Circumcision

Circumcision is the practice of surgically removing parts of a person's genitalia, usually involving skin covering the clitoris or glans of the penis. This surgery is most commonly performed on children: either newborn infants or adolescents. The practices, meanings, and implications attached to this activity vary greatly by region, religion, and gender. Because the implications and types of procedures differ immensely across gender lines, it is important to consider male and female circumcision separately. However, great controversy surrounds the practice of circumcision of both genders. The controversies center on the health implications, effects on sexuality, natural states of bodies, social acceptance, religious rites, and proper treatment of children. These issues become especially compelling in the context of globalization, secularization, and competing views of health.

Male Circumcision

Male circumcision entails the removal of the penis foreskin, the flap of skin that covers the penile glans. (Male circumcision does not usually include such practices as piercings of the penis or scrotum, penile implants, gender modifications, or an Aboriginal Australian tradition of splitting the penis.) Male circumcision is most widely practiced among Jewish, Islamic, African, and North American populations. It is uncommon in Asia, South America, Central America, and most of Europe (American Academy of Pediatrics 1999). Approximately 60 percent of males in the United States are circumcised, compared to only 6 percent of males in the United Kingdom (Smith 1998). An estimated 1.2 million newborn males are circumcised annually within the United States (American Academy of Pediatrics 1999). For both cultural and medical reasons, the percentage of newborn infants being circumcised in the United States has been decreasing since the mid-twentieth century.

The surgery is usually performed on children ranging from newborns to adolescents. In secular and Christian North American culture, no explicit ceremony surrounds the operation, which physicians perform in clinical settings as elective procedures. Increasingly, physicians administer local anesthesia during the procedure. Complication rates range between 0.2 percent and 0.6 percent and include such problems as postoperative bleeding and unintended surgical damage to the penis (American Academy of Pediatrics 1999). Circumcision is occasionally performed on uncircumcised adult males when the foreskin becomes infected and adheres to the glans.

The claimed medical advantages of circumcision include decreases in occurrences of penile cancer, local infections, urinary tract infections in the first year of life, and STD/HIV infection later in life. The medical disadvantages described include the chance of postoperative bleeding, pain during the operation, and loss of sexual sensitivity. For claimed advantages and disadvantages both, great controversy surrounds the veracity and magnitude.

Among other populations, circumcision is tied to religion. A Jewish circumcision ceremony is called a brit milah or bris and is performed on the eighth day after birth by a mohel. An Islamic circumcision ceremony is referred to as khitan. In Islam this practice is supported by Sunnah teachings, as opposed to teachings directly from the Qur'an. Traditional African ceremonies vary greatly among cultural groups, with circumcision being performed as part of a coming-of-age ritual at puberty. In these circumstances, traditionally trained males from within the community perform the surgery.

Several common themes run through the cultural and religious reasons for circumcision. Ceremonially, circumcision marks membership in a particular group of people, a shedding of femaleness in order to become fully male, and at times an agreement with, or pledge to, a deity. The circumcised penis is understood as being a cleaner state of a male both in a ceremonial and physical sense. Beyond this is an aesthetic argument that the circumcised penis is more attractive and natural looking than an uncircumcised penis, even though all healthy males are born with a foreskin.

Although carried out infrequently, there are procedures that aid circumcised adults in redeveloping parts of the foreskin. These include various methods of stretching the foreskin not removed during the original circumcision. Circumcised males may undergo this procedure to become fully intact and unmutilated or to regain sexual sensitivity of the glans.

Male Issues

In North American medicine, the trend is to offer circumcision only as an elective procedure, rather than a standard practice as was the tradition. The primary debates revolve around issues of cleanliness, health benefits, social inclusion, infliction of pain on infants, mutilation, and cultural or religious identity. The widespread continued support for male circumcision in the United States relies on the potential health benefits of the surgery. The stance of the American Academy of Pediatrics is to give parents information about the advantages and disadvantages so that they may make an informed decision (1999). The traditional medical benefits are not as significant as physicians once thought, although well-documented studies do show some prophylactic benefit from the procedure. In the face of a decline in circumcisions, a greater emphasis is being placed on good hygiene for those who are uncircumcised.

A debate continues concerning whether routine circumcision is cost-effective. To achieve a statistically significant drop in cases of urinary tract infection or penile cancer, a large number of males must be circumcised; the rates of both diseases are low. For instance, the rate of penile cancer increases from 0.00001 percent to 0.00009 percent for uncircumcised males (American Academy of Pediatrics 1999). Although this is a statistically significant increase, penile cancer is still rare in the uncircumcised population. The percentage of risk as well as the actual rarity of occurrence should be weighed when evaluating the importance of the procedure.

The final issues center on a worldview of fundamental rights, a natural state as good, and social inclusion. Anticircumcision groups use the descriptors of mutilation and amputation for male circumcision. They label it as abuse. The language invokes rights and autonomy, as well as the constitution of a valued body. Using this language, the unaltered and natural state is the one that should be highly prized, and circumcision moves the male away from that. Further, the child has a right to make decisions about long-term health care. By performing the operation before the child reaches an age of assent or consent, we remove this possibility.

The flip side to this debate is that parents have the right to decide what is best for their children. Even if the health benefits may be slight, religious ceremony and social inclusion weigh importantly when the risks are relatively low. Also, geriatric health care issues arise when considering the implications of keeping the penis clean for an uncircumcised elderly male who can no longer carry out basic self-cleaning tasks (Frank et al. 2000).

