retrieved on 2007-08-15.

</ref> Opponents of circumcision condemn infant circumcision as being medically unjustified and an infringement upon individual bodily rights<ref name = "Milos">Modèle:Cite journal </ref>, while advocates of circumcision regard it as a worthwhile public health measure,<ref name="Schoen">Modèle:Cite journal </ref> particularly in the control of HIV in Sub-Saharan Africa.<ref name = "Newell">Modèle:Cite journal </ref><ref name="baileyrct">Modèle:Cite journal </ref><ref name="grayrct">Modèle:Cite journal </ref>

In March 2007 the World Health Organization and UNAIDS recognized male circumcision as an effective intervention for HIV prevention, but warned that male circumcision only provides partial protection and should not replace other interventions to prevent the heterosexual transmission of HIV.<ref name="WHO-C&R">Modèle:Cite paper </ref>

Circumcision may also be used to treat inflammation of the glans and penile cancer.<ref name="aafpadult">Modèle:Cite journal </ref><ref>Modèle:Cite journal</ref> Using circumcision to treat phimosis (see section below) is debated in medical literature.<ref name="dewan">Modèle:Cite journal</ref><ref name="beauge">Modèle:Cite journal</ref>

Sommaire 1 Circumcision procedures 2 Cultures and religions 3 Ethical, emotional and legal considerations 3.1 Ethical issues 3.1.1 Consent 3.2 Emotional consequences 3.3 Legality 4 Pain and pain relief during circumcision 5 Sexual effects 6 Medical aspects 6.1 Risks of circumcision 6.2 HIV and other sexually transmitted diseases 6.3 Hygiene, and infectious and chronic conditions 6.4 Penile cancer 6.5 Policies of various national medical associations 6.5.1 United States 6.5.2 Canada 6.5.3 United Kingdom 6.5.4 Australasia 7 History of circumcision 7.1 Medical circumcision in the 19th century and early 20th century 7.2 Circumcision since 1950 8 Prevalence of circumcision 9 See also 10 Notes 11 External links 11.1 Circumcision opposition 11.2 Circumcision promotion 11.3 Circumcision techniques 12 Further reading

Circumcision procedures

For infant circumcision, clamps, such as the Gomco clamp, Plastibell, and Mogen are often used.<ref>Modèle:Cite journal </ref> Clamps are designed to cut the blood supply to the foreskin, stop any bleeding and protect the glans. Before using a clamp, the foreskin and the glans are separated with a blunt probe and/or curved hemostat.

• With the Plastibell, the foreskin and the clamp come away in three to seven days.

• With a Gomco clamp, a section of skin is first crushed with a hemostat then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp and the clamp is tightened, "crushing the foreskin between the bell and the base plate." The crushing limits bleeding (provides hemostasis). While the flared bottom of the bell fits tightly against the hole of the base plate, the foreskin is then cut away with a scalpel from above the base plate. The bell prevents the glans being reached by the scalpel.<ref>Modèle:Cite journal

</ref>

• With a Mogen clamp, the foreskin is grabbed dorsally with a straight hemostat, and lifted up. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result," than with Gomco or Plastibell circumcisions. The clamp is locked shut, and a scalpel is used to cut the foreskin from the flat (upper) side of the clamp.<ref name="Pfenninger">Modèle:Cite book

</ref><ref name="Reynolds">Modèle:Cite journal </ref>

Cultures and religions

Modèle:See also Modèle:See also

Circumcising cultures may circumcise their males either shortly after birth, during childhood or around puberty as part of a rite of passage. Circumcision is most prevalent in Muslim countries, Israel, the United States, the Philippines and South Korea and is commonly practised in the Jewish and Muslim faiths. It is less common in Europe, Latin America, China and India.

Circumcision is a positive commandment obligatory under Jewish law for Jewish males, and is only postponed or abrogated in the case of threat to the life or health of the child.<ref name="GlassJM">Modèle:Cite journal </ref> It is usually performed by a mohel on the eighth day after birth in a ceremony called a Brit milah (or Bris milah, colloquially simply bris) (Hebrew for "Covenant of circumcision").

While in most countries, Christians do not circumcise,<ref name = "CoF">Modèle:Cite book </ref> it is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches<ref name=Christian/>. Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya<ref>Mattson CL, Bailey RC, Muga R, Poulussen R, Onyango T (2005) Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza province Kenya. AIDS Care 17:182–194.</ref><ref name=Christian/>, require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ. <ref>Greek Orthodox Archdiocese calendar of Holy Days</ref><ref>Russian Orthodox Church, Patriarchate of Moscow</ref>

In Islam, circumcision is mentioned in some hadith, but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended (Sunnah); others that it is obligatory.<ref> Al-Munajjid , Muhammed Salih

.    Question #9412: Circumcision: how it is done and the rulings on it 
. Islam Q&A 
   

. Retrieved on 2006-07-01.

</ref> Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham.<ref> Al-Munajjid , Muhammed Salih

.    Question #7073: The health and religious benefits of circumcision 
. Islam Q&A 
   

. Retrieved on 2006-07-01.

