Circumcision
Circumcision is a surgical procedure that removes the foreskin from the human penis. In the procedure's most common form, the foreskin is extended with forceps, then a circumcision device may be placed, after which the foreskin is excised. Topical or locally injected anesthesia is generally used to reduce pain and physiologic stress. Circumcision is undertaken for religious, cultural, social, and medical reasons. It may be medically necessary in cases of phimosis, chronic urinary tract infections, and other pathologies of the penis that do not resolve with other treatments. The procedure is contraindicated in cases of certain genital structure abnormalities or poor general health.
The procedure is associated with reduced rates of sexually transmitted infections and urinary tract infections. This includes reducing the incidence of cancer-causing forms of human papillomavirus and reducing HIV transmission among heterosexual men in high-risk populations by up to 60%; its prophylactic efficacy against HIV transmission in the developed world or among men who have sex with men is debated. Neonatal circumcision decreases the risk of penile cancer. Complication rates increase significantly with age. Bleeding, infection, and the removal of either too much or too little foreskin are the most common acute complications, while meatal stenosis is the most common long-term. There are various cultural, social, legal, and ethical views on circumcision. Major medical organizations hold differing views on circumcision's prophylactic efficacy in developed countries. Some medical organizations take the position that it carries prophylactic health benefits that outweigh the risks, while others hold that its medical benefits are not sufficient to justify it.
Circumcision is one of the world's most common and oldest medical procedures, with 37–39% of men globally circumcised. Prophylactic usage originated in England during the 1850s and has since spread globally, becoming established as a way to prevent sexually transmitted infections. Beyond use as a prophylactic or treatment option in healthcare, circumcision plays a major role in many of the world's cultures and religions, most prominently Judaism and Islam. Circumcision is among the most important commandments in Judaism and considered obligatory for men. In some African and Eastern Christian denominations male circumcision is required. It is widespread in the United States, South Korea, Israel, Muslim-majority countries, and most of Africa. It is relatively rare for non-religious reasons in Latin America, Europe, Australia, most of Asia, and parts of Southern Africa. The origin of circumcision is not known with certainty, but the oldest documentation comes from ancient Egypt.
Uses
Disease prevention
Approximately half of all circumcisions worldwide are performed for reasons of prophylactic healthcare.Prophylactic usage in high-risk populations
There is a consensus among the world's major medical organizations and in the academic literature that circumcision is an efficacious intervention for HIV prevention in high-risk populations if carried out by medical professionals under safe conditions.In 2007, the WHO and the Joint United Nations Programme on HIV/AIDS recommended adolescent and adult circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV, as long as the program includes "informed consent, confidentiality, and absence of coercion"—known as voluntary medical male circumcision, or VMMC. In 2010, this expanded to routine neonatal circumcision, as long as the infant's parents consented. In 2020, the WHO again concluded that male circumcision is an efficacious intervention for HIV prevention and that male circumcision is an essential strategy, in addition to other measures, to prevent heterosexually acquired HIV infection in men. Eastern and southern Africa had a particularly low prevalence of circumcised males. This region has a disproportionately high HIV infection rate, with a significant number of infections stemming from heterosexual transmission. As a result, the promotion of prophylactic circumcision has been a priority intervention in that region since the WHO's 2007 recommendations. The International Antiviral Society–USA also suggests circumcision be discussed with men who have insertive anal sex with men, especially in regions where HIV is common. There is evidence that circumcision is associated with a reduced risk of HIV infection for such men, particularly in low-income countries.
The finding that circumcision significantly reduces female-to-male HIV transmission has prompted medical organizations serving communities affected by endemic HIV/AIDS to promote circumcision as a method of controlling the spread of HIV.
Prophylactic usage in developed countries
Major medical organizations hold varying positions on the prophylactic efficacy of the elective circumcision of minors in developed countries. Literature on the matter is polarized, with the cost-benefit analysis highly dependent on the kinds and frequencies of health problems in the population under discussion and how circumcision affects them.The World Health Organization, UNAIDS, and American medical organizations take the position that its prophylactic health benefits outweigh the risks, while European, Australian, and New Zealand medical organizations generally hold that its medical benefits are insufficient to justify it. Advocates of circumcision recommend performing it during the neonatal period when it is less expensive and has a lower risk of complications. The American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and Centers for Disease Control and Prevention have said that circumcision's potential benefits outweigh the risks.
In 2010, the World Health Organization said:
Pathologies
Circumcision is also used to treat various pathologies. These include pathological phimosis, refractory balanoposthitis and chronic or recurrent urinary tract infections.Contraindications
Circumcision is contraindicated in certain cases.These include infants with certain genital structure abnormalities, such as a misplaced urethral opening, curvature of the head of the penis, or ambiguous genitalia, because the foreskin may be needed for reconstructive surgery. Circumcision is contraindicated in premature infants and those who are not clinically stable and in good health.
If a person is known to have or has a family history of serious bleeding disorders such as hemophilia, it is recommended that the blood be checked for normal coagulation properties before the procedure is attempted.
Technique
The foreskin is the double-layered fold of tissue at the distal end of the human penis that covers the glans and the urinary meatus. Different amounts of skin can be removed during circumcision. The practice is differentiated from other surgeries for the treatment of phimosis or treatment-resistant infection by the complete removal of the preputial orifice.For adult medical circumcision, superficial wound healing takes up to a week, and complete healing 4 to 6 months. For infants, healing is usually complete within one week.
Removal of the foreskin
For infant circumcision, devices such as the Gomco clamp, Plastibell and Mogen clamp are commonly used in the USA. These follow the same basic procedure. First, the amount of foreskin to be removed is estimated. The practitioner opens the foreskin via the preputial orifice to reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin from its attachment to the glans. The practitioner then places the circumcision device, which remains until blood flow has stopped. Finally, the foreskin is amputated. For older babies and adults, circumcision is often performed surgically without specialized instruments, and alternatives such as Unicirc or the Shang ring are available.Pain management
The circumcision procedure causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes, so the use of analgesia is advocated and required by law in some countries. Ordinary procedural pain may be managed in pharmacological and non-pharmacological ways. Pharmacological methods, such as localized or regional pain-blocking injections and topical analgesic creams, are safe and effective. The ring block and dorsal penile nerve block are the most effective at reducing pain, and the ring block may be more effective than the DPNB. They are more effective than EMLA cream, which is more effective than a placebo. Topical creams have been found to irritate the skin of low birth weight infants, so penile nerve block techniques are recommended in this group. Circumcision is contraindicated for premature babies partially because of complications with anesthesia.For infants, non-pharmacological methods such as the use of a comfortable, padded chair and a sucrose or non-sucrose pacifier are more effective at reducing pain than a placebo, but the American Academy of Pediatrics states that such methods are insufficient alone and should be used to supplement more effective techniques. A quicker procedure reduces duration of pain; use of the Mogen clamp was found to result in a shorter procedure time and less pain-induced stress than the use of the Gomco clamp or the Plastibell. The available evidence does not indicate that post-procedure pain management is needed. Some doctors recommend the use of petroleum jelly to prevent blood from adhering the genitals to the diaper during healing. For adults, topical anesthesia, ring block, dorsal penile nerve block and general anesthesia are all options, and the procedure requires four to six weeks of abstinence from masturbation or intercourse to allow the wound to heal.