Female Circumcision

The term female circumcision has a greater range of meanings and implications than does male circumcision. It refers to anything from the removal of the clitoral hood, the small flap of skin covering the clitoris, to the removal of the labia and clitoris, as well as to the stitching shut of the vulva. Opponents of the practice often refer to female circumcision as female genital mutilation (FGM). (Female circumcision does not usually refer to such practices as consensual piercing of the labia and clitoris or gender modifications) Ceremonially, female circumcision is performed only in populations in Middle and Northern sections of Africa, parts of the Middle East, and parts of Malaysia. Worldwide, more than 100 million women have been circumcised. (Hosken 1994). It is estimated that at least 95 percent of the women in Somalia, Djibouti, and Egypt are circumcised (Gruenbaum 2001). Circumcision is traditionally performed in more than thirty countries, at least twenty-eight of which are in Africa. At the same time, given contemporary emigration patterns, circumcised women are found among immigrant populations in countries of Europe and North America. When performed on adolescents, the operation accompanies traditional instruction about womanhood. Although there appears to be no textual support for female circumcision in Islamic holy writings, the geographic areas of practice are primarily Islamic.

Nonceremonial genital modification was briefly practiced in Western medicine as a medical treatment. Western physicians recommended the practice of removing the clitoris as a treatment for women with certain nervous and sexual problems in the nineteenth and early twentieth century (Hosken 1994). This was bolstered by a belief that masturbation could cause insanity. The practice did not continue, and genital modification was never adopted as a religious ceremony or as a routine operation for females in Western culture.

Ceremonial female circumcision is variously thought to remove the maleness from the female by removing a undeveloped penis, the clitoris, to assure chastity among wives and young women, to purify and cleanse, and to make a woman more beautiful and sexually attractive to men. In places where this is most widely practiced, women must be circumcised before they can be married.

There are at least three categories of female circumcision: Sunna, Excision, and Infibulation. Sunna circumcision refers to the practice of letting a small amount of blood from the clitoral hood or removing sections of the clitoral hood. This is not a widely practiced type of circumcision and is confined primarily to sections of Malaysia. Sunna circumcision is the closest analogue to male circumcision, although the delicate nature of the operation increases chances of surgical error.

Excision is the practice of removing, that is, excising, a portion of the genitalia. This ranges from the removal of the clitoris to the removal of the clitoris, labia major, and labia minor. The medicalized term of clitorectomy is used in the historic medical literature to refer to the removal of the clitoris alone.

Infibulation involves the excision of the clitoris, labia major, and labia minor, and the stitching shut of the vulva with only a small hole left for urination and menses. This is also referred to as pharonic circumcision because of a traditional attribution of this practice as being imposed on the female Jewish population by ancient Egyptian Pharaohs. Infibulation is the most radical procedure and carries the most significant medical implications. The procedure is most common in populations from Somalia, Ethiopia, Sudan, and Egypt. The procedure leaves a girl with a smooth, nondescript genital area that is considered by some to be aesthetically pleasing. However, it also leaves a girl with significant health problems, such as chronic urinary infections, menstrual difficulties, sexual dysfunction, and difficulties when giving birth.

Female Issues

A fundamental difference between male and female circumcisions is that female circumcision does not have the potential for medical benefit. Both excision and infibulation carry very significant negative health consequences. All types of female circumcision rely on cultural and religious reasoning. Opponents greatly resist naming this practice circumcision because using the term may diminish the seriousness of the practices of infibulation and excision. Health organizations, Islamic groups, women's groups, and Western governments continue to press for the abolition of these practices. They have used various strategies to try to achieve this. For example, the Kenyan Family Planning Association has proposed alternate ceremonies that would be accompanied by the traditional educational information given when an adolescent is circumcised. This strategy helps make proponents of change seem to respect tradition and culture while changing an unhealthy aspect of a particular tradition.

Some of the issues that surround female circumcision are similar to those related to male circumcision: pain, the risk of infection, alteration of a natural state, and the status of children. Female circumcision, however, carries more serious implications, which include significant chance of damage to the clitoris during surgery (in the Sunna form), loss of sexual pleasure, patriarchal control, birthing complications, increased infections throughout life, refugee status in developed countries, and loss of mobility (in the infibulation form). Support for maintaining the practice relies on arguments from tradition and religion, and from the concern that daughters will not make fit wives if they are not circumcised. However, as women become more educated and empowered within these societies, practices of female circumcision are being modified.

In Western countries, questions are raised as to whether female circumcisions should be offered in clinical settings when parents who have emigrated request it. This would be done to avoid complications brought about when unskilled people perform the surgery in nonsterile environments; however, this would seem to go against a principle of basic Western medicine—to do no harm to patients. Some suggest the practice is a type of child abuse or persecution such that young, uncircumcised girls should be granted refugee status. These issues are being continuously challenged and debated in legislatures and medical governing associations.

See also:Family Planning; Family Rituals; Islam; Judaism; Religion; Sexuality; Sexuality Education

Bibliography

american academy of pediatrics. (1999). "circumcisionpolicy statement." pediatrics (march) 103:686–693.

denniston, g., and milos, m., eds. (1997). sexual mutilations: a human tragedy. new york: plenum press.

frank, r. et al. (2000). "a trade-off analysis of routinenewborn circumcision / reply." pediatrics (october) 106:954.

gollaher, d. (2000). circumcision: a history of the world'smost controversial surgery. new york: basic books.

gruenbaum, e. (2001). the female circumcision controversy: an anthropological perspective. philadelphia: university of pennsylvania press.

hosken, f. (1994). the hosken report: genital and sexualmutilation of females, 4th edition. lexington, ma: women's international network news.

hicks, e. (1993). infibulation: female mutilation in islamic northeastern africa. new brunswick: transaction publishers.

igwegbe a., and egbuonu, i. (2000). "the prevalence andpractice of female genital mutilation in nnewi, nigeria: the impact of education." journal of obstetrics and gynecology (september) 20:520–522.

magied, a. a., and omram, m. (1999). "the uncircumcised female is an ideal state of circumcision—a case study from sudan." ahfad journal (december) 16:2–15.

preiser, g., et. al. (2000). "circumcision—the debategoes on / in reply." pediatrics (march) 105:681–684.

toubia, n. (1994). "female circumcision as a publichealth issue." the new england journal of medicine. 331:712–716.

other resources

smith, jacqueline. (1998). "male circumcision and therights of the child." in to baehr in our minds: essays in human rights from the heart of the netherlands, ed. m. bulterman, a. hendriks; and j. smith. utrecht: sim. available from http://www.nocirc.org.

united nations high commissioner for human rights.(1989). "convention on the rights of the child." available from http://www.unhchr.ch.

world health organization. "female genital mutilation."available from http://www.who.int/frh-whd/.

paul j. ford

Circumcision

Definition

The surgical removal of the foreskin of the penis, or prepuce of the clitoris.

