Circumcision

Removal of the human foreskin

Not to be confused with female circumcision.

For the paintings, see The Circumcision.

Medical intervention

Circumcision

Circumcision surgery with hemostats and scissors

ICD-10-PCS| Z41.2
ICD-9-CM| V50.2
MeSH| D002944
OPS-301 code| 5–640.2
MedlinePlus| 002998
eMedicine| 1015820

[edit on Wikidata]

Circumcision is a surgical procedure that removes the foreskin from the human penis. In the most common form of the operation, 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.[1] Circumcision is generally electively performed, most commonly done as a form of preventive healthcare, as a religious obligation, or as a cultural practice.[2] It is also an option for cases of phimosis, chronic urinary tract infections (UTIs),[3][4] 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.[4][5]

The procedure is associated with reduced rates of sexually transmitted infections[6] and urinary tract infections.[1][7][8] This includes reducing the incidence of cancer-causing forms of human papillomavirus (HPV) and reducing HIV transmission among heterosexual men in high-risk populations by up to 60%;[9][10] its prophylactic efficacy against HIV transmission in the developed world or among men who have sex with men is debated.[11][12][13] Neonatal circumcision decreases the risk of penile cancer.[14] Complication rates increase significantly with age.[15] 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.[16] There are various cultural, social, legal, and ethical views on circumcision. Major medical organizations hold variant views on the strength of circumcision's prophylactic efficacy in developed countries. Some medical organizations take the position that it carries prophylactic health benefits which outweigh the risks, while other medical organizations generally hold the belief that in these situations its medical benefits are not sufficient to justify it.[17][18][19][20]

Circumcision is one of the world's most common and oldest medical procedures.[2] Prophylactic usage originated in England during the 1850s and has since spread globally, becoming predominately established as a way to prevent sexually transmitted infections.[21][22] 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.[23][24] In some African and Eastern Christian denominations male circumcision is an established practice, and require that their male members undergo circumcision.[25][26] It is widespread in the United States, South Korea, Israel, Muslim-majority countries and most of Africa.[2] It is relatively rare for non-religious reasons in parts of Southern Africa, Latin America, Europe, and most of Asia, as well as nowadays in Australia.[2] The origin of circumcision is not known with certainty, but the oldest documentation comes from ancient Egypt.[2][27][28][29]

## Uses

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### Disease prevention

[edit]

Approximately half of all circumcisions worldwide are performed for reasons of prophylactic healthcare.[4]

#### Prophylactic usage in high-risk populations

[edit]

Actor Melusi Yeni became the 1 millionth VMMC against HIV/AIDS transmission in the province of KwaZulu-Natal, South Africa.[30]

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.[31][12][9]

In 2007, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that they 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.[31] In 2010, this was expanded to routine neonatal circumcision, as long as those performing the procedure received assent from the parents of the infant.[18] In 2020, the World Health Organization again concluded that male circumcision is an efficacious intervention for HIV prevention and that the promotion of male circumcision is an essential strategy, in addition to other preventive measures, for the prevention of 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 those 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.[31][18] 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.[32] There is evidence that circumcision is associated with a reduced risk of HIV infection for such men, particularly in low-income countries.[6]

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.[19]

#### Prophylactic usage in developed countries

[edit]

Major medical organizations hold varying positions on the prophylactic efficacy of the elective circumcision of minors in the context of developed countries.[19] Literature on the matter is polarized, with the cost-benefit analysis being highly dependent on the kinds and frequencies of health problems in the population under discussion and how circumcision affects them.[20][33][34]

The World Health Organization (WHO), UNAIDS, and American medical organizations take the position that it carries prophylactic health benefits which outweigh the risks, while European, Australian and New Zealand medical organizations generally hold the belief that in these situations its medical benefits are not sufficient to justify it.[17][18][19][20] Advocates of circumcision consider it to have a net health benefit, and therefore feel that increasing the circumcision rate is "imperative".[35] They recommend performing it during the neonatal period when it is less expensive and has a lower risk of complications.[33] The American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and Centers for Disease Control and Prevention stated that the potential benefits of circumcision outweigh the risks.[1][36][37]

The World Health Organization in 2010 stated:[18]

> There are significant benefits in performing male circumcision in early infancy, and programmes that promote early infant male circumcision are likely to have lower morbidity rates and lower costs than programmes targeting adolescent boys and men.[18]

### Pathologies

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Circumcision is also used to treat various pathologies. These include pathological phimosis, refractory balanoposthitis and chronic or recurrent urinary tract infections (UTIs).[3][4]

## Contraindications

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Circumcision is contraindicated in certain cases.[5][4][38]

These include infants with certain genital structure abnormalities, such as a misplaced urethral opening (as in hypospadias and epispadias), curvature of the head of the penis (chordee), 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.[5][4][38]

If an individual 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.[4][38]

## Technique

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Main article: Circumcision surgical procedure

Before (left) and after (right) an adult circumcision that was undertaken to treat phimosis. After the operation, the glans is exposed even when the penis is flaccid.