</ref> While endorsing circumcision for males, scholars note that it is not a requirement for converting to Islam.<ref>Modèle:Cite book</ref>

Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War. In West Africa infant circumcision may have had tribal significance as a rite of passage or otherwise in the past; today in some non-Muslim Nigerian societies it is medicalised and is simply a cultural norm.<ref>Ajuwon et al., "Indigenous surgical practices in rural southwestern Nigeria: Implications for disease," Health Educ. Res..1995; 10: 379-384 Health Educ. Res..1995; 10: 379-384 Retrieved 3 October 2006</ref>

Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land,<ref>Modèle:Cite paper </ref> where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.<ref> Migration and Trade

. Green Turtle Dreaming  
 

 

. Retrieved on 2006-10-18.

 “In exchange for turtles and trepang the Makassans introduced tobacco, the practice of circumcision and knowledge to build sea-going canoes.”

</ref> Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature, including subincision for some aboriginal peoples in the Western Desert.<ref>Modèle:Cite journal </ref> In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu;<ref> RECENT GUEST SPEAKER

. Australian AIDS Fund Incorporated 
 
   (2006)
     
   
 

. Retrieved on 2006-07-01.

</ref> participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.<ref> Weird & Wonderful

. United Travel  
 

 

. Retrieved on 2006-07-01.

</ref>

Circumcision is also commonly practiced in the Polynesian islands of Samoa, Tonga, Niue, and Tikopia. In Samoa, it is accompanied by a celebration. Among some West African animist groups, such as the Dogon and Dowayo, it is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males.<ref> Circumcision amongst the Dogon

. The Non-European Components of European Patrimony (NECEP) Database 
 
   (2006)
     
   
 

. Retrieved on 2006-09-03.

</ref> Among the Urhobo of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te Oshare ("the boy is now man"), constitutes a rite of passage from one age set to another.<ref>Modèle:Cite journal </ref> For Nilotic peoples, such as the Kalenjin and Maasai, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set.<ref> Masai of Kenya

. Retrieved on 2007-04-06.

 “Authority derives from the age-group and the age-set. Prior to circumcision a natural leader  or olaiguenani is selected; he leads his age-group through a series of rituals until old age, sharing responsibility with a select few, of whom the ritual expert (oloiboni) is the ultimate authority. Masai youths are not circumcised until they are mature, and a new age-set is initiated together at regular intervals of twelve to fifteen years.  The young warriors (ilmurran) remain initiates for some time, using blunt arrows to hunt small birds   which are stuffed and tied to a frame to form a head-dress.”

</ref>

Ethical, emotional and legal considerations

Ethical issues

Main article: Bioethics of neonatal circumcision

The American Medical Association defines “non-therapeutic” circumcision as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. It states that medical associations in the US, Australia, and Canada do not recommend the routine non-therapeutic circumcision of newborns.<ref name = "CSA:I-99"> Report 10 of the Council on Scientific Affairs (I-99):Neonatal Circumcision

. 1999 AMA Interim Meeting: Summaries and Recommendations of Council on Scientific Affairs Reports
 17
. American Medical Association 
 
   (December 1999)
       
   
 

. Retrieved on 2006-06-13.

</ref>

Circumcision advocates argue that circumcision is a significant public health measure, preventing infections, and slowing down the spread of AIDS.<ref name = "ANRS">Modèle:Cite journal </ref> Opponents of circumcision question the ethical validity of removing genital tissue from a minor, arguing that infant circumcision infringes upon individual autonomy and represents a human rights violation.<ref name = "Somerville">Modèle:Cite book </ref><ref name = "VanHoweLegal">Modèle:Cite journal </ref>

Consent

Views differ on whether limits should be placed on caregivers having a child circumcised.

Some medical associations take the position that the parents should determine what is in the best interest of the infant or child,<ref name = "AAP1999">Modèle:Cite journal </ref><ref name = "CSA:I-99" /><ref name="CMAJ2"/> but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue.<ref name = "RACPSumm"> Policy Statement On Circumcision

 (PDF)
. Royal Australasian College of Physicians 
 
   (September 2004)
       
   
 

. Retrieved on 2007-02-28.

 “The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision. Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It remains an important ritual in some religious and cultural groups.…In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis.…The complication rate of neonatal circumcision is reported to be around 1% to 5% and includes local infection, bleeding and damage to the penis. Serious complications such as bleeding, septicaemia and meningitis may occasionally cause death. The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law. If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate.”

</ref><ref name = "BMAGuide"> Medical Ethics Committee

       (June 2006)
       
   
 
.    The law and ethics of male circumcision - guidance for doctors 
. British Medical Association 
   

. Retrieved on 2006-07-01.

</ref> The BMA state that in general, "the parents should determine how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices." They state that because the parents' interests and the child's interests sometimes differ, there are "limits on parents' rights to choose and parents are not entitled to demand medical procedures contrary to their child's best interests." They state that competent children may decide for themselves.<ref name = "BMAGuide" />

Some argue that the medical problems that have their risk reduced by circumcision are already rare, can be avoided, and, if they occur, can usually be treated in less invasive ways than circumcision. Somerville states that the removal of healthy genital tissue from a minor should not be subject to parental discretion and that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient.<ref name = "Somerville" /> Denniston contends that circumcision is harmful and asserts that in the absence of the individual's consent, non-therapeutic child circumcision violates several ethical principles that govern medicine.<ref>Circumcision and the Code of Ethics, George C. Denniston, Humane Health Care Volume 12, Number 2</ref>

Others believe neonatal circumcision is permissible, if parents should so choose. Benatar and Benatar argue that circumcision can be beneficial to a male before he would be able to otherwise provide consent, that "it is far from obvious that circumcision reduces sexual pleasure," and that "it is far from clear that non-circumcision leaves open a future person’s options in every regard."<ref>Modèle:Cite journal</ref> In a cultural or religious context, Levenson argues that circumcision is of significant enough importance that parental consent is sufficient and that any possible misgivings surrounding the issue of consent are not significant enough to limit the exercise of infant/childhood circumcision.<ref>The New Enemies of Circumcision, Jon D. Levenson, Commentary Magazine</ref>

Emotional consequences

Moses et al. (199Image:Cool.gif state that "scientific evidence is lacking" for psychological and emotional harm, and cite a longitudinal study finding no difference in developmental and behavioural indices.<ref>Modèle:Cite journal</ref> Goldman (1999) discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure.<ref>Modèle:Cite journal </ref> Some organizations have been formed as support groups for men who are resentful about being circumcised.<ref name="Milos"/>

Legality

Main article: Circumcision and law

In 2001, Sweden allowed only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anaesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the law,<ref> Sweden restricts circumcisions

. BBC Europe 
 
 (October 1, 2001)
   

. Retrieved on 2006-10-18.

 “Swedish Jews and Muslims object to the new law, saying it violates their religious rights.”

</ref> and in 2001, the World Jewish Congress stated that it was “the first legal restriction on Jewish religious practice in Europe since the Nazi era.”<ref> Reuters

     (June 7, 2001)
   
.    Jews protest Swedish circumcision restriction 
. Canadian Children's Rights Council 
   

. Retrieved on 2006-10-18.

 “A WJC spokesman said, ‘This is the first legal restriction placed on a Jewish rite in Europe since the Nazi era. This new legislation is totally unacceptable to the Swedish Jewish community.’”

</ref> However, in 2006, the United States State Department stated, in a report on Sweden, that most Jewish mohels had been certified under the law and 3000 Muslim and 40-50 Jewish boys were circumcised each year. The Swedish National Board of Health and Welfare reviewed the law in 2005 and recommended that it be maintained.<ref> Bureau of Democracy, Human Rights, and Labor

     (September 15, 2006)
   
.    Sweden 
. International Religious Freedom Report 2006
. US Department of State 
   

. Retrieved on 2007-07-04.

</ref>

In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised were illegal. The prosecutor claimed that, "part of healthy genitalia is removed without medical foundation, or competent consent". No punishment was assigned by the court.<ref> Court rules circumcision of four-year-old boy illegal

. HELSINGIN SANOMAT, INTERNATIONAL EDITION 
 
 (2006-08-07)
   

. Retrieved on 2007-09-17. </ref>

Pain and pain relief during circumcision

According to the American Academy of Pediatrics' 1999 Circumcision Policy Statement, “There is considerable evidence that newborns who are circumcised without analgesia experience pain and psychologic stress.”<ref name="AAP1999"/> It therefore recommended using pain relief for circumcision.<ref name="AAP1999"/> One of the supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response during vaccination months later. While acknowledging that there may be "other factors" besides circumcision to account for different levels of pain response, they stated that they did not find evidence of such. They concluded "[p]retreatment and postoperative management of neonatal circumcision pain is recommended based on these results." <ref name = "Taddio">Modèle:Cite journal </ref> Other medical associations also cite evidence that circumcision without anesthetic is painful. <ref name = "AAFP"> Circumcision: Position Paper on Neonatal Circumcision

. American Academy of Family Physicians 
 
   (2007)
     
   
 

. Retrieved on 2007-01-30.

</ref> <ref name="CPSIFP2"/>

Stang, 1998, found 45% of physicians used anaesthesia - most commonly a dorsal penile nerve block - for infant circumcisions. Obstetricians used anaesthesia significantly less often (25%) than family practitioners (56%) or pediatricians (71%).<ref name = "Stang">Modèle:Cite journal </ref>

J.M. Glass, 1999, stated that Jewish ritual circumcision is so quick that "most mohelim do not routinely use any anaesthesia as they feel there is probably no need in the neonate. However, there is no Talmudic objection and should the parents wish for local anaesthetic cream to be applied there is no reason why this cannot be done."<ref name="GlassJM"/> Tannenbaum and Shechet, 2000, stated that an “authentic, traditional bris performed by a mohel does not use clamps, so there is no pain associated with crushing tissue.”<ref name = "Shechet">Modèle:Cite journal </ref> They also asserted that due to the speed of the procedure and rarity of complication, it is “more humane not to subject the infant to a local anesthetic.”<ref name = "Shechet" />

Lander et al., found that babies circumcised without pain relief "exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the circumcision and following. Two newborns ... became ill following circumcision (choking and apnea)."[2] A 2004 Cochrane review, which compared the dorsal penile nerve block and EMLA (topical anaesthesia) found both anaesthetics appear safe, but neither of them completely eliminated pain.<ref>Modèle:Cite journal </ref> Razmus et al. reported that newborns circumcised with the dorsal block and the ring block in combination with the concentrated oral sucrose had the lowest pain scores.<ref>Modèle:Cite journal</ref> Ng et al. found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.<ref>Modèle:Cite journal</ref>

Sexual effects

Main article: Sexual effects of circumcision

The American Academy of Pediatrics (1999) stated "a survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men. There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males. Masters and Johnson noted no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men."<ref name = "AAP1999" /> In January 2007, The American Academy of Family Physicians (AAFP) stated "The effect of circumcision on penile sensation or sexual satisfaction is unknown. Because the epithelium of a circumcised glans becomes cornified, and because some feel nerve over-stimulation leads to desensitization, many believe that the glans of a circumcised penis is less sensitive. ... No valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction."<ref name = "AAFP" />

Boyle et al. (2002) stated that "the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings—many of which are lost to circumcision."<ref> Boyle , Gregory J

 ; Svoboda, J Steven; Goldman, Ronald; Fernandez, Ephrem 

       (2002)
     
   
 
.    Male circumcision: pain, trauma, and psychosexual sequelae 
. Bond University Faculty of Humanities and Social Sciences 
   

.</ref> They concluded, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well."

Medical aspects

Main article: Medical analysis of circumcision

The British Medical Association, states “there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.”<ref name = "BMAGuide" /> Cost-benefit analyses have varied. Some found a small net benefit of circumcision,<ref>Modèle:Cite journal </ref><ref>Modèle:Cite journal </ref>Modèle:Verify source some found a small net decrement,<ref>Modèle:Cite journal </ref><ref>Modèle:Cite journal </ref> and one found that the benefits and risks balanced each other out and suggested that the decision could "most reasonably be made on nonmedical factors."<ref>Modèle:Cite journal </ref>

Risks of circumcision

Main article: Medical analysis of circumcision

While the risk in a competently performed medical circumcision is very low,<ref name="UWstudy">Modèle:Cite journal </ref> complications from bleeding, infection and poorly carried out circumcisions can be catastrophic.<ref>Modèle:Cite journal </ref> According to the American Medical Association (AMA), blood loss and infection are the most common complications, and most bleeding is minor and can be stopped by applying pressure.<ref name = "CSA:I-99" /> Kaplan identified other complications, including urinary fistulas, meatal stenosis, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias, impotence and removal of too much tissue, sometimes causing secondary phimosis. He stated “Virtually all of these complications are preventable with only a modicum of care" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.”<ref name="kaplan">Modèle:Cite journal

</ref>

Complication rates ranging from 0.06% to 55% have been cited.<ref name = "CMAJ">Modèle:Cite journal</ref> Infant circumcision may result in skin bridges,<ref>Modèle:Cite journal </ref> and meatal stenosis may be a common longer-term complication from circumcision. <ref>Modèle:Cite journal </ref> <ref> Angel , Carlos A.

     (June 12, 2006)
   
.    http://www.emedicine.com/PED/topic2356.htm 
. eMedicine
. WebMD 
   

. Retrieved on 2006-07-02.

</ref> The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.<ref name = "RACPComp"> Complications Of Circumcision

. Paediatric Policy - Circumcision
. The Royal Australasian College of Physicians 
 
   (October 2004)
       
   
 

. Retrieved on 2006-07-11.

</ref>

Deaths have been reported.<ref name="kaplan"/><ref> Paediatric Death Review Committee: Office of the Chief Coroner of Ontario

       (April 2007)
       
   
 
.    Coroner's Corner Circumcision: A minor procedure? 
. Paediatric Child Health Vol 12 No 4, April 2007 pages 311-312
. Pulsus Group Inc. 
   

. Retrieved on 2007-06-17.

</ref> The American Academy of Family Physicians states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision.<ref name = "AAFP" /> Gairdner's 1949 study reported that an average of 16 children per year out of about 90,000 died following circumcision in the UK. He found that most deaths had occurred suddenly under anaesthesia and could not be explained further, but hemorrhage and infection had also proven fatal. Deaths attributed to phimosis and circumcision were grouped together, but Gairdner argued that such deaths were probably due to the circumcision operation.<ref name = "Gairdner">Modèle:Cite journal </ref>

Adult circumcisions are often performed without clamps, and require 4 to 6 weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.<ref name="aafpadult" />

HIV and other sexually transmitted diseases

The World Health Organization (WHO) stated that studies of three trials, one of which was completed, provide compelling evidence that male circumcision provides a 50-60% reduction in HIV transmission from female to male.<ref name="WHOsec"> WHO and UNAIDS Secretariat welcome corroborating findings of trials assessing impact of male circumcision on HIV risk

. World Health Organization 
 
 (February 23, 2007)
   

. Retrieved on 2007-02-23. </ref> In 2007, the WHO and UNAIDS recommended that male circumcision should now be recognized as an efficacious intervention for HIV prevention,<ref name="WHO-C&R" /> but emphasised that it does not provide complete protection against HIV infection.<ref name="WHOpr0307"> WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention

. World Health Organisation 
 
   (March 2007)
       
   
 

.</ref> They have stated that scientific findings regarding the role of male circumcision in preventing heterosexual HIV infection are particularly relevant in regions where the incidence of heterosexually acquired HIV infection is high, such as Sub-Saharan Africa, and stressed that the procedure must be carried out safely and under conditions of informed consent.<ref>http://www.who.int/hiv/mediacentre/news68/en/index.html WHO - HIV/AIDS Media Centre</ref><ref>http://www.who.int/hiv/topics/malecircumcision/JC1320_MaleCircumcision_Final_UNAIDS.pdf WHO/UNAIDS - Male circumcision: Global trends and determinants of prevalence, safety and acceptability</ref>

McCoombe et al. stated that a layer of keratin could provide protection from viral entry, and found that the keratin is thinner on the foreskin than the glans penis, and thinnest on the inner surface of the foreskin.<ref>Modèle:Cite paper </ref>

A meta-analysis found that circumcision is associated with lower rates of syphilis, chancroid and possibly genital herpes. <ref name = "Weiss">Modèle:Cite journal</ref>

Hygiene, and infectious and chronic conditions

Studies have found that boys with foreskins tend to have higher rates of various infections and inflammations of the penis than those who are circumcised.<ref name = "Ferg">Modèle:Cite journal</ref><ref>Modèle:Cite journal</ref><ref>Modèle:Cite journal</ref> The foreskin may harbor bacteria and become infected if it is not cleaned properly,<ref>Modèle:Cite journal Editor’s note: I cannot confirm that the article substantiates the claim as I cannot access the full article.</ref> but may become inflamed if it is cleaned too often with soap.<ref name="birley">Modèle:Cite journal </ref> Also, the forcible retraction of the foreskin in boys can lead to infections.<ref name ="CMAJ" />

The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams.<ref> Osipov , Vladimir O.

 ; Scott M. Acker 

     (November 14, 2006)
   
.    Balanoposthitis 
. Reactive and Inflammatory Dermatoses
. EMedicine 
   

. Retrieved on 2006-11-20.

</ref>

Circumcision is sometimes used to treat balanitis, although there are less invasive treatments than circumcision that have been shown to be effective in treating most mild cases.<ref name = "HKhandbook">Modèle:Cite book </ref> The less invasive procedures are not as successful in treating balanitis xerotica obliterans, or BXO,<ref>Modèle:Cite journal </ref><ref>Modèle:Cite journal </ref><ref>Modèle:Cite journal </ref> which is much less common but harder to treat.<ref> Scheinfeld , Noah S.

 ; George C. Keough, Daniel Lehman 

     (January 11, 2006)
   
.    http://www.emedicine.com/derm/topic46.htm 
. Diseases Of The Dermis
. EMedicine 
   

. Retrieved on 2006-09-21.

</ref> Circumcision is believed to reliably reduce the threat of BXO.<ref>Modèle:Cite journal </ref>

Several studies have shown that uncircumcised men are at greater risk of human papilloma virus (HPV) infection.<ref>Modèle:Cite journal </ref><ref>Modèle:Cite journal </ref> One study found no statistically significant difference in the incidence of HPV infection between circumcised and uncircumcised men, but did note a higher prevalence of urethritis in the uncircumcised.<ref>Modèle:Cite journal </ref> Twelve studies have indicated that neonatal circumcision reduces the rate of Urinary tract infections (UTI's) in male infants by a factor of about 10.<ref name="singhgrewal2005">Modèle:Cite journal </ref> Some UTI studies have been criticized for not taking into account a high rate of UTI's among premature infants, [3] who are usually not circumcised because of their fragile health status.<ref name = "AAP1999" /> The AMA stated that “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI," and noted one decision analysis model that concluded that circumcision was not justified as a preventative measure against UTI.<ref name = "CSA:I-99" />

Penile cancer

Penile cancer affects from 0.82 per 100,000 in Denmark to 10.5 per 100,000 men per year in parts of India (0.9 to 1 per 100,000 in the United States).<ref name = "AAP1999" /> Studies have reported a rate of penile cancer from 3 to 22 times higher in uncircumcised than circumcised men.<ref>Modèle:Cite journal</ref><ref>Modèle:Cite journal</ref>

The American Academy of Pediatrics (1999) stated that studies suggest that neonatal circumcision confers some protection from penile cancer, but circumcision at a later age does not seem to confer the same level of protection. Further, because penile cancer is a rare disease, the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low.<ref name = "AAP1999" />

Policies of various national medical associations

United States

The American Academy of Family Physicians (2007) recommends that physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering circumcision for newborn boys.<ref name = "AAFP2"> Circumcision: Position Paper on Neonatal Circumcision

. American Academy of Family Physicians 
 
   (2007)
     
   
 

. Retrieved on 2007-01-30.