Purpose

In the United States, circumcision in infant boys is performed for social, medical, or cultural/religious reasons. Once a routine operation urged by pediatricians and obstetricians for newborns in the middle of the twentieth century, circumcision has become an elective option that parents make for their sons on an individual basis. Families who practice Judaism or Islam may select to have their sons circumcised as a religious practice. Others choose circumcision for medical benefits.

Female circumcision (also known as female genital mutilation) is usually performed for cultural and social reasons by family members and others who are not members of the medical profession, with no anesthesia. Not only is the prepuce of the clitoris removed but often the vaginal opening is sewn to make it smaller. This practice is supposed to ensure the virginity of a bride on her wedding day. It also prevents the woman from achieving sexual pleasure during coitus. This practice is not universally approved by the medical profession and is considered by many to be a human rights violation.

Some of the medical reasons parents of male infants choose circumcision are to protect against infections of the urinary tract and the foreskin, prevent cancer, lower the risk of getting sexually transmitted diseases, and prevent phimosis (a tightening of the foreskin that may close the opening of the penis). Though studies indicate that uncircumcised boys under the age of five are 20 times more likely than circumcised boys to have urinary tract infections (UTIs), the rate of incidence of UTIs is quite low and treatable with antibiotics . There are also indications that circumcised men are less likely to suffer from penile cancer, inflammation of the penis, or have many sexually transmitted diseases. Here again, there is a low rate of incidence. Good hygiene usually prevents most infections of the penis. Phimosis and penile cancer are very rare, even in men who have not been circumcised. Education and safe sex practices can prevent sexually transmitted diseases in ways that a surgical procedure cannot because these are diseases acquired through risky behaviors.

In 2002, however, new research indicated that circumcised men may be less at risk for contracting HIV infections than uncircumcised men, whose foreskins have higher concentrations of cells that are targeted specifically by HIV. Genital hygiene and safe sex practices are still crucial to preventing the spread of HIV.

Another study during that same year found that circumcised men who engaged in risky sexual behaviors were less likely to contract penile human papillomavirus (HPV), which has been implicated in the incidence of cervical cancer in women. There was little difference between circumcised and noncircumcised men's incidence of the virus if the men were in a monogomous relationship.

With these factors in mind, the American Academy of Pediatrics has issued a policy statement that maintains that though there is existing scientific evidence that indicates the medical benefits of circumcision, the benefits are not strong enough to recommended circumcision as a routine practice.

Demographics

Though the incidence of male circumcision has decreased from 90% in 1979 to 60% in 1999, it is still the most common surgical operation in the United States. Circumcision rates are much lower for the rest of the industrialized world. In Britain, it is only done for religious practices or to correct a specific medical condition of the penis.

Description

The foreskin of the penis protects the sensitivity of the glans and shields it from irritation by urine, feces, and foreign materials. It also protects the urinary opening against infection and incidental injury.

In circumcision of infants, the foreskin is pulled tightly into a specially designed clamp, which forces the foreskin away from the broadened tip of the penis. Pressure from the clamp stops bleeding from blood vessels that supplied the foreskin. In older boys or adults, an incision is made around the base of the foreskin, the foreskin is pulled back, and then it is cut away from the tip of the penis. Stitches are usually used to close the skin edges.

Circumcision should not be performed on infants with certain deformities of the penis that may require a portion of the foreskin for repair. The most common condition for surgery using the foreskin is hypospadias, a congenital deformity of the penis where the urinary tract opening is not at the tip of the glans. Also, infants with a large hydrocele, or hernia, may suffer complications through circumcision. Premature infants and infants with serious infections are also poor candidates to be circumcised, as are infants with hemophilia, other bleeding disorders, or whose mothers had taken anticoagulant drugs. In older boys or men, circumcision is a minor procedure and can be performed on virtually anyone without a serious illness or unusual deformity.

Diagnosis/Preparation

Despite a long-standing belief that infants do not experience serious pain from circumcision, physicians now believe that some form of local anesthesia is necessary. Over 80% of pediatric residents, 80% of family practice residents, and 60% of obstetric/gynecological residents are routinely given instruction on pain control for circumcisions. Local anesthesia is often injected at the base of the penis (dorsal penile nerve block) or under the skin around the penis (subcutaneous ring block). Both anesthetics block key nerves and provide significantly lowered perceived pain. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) can also be used.

Aftercare

After circumcision, the wound should be washed daily. An antibiotic ointment or petroleum jelly may be applied to the site. If there is an incision, a wound dressing will be present and should be changed each time the diaper is changed. Sometimes a plastic ring is used instead of a bandage. The ring will usually fall off in five to eight days. The penis will heal in seven to 10 days.

Infants who undergo circumcision may be fussy for some hours afterward, so parents should be prepared for crying, feeding problems, and sleep problems. Generally, these go away within a day. In older boys, the penis may be painful, but this will go away gradually. A topical anesthetic ointment or spray may be used to relieve this temporary discomfort. There may also be a bruise on the penis, which typically disappears with no particular attention.

Risks

Complications following newborn circumcision appear in between two and six of every 1,000 procedures. Most complications are minor. Bleeding occurs in half of the complications and is usually easy to control. Infections are rare and occur at the circumcision site, the opening to the bladder, or at the tip of the penis as a result of contact with urine or feces. Infections are indicated by fever and signs of inflammation, and are treatable with antibiotics.

There may be injuries to the penis itself, and these may be difficult to repair. In 2000, there were reports that the surgical clamps used in circumcision were at fault in over 100 injuries reported between July 1996 and January 2000. In nearly all cases, the clamps were assumed to be in working order but had been repaired with replacement parts that were not of the manufacturer's specifications. Physicians were urged to inspect the clamps before use and ensure that their dimensions fit their infant patients.

