Wednesday, June 25, 2014

Circumcision or removal of penile foreskin: Information






Circumcision or removal of penile foreskin

Circumcision is the removal of the foreskin, which is the skin that covers the tip of the penis. Circumcision is considered a very safe procedure for both newborns and older children. Neonatal circumcision is generally a rapid and safe procedure when performed by an experienced physician.
There are medical benefits and risks to circumcision. Possible benefits include a lower risk of urinary tract infections, penile cancer and sexually transmitted diseases. The risks include pain and a low risk of bleeding or infection. These risks are higher for older babies, boys and men.

Some research has suggested that uncircumcised male infants have an increased risk of certain conditions, including:
  • Cancer of the penis
  • Certain sexually transmitted diseases including HIV
  • Infections of the penis
  • Phimosis (tightness of the foreskin that prevents it from retracting)
  • Urinary tract infections.

 

Risks of circumcision:

  • Bleeding.
  • Infection. Injury to the penis.
  • Redness around the surgery site.

 

The benefits

Circumcision may have health benefits, including:
  • Easier hygiene. Circumcision makes it easy to wash the penis — although it's simple to clean an uncircumcised penis, too.
  • Decreased risk of urinary tract infections. The risk of urinary tract infections in the first year is low, but these infections may be up to 10 times as common in uncircumcised baby boys. Severe infections early in life can lead to kidney problems later on.
  • Prevention of penile problems. Occasionally, the foreskin on an uncircumcised penis may be difficult or impossible to retract (phimosis). This can also lead to inflammation of the head of the penis.
  • Decreased risk of penile cancer. Although cancer of the penis is rare, it's less common in circumcised men.
  • Decreased risk of sexually transmitted diseases. Safe sexual practices remain essential, but circumcised men may have a slightly lower risk of certain sexually transmitted diseases — including HIV, the virus that causes AIDS.

 

The drawbacks

Circumcision also has drawbacks, including:
  • Surgical risks. Excessive bleeding and infection are uncommon, but possible. The foreskin may be cut too short or too long or fail to heal properly. If the remaining foreskin reattaches to the end of the penis, minor surgery may be needed to correct it.
  • Pain. Circumcision hurts. Local anaesthesia can block nerve sensations during the procedure.
Circumcision is done in the hospital as out patient procedure and using local anaesthesia. In very small children, general anaesthesia is preferred.
Problems after circumcision are rare. Contact your son's doctor if:
  • Your son doesn't urinate normally within six to eight hours after the circumcision.
  • There's persistent bleeding or redness around the tip of the penis.
  • There's foul-smelling drainage from the tip of the penis or crusted sores fill with fluid.





The effects of circumcision
I don't have a foreskin. I wish I did. I think it would make playing with my penis much more fun. After 30 odd years of having underwear rubbing on my penis head, it has become dry and a bit rough. Now I can't masturbate without lube, like baby oil, and if I use a condom, it needs to have a bit of lube inside as well as outside it.

When I was a kid I had adhesions between the glans and the foreskin, and they took off my foreskin to "solve" this problem. They didn't ask me what I wanted, though. Anyway, they took it off, and the adhesions were torn away. Normally they separate by the age of five, but they can hang around till puberty. It is possible to separate them more gently but mine were torn, and the result has been an extremely sensitive coronal ridge, which in fact is so sensitive that it can be downright uncomfortable in cold weather, especially if my underwear is rubbing on it.
I haven't found a solution to this problem. Even daily moisturizing lotion doesn't help a lot. I hear some guy has designed briefs with a soft cotton special penis sleeve to help with this exact same problem. He calls it the "manhood". Very funny.

I recently saw some men's undies made from some special cotton fabric designed to help reduce eczema. I am going to see if that helps. When I was a teenager the stimulation of fabric on my glans seemed to give me loads of spontaneous erections, which I always enjoyed. Or maybe I was just very horny. Now the stimulation of underwear is just a pain in the ass....or something....

Why is a foreskin an advantage? 