 “Considerable controversy surrounds neonatal circumcision. Putative indications for neonatal circumcision have included preventing UTIs and their sequelae, preventing the contraction of STDs including HIV, and preventing penile cancer as well as other reasons for adult circumcision. Circumcision is not without risks. Bleeding, infection, and failure to remove enough foreskin occur in less than 1% of circumcisions. Evidence-based complications from circumcision include pain, bruising, and meatitis. More serious complications have also occurred. Although numerous studies have been conducted to evaluate these postulates, only a few used the quality of methodology necessary to consider the results as high level evidence.

The evidence indicates that neonatal circumcision prevents UTIs in the first year of life with an absolute risk reduction of about 1% and prevents the development of penile cancer with an absolute risk reduction of less than 0.2%. The evidence suggests that circumcision reduces the rate of acquiring an STD, but careful sexual practices and hygiene may be as effective. Circumcision appears to decrease the transmission of HIV in underdeveloped areas where the virus is highly prevalent. No study has systematically evaluated the utility of routine neonatal circumcision for preventing all medically-indicated circumcisions in later life. Evidence regarding the association between cervical cancer and a woman’s partner being circumcised or uncircumcised, and evidence regarding the effect of circumcision on sexual functioning is inconclusive. If the decision is made to circumcise, anesthesia should be used.

The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son.”

</ref>

The American Academy of Pediatrics (1999) found both potential benefits and risks in infant circumcision. It felt that there was insufficient data to recommend routine neonatal circumcision, and recommended that parental decisions on circumcision should be made with as much accurate and unbiased information as possible, taking medical, cultural, ethnic, traditional, and religious factors into account. The AAP also recommended using analgesia as a safe and effective method for reducing pain associated with circumcision, and that circumcision only be performed on newborns who are stable and healthy.<ref name = "AAP19992">Modèle:Cite journal “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. It is legitimate for parents to take into account cultural, religious, and ethnic traditions, in addition to the medical factors, when making this decision. Analgesia is safe and effective in reducing the procedural pain associated with circumcision; therefore, if a decision for circumcision is made, procedural analgesia should be provided. If circumcision is performed in the newborn period, it should only be done on infants who are stable and healthy.” </ref>

The American Medical Association supports the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics.<ref name = "CSA:I-99" />

The American Urological Association (2007) believes that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. In the context of HIV studies carried out in Africa, the AUA states that while "the results of studies in African nations may not necessarily be extrapolated to men in the United States at risk for HIV infection," the AUA "recommends that circumcision should be presented as an option for health benefits."<ref name="AUApolicy"> American Urological Association

.    [[4] Circumcision] 

. Retrieved on 2007-08-26.

</ref>

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Circumcision: Information for Parents" in November 2004,<ref name = "CPSIFP2"> Circumcision: Information for parents

. Caring for kids
. Canadian Paediatric Society 
 
   (November 2004)
       
   
 

. Retrieved on 2006-10-24.

 “Circumcision is a “non-therapeutic” procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social or cultural reasons. To help make the decision about circumcision, parents should have information about risks and benefits. It is helpful to speak with your baby’s doctor. After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.”

</ref> and "Neonatal circumcision revisited" in 1996. The 1996 position statement says that "circumcision of newborns should not be routinely performed," (a statement with which the Royal Australasian College of Physicians concurs,) and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many paediatricians no longer perform circumcisions."<ref name = "CMAJ2"> Modèle:Cite journal “We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors. </ref>

United Kingdom

The British Medical Association's position (June 2006) was that male circumcision for medical purposes should only be used where less invasive procedures are either unavailable or not as effective. The BMA specifically refrained from issuing a policy regarding “non-therapeutic circumcision,” stating that as a general rule, it “believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.”<ref name = "BMAGuide2">

  Medical Ethics Committee
   
 

       (June 2006)
       
   
 
.    The law and ethics of male circumcision - guidance for doctors 
. British Medical Association 
   

. Retrieved on 2006-07-01.

 “Circumcision for medical purposes

Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate.

Male circumcision in cases where there is a clear clinical need is not normally controversial. Nevertheless, normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal. The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. Doctors should be aware of this and reassure parents accordingly.

Non-therapeutic circumcision
Male circumcision that is performed for any reason other than physical clinical need is termed non-therapeutic (or sometimes “ritual”) circumcision. Some people ask for non-therapeutic circumcision for religious reasons, some to incorporate a child into a community, and some want their sons to be like their fathers. Circumcision is a defining feature of some faiths.