Normal results

When an infant or an adult is circumcised, the surgical wound should heal quickly, with normal urinary function resuming immediately. An infant or older child should have no complications and should be able to pass through adolescence and eventual sexual activity normally. After a period of recovery, an adult male should be able to resume sexual intercourse normally.

Morbidity and mortality rates

Complications as a result of circumcision are usually minor if the physician is experienced and makes sure the Mogen or Gomco clamps that are used are in good working order. Severe penile injuries are rare, but they are serious, and include penile amputation (partial or total), laceration, hemorrhage, and damage to the urinary tract. Other serious complications such as meningitis, penile necrosis, necrotizing faciitis, and sepsis can occur. Some of these, like meningitis and sepsis, can even cause death.

Hidden complications also occur. Subcutaneous masses have been detected under the skin of the penis. These masses usually have no symptoms, but, left untreated, could lead more serious outcomes. Physicians should examine the penis at every well-baby checkup during the first year. If a mass is detected, it can easily be removed under a local anesthesia and sent to a pathology lab.

Alternatives

The only alternative to this surgery is to make an informed decision not to have an infant circumcised. Some Jewish parents are even electing not to hold a Bris Milah, a religious circumcision, for their sons, and choosing instead to hold a Brit Shalom, a naming ceremony, similar to that given for their infant daughters.

Resources

books

Gollaher, David L. Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000.

periodicals

"Circumcision." Harvard Men's Health Watch 6, no. 3 (October 2001).

Imperio, Winnie Anne. "Circumcision Appears Safe, But Not Hugely Beneficial." OB GYN News 35, no. 7 (1 April 2000): 9.

"Link to Uncircumcised Males Found." Women's Health Weekly (May 9, 2002): 10.

Schmitt, B. D. "The Circumcision Descision: Pros and Cons." Clinical Reference Systems (2000): 1579.

other

American Academy of Pediatrics. New AAP Circumcision Policy Released (Press Release). March 1, 1999. <http://www.aap.org/advocacy/archives/marcircum.htm>.

Janie F. Franz

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Medical circumcisions are performed in the hospital by a pediatrician for an infant or child. For an adult, a general surgeon or urologist may perform a circumcision, especially if there are other urinary tract repairs to be made.

A Jewish religious circumcision, a Bris Milah, is performed when an infant male is eight days old. It is conducted by a trained mohel, with family and friends present, in a nonmedical setting.

QUESTIONS TO ASK THE DOCTOR

• Is there a medical reason for performing a circumcision on my child?
• Is there new research about the benefits of circumcisions that I should be aware of?
• What kind of anesthesia will be used during the procedure?
• What should I be aware of when I go home with the baby?
• When should I call the doctor?

Circumcision

Definition

The surgical removal of the foreskin of the penis in a male or the prepuce of a clitoris in a female.

Purpose

In the United States, circumcision in infant boys is performed for social, medical, cultural, or religious reasons. Once a routine operation urged by pediatricians and obstetricians for newborns in the middle of the twentieth century, circumcision has become an elective option that parents make for their sons on an individual basis. Families who practice Judaism or Islam may select to have their sons circumcised as a religious practice. Others may elect circumcision for medical reasons.

Female circumcision (also known as female genital mutilation) is usually performed for cultural and social reasons by family members and others who are not members of the medical profession, with no anesthesia. Not only is the prepuce of the clitoris removed but often the vaginal opening is sewn to make it smaller. This practice is supposed to ensure the virginity of a bride on her wedding day. It also prevents the woman from achieving sexual pleasure during coitus. Female circumcision is illegal in most countries of the world. It is considered by most people to be a human rights violation.

Though the incidence of male circumcision has decreased from 90 percent in 1979 to 60 percent in 2002, it is still the most common surgical procedure in the United States. Circumcision rates are much lower for the rest of the industrialized world. In Britain, it is only performed for religious practices or to correct a specific medical condition of the penis.

Parents may choose circumcision because they believe the surgery protects against infections of the urinary tract and the foreskin, prevents cancer , lowers the risk of getting sexually transmitted diseases , and prevents phimosis (a tightening of the foreskin that may close the opening of the penis). Though studies indicate that uncircumcised boys under the age of five are 20 times more likely than circumcised boys to have urinary tract infections (UTIs), the rate of incidence of UTIs is quite low. There are also indications that circumcised men are less likely to suffer from penile cancer, inflammation of the penis, or have many sexually transmitted diseases. Here again, the rate of incidence is low. Good hygiene usually prevents most infections of the penis. Phimosis and penile cancer are very rare, even in men who have not been circumcised. Education and good safe-sex practices can prevent sexually transmitted diseases in ways that a surgical procedure cannot because these are diseases acquired through risky behaviors.

With these factors in mind, the American Academy of Pediatrics issued a policy pronouncement that states although there is existing scientific evidence that support the medical benefits of circumcision, the benefits are not strong enough to recommended circumcision as a routine practice.

Description

The foreskin of the penis safeguards the sensitivity of the glans and shields it from irritation by urine, feces, and foreign materials. It also protects the urinary opening against infection and accidental injury.

Despite a long-standing belief that infants do not experience serious pain from circumcision, most authorities in the early 2000s believe that some form of local anesthesia is necessary. The physician injects local anesthesia at the base of the penis or under the skin around the penis (subcutaneous ring block). Both anesthetics block key nerves. EMLA cream, a topical formula of several anesthetics, can also be used.

In circumcision of infant boys, the foreskin is pulled tightly into a specially designed clamp. Pressure is applied and the foreskin pulls away from the broadened tip of the penis. Pressure from the clamp stops bleeding from blood vessels that supplied the foreskin. In older boys or adults, an incision is made around the base of the foreskin, the foreskin is pulled back, and then it is cut away from the tip of the penis. Stitches are usually used to close the skin edges.

After circumcision, the wound should be washed daily. An antibiotic ointment or petroleum jelly may be applied to the site. If there is an incision, a wound dressing will be present and should be changed each time the diaper is changed. Sometimes a plastic ring is used instead of a bandage. The ring usually falls off in five to eight days. The penis heals in seven to 10 days.

Infants who undergo circumcision may be fussy for some hours afterward, so parents should be prepared for crying, feeding problems, and sleep problems. Generally these go away within a day. In older boys, the penis may be painful, but the pain goes away gradually. A topical anesthetic ointment or spray may be used to relieve this temporary discomfort. There may also be a bruise on the penis, which typically goes away with no particular attention.

The clitoral prepuce of infant girls is drawn up and away from the body before being removed. In this procedure, the clitoris is also frequently removed. The vaginal opening may be partially closed. Healing is slower in girls than for boys. Most female circumcisions are performed under unhygienic conditions using primitive, homemade implement such as rusty razor blades and thorns. Infections are common.

Risks

Complications following newborn circumcision appear in one out of every 500 procedures. Most complications are minor. Bleeding occurs in half of the complications and is usually easy to control. Infections are rare and present with fever and signs of inflammation. Uneven healing of skin may lead to laterally curving erections in adulthood.

There may be injuries to the body of the penis that may be difficult to repair. In 2000, there were reports that the surgical clamps used in circumcision were at fault in over 100 injuries reported between July 1996 and January 2000. In nearly all cases, the clamps were assumed to be in working order but had been repaired with replacement parts that were not of the manufacturer's specifications. Physicians were urged to inspect the clamps before use and ensure that their dimensions fit the infant's body parts.

Circumcised girls have a high incidence of infertility and sexual dysfunction as adults. Most experience infections immediately after the procedure.

Normal results

Among boys who are circumcised, most have no penile, urologic, or sexual dysfunction as adults. A majority of girls who are circumcised experience urologic, reproductive, and sexual dysfunction as adults.

KEY TERMS

Foreskin —A covering fold of skin over the tip of the penis.

Glans penis —The cone-shaped tip of the penis.

Hernia —A rupture in the wall of a body cavity, through which an organ may protrude.

Hydrocele —A collection of fluid between two layers of tissue surrounding the testicle; the most common cause of painless scrotal swelling.

Hypospadias —A congenital abnormality of the penis in which the urethral opening is located on the underside of the penis rather than at its tip.

Phimosis —A tightening of the foreskin that may close the opening of the penis.

Prepuce —A fold of skin, such as the foreskin of the penis or the skin that surrounds the clitoris.

Parental concerns

The only medical justification for male circumcision is to correct a health problem or condition. There are no medical justifications for female circumcision. The only other justification for male or female circumcision is religious or cultural. Leaders of the vast majority of religions throughout the world condemn any form of female circumcision.

Resources

BOOKS

Darby, Robert. A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain. Chicago: University of Chicago Press, 2005.

Elder, Jack S. "Anomalies of the Penis and Urethra." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman, et al. Philadelphia: Saunders, 2003, pp. 1812–6.

Fleiss, Paul M., and Frederick Hodges. What Your Doctor May Not Tell You about Circumcision: Untold Facts on America's Most Widely Performed—and Most Unnecessary Surgery. New York: Warner Books, 2002.

Gollaher, David L. Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000.

Lewis, Joseph, et al. In the Name of Humanity: Speaking Out against Circumcision. San Diego, CA: Book Tree, 2003.

PERIODICALS

Adelman, W. P., and A. Joffe. "Controversies in male adolescent health: varicocele, circumcision, and testicular self-examination." Current Opinions in Pediatrics 16, no. 4 (2004): 363–7.

Campbell, C. C. "Care of women with female circumcision." Journal of Midwifery and Women's Health 49, no. 4 (2004): 364–5.

Essen, B., and S. Johnsdotter. "Female genital mutilation in the West: traditional circumcision versus genital cosmetic surgery." Acta Obstetrics and Gynecology of Scandinavia 83, no. 7 (2004): 611–3.

Hiss, J., A. Horowitz, and T. Kahana. "Fatal hemorrhage following male ritual circumcision." Journal of Clinical Forensic Medicine 7, no. 1 (2000): 32–4.

ORGANIZATIONS

American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: <www.aafp.org/>.

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007–1098. Web site: <www.aap.org/>.

American College of Surgeons. 633 North St. Clair Street, Chicago, IL 60611–32311. Web site: <www.facs.org/>.

American Medical Association. 515 N. State Street, Chicago, IL 60610. Web site: <www.ama-assn.org/>.

American Urological Association. 1120 North Charles Street, Baltimore, MD 21201. Web site: <www.auanet.org/index_hi.cfm>.

WEB SITES

"Circumcision." Circumcision Information Resource Pages. Available online at <www.cirp.org/> (accessed November 2, 2004).

"Circumcision." Available online at Circumcision Resource Center. Available online at <www.circumcision.org/> (accessed November 2, 2004).

"Circumcision." Mothers Against Circumcision. Available online at <www.mothersagainstcirc.org> (accessed November 2, 2004).

"Doctors Opposing Circumcision." University of Washington. Available online at <http://faculty.washington.edu/gcd/DOC/> (accessed November 2, 2004).

L. Fleming Fallon Jr., MD, DrPH

circumcision or posthetomy, is the operative removal of all or part of the prepuce of the penis. By extension to the female the term is also used for clitoridectomy, which can range from the ritual drawing of blood to infibulation (the removal of the clitoris and parts of the labia). Male circumcision has been read in the West to be a sign of everything from sexual hygiene, to cosmetic appearance, to tribal identity or a mark of adulthood, to either diminishing or enhancing sexual desire, to increased or decreased fertility, to patriarchal subjugation, to enhanced purity, to the improvement of sexual endurance, to a form of attenuated castration, to menstrual envy, to a substitute for human sacrifice.

In Pharaonic Egypt boys were circumcized between the ages of 6 and 12. The Jews were the group which continued to practise infant male circumcision in Western Europe after the advent of Christianity. Infant male circumcision as practised by the Jews occurs on the eighth day after birth. It represents the covenant of God with Abraham (Genesis 17: 10–14). Even after the Shoah and the increased presence of Muslims, who also ritually circumcize their infants in Europe, circumcision continues to be associated with the image of the Jews.

There are four ‘traditional’ views of the ‘meaning’ of circumcision in connection with the Jews. Following the writings of Paul (Acts 15), the first view saw circumcision as inherently symbolic and, therefore, no longer valid after the rise of Christianity. This view was espoused by the Church Fathers, Eusebius and Origen; it continued through the Renaissance (Erasmus) and through the Reformation (Luther). It forms the theological basis for the distinction which Christians were able to make between their bodies and the bodies of the Jews.

The second view saw circumcision as a sign of a political or group identity. The rhetoric in which the accepted science of the late nineteenth century clothed its rejection of circumcision is of importance. It was intense and virulent, and never free from negative value judgments. One central example should suffice. The liberal Italian physician Paolo Mantegazza (1831–1901), one of the standard ‘ethnological’ sources from the late nineteenth century for the nature of human sexuality, decried the ‘mutilation of the genitals’ among ‘savage tribes’ including the Jews.

The third reading of circumcision saw it as a remnant of the early Jewish idol or phallus worship. Thus J. H. F. Autenrieth saw circumcision as but a primitive act practised by culturally inferior peoples such as Jews and African Blacks. Autenrieth, by 1829 the Chancellor of the University of Tübingen, entered the discussion of the meaning of circumcision with a public lecture on its history. For him, as for others, circumcision was a surrogate for human sacrifice. The nineteenth-century British anthropologist John Lubbock saw such rites of sacrifice as a ‘stage through which, in any natural process of development, religion must pass’. But the Jews also sacrificed their animals at the Temple as ‘symbols of human sacrifice … [which] were at one time habitual among the Jews’. Circumcision was a sign of ‘the inherent barbarism of this people’, a view seconded by a Dr Hacker in a medical journal during 1843. Here again the medical discussion of a social practice becomes contaminated by the racial context into which it is placed. Indeed, this view dominates the discussion of the ethno-psychologists into the late nineteenth and early twentieth centuries about the meaning of circumcision as a semantic sign. The experimental psychologist Wilhelm Wundt sees circumcision as
of the nature of sacrifice. Along with the offering of hair in the cult of the dead and with the pouring out of blood in connection with deity worship, it belongs to that form of sacrifice in which the sacrificial object gains its unique value by virtue of its being the vehicle of the soul. Thus, the object of sacrifice, in the case of circumcision, may perhaps be interpreted as a substitute for such internal organs as the kidneys or testicles, which are particularly prized as vehicles of the soul but which can either not be offered at all, on the part of the living, or whose sacrifices involves serious difficulties.

For Wundt, politically a liberal in his time, Judaism is ‘… but one of those vanquished cults which struggled for supremacy in the pre-Constantinian period of the Roman World Empire’. And the practice of this substitute for ritual sacrifice is a sign of the barbarism and marginality of the Jew.

The fourth reading of circumcision saw it as a form of medical prophylaxis. This seems to be first claimed in the writing of the Greco-Jewish historian Philo, who was writing in a strongly Hellenistic culture which found any mutilation of the body abhorrent. He claimed that it was a prophylaxis against diseases of the penis, which also promoted the well being of the individual and assured fertility. But the hygienic rationale was also evoked, as we have seen, in the work of Johann David Michaelis, the central German commentator on this practice in the eighteenth century. It is only in the middle of the nineteenth century that the debate about the medical meaning of circumcision impacts upon the Jewish community in Central Europe. Prior to this the discussions concerning the meaning of circumcision in the Christian community remained separate from Jewish concern in Europe. While the image of the circumcized Jew was raised as a central metaphor for Jewish difference in Great Britain with the presentation of the Jewish Naturalization Act in 1753, it only became of importance with the gradual acculturation of the Jewish in Germany and Austria toward the middle of the nineteenth century. The debates within and without the Jewish communities concerning the nature and implication of circumcision surfaced in Germany during the 1840s.

By the end of the nineteenth century, ritual circumcision had grown in disrepute in Germany because of its association with questions of ‘race’. However, when Jewish practice was understood as hygienic and could be emulated, circumcision came to be held in higher repute. In a study undertaken by the British surgeon Jonathan Hutchinson in 1854, the incidence of syphilis among London Jews was found to be one-fifteenth of that of the general community. He found that this did not reflect a higher moral stance (as the gonorrhea rate was the same in both groups), but assumed that it was the result of a more general immunity. Hutchinson's views echo the more general assumption of the time, that ‘Jews escape the great epidemics more readily than the other races with whom they live’. In the US it came to be associated with the hygiene movement after the Spanish–American war and was seen as a universal panacea for venereal disease. By the late twentieth century, circumcision for prophylactic reasons had come to be common medical practice in the US, but very uncommon in the UK, and even after the Holocaust it remained a relatively rare medical procedure in Germany.

Sander L. Gilman

Bibliography

Gilman, S. L. (1993). Freud, race and gender. Princeton University Press, Princetown.
Hoffman, L. A. (1996). Covenant of blood: circumcision and gender in Rabbinic Judaism. University of Chicago Press, Chicago.
Remondino, P. C. (1891). History of circumcision: from the earliest times to the present: moral and physical reasons for its performance: history of eunuchism, hermaphrodism, etc. and of the different operations practised upon the prepuce. F. A. Davis, Philadelphia and London.

Circumcision

Definition

The surgical removal of the foreskin of the penis or prepuce.

Purpose

In the United States, circumcision in infant boys is performed for social, medical, or cultural/religious reasons. Once a routine operation urged by pediatricians and obstetricians for newborns in the middle of the twentieth century, circumcision has become an elective option that parents make for their sons on an individual basis. Families who practice Judaism or Islam may select to have their sons circumcised as a religious practice. Others choose circumcision for medical benefits.

Female circumcision (also known as female genital mutilation ) is usually performed for cultural and social reasons by family members and others who are not members of the medical profession, with no anesthesia. Not only is the prepuce removed but often the vaginal opening is sewn to make it smaller. This practice is supposed to ensure the virginity of a bride on her wedding day. It also prevents the woman from achieving sexual pleasure during coitus. This practice is not universally approved by the medical profession and is considered by some as a human rights violation.

Though the incidence of male circumcision has decreased from 90% in 1979 to 60% in 1996, it is still the most common surgical operation in the United States. Circumcision rates are much lower for the rest of the industrialized world. In Britain, it is only done for religious practices or to correct a specific medical condition of the penis.

Some of the medical reasons parents choose circumcision are to protect against infections of the urinary tract and the foreskin, prevent cancer, lower the risk of getting sexually transmitted diseases, and prevent phimosis (a tightening of the foreskin that may close the opening of the penis). Though studies indicate that uncircumcised boys under the age of five are 20 times more likely than circumcised boys to have urinary tract infections (UTIs), the rate of incidence of UTIs is quite low. There are also indications that circumcised men are less likely to suffer from penile cancer, inflammation of the penis, or have many sexually transmitted diseases. Here again, the rate of incidence is low. Good hygiene usually prevents most infections of the penis. Phimosis and penile cancer are very rare, even in men who have not been circumcised. Education and good safe sex practices can prevent sexually transmitted diseases in ways that a surgical procedure cannot because these are diseases acquired through risky behaviors.

With these factors in mind, the American Academy of Pediatrics has issued a policy statement that states though there is existing scientific evidence that indicates the medical benefits of circumcision, the benefits are not strong enough to recommended circumcision as a routine practice.

Precautions

Circumcision should not be performed on infants with certain deformities of the penis that may require a portion of the foreskin for repair. The most common condition for surgery using the foreskin is hypospadias, a congenital deformity of the penis where the urinary tract opening is not at the tip of the glans. Also, infants with a large hydrocoele or hernia may suffer important complications through circumcision. Premature infants and infants with serious infections are also poor candidates to be circumcised, as are infants with hemophilia, other bleeding disorders, or whose mothers had taken anticoagulant drugs. In older boys or men, circumcision is a minor procedure. Therefore, it can be performed in virtually anyone without a serious illness or unusual deformity.

Description

The foreskin of the penis protects the sensitivity of the glans and shields it from irritation by urine, feces, and foreign materials. It also protects the urinary opening against infection and incidental injury.

In circumcision of infants, the foreskin is pulled tightly into a specially designed clamp, and the foreskin pulls away from the broadened tip of the penis. Pressure from the clamp stops bleeding from blood vessels that supplied the foreskin. In older boys or adults, an incision is made around the base of the foreskin, the foreskin is pulled back, and then it is cut away from the tip of the penis. Stitches are usually used to close the skin edges.

Preparation

Despite a long-standing belief that infants do not experience serious pain from circumcision, most authorities now believe that some form of local anesthesia is necessary. The physician injects local anesthesia at the base of the penis or under the skin around the penis (subcutaneous ring block). Both anesthetics block key nerves. EMLA cream, a topical formula of several anesthetics can also be used.

Aftercare

After circumcision, the wound should be washed daily. An antibiotic ointment or petroleum jelly may be applied to the site. If there is an incision, a wound dressing will be present and should be changed each time the diaper is changed. Sometimes a plastic ring is used instead of a bandage. The ring will usually fall off in five to eight days. The penis will heal in seven to 10 days.

Infants who undergo circumcision may be fussy for some hours afterward, so parents should be prepared for crying, feeding problems, and sleep problems. Generally these go away within a day. In older boys, the penis may be painful, but this will go away gradually. A topical anesthetic ointment or spray may be used to relieve this temporary discomfort. There may also be a "bruise" on the penis, which typically goes away with no particular attention.

Risks

Complications following newborn circumcision appear in one out of every 500 procedures. Most complications are minor. Bleeding occurs in half of the complications and is usually easy to control. Infections are rare and present with fever and signs of inflammation.

KEY TERMS

Foreskin— A covering fold of skin over the tip of the penis.

Glans— The cone-shaped tip of the penis.

Hernia— Bulging of abdominal structures through an abnormal opening in the muscular wall.

Hydrocele— Collection of fluid in the scrotum.

Hypospadias— A congenital deformity of the penis where the urinary tract opening is not at the tip of the glans.

Phimosis— A tightening of the foreskin that may close the opening of the penis.

Prepuce— A fold like the foreskin that covers the clitoris; another name for foreskin.

There may be injuries to the penis itself, and these may be difficult to repair. In 2000, there were reports that the surgical clamps used in circumcision were at fault in over 100 injuries reported between July 1996 and January 2000. In nearly all cases, the clamps were assumed to be in working order but had been repaired with replacement parts that were not of the manufacturer's specifications. Physicians were urged to inspect the clamps before use and ensure that their dimensions fit their infant patients.

Resources

BOOKS

Gollaher, David L. Circumcision: A History of the World's Most Controversial Surgery. Basic Books, 2000.

PERIODICALS

Imperio, Winnie Anne. "Circumcision Appears Safe, But Not Hugely Beneficial." OB GYN News 35, no. 7 (April 1, 2000): 9.

Schmitt, B. D. "The Circumcision Decision: Pros and Cons." Clinical Reference Systems 2000: 1579.

OTHER

American Academy of Pediatrics. New AAP Circumcision Policy Released (Press Release). March 1, 1999. 〈http://www.aap.org/advocacy/archives/marcircum.htm〉.

CIRCUMCISION

for males, circumcision involves removal of the foreskin of the penis. for females, it is the excision of all or part of the external genitalia, and is commonly referred to as clitoridectomy or female genital mutilation.

When done as part of tradition, male circumcision often signifies a rite of passage—admission into group membership, or the achievement of a particular status. Jewish boys are circumcised on their eighth day of life (unless the procedure will complicate their health) in accordance with the biblical commandment symbolizing the covenant (brit) with God. The ritual, called brit milah in Hebrew, is also required of male proselytes. Male proselytes who were previously circumcised are required to have a drop of blood, called tipat dam in Hebrew, removed from the penis. Both rituals are to be performed by a mohel, a Jewish person trained in the ritual. Male circumcision is also widely prevalent in Muslim society. Deviation from this practice in both societies is related to an attenuated degree of observance of religious observance in general.

The practice of circumcising females may be attributable to an attempt to depress sexual desire and preserve the virginity of young girls, but the original motivation is unclear. (Major religions neither support the practice nor refer to it explicitly.) Female circumcision is often performed between five and twelve years of age, or after childbirth. It is widely criticized for medical and sexual reasons, and because of the pain, disfigurement, and mental anguish it may cause. The World Medical Association condemned the act in 1993, calling it "female genital mutilation." The practice is more widespread in African countries than it is in Western countries, despite criticism by African leaders.

Male circumcision has its medical proponents. About 60 percent of U.S. male infants undergo circumcision, but the practice is being increasingly challenged. Medical associations now render a more cautious appraisal of the medical benefits of male circumcision, and raise new questions about possible physiological, sexual, and psychological consequences.

see also female genital mutilation.

Bibliography

Aldeeb Abu-Sahlieh, Sami Awad. Male and Female Circumcision Among Jews, Christians and Muslims: Religious, Medical, Social, and Legal Debate. Warren Center, PA: Shangri-La Publications, 2001.

Gollaher, David L. Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000.

Mark, Elizabeth, ed. My Covenant in Your Flesh: Circumcision, Gender, and Culture Across Jewish History. Boston: University Press of New England/Brandeis University Press, 2003.

Ephraim Tabory

circumcision , operation to remove the foreskin covering the glans of the penis. It dates back to prehistoric times and was widespread throughout the Middle East as a religious rite before it was introduced among the Hebrews. It is performed by Jews on the eighth day after the birth of the male child, unless postponed for reasons of health. It is also practiced among Muslims and by other peoples in many parts of the world.

Explanations of the origin of circumcision are entirely conjectural. It is related to rites of initiation. Among Jews it is considered to involve membership in the community and to be a sign of the covenant between God and humans. 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. Despite some controversy, it also has been widely practiced in modern times, especially in the United States, as a sanitary measure believed to give some preventive advantage against penile cancer and sexually transmitted diseases (studies have shown it to be associated with a significant reduction in the risk of HIV transmission, particularly among heterosexuals). Since 1971, when the American Academy of Pediatrics stopped recommending routine infant circumcision, the number of circumcised newborns in the United States has declined; the infant circumcision rate is now around 33%.

So-called female circumcision, in the form of excision of the labia minora and clitoris (clitoridectomy) aimed at destroying sexual sensation, is known in Islam (although it is a cultural, not a religious practice) and in certain societies of Africa, South America, and elsewhere. Also called female genital mutilation, it is a controversial practice, but deeply rooted in local custom; there are movements toward prohibition in some countries. In the United States it is illegally practiced among some immigrant populations. In some instances women have sought asylum in the United States or other Western nations to prevent forced operations on themselves or their daughters. A World Health Organization study released in 2006, which involved more than 28,000 women in six African countries, found that the practice increased the risk of complications and death during and after childbirth for mothers and their newborns.

Bibliography: See study by D. L. Gollaher (2000).

Circumcision

Judaism

(Heb., berit milah ‘covenant of circumcision’). Following Genesis 17. 11–12, any child born of a Jewish mother is Jewish whether circumcised or not. None the less it is the duty of a Jewish father to have his son circumcised on the eighth day (Shulḥān Arukh YD 260. 1). The operation is done by a mohel who must be an observant Jew (Sh.Ar. YD 264. 1).

Islam

Khitān is male circumcision. It is obligatory, though the details, and the age at which it is done, vary. Khafḍ is female circumcision, which is not obligatory, but which is nevertheless regarded by many as according to sunna—i.e. customary in the strong and religious sense.

111. Circumcision

1. Abraham initiated rite in covenant with God. [O.T.: Genesis 17:11–14]
2. Berith Jewish rite of circumcising male child eight days after birth. [Judaism: Misc.]
3. Elijah traditionally represented at ceremony by empty chair. [Judaism: Wigoder, 172]
4. Gibeath-haaraloth Hill of Foreskins; where Joshua circumcised Israelites. [O.T.: Joshua 5:3]
5. Shandy, Tristram accidentally circumcised by a loose window in a sash. [Br. Lit.: Tristram Shandy in Magill I, 1027]

cir·cum·cise / ˈsərkəmˌsīz/ • v. [tr.] cut off the foreskin of (a young boy or man, esp. a baby) as a religious rite, esp. in Judaism and Islam, or as a medical treatment. ∎  cut off the clitoris, and sometimes the labia, of (a girl or young woman) as a traditional practice among some peoples.

circumcision (ser-kŭm-sizh-ŏn) n. surgical removal of the foreskin of the penis. This operation is usually performed for religious and ethnic reasons but is sometimes required for medical conditions, mainly phimosis and paraphimosis. female c. surgical removal of the clitoris, labia minora, and labia majora. See clitoridectomy, infibulation.

cir·cum·ci·sion / ˌsərkəmˈsizhən; ˈsərkəmˌsizhən/ • n. the action or practice of circumcising a young boy or man.See also female circumcision. ∎  (Circumcision) (in church use) the feast of the Circumcision of Jesus, January 1.

circumcision Operation of removing part or the whole of the foreskin of the penis or of removing the clitoris. Male circumcision is ritual in some groups, notably Jews and Muslims, and is said to have sanitary benefits. Female circumcision is intended to reduce sexual pleasure and has no medical benefit.

circumcision. Though circumcision had long been in use as a religious rite among the Jews, it was abandoned at an early date by nearly the whole Church. In St Paul's Epistles ‘the circumcision’ is used substantively of the Jewish people.

circumcise XIII. — OF. circonciser or f. F. circoncis-, stem of circoncire — L. circumcīdere, f. CIRCUM- + cædere cut.
So circumcision XII.

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