Well, for one thing it is full of nerve endings that heighten sexual pleasure. For another it makes masturbation easier. The back and forth movement of the foreskin over the glans and shaft is eased by a naturally lubricated mucous membrane. And women who have sex with uncircumcised men say that the sensation of having an uncut penis in their vagina, moving inside its own natural skin sheath as the man thrusts, is very different to that produced by a "cut" penis in the vagina. You'd expect that, I guess. I'd like to know what I'm missing, but short of restoring my foreskin (a stretchy process which takes ages - I don't have the patience) I am going to have to be happy with what I've got. Actually, this is one area where I would like things to be different.

The question, though, is does not having a foreskin actually matter? There is a huge body of work on the web, all devoted to the campaign to stop routine circumcision. And quite right too: it is abusive to cut off any part of a person's body - especially without its owner's consent. I ask you! How could anyone put a baby through such an ordeal? The answer is probably because we've been conditioned to believe that the demi-gods of the medical profession know better than we do.......

I remember a scene in that mildly amusing drama "Thirty-something’s" - a few years ago now - in which the two main characters (whose names I have completely forgotten) agonize over whether or not to have their baby circumcised. I remember at the time thinking that if this was the program's best effort at representing a white middle class dilemma, then I had no time for it, and yet now I see how much of an issue it really is.

I mean - there you are, as a new parent, with the entire responsibility for the whole being of your new baby boy - and you have to decide whether to have his penis put in a clamp, have a doctor tear off the natural adhesions between the glans and foreskin, pull the skin harshly upwards and then slice through the most sensitive part of his body with a scalpel blade - and all without an anesthetic. Now, that sure is a dilemma.

I speak strongly on this matter because my penis - without its foreskin - has given me a lot of problems over the years. It is so sensitive in cold weather that even just the gentle rubbing of the softest cotton underwear is almost painful: this is probably because the glans was damaged by the tearing of the adhesions when they took my foreskin off. (When these adhesions are prematurely torn, some scar tissue forms on the glans.) There is however, one strange advantage that I have. When they removed my foreskin, they did it so unevenly and loosely that the remaining skin bunches up around the coronal rim of my penis. And when I put a condom on, there is, in fact, a real ridgey, bumpy, lumpy protrusion of skin around the upper surface of the penis head just below the corona.

Why is this so interesting, you ask?
Well, my penis also bends upwards somewhat (it is one of those which curves upwards rather than downwards), and the combination of these two quirks of nature means that when I push my penis into my girlfriend's vagina, it is exactly the right shape to produce the most exquisite stimulation of her G-spot. Indeed, she pretty quickly goes into G-spot mode, characterized by - so she tells me - waves of sexual energy coursing outwards from her G-spot through her whole body, producing long lasting pre-orgasmic plateaus of almost unbearable ecstasy. I have to admit she has not yet come from my penis thrusting inside her - I can't quite last long enough, Dammit, but I am sure it is only a matter of time before she does. Judging by the bliss she is currently experiencing, when she does it will be the most wonderful experience imaginable. For both of us.

There is certainly something very different about Jan's G spot orgasm - different to her clitoral orgasm, I mean. She can come with my finger on her G spot, and her whole experience of this orgasm is different to the orgasm produced by having her clit stimulated - it is much more whole body-centered, for one thing, and it involves a different kind of sexual energy - the experience is almost spiritual, in fact. And her vagina behaves differently, as well: when a G spot orgasm is approaching, instead of gripping tightly, as it does when she comes with her clit, her vagina balloons out and exerts an outward pressure, almost as if it is expelling my finger.

All of the differences between clitoral and vaginal orgasm have left us in no doubt that there are some very different things going on here: that Freud's distinction between the vaginal and clitoral orgasm is actually correct, and despite some efforts to rubbish the idea of vaginal orgasm by the medical profession, our experience as a couple tells us it is a real thing, different to a clitoral orgasm. But students of Tantric Sex have known this for ages, of course.