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.[2] 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.

Erect comparison of the penis, one (left) is uncircumcised, while the other (right) is circumcised

For adult medical circumcision, superficial wound healing takes up to a week, and complete healing 4 to 6 months.[39] For infants, healing is usually complete within one week.[38]

### Removal of the foreskin

[edit]

For infant circumcision, devices such as the Gomco clamp, Plastibell and Mogen clamp are commonly used in the USA.[1] 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 (preputial epithelium) from its attachment to the glans. The practitioner then places the circumcision device (this sometimes requires a dorsal slit), which remains until blood flow has stopped. Finally, the foreskin is amputated.[1] For older babies and adults, circumcision is often performed surgically without specialized instruments,[38] and alternatives such as Unicirc or the Shang ring are available.[40]

### Pain management

[edit]

The circumcision procedure causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes,[41] so the use of analgesia is advocated and required by law in some countries.[1][42] 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.[1][43][44] The ring block and dorsal penile nerve block (DPNB) are the most effective at reducing pain, and the ring block may be more effective than the DPNB. They are more effective than EMLA (eutectic mixture of local anesthetics) cream, which is more effective than a placebo.[43][44] Topical creams have been found to irritate the skin of low birth weight infants, so penile nerve block techniques are recommended in this group.[1] Circumcision is contraindicated for premature babies partially because of complications with anesthesia.[4][5]

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,[44] but the American Academy of Pediatrics (AAP) states that such methods are insufficient alone and should be used to supplement more effective techniques.[1] 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.[44] The available evidence does not indicate that post-procedure pain management is needed.[1] 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 (DPNB) and general anesthesia are all options,[45] and the procedure requires four to six weeks of abstinence from masturbation or intercourse to allow the wound to heal.[38]

## Effects

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### Sexually transmitted infections

[edit]

#### Human immunodeficiency virus

[edit]

See also: Circumcision in Africa § Circumcision to prevent the spread of human immunodeficiency virus in Africa

This section is an excerpt from Circumcision and HIV.[edit]

Male circumcision reduces the risk of human immunodeficiency virus (HIV) transmission from HIV positive women to men in high risk populations.[46] In 2020, the World Health Organization (WHO) reiterated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions.[47]

Circumcision reduces the risk that a man will acquire HIV and other sexually transmitted infections (STIs) from an infected female partner through vaginal sex.[48] The evidence regarding whether circumcision helps prevent HIV is not as clear among men who have sex with men (MSM).[47] The effectiveness of using circumcision to prevent HIV in the developed world is not determined.[47][49]

#### Human papillomavirus

[edit]

Human papillomavirus (HPV) is the most commonly transmitted sexually transmitted infection, affecting both men and women. While most infections are asymptomatic and are cleared by the immune system, some types of the virus cause genital warts, and other types, if untreated, cause various forms of cancer, including cervical cancer and penile cancer. Genital warts and cervical cancer are the two most common problems resulting from HPV.[50]

Circumcision is associated with a reduced prevalence of oncogenic types of HPV infection, meaning that a randomly selected circumcised man is less likely to be found infected with cancer-causing types of HPV than an uncircumcised man.[51][52] It also decreases the likelihood of multiple infections.[7] As of 2012[update], there was no strong evidence that it reduces the rate of new HPV infection,[8][7][53] but the procedure is associated with increased clearance of the virus by the body,[8][7] which can account for the finding of reduced prevalence.[7]

Although genital warts are caused by a type of HPV, there is no statistically significant relationship between being circumcised and the presence of genital warts.[8][52][53]

#### Other infections

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Studies evaluating the effect of circumcision on the rates of other sexually transmitted infections have, generally, found it to be protective. A 2006 meta-analysis found that circumcision was associated with lower rates of syphilis, chancroid, and possibly genital herpes.[54] A 2010 review found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%.[55] The researchers found mixed results for protection against trichomonas vaginalis and chlamydia trachomatis, and no evidence of protection against gonorrhea or syphilis.[55] It may also possibly protect against syphilis in MSM.[56]

### Phimosis, balanitis and balanoposthitis

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Phimosis is the inability to retract the foreskin over the glans penis.[57] At birth, the foreskin cannot be retracted due to adhesions between the foreskin and glans, and this is considered normal (physiological phimosis).[57] Over time the foreskin naturally separates from the glans, and a majority of boys are able to retract the foreskin by age three.[57] Less than one percent are still having problems at age 18.[57] If the inability to do so becomes problematic (pathological phimosis) circumcision is a treatment option.[3][58] A preputioplasty, where the foreskin is surgically widened instead of removed, is another possible surgical treatment option for phimosis.[59][60] This pathological phimosis may be due to scarring from the skin disease balanitis xerotica obliterans (BXO), repeated episodes of balanoposthitis or forced retraction of the foreskin.[61] Steroid creams are also a reasonable option and may prevent the need for surgery including in those with mild BXO.[61][62] The procedure may also be used to prevent the development of phimosis.[4] Phimosis is also a complication that can result from circumcision.[63]

An inflammation of the glans penis and foreskin is called balanoposthitis, and the condition affecting the glans alone is called balanitis.[64][65] Most cases of these conditions occur in uncircumcised males,[66] affecting 4–11% of that group.[57] The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor. Yeasts, especially Candida albicans, are the most common penile infection and are rarely identified in samples taken from circumcised males.[66] Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams.[64][65] Circumcision is a treatment option for refractory or recurrent balanoposthitis, but in the twenty-first century the availability of the other treatments has made it less necessary.[64][65]

### Urinary tract infections

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A UTI affects parts of the urinary system including the urethra, bladder, and kidneys. There is about a one percent risk of UTIs in boys under two years of age, and the majority of incidents occur in the first year of life. There is good but not ideal evidence that circumcision of babies reduces the incidence of UTIs in boys under two years of age, and there is fair evidence that the reduction in incidence is by a factor of 3–10 times (100 circumcisions prevents one UTI).[1][67][conflicted source][68] Circumcision is most likely to benefit boys who have a high risk of UTIs due to anatomical defects,[1] and may be used to treat recurrent UTIs.[3]

There is a plausible biological explanation for the reduction in UTI risk after circumcision. The orifice through which urine passes at the tip of the penis (the urinary meatus) hosts more urinary system disease-causing bacteria in uncircumcised boys than in circumcised boys, especially in those under six months of age. As these bacteria are a risk factor for UTIs, circumcision may reduce the risk of UTIs through a decrease in the bacterial population.[1][68]

### Cancers

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Not being circumcised is the primary risk factor for penile cancer.[69][70] Pre-adolescent circumcision has a strong protective effect against penile cancer in later life.[14] Penile cancer is a rare disease in the developed world but much more prevalent in the developing world.[14] The penile tissue removed during circumcision is a potential origin for penile cancer.[71] Risk-benefit considerations around the use of circumcision as a cancer-preventive measure are a source of debate.[69]

Penile cancer development can be detected in the carcinoma in situ (CIS) cancerous precursor stage and at the more advanced invasive squamous cell carcinoma stage.[1] There is an association between adult circumcision and an increased risk of invasive penile cancer; this is believed to be from men being circumcised as a treatment for penile cancer or a condition that is a precursor to cancer rather than a consequence of circumcision itself.[72] Penile cancer has been observed to be nearly eliminated in populations of males circumcised neonatally.[57]

Important risk factors for penile cancer include phimosis and HPV infection, both of which are mitigated by circumcision.[72] The mitigating effect circumcision has on the risk factor introduced by the possibility of phimosis is secondary, in that the removal of the foreskin eliminates the possibility of phimosis. This can be inferred from study results that show uncircumcised men with no history of phimosis are equally likely to have penile cancer as circumcised men.[1][72] Circumcision is also associated with a reduced prevalence of cancer-causing types of HPV in men[7] and a reduced risk of cervical cancer (which is caused by a type of HPV) in female partners of men.[4]

There is some evidence that circumcision is associated with reduced risk of prostate cancer.[73]

### Women's health

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A 2017 systematic review found consistent evidence that male circumcision prior to heterosexual contact was associated with a decreased risk of cervical cancer, cervical dysplasia, HSV-2, chlamydia, and syphilis among women. The evidence was less consistent in regards to the potential association of circumcision with women's risk of HPV and HIV.[74]

### Sexual effects

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The accumulated data show circumcision does not have an adverse physiological effect on sexual pleasure, function, desire, or fertility.[75][76] There is some evidence that circumcision has no effect on pain with intercourse, premature ejaculation, intravaginal ejaculation latency time, erectile dysfunction or difficulties with orgasm.[77] There are popular misconceptions that circumcision benefits or adversely impacts the sexual pleasure of the circumcised person.[76]

According to a 2014 review, the effect of circumcision on sexual partners' experiences is unclear as this has not been well studied.[78] According to a policy statement from the Canadian Paediatric Society that was reaffirmed in 2021,[79] "medical studies do not support circumcision as having an impact on sexual function or satisfaction for partