Circumcision

Male circumcision is the surgical removal of some or all of the foreskin (prepuce) from the penis. The word "circumcision" comes from Latin circum (meaning "around") and cædere (meaning "to cut"). Early depictions of circumcision are found in cave paintings and Ancient Egyptian tombs, though some pictures are open to interpretation. Religious male circumcision is considered a commandment from God in Judaism. In Islam, though not discussed in the Qur'an, male circumcision is widely practised and most often considered to be a sunnah. It is also customary in some Christian churches in Africa.

Global estimates by the World Health Organization (WHO) suggest that 30 percent of males are circumcised, of whom 68 percent are Muslim. The prevalence of circumcision varies mostly with religious affiliation, and sometimes culture. Most circumcisions are performed during adolescence for cultural or religious reasons; in some countries they are more commonly performed during infancy. Circumcision is also used therapeutically, as one of the treatment options for balanitis xerotica obliterans, paraphimosis, balanitis, posthitis, balanoposthitis and urinary tract infections.

Circumcision reduces the risk of HIV infection in heterosexual populations that are at high risk. Evidence among heterosexual men in sub-Saharan Africa shows a decreased risk of between 38 percent and 66 percent over two years and in this population it appears cost effective. Evidence of benefit for women is controversial and evidence of benefit in developed countries and among men who have sex with men is yet to be determined. The WHO currently recommends circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV. Ethical concerns remain regarding the implementation of campaigns to promote circumcision. According to the Royal Dutch Medical Association (2010), no professional association of physicians currently recommends routine circumcision. Some bodies have discussed under what circumstances neonatal circumcision is ethical.

There is controversy regarding circumcision. Arguments that have been raised in opposition to circumcision include that it adversely affects penile function and sexual pleasure, is justified only by medical myths, is extremely painful, and is a violation of human rights. Those raised in favour of circumcision include that it provides important health advantages which outweigh the risks, has no substantial effects on sexual function, has a low complication rate when carried out by an experienced physician, and is best performed during the neonatal period.

Modern procedure

Plastibell Circumcision day 4 post operation

If anesthesia is to be used there are several options: local anesthetic cream (EMLA cream) can be applied to the end of the penis 60–90 minutes prior to the procedure; local anesthetic can be injected at the base of the penis to block the dorsal penile nerve; local anesthetic can be injected in a ring around the middle of the penis in what is called a subcutaneous ring block. It is also possible to use general anesthetics in the case of adult surgery, though not the standard practice.

For infant circumcision, devices such as the Gomco clamp, Plastibell, and Mogen clamp are commonly used, together with a restraining device.

With all these devices the same basic procedure is followed. First, the amount of foreskin to be removed is estimated. The foreskin is then opened via the preputial orifice to reveal the glans underneath and ensure it is normal. The inner lining of the foreskin (preputial epithelium) is then bluntly separated from its attachment to the glans. The device is then placed (this sometimes requires a dorsal slit) and remains there until blood flow has stopped. Finally, the foreskin is amputated. Sometimes, the frenulum band may need to be broken or crushed and cut from the corona near the urethra to ensure that the glans can be freely and completely exposed.

• With the Plastibell, once the glans is freed the Plastibell is placed over the glans, and the foreskin is placed over the Plastibell. A ligature is then tied firmly around the foreskin and tightened into a groove in the Plastibell to achieve hemostasis. Foreskin distal to the ligature is excised and the handle is snapped off the Plastibell device. The Plastibell falls from the penis after the wound has healed, typically in four to six days.
• With a Gomco clamp, a section of skin is dorsally crushed with a hemostat and 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. The clamp is tightened, "crushing the foreskin between the bell and the base plate." The crushed blood vessels provide hemostasis. The flared bottom of the bell fits tightly against the hole of the base plate, so the foreskin may be cut away with a scalpel from above the base plate.
• With a Mogen clamp, the foreskin is pulled dorsally with a straight hemostat, and lifted. 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" to Gomco or Plastibell circumcisions. The clamp is locked, and a scalpel is used to cut the skin from the flat (upper) side of the clamp.

Adult circumcisions are often performed without clamps and require four to six weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal. In some African countries, male circumcision is often performed by non-medical personnel under unsterile conditions. After hospital circumcision, the foreskin may be used in biomedical research, consumer skin-care products, skin grafts, or β-interferon-based drugs. In parts of Africa, the foreskin may be dipped in brandy and eaten by the patient, eaten by the circumciser, or fed to animals. According to Jewish law, after a Brit milah , the foreskin should be buried.

Ethical, psychological, and legal considerations

Main article: Circumcision controversies

Ethical issues

Ethical questions have been raised over removing healthy, functioning genital tissue from a minor. Opponents of circumcision state that infant circumcision infringes upon individual autonomy and represents a human rights violation. Rennie et al. note that using circumcision as a way of preventing HIV in high prevalence, low-income countries in sub-Saharan Africa, is controversial, but argue that "it would be unethical to not seriously consider one of the most promising new approaches to HIV-prevention in the 25-year history of the epidemic".

Consent

Main article: Ethics of circumcision

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, but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue. 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. UNAIDS states that "ale circumcision is a voluntary surgical procedure and health care providers must ensure that men and young boys are given all the necessary information to enable them to make free and informed choices either for or against getting circumcised."

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. Denniston states 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.

Others believe neonatal circumcision is permissible, if parents should so choose. Viens argues that, in a cultural or religious context, circumcision is of significant enough importance that parental consent is sufficient and that there is "an absence of sufficient evidence or persuasive argumentation" to support changing the present policy. 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."

Acknowledgment of pain

Williams (2003) argued that human attitudes toward the pain that animals (including humans) experience may not be based on speciesism, developing an analogy between attitudes toward the pain pigs endure while having their tails docked, and "our culture's indifference to the pain that male human infants experience while being circumcised."

Psychological issues

The British Medical Association (BMA) states that "it is now widely accepted, including by the BMA, that this surgical procedure h