So I suppose your question might be: If my penis is so good for stimulating her G spot, what do I do with it? Well. Why? Because the best techniques that I have found for stimulating her G spot also just happen to be the ones which help me - and very possibly you as well, dear reader - to last longer.

By the way, you can see pictures of all these types of penises, cut and uncut, at Images of Size You can read about penile anatomy, circumcision and foreskin restoration at The-penis.com. This has good information on circumcision, or at least it lists loads of other sites you can follow to get information. Some other good sites on circumcision are: CIRP and Circumstitions

Now, what about the merits of circumcision versus no circumcision? My simple view is that anything which evolved on the human body - except the appendix - must have a function. And since I don't see the foreskin as an appendix, we must ask - what is its function? The foreskin, I mean, not the appendix. First, both inside and out, the foreskin is covered with sensitive nerve endings, all of which have a direct role in sexual stimulation and the orgasmic response of the man.

It is composed of sensitive mucosal tissue, protected from the atmosphere and full of sexual glands that produce smegma - which, far from just being a smelly substance turns out to have a vital role in sexual mating. And it makes sex more satisfying for the female partner. Sorry guys, but there you are.

Some eager scientists, pushing back the boundaries of knowledge as a good scientist should, interviewed women with experience of both circ'd and non-circ'd men. The researchers were looking for vaginal orgasms produced through intercourse in all these studies. What they found was very clear: with circumcised men, women were more likely to experience vaginal dryness, discomfort, and to want "to get the experience over with" because "they weren't really into it" than with uncirc'd men. As if that weren't discouraging enough, women were significantly less likely to have a vaginal orgasm with a cut man. And worst of all, at least for the men, the women reported that circumcised men were more likely to ejaculate prematurely (defined as coming within 3 minutes of penile insertion in more than half of the times the partners had sex).

Women with more than ten partners in their sexual history were more likely to achieve orgasm with their circumcised partners than those women with fewer partners, but they still had less frequent orgasms than they had with their uncircumcised partners. So clearly female choice and sexual experience are important factors, but they are not important enough to alter the fact that circ'd men seem to produce less satisfying feelings for a woman during lovemaking than a man with a foreskin.

And women who preferred their orgasms to come through vaginal intercourse rather than oral sex or masturbation preferred uncut men and they also preferred being on top during sex. They were also more likely to have an unaltered man as their most recent partner. And get this, guys: women with uncircumcised partners had a higher rate of orgasms with them, and they rated circumcised partners lower as lovers.

And the women overwhelmingly agreed that making love to circ'd and uncirc'd men was different: circumcised men tend to thrust harder and deeper, using long strokes, while unaltered men tend to thrust more gently, to have shorter thrusts, and tend to be in contact with the mons pubis and clitoris more.

All in all, conclude our intrepid scientists, it's clear that women prefer vaginal intercourse with an anatomically complete penis over sex with a circumcised penis. There may be many reasons for this. First, when the anatomically complete penis thrusts in the vagina, it does not slide, but rather glides on its own 'bedding' of movable skin.


The underlying corpus cavernosa and corpus spongiosum slide within the penile skin, while the skin juxtaposed against the vaginal wall moves very little. This sheath-within-a-sheath alignment allows penile movement, and vaginal and penile stimulation, with minimal friction or loss of secretions. Second, when the penile shaft is withdrawn slightly from the vagina, the foreskin bunches up behind the coronal ridge so that the tip of the foreskin (which contains the highest density of fine-touch neuroreceptors in the penis) comes into contact with the coronal ridge (which has the highest concentration of fine-touch receptors on the glans). This intense stimulation discourages the penile shaft from further withdrawal, explaining the short thrusting style that women noted in their unaltered partners.

Third, circumcision removes 33-50% of the penile skin. With this skin missing, there is less tissue for the swollen corpus cavernosa and corpus spongiosum to slide against. Instead, the skin of the circumcised penis rubs against the vaginal wall, increasing friction, abrasion and the need for artificial lubrication. Because of the tight penile skin, the corona of the glans (which works as a one-way valve in the vagina) pulls the vaginal secretions from the vagina when the shaft is withdrawn.

Unlike the anatomically complete penis, there is no sensory input to limit withdrawal. Because the vast majority of the fine-touch receptors are missing from the circumcised penis, their role as ejaculatory triggers is also absent. The loss of these receptors creates an imbalance between the deep pressure sensed in the glans, corpus cavernosa and corpus spongiosum and the missing fine touch.

To compensate for the imbalance, to achieve orgasm, the circumcised man must stimulate the glans, corpus cavernosa, and corpus spongiosum by thrusting deeply in and out of the vagina. As a result, coitus with a circumcised partner reduces the amount of vaginal secretions in the vagina, and decreases continual stimulation of the mons pubis and clitoris.

Although this was not directly measured, some women commented that unaltered men appeared to enjoy vaginal sex more than circumcised men. Men with a foreskin certainly had less fellatio, masturbation and anal sex than circ'd men.

As the scientists say: "Clearly, the anatomically complete penis offers a more rewarding experience for the female partner during coitus......the negative effect of circumcision on the sexual enjoyment of the female partner needs to be part of any discussions providing 'informed consent' before circumcision."

There may be other ways in which circumcision can affect a man's enjoyment of intercourse. This is an email I received:

I previously suffered from partner Anorgasmia [that means he couldn't come during sex]. I could masturbate and ejaculate without a problem but during unprotected vaginal sex I could last usually indefinitely. The few times where I was able to ejaculate during intercourse I had to expend so much effort as to leave myself exhausted and my partner sore. This wasn't a problem when I was younger but as the years go by my glans seemed even less sensitive than it used to be. The urologist I spoke to told me there was nothing wrong with me physically and that I should go see a sex therapist. Because of the quality of the sexual banter and openness within the relationship I knew this wasn't the problem. I began reading about circumcision (btw your section on the subject is excellent) and I learned that my situation is much more common than previously thought.

After communicating with others who had trouble ejaculating during vaginal sex I decided I to go through the arduous process of foreskin restoration. Now most of my sensitivity has returned to the point and now I am able to ejaculate during intercourse again and with much more control over when too. All I can say is thank God for the internet because otherwise I would have believed my doctor and thought the problem was me when really it was the result of being circumcised leaving my glans to be desensitized. I suspect this might also explain some the others with a similar problem.

know more about circumcision
It is estimated that there are currently in the world 650 million males who have been circumcised. think of what that means: the foreskin is removed from the penis without anesthetic. The most sensitive part of the body - the penis - is effectively mutilated for social or religious reasons. Do you think that this will have an impact on a man's pleasure?

Circumcision is a unique medical procedure in that the majority of circumcisions are not performed for medical reasons or by qualified medical practitioners. The historical origins of circumcision are unclear, but the practice is found throughout the world - in Native Americans, Australian Aboriginals, African and Middle Eastern tribesmen, and in the earliest Egyptian mummies. Almost all of these circumcisions were carried out for cultural or religious reasons, and in much of the world this continues to the present day, with circumcision a part of defining religious or tribal identity.

A wonderful example of this can be found in the autobiography of Nelson Mandela, in which he describes his own circumcision as part of his rite of passage to adulthood. In the USA, circumcision remains the cultural norm, and 70-90% of all male babies are circumcised. In this chapter we detail the medical indications for circumcision and the complications of surgery. Some of the issues that govern circumcision for religious purposes are discussed, and we examine the ethical and legal implications that are pertinent to the circumcision of minors. Medical practitioners need to be familiar with all these aspects of circumcision, to be able to advise on the wide range of questions that can arise when counselling parents and patients.

