1. Circumcision
What is circumcision?
Circumcision is a surgical procedure that involves partial or
complete removal of the foreskin (prepuce) of the penis. The
first evidence of circumcision comes from early Egyptian wall
paintings that are more than 5000 years old.
How common is circumcision?
About one-fifth of men worldwide have been circumcised,
mostly for religious and cultural reasons when the procedure
is commonly performed shortly after birth or around puberty.
Although adults are occasionally circumcised as an act of
religious dedication, adult circumcision is most commonly
performed for medical reasons.
At present, around 80 per cent of US males have been
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circumcised, mostly for non-religious reasons. The
frequency of newborn circumcision has fallen in the USA
from 90 per cent in the 1950s to around 60 per cent
today.
In Korea, more than 90 per cent of men have been
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circumcised, usually in their teens and twenties.
In the UK in 1948, around 20 per cent of boys were
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circumcised shortly after birth, more commonly among
middle class families and those living in the south of
England. Then, 50 per cent of grammar school boys, 84
per cent of public school boys and 60 per cent of
graduates were circumcised. By 1975, only 6 per cent
of boys born in the UK were circumcised.
Why circumcise?
Reasons for circumcision fall into three broad groups:
for an immediate medical indication
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to prevent future disease
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2. as an act of religious dedication.
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Circumcision for an immediate medical reason
Non-retractable foreskin in children
Contrary to common belief, the foreskin cannot be
pulled back (retracted) in almost all newborn babies.
Well-meaning parents do not need to try cleaning under
the foreskin until it has become fully retractable of its
own accord because attempts to pull back a non-
retractable foreskin can result in pain and possibly
injury.
About 50 per cent of one-year-old boys will have a non-
retractable foreskin, 30 per cent of two-year-olds, about
10 per cent of four-year-olds and about 5 per cent of
10-year-olds.
The small percentage of adults who have a persistently
non-retractable foreskin have a slightly increased
chance of developing phimosis (see below), but this
persistence is not a reason for circumcision.
Phimosis
In phimosis (foreskin contraction), the opening of the
foreskin is narrowed, preventing retraction. Provided
that the skin of the foreskin is normal and inability to
retract it does not cause problems with intercourse or
recurrent infections, no action is necessary.
Occasionally, the edge of the foreskin has a white,
scarred, inelastic appearance and will not pucker open
as it is retracted. Between 1 and 1.5 per cent of boys
will develop this condition by the time they are 17 years
old. Symptoms can include
irritation or bleeding from the edge of the
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foreskin
stinging or pain on passing urine (dysuria)
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inability to pass urine (acute or, rarely, chronic
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urinary retention).
The changes in the prepuce are known as balanitis

3. xerotica obliterans, which can become cancerous if left
untreated. Circumcision is advisable in most cases.
Acute balanoposthitis
This condition involves redness and swelling of the
foreskin, together with a discharge of pus from the
space between the foreskin and the glans.
Sometimes the whole penis may be swollen and
inflamed. Between 3 and 10 per cent of boys will
develop this condition, depending on how the condition
is defined.
Balanoposthitis is very occasionally the first sign of
diabetes. If there is no underlying cause, simple
hygiene measures, mild painkillers and the avoidance of
tugging the foreskin are the only necessary treatments.
Most cases will recover without further intervention.
Circumcision is only done for recurrent and troublesome
cases.
Paraphimosis
This condition is caused by forcibly pulling back the
foreskin behind the coronal ridge of the glans or head of
the penis, without its subsequent replacement.
The foreskin then forms a tight tourniquet around the
glans, causing severe pain. The condition can
sometimes be treated by firmly but gently squeezing
the trapped glans until the foreskin can slip over it
again.
If this is not possible, the paraphimosis needs to be
reduced under a general anaesthetic. Circumcision is
only very rarely necessary.
Circumcision to prevent future disease
Prevention of disease is the second most commonly given
reason for circumcision after religious reasons, although the
evidence that it has any beneficial effect on future health is
very poor. The practice is, more likely, rooted in cultural
traditions, although western societies may find this an
uncomfortable conclusion.

