Circumcision

Male circumcision is the 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, including some Oriental Orthodox Churches. According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, of whom 68% 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.

There is controversy regarding circumcision. An advocate of circumcision argues, for example, 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. Two opponents of circumcision argue, for example, that it adversely affects penile function and sexual pleasure, is justified by medical myths, is extremely painful, and is comparable to female genital cutting.

The American Medical Association stated in 1999: "Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice."

The World Health Organization (WHO; 2007), the Joint United Nations Programme on HIV/AIDS (UNAIDS; 2007), and the Centers for Disease Control and Prevention (CDC; 2008) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides minimal protection and should not replace other interventions to prevent transmission of HIV.

History

Main article: History of male circumcision

Origins

It has been variously proposed that circumcision began as a religious sacrifice, an offering to ensure fertility, a tribal mark, a rite of passage, an attempt to emphasise masculinity, as a means of humiliating enemies and slaves, as a hygienic measure. Darby describes these theories as "conflicting", and states that "the only point of agreement among proponents of the various theories is that promoting good health had nothing to do with it." Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practising circumcision, leading to its spread.

The oldest documentary evidence for circumcision comes from ancient Egypt. Circumcision was common, although not universal, among ancient Semitic peoples. In the aftermath of the conquests of Alexander the Great, however, Greek dislike of circumcision (they regarded a man as truly "naked" only if his prepuce was retracted) led to a decline in its incidence among many peoples that had previously practiced it.

Circumcision has ancient roots among several ethnic groups in sub-equatorial Africa, and is still performed on adolescent boys to symbolize their transition to warrior status or adulthood.

Non-religious circumcision in the English-speaking world

Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada, South Africa, New Zealand and to a lesser extent in the United Kingdom. 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. The penis became "dirty" by association with its function, and from this premise circumcision was seen as preventative medicine to be practised universally. In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation. Aggleton wrote that John Harvey Kellogg viewed male circumcision in this way, and further "advocated an unashamedly punitive approach." Circumcision was also said to protect against syphilis, phimosis, paraphimosis, balanitis, and "excessive venery" (which was believed to produce paralysis). Gollaher states that physicians advocating circumcision in the late nineteenth century expected public scepticism, and refined their arguments to overcome it.

Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 32% of newborn American boys were being circumcised in 1933. Laumann et al. reported that the prevalence of circumcision among US-born males was approximately 70%, 80%, 85%, and 77% for those born in 1945, 1955, 1965, and 1971 respectively. Xu et al. reported that the prevalence of circumcision among US-born males was 91% for males born in the 1970s and 84% for those born in the 1980s. Between 1981 and 1999, National Hospital Discharge Survey data from the National Center for Health Statistics demonstrated that the infant circumcision rate remained relatively stable within the 60% range, with a minimum of 60.7% in 1988 and a maximum of 67.8% in 1995. A 1987 study found that the most prominent reasons US parents choose circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns. However, a later study speculated that an increased recognition of the potential benefits of neonatal circumcision may have been responsible for the observed increase in the US rate between 1988 and 2000. A report by the Agency for Healthcare Research and Quality placed the 2005 national circumcision rate at 56%.

In 1949, the United Kingdom's newly-formed National Health Service removed infant circumcision from its list of covered services, and circumcision has since been an out-of-pocket cost to parents. Among men (aged 15 years or older) who are neither Jews nor Muslims, the overall prevalance of circumcision in the UK is 6% according to the WHO's estimates. When "data from targeted oversampling of black Caribbean, black African, Indian, and Pakistani groups (the Natsal ethnic minority boost) were combined with the main survey data", it was found that the prevalence of circumcision in the UK is age-graded, with 11.7% of those aged 16–19 years circumcised and 19.6% of those aged 40–44 years. There is a clear ethnic division: "With the exception of black Caribbeans, men from all ethnic minority backgrounds were significantly more likely to report being circumcised compared to men who described their ethnicity as white". These particular findings "confirm that the prevalence of male circumcision among British men appears to be declining. This is despite an increase in the proportion of the British population describing their ethnicity as nonwhite"; indeed, the proportion of newborns circumcised in England and Wales has fallen to less than one percent.

The circumcision rate has declined sharply in Australia since the 1970s, leading to an age-graded fall in prevalence, with a 2000-01 survey finding 32% of those aged 16–19 years circumcised, 50% for 20–29 years and 64% for those aged 30–39 years.

In Canada, Ontario health services delisted circumcision in 1994.

Cultures and religions

In some cultures, males must be circumcised shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is commonly practised in the Jewish and Islamic faiths.

Jewish law states that circumcision is a ' mitzva aseh ("positive commandment" to perform an act) and is obligatory for Jewish-born males and for non-circumcised Jewish male converts. It is only postponed or abrogated in the case of threat to the life or health of the child. 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 ), which means "Covenant of circumcision" in Hebrew. It is considered of such importance that in some Orthodox communities the body of an uncircumcised Jewish male will sometimes be circumcised before burial. Although 19th century Reform leaders described it as "barbaric", the practice of circumcision "remained a central rite" and the Union for Reform Judaism has, since 1984, trained a