Religious circumcision
Amongst the major religions of the world, only in Judaism and Islam is circumcision an accepted religious rite. The origins of Christianity are found in Judaism and there are many similarities in the rites and laws of both religions, but there is no mandatory circumcision in Christianity. Similarly, there is no obligation for circumcision in the Buddhist, Sikh and Hindu religions. Circumcision of a male neonate is an essential undertaking within the Jewish religion, and is performed by a specifically trained mohel (pt. mohelim). In the United Kingdom (UK), mohelim are trained according to strict guidelines under the auspices of the Initiation Society. It is a requirement that a mohel is a practicing Jew himself (it is generally accepted that a mohel has been circumcised, thus precluding women), attends around 50 circumcisions before actually performing one, and is examined through both written and practical assessments. Although the Torah states that circumcision occurs on the eighth day, the mohel visits the family a few days prior to this to ensure that the child is healthy. Jewish law allows for a delay in circumcision should the child be suffering from any ailment, since the welfare of the child is paramount. For the procedure itself the use of local anesthetics, though not routine, is not prohibited within the Jewish Talmud (an explanatory commentary and debate on the various biblical laws) and may occur at the request of the family. The cut edge of the prepuce is not sutured and haemostasis is achieved by means of bandaging. The mohel is required to visit at least once after the procedure to check the wound, and leaves aftercare instructions. Although no precise figures are available, the complication rates of Jewish circumcisions in the UK are thought to be low. Given its place as part of the covenant of Abraham, it is likely that circumcision will remain a central part of Judaism and, as such, it may be of the utmost importance to a Jewish parent that their son be circumcised, even if the other parent is not a Jew.

Medical considerations in circumcision
Embryology and functional anatomy of the prepuce The prepuce develops from ectoderm, neuroectoderm and mesenchyme to form a structure that is comprised of an inner epithelial-lined mucosa, a lamina propria, dartos muscle, with dermis and glabrous skin on the outer surface. The prepuce first appears at 8 weeks' gestation as an epithelial thickening that grows forward over the developing glans, covering the glans completely by 16 weeks. During development, there is no plane of separation between the epithelium of the glans and that of the under-surface of the prepuce, and at birth the prepuce is almost always non-retractile. Separation of the two layers occurs as a result of spontaneous desquamation that commences in the distal prepuce at the end of gestation and proceeds proximally at varying rates. Hence, there is a considerable variation in the age at which the prepuce is fully retractile in different individuals, with 90% having a non-retractile prepuce at birth and 98% having a fully retractile prepuce at puberty. Importantly, even though a child may not have a fully retractile foreskin, partial retraction of the foreskin to its limit produces a characteristic 'flowering' appearance around the prepuce. The importance and significance of this are discussed later. The somatosenory innervation of the prepuce is by the dorsal nerve of the penis and branches of the perineal nerve. Additionally, the prepuce receives an autonomic innervation - parasympathetic visceral efferents and afferents from the sacral plexus and sympathetic visceral afferents from the lateral horns of T1 I-L2. Thus, neither a block of the dorsal penile nerve nor topical EMLA cream completely relieve the pain of circumcision. Microscopically, the prepuce has a dense population of fine touch nerve endings (mainly Meissner's corpuscles). Conversely, the glans has very few such nerve endings and is instead innervated by those associated with pain and temperature sensation, with the exception of the corona and frenulum. During intercourse, the glans glides over the prepuce whereas in the circumcised male it slides directly against the vaginal wall resulting in considerably more friction. Interestingly, there is some suggestion that women having experience of intercourse with both circumcised and uncircumcised find the latter to be preferable. The prepuce is therefore a specialized erogenous tissue, and surgical removal of the normal prepuce results in the loss of most of the fine touch receptors of the penis, and the glans itself becomes thickened and keratinized.

Medical indications for circumcision
The pathology that provokes the need for circumcision is different in infants and adults. In infants there is often a dilemma whether a non-retractile prepuce is truly phimosed. The appearance of ballooning of the prepuce during micturition is often thought to indicate a significant degree of phimosis, but this is not so. The only absolute evidence in an infant that circumcision is essential is when, on attempted retraction, the prepuce takes on the appearance of a helmet. If the prepuce begins to open and to take on the appearance of a flower, then no true phimosis exists. There is seldom any contraindication to pursuing a conservative management policy, and reviewing the child after an interval of 6-12 months. In an adult the only absolute indication for circumcision is true pathological phimosis, which is almost invariably due to balanitis xerotica obliterans (BXO, diagnosed on histological examination). This condition is essentially genital lichen sclerosis in males. It is characterized by hyperkeratinization, collagen deposition within the papillary dermis and lymphocyte infiltration into the inner dermis. Macroscopically, there is scarring of the preputial opening (with or without narrowing of the urethral meatus). Affected areas appear white, scarred and indurated. Attempts to retract the foreskin do not produce the normal 'flowering' of a developmentally incompletely retractile foreskin. The most florid cases of BX0 affect the whole of the preputial sac, resulting in a scarred prepuce that is densely adherent to the underlying glans. Although there has been the suggestion that BXO is a premalignant condition, this is not a universally accepted belief and a full consideration of this topic is beyond the scope of this chapter. Other conditions such as balanoposthitis (inflammation of the prepuce) and paraphimosis can usually be managed without resorting to circumcision, which should be reserved for frequent troublesome recurrences (although circumcision does offer permanent cure).

Surgical procedures and complications in circumcision
The operative procedure is similar in all age groups. Some form of topical analgesia is necessary, but without a general anesthetic the procedure will always be very uncomfortable. A dorsal penile block can be used to provide worthwhile postoperative analgesia. The adhesions between the glans and the inner layer of the prepuce must be broken down. This may leave the glans raw if there is a severe extent of BXO. The penile skin at the level of the corona should be marked circumferentially and incised cleanly. The two layers of the prepuce should be divided dorsally in the midline longitudinally between artery forceps from the preputial opening to 5 mm proximal to the corona. The inner layer of the prepuce should then be incised circumferentially, maintaining the 5-mm distance from the corona. Ventrally the frenular artery will be divided and must be ligated with a stitch ligature. The subcutaneous tissue by which the prepuce then remains attached should be divided, and any veins encountered should either be coagulated with diathermy or ligated with a fine absorbable ligature. If diathermy is used it is essential to use bipolar and not monopolar diathermy (see below).

The penile and inner preputial layers of skin are then approximated with a fine absorbable suture material. Ventrally the inner layer of the prepuce should be closed longitudinally for a distance of a few millimetres, before commencing a circumferential closure. This will ensure that there is no tight band ventrally, which can be uncomfortable on erection and intercourse. Recognized complications occur both early and late. If the frenular artery or a significant penile vein is not secured, significant bleeding can occur, necessitating ligation of the vessel under general anesthesia. Infection can develop, most commonly at the level of the corona, particularly if there has been balanitis at the time of the circumcision. Systemic antibiotics and cleaning the infected area with saline will usually result in an acceptable cosmetic and functional result, though this may take several weeks. In patients with BXO the external urethral meatus may be affected, resulting in meatal stenosis, which can be a difficult problem to resolve. Erections may be impaired if too much penile skin is removed. The most devastating complication of all can occur if the 'guillotine' technique is used for circumcision. The practitioner pulls on the end of the prepuce and with a swift motion cuts across what is thought to be prepuce, but which in reality is glans and prepuce. The resulting distal penile amputation is an irretrievable disaster.

Uncircumcision
Some men who were circumcised soon after birth request an operative procedure to reverse their circumcision. This is not at all easy to do. Some men attempt to lengthen the penile skin by attaching small weights to tapes attached to the skin of the penis. The lengthening process may take more than a year and the end result is often disappointing. Reconstructive surgical procedures have been described, but are risky. Descriptions of surgical technique have usually been anecdotal, and results of long term follow-up are virtually non-existent in the literature, but are probably poor.

Sexually transmitted disease (STD’S) and circumcision
Although Islam and Judaism account for only a small proportion of religious identities within the USA, up to 90% of all newborn males are circumcised. One of the reasons for this practice is the long held conviction that circumcision significantly lowers the risk of the development in adult life of a number of disorders of the penis, and of contracting sexually transmitted diseases. There is variable evidence for such a 'protective' role for circumcision, but with little consistency in either the quality of different reports, or in the degree of attention given to different disorders. It is beyond the scope of this chapter to provide the reader with a full analysis of the merits and weaknesses of the evidence pertaining to each condition, and so a summary is presented. A large population-based study from the USA found no clear association between circumcision status and hepatitis B, syphilis, gonorrhoea or nongonococcal urethritis. In addition, there has been no consistent difference between circumcised and uncircumcised men for herpes simplex. Because of its association with penile and cervical carcinomas, the differing incidences of human papilloma virus (HPV) in circumcised and uncircumcised men have been closely examined. Although in the USA penile cancer has been reported to be more common in uncircumcised men, more recent evidence suggests that HPV infection is equally common. However, the results of population studies of circumcised and uncircumcised men are awaited to see if there is a corresponding change in the incidence of penile cancer.Perhaps most interesting, and certainly most topical, is the suggestion that circumcision protects against human immunodeficiency virus (HIV) infection. Although large meta-analyses of this issue have reached vastly differing conclusions, in one study a very strong suggestion that circumcision is indeed protective against HIV has been shown. As part of a study on HIV infection in Africa in couples with disparate HIV status9 it was noted that, of the 60 couples where the mate was HIV negative and the female HIV positive, none of the circumcised males became infected whereas 17% of the uncircumcised males contracted HIV. Legal and ethical issues surrounding circumcision It is widely recognized internationally that circumcision (medically irreversible removal of a specialized erogenous tissue which confers no unequivocal prophylactic medical benefit and carries potential risks and long term consequences) is still accepted as a right within certain religious groups, is encouraged in many other societies, and is the norm in the USA. More recently, some have challenged the idea that circumcision is a pre-requisite for a newborn male to be accepted into Jewish religion and culture, and this has come from within the Jewish community - both in the USA and in Israel itself. To fully examine this complex and highly sensitive issue, two concepts have to be considered: the right of an individual (adult or child) to be circumcised, and the right of a child to be protected from being circumcised until he is adequately competent to make a decision for himself.

The right to be circumcised
It would be difficult to argue that a competent adult requesting circumcision for religious, cultural or perceived medical reasons does not have the right to the procedure. Although UK law has found that consent from a competent adult does not guard against prosecution for extreme acts of sadomasochism through torture or genital mutilation, circumcision does not at present fall into this category and it would require a direct legal challenge to change this. The distinction as to when it becomes a matter for the individual concerned or for the parents of a minor depends on, in the UK, the child being 'Gillick competent'. This means that the child must have the mental capacity to make a decision for himself based on an analysis of the risk and benefits. Where a child lacks this ability, the decision rests with the parents and thus it is essential to be sure that they are acting in the child's best interests. The argument that a child has the legal right to be circumcised for cultural or religious reasons, or put differently that the parents have a right to circumcise their child for their religious or cultural beliefs, relies on the assumption that not to do so would be to the detriment of the child's welfare. Whilst arguably not in the interests of the child's physical welfare at the time, ritual circumcision is part of long established practice and it is argued that denying this to a child excludes him from fully participating in his community or religious life. Thus it can be argued that failure by Jewish or Muslim parents to circumcise their child constitutes abuse as this would result in psychological harm from exclusion at school or in the community. The International Convention on the Rights of the Child states in Article 8 that 'States Parties undertake to respect the right of the child to preserve his or her identity', although the Article does not assist by defining or elucidating on the term 'identity'. Furthermore, Article 14 gives further support to a parent's right to bring up their child according to established ritual practices since States "shall respect the rights of and duties of parents ... to provide direction to the child in the exercise of his or her right in a manner consistent with the evolving capacities of the child", and thus circumcision can be argued to be consistent with 'direction'. Hence, when viewed in the long term, the best interests of Jewish and Muslim children and children from cultures where childhood circumcision forms a rite of passage require that parents allow them to undergo circumcision.

A child's right to protection from circumcision
As noted earlier, an adult has the capacity to give consent for circumcision for religious or cultural reasons, and certainly it cannot be argued that an adult cannot consent for circumcision for medical reasons. Thus it follows that in such situations, a medical practitioner has a legal defence against malpractice and a religious circumciser against actual bodily harm. The legal position of involuntary circumcision (of children) is controversial, especially when considering religious circumcision. The argument by opponents of circumcision is that it is tantamount to child abuse. Such a claim potentially carries very serious consequences and its validity must be examined closely. Given that a child cannot give consent for circumcision, this must be obtained from a parent acting on behalf of the child. But for parents to give informed consent for a medical procedure, it is required that the child must be suffering from an illness or trauma that would result in injury, deformity, disability or death were treatment withheld. For non-emergency conditions, where delay would not endanger the child, it is now considered that treatment should be delayed until the child can make his or her own informed decision. Courts in both the USA and elsewhere have consistently ruled to uphold the bodily integrity of incompetent people, minors and adults. Likewise, the ability of parents to secure medical interventions for their children has been limited if the intervention could pose a risk to the health or safety of the child. A court in Texas prevented an incompetent girl from being put forward as a kidney donor, ruling that consent for surgical intrusions is limited to 'treatment'. All similar rulings have upheld that the removal of normal tissue or organs is not treatment. Article 24.3 of the International Convention on the Rights of the Child, which has been ratified by all countries of the United Nations except Somalia and the USA, requires that all practices prejudicial to the health of the child be abolished. Article 19.1 requires that states ensure that no abuse or harm come to a child whilst in the care of parents or guardians. Article 16 requires that there be no unlawful or arbitrary interference with the privacy of children. Because of the persisting legality of corporal punishment, the UK has been found to be in breach of the Convention. Thus, the overriding importance of the child's best interest limits parental power. Parents must be seen to act in accordance with what children would wish for themselves. In a survey of American men circumcised as neonates, only 0.3% responded that they would have undergone the procedure later in life if given the choice. Hence, parental consent can only be valid if circumcision is required as the immediate treatment for a medical pathology, and it is hard to defend it on the dubious grounds of being a preventative measure. It is further argued by some that involuntary circumcision cannot constitute child abuse because it is only a 'minor procedure' and, in neonates, causes only mild discomfort. Compare this with the observation that, although frequently a day case procedure in adults, circumcision is seldom performed under regional or local anesthesia. Although neonates exhibit reactions to painful stimuli that are different from those expressed by children or adults, there is no doubt that circumcision is a highly noxious stimulus. Certainly, the DSM-1V definition of trauma (an experience outside normal experience including torture, assault or threat to physical integrity) certainly applies to circumcision when looked at from the infant's point of view. Studies have in fact shown that there is a considerable rise in heart rate` and serum cortisol, and that children circumcised as neonates demonstrate a grossly exaggerated response to routine vaccinations compared to uncircumcised children. Additionally, there are many cases of mothers whose babies are circumcised in their presence (especially Jewish women) who report considerable psychological trauma arising from the experience. Of the different cultural and religious groups that promote or require circumcision, Judaism has a very strong basis for the practice. It is perhaps significant therefore that there is growing cultural practice of 'anti -circumcision' arising from Jewish groups within both the USA and Israel. Their contention is that the sole requirement to a Jewish identity is to be born of a Jewish mother and that, contrary to popular belief, circumcision is not a necessity for this identity. They also contend that there is very little understanding within the Jewish authorities concerning the psychological harm arising from circumcision and that, despite the above evidence to the contrary, it is standard belief amongst mohelim and rabbis that neonatal circumcision is entirely harmless and pain free (or that there is 'mild discomfort' only). Whilst it is certainly not our intention to challenge thousands of years of religious practice, it is important to be fully aware of changing beliefs regarding circumcision, and to be able to advise and support parents accordingly.

Finally
Traditions dictate much of the behaviour that occurs in society. Whether circumcision should remain a tradition will be strongly debated and any medical practitioner who has dealings with such patients or parents must be fully aware of the how ethical and social trends are changing. The operation, when performed for medical reasons, requires skill, care and time and patients should be aware of the need to arrange a period of convalescence.




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