4. Penile cancer
Cancer of the penis is an extremely rare disease and, in
the early part of the last century, was almost unheard
of in circumcised men. However, there is some evidence
that circumcision may only offer protection from penile
cancer if done in childhood, and adult surgery may not
offer any protection.
Poor personal hygiene, smoking and exposure to wart
virus (human papilloma virus) increase the risk of
developing penile cancer at least as much as being
uncircumcised.
Circumcised men are more at risk from penile warts
than uncircumcised men, and the risk of developing
penile cancer is now almost equal in the two groups.
Therefore, routine circumcision cannot be recommended
to prevent penile cancer.
Sexually transmitted diseases
Sexually transmitted infections that cause ulcers on the
genitals (syphilis, chancroid, herpes simplex) are more
common in uncircumcised men. However, urethritis or
inflammation of the tube that carries urine through the
penis (caused by gonorrhoea and non-gonococcal
urethritis) is more common in circumcised men, as are
penile warts.
Yeast infection (caused by candida or thrush) is equally
common in circumcised and uncircumcised men,
although circumcised men are less likely to have
symptoms with this infection so they are more likely to
unknowingly pass on thrush to their sexual partners.
Far more effective and reliable methods than
circumcision exist to reduce the risk of contracting
sexually transmitted diseases, such as the use of
condoms and adoption of safer sexual practices. Thus
circumcision cannot be recommended to prevent these
infections.

5. Human immunodeficiency virus (HIV) infection
Views conflict on whether circumcision can prevent HIV
infection. A recent review in the British Journal of
Urology concluded that there is no link between having
an intact foreskin and HIV infection, whereas another
paper in the British Medical Journal takes exactly the
opposite view.
Circumcision may be appropriate as a routine
preventive measure only in regions that have a high
rate of HIV infection, such as sub-Saharan Africa. The
existing evidence is inadequate to recommend
circumcision as an HIV-preventive measure in the UK.
Cervical cancer
A study in 1947 reported that Jewish women rarely
developed cervical cancer and the author attributed this
finding to the fact that their sexual partners were
circumcised.
Further studies over the past 50 years have had
contradictory conclusions, with experts enthusiastically
championing the case for and against circumcision. The
evidence is inadequate to recommend it as a preventive
measure against cervical cancer.
Urinary tract infection (UTI)
Since 1987, several studies have suggested that
uncircumcised male infants are up to 10 times more
likely to contract a urinary tract infection (UTI). One in
100 uncircumcised infants will develop a UTI, compared
with 1 in 1000 circumcised infants.
A UTI is not usually a great risk to health, so it does not
seem reasonable to perform a surgical procedure on
100 infants to reduce the risk of one developing UTI.
Circumcision as an act of religious dedication
The circumcision of male children is a central feature of both
Judaism and Islam. It is also important in many African and
New World cultures.

6. An increasing number of committed Jewish and Muslim people
reject circumcision on ethical grounds, although they are
certainly the minority at present. Attitudes to circumcision
may provoke fierce hostility within families and among
communities. In the past, wars have been fought, and
thousands have died, to preserve the right to circumcise when
rulers from other cultures forbade it.
Judaism
In the book of Genesis (17: 10-14), circumcision
represents the covenant made by God with Abraham
and his descendants.
Traditional religious circumcision is performed by a
mohel (pronounced mo-hell in Hebrew or moyle in
Yiddish). It is usually carried out on the eighth day after
birth, unless there is a danger to the child's health, in
which case it should be delayed until that danger has
passed. In the UK, mohelim attend 40 to 50
circumcisions and have to pass practical and theoretical
examinations during their training before performing
circumcision alone.
Islam
The divine law or sharia defines every aspect of Muslim
life. It is based upon the Holy Koran, the hadith (the
sayings of the Prophet Mohammed) and the sunnah
(Prophet's tradition).
All Muslims agree that these are the three sources of
Islamic law, but different groups interpret their
application in different ways. Circumcision is not
mentioned in the Koran, but has the status of sunnah.
Only the Shafiite school of law regards circumcision as
obligatory (wajib), while the Hanafite, Jafarite, Malikite,
Hanbalite and Zaidite regard it as only recommended,
because it is sunnah.
Even those who consider circumcision an obligatory
duty for themselves do not see it as an essential
requirement for others to become a Muslim. However,
the procedure is very commonly practised and is
certainly seen as an important external symbol of
submission to God's will.