There is a spectrum of views within the BMA’s membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly. The Association has no policy on these issues. Indeed, it would be difficult to formulate a policy in the absence of unambiguously clear and consistent medical data on the implications of the intervention. As a general rule, however, the BMA believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.”

</ref>

Australasia

The Royal Australasian College of Physicians states there is no medical indication for routine neonatal circumcision (emphasis as in the original). It states, "If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment"<ref name = "RACPSumm" />

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 or to increase a man's attractiveness to women, or as an aid to hygiene where regular bathing was impractical, among other possibilities. Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practicing circumcision, leading to its spread regardless of whether the people understood this.<ref>Modèle:Cite journal</ref> It is possible that circumcision arose independently in different cultures for different reasons.

The oldest documentary evidence for circumcision comes from ancient Egypt.<ref> Tomb artwork from the Sixth Dynasty (2345-2181 BCE) shows men with circumcised penises, and one relief from this period shows the rite being performed on a standing adult male. The Egyptian hieroglyph for "penis" depicts either a circumcised or an erect organ. The examination of Egyptian mummies has found some with foreskins and others who were circumcised.</ref> Circumcision was common, although not universal, among ancient Semitic peoples. <ref> The Book of Jeremiah, written in the sixth century BCE, lists the Egyptians, Jews, Edomites, Ammonites, and Moabites as circumcising cultures. Herodotus, writing in the fifth century BCE, would add the Colchians, Ethiopians, Phoenicians, and Syrians to that list.</ref> In the aftermath of the conquests of Alexander the Great, however, Greek dislike of circumcision led to a decline in its incidence among many peoples that had previously practised it. <ref>The writer of the 1 Maccabees wrote that under the Seleucids, many Jewish men attempted to hide or reverse their circumcision so they could exercise in Greek gymnasia, where nudity was the norm. First Maccabees also relates that the Seleucids forbade the practice of brit milah (Jewish circumcision), and punished those who performed it–as well as the infants who underwent it–with death.</ref>

Medical circumcision in the 19th century and early 20th century

There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The germ theory of disease elicited an image of the human body as a conveyance for many dangerous germs, making the public "germ phobic" and suspicious of dirt and bodily secretions. Because of its function, the penis became "dirty" by association, and from this premise circumcision was seen as preventative medicine to be practiced universally.<ref name="Gollaher1994">Modèle:Cite journal</ref> In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation.<ref name="Gollaher1994"/> It was also said to protect against syphilis,<ref>Modèle:Cite journal</ref> phimosis, paraphimosis, balanitis, and "excessive venery" (which was believed to produce paralysis).<ref name="Gollaher1994" /> Gollaher states that physicians advocating circumcision in the late nineteenth century expected public skepticism, and refined their arguments to overcome it.<ref name="Gollaher1994" />

Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada, South Africa and to a lesser extent in the United Kingdom and New Zealand. Although it is difficult to determine historical circumcision rates, one estimate[5] 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, the United Kingdom's newly-formed National Health Service removed infant circumcision from its list of covered services. Since then, circumcision has been an out-of-pocket cost to parents, and the proportion of newborns circumcised in England and Wales has fallen to less than one percent. In Canada, individual provincial health services began delisting circumcision in the 1980s.

In South Korea, circumcision grew in popularity following the establishment of the United States trusteeship in 1945 and the spread of American influence. More than 90% of South Korean high school boys are now circumcised, but the average age of circumcision is 12 years.<ref>Modèle:Cite journal</ref>

In some South African ethnic groups, circumcision has roots in several belief systems, and is performed most of the time on teenage boys.

A study in 1987 found that the prominent reasons for parents choosing circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns.[6] A 2005 study speculated that increased recognition of the potential benefits may be responsible for an observed increase in the rate of neonatal circumcision in the USA between 1988 and 2000.[7]

Prevalence of circumcision

Main article: Prevalence of circumcision

Estimates of the proportion of males that are circumcised worldwide vary from one sixth (16.7%)<ref name="WillKap">Modèle:Cite journal </ref> to one third (33.3%).<ref name="crawford2002">Crawford DA. Circumcision: a consideration of some of the controversy. J Child Health Care. 2002 December;6(4):259-70. PMID 12503896</ref> According to one author, the practice is "a falling trend internationally",<ref>Modèle:Cite journal</ref>Modèle:Verify source although another notes indications of increasing demand in Southern Africa.<ref>Modèle:Cite journal</ref> and Papua New Guinea.<ref>Gabriel Fito, "Circumcision stops [sic HIV/AIDS spread," The National (Papua New Guinea), 3 December 2007.] Retrieved 3 December 2007.</ref>

It has been estimated on the basis of an academic medical survey that some 78% of South Korean men may be circumcised, possibly the largest absolute number of teenage or adult circumcisions anywhere in the world.<ref>J.H. Ku, M.E. Kim, N.K. Lee and Y.H. Park, "Circumcision practice patterns in South Korea: community based survey" (Sex Transm Inf 2003;79:65-67 http://sti.bmjjournals.com/cgi/content/full/79/1/65 retrieved 1 October 2006</ref> For the United States, statistics from different sources give widely varying estimates of circumcision rates, from 55.9%<ref name = "NHDS">Modèle:Cite journal</ref> to 91%<ref>Modèle:Cite paper </ref>

Rickwood et al reported that the proportion of English boys circumcised for medical reasons had fallen from 35% in the early 1930s to 6.5% by the mid-1980s. An estimated 3.8% of male children in the UK in 2000 were being circumcised by the age of 15 [8].

According to the Sydney Morning Herald, the infant circumcision rate in Australia was 12.9% in 2003.<ref> Skatssoon , Judy

       (July 2004)
       
   
 
.    Circumcision rates rise for some 
. Sydney Morning Herald (reprint: CIRP.org) 
   

.</ref> In 1986, only 511 out of approximately 478,000 Danish boys aged 0-14 years were circumcised. This corresponds to a cumulative national circumcision rate of around 1.6% by the age of 15 years [9].

See also

• Brit milah
• Circumcision scar
• Foreskin restoration
• Genital integrity
• Holy Prepuce
• Preputioplasty, alternative to circumcision in the treatment for phimosis

Notes

Some referenced articles are available on-line only in the Circumcision Information and Resource Page’s (CIRP) library or in The Circumcision Reference Library (CIRCS). CIRP articles are chosen from an anti-circumcision point of view, and text in support of this position is often highlighted on-screen using HTML. CIRCS articles are chosen from a pro-circumcision point of view. If documents are not freely available on-line elsewhere, links to articles in one or other of these two websites may be provided.

External links

Circumcision opposition

• The Circumcision Information and Resource Pages by Geoffrey T. Falk
• Doctors Opposing Circumcision presided by George C. Denniston, MD, MPH
• National Organization of Circumcision Information Resource Centers by Marilyn Milos, RN
• Sex as Nature Intended It by Kristen O'Hara.

Circumcision promotion

• Benefits of circumcision: medical, health and sexual by Professor Brian Morris
• Circumcision: a lifetime of medical benefits by Edgar Schoen, BSc., M.D.
• Circumcision Information by Gerald N. Weiss, M.D.

Circumcision techniques

• Description of an adult circumcision from the American Academy of Family Physicians.
• Description of a Plastibell circumcision from the Medical College of Georgia.
• Visualisation of amount of skin removed, showing 'styles' of circumcision.

Further reading

• Billy Ray Boyd. Circumcision Exposed: Rethinking a Medical and Cultural Tradition. Freedom, CA: The Crossing Press, 1998. (ISBN 978-0-89594-939-4)
• Anne Briggs. Circumcision: What Every Parent Should Know. Charlottesville, VA: Birth & Parenting Publications, 1985. (ISBN 978-0-9615484-0-7)
• Robert Darby. A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain. Chicago: University of Chicago Press, 2005. (ISBN 978-0-226-13645-5)
• Aaron J. Fink, M.D. Circumcision: A Parent's Decision for Life. Kavanah Publishing Company, Inc., 1988. (ISBN 978-0-9621347-0-Image:Cool.gif
• Paul M. Fleiss, M.D. and Frederick Hodges, D. Phil. What Your Doctor May Not Tell You About Circumcision. New York: Warner Books, 2002. (ISBN 978-0-446-67880-3)
• Leonard B. Glick. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. New York: Oxford University Press, 2005. (ISBN 978-0-19-517674-2)
• David Gollaher. Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000. (ISBN 0465026532)
• Ronald Goldman, Ph.D. Circumcision: The Hidden Trauma. Boston: Vanguard, 1996. (ISBN 978-0-9644895-3-0)
• Paysach J. Krohn, Rabbi. Bris Milah. Circumcision-The Covenant Of Abraham/A Compendium of Laws, Rituals, And Customs From Birth To Bris, Anthologized From Talmudic, And Traditional Sources. New York: Mesorah Publications, 1985, 2005.
• Brian J. Morris, Ph.D., D.Sc. In Favour of Circumcision. Sydney: UNSW Press, 1999. (ISBN 978-0-86840-537-7)
• Peter Charles Remondino. History of Circumcision from the Earliest Times to the Present. Philadelphia and London; F. A. Davis; 1891.
• Rosemary Romberg. Circumcision: The Painful Dilemma. South Hadley, MA Bergan & Garvey, 1985. (ISBN 978-0-89789-073-1)
• Edgar J Schoen, M.D. Ed Schoen, MD on Circumcision. Berkeley, CA: RDR Books, 2005. (ISBN 978-1-57143-123-3)
• Edward Wallerstein. Circumcision: An American Health Fallacy. New York: Springer, 1980 (ISBN 978-0-8261-3240-6)
• Gerald N. Weiss M.D. and Andrea W Harter. Circumcision: Frankly Speaking. Wiser Publications, 1998. (ISBN 978-0-9667219-0-4)
• Yosef David Weisberg, Rabbi. Otzar Habris. Encyclopedia of the laws and customs of Bris Milah and Pidyon Haben. Jerusalem: Hamoer, 2002.

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