7. Should we avoid circumcision?
The foreskin is not simply a useless piece of skin, to be
disposed of without careful thought. It forms the covering of
the head (glans) of the penis in men and the clitoris in
women. It is very rich in nerves responsible for touch and the
movement of the foreskin backwards and forwards over the
glans provides some of the pleasurable sensation experienced
during sex.
Adult males that were circumcised as infants do not usually
report sexual problems linked with their circumcision, perhaps
because they have never experienced sexual sensation with a
foreskin. However, men circumcised as sexually active adults
quite frequently complain of sexual problems arising from
either reduced or altered penile sensation.
How is circumcision performed?
Although religious and cultural circumcision is frequently
performed without anaesthetic as part of an important ritual
act, it is an intensely painful procedure, even in newborn
babies. Adults can testify to the pain for themselves and can
give informed consent to the procedure. Infants, however,
cannot. Physiological research has repeatedly shown bodily
responses that indicate infants experience severe pain during
circumcision.
It is difficult to justify subjecting infants to this experience
when pain could be avoided with a brief general anaesthetic.
Anaesthetic injections that numb the penis or the whole
genital region are not a reliable substitute for general
anaesthesia. If circumcision is important for religious or
cultural reasons, then the mohel, or other ritual circumciser,
can still perform the procedure and prayers with the
assistance of an anaesthetist and surgical team at hand. This
practice may not be the traditional family gathering associated
with circumcision, but would fulfil religious obligation without
causing unnecessary suffering.
When circumcision is necessary for an immediate medical
reason, the surgeon would be prudent to try to preserve as
much of the foreskin as possible, through some form of
preputioplasty (a plastic surgery procedure that alters the
shape of the foreskin but minimises the amount of skin
removed). Preputioplasty may preserve sexual sensation,

8. although its advantage over circumcision is not yet
established.
Complications of circumcision
Happily, complications of circumcision are relatively rare,
although they may be under-reported following religious or
cultural circumcision. For this reason, figures on the rate of
complications may not be reliable. Complications include:
reduction in penile sensation (an almost universal
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experience)
bleeding
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damage to the urethra (urine tube in the penis)
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amputation of the glans (rare)
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infection in the blood or septicaemia (rare).
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Can circumcision be reversed?
Attempts have been made to restore the foreskin following
circumcision since ancient times. Unfortunately, no procedure
had satisfactory results. Modern surgical procedures may have
more success, but they are still experimental and the long-
term results are unknown. If foreskin restoration is being
considered, a urologist should be consulted.
Female circumcision is not required by any religious group and
is a traditional practice prevalent in Africa, Southeast Asia and
South America. It is far more disfiguring, disabling and
potentially dangerous than male circumcision so cannot be
viewed in the same light. The author fully supports the World
Health Organisation's policy that this procedure should cease
throughout the world.
Conclusions
Circumcision remains a controversial procedure, as it has been
for thousands of years.
Male circumcision is vitally important to some religious and
cultural groups. Hopefully, the use of general anaesthesia for
infant circumcision will increase. Medical and religious
authorities should work together to promote this change.
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9. Very few absolute medical reasons exist for circumcision, and
no reasons exist to justify routine circumcision of infants
outside areas with a high rate of HIV infection. Far too many
circumcisions are performed without good reason in Europe
and the USA. The best advice is 'if it isn't absolutely
necessary, don't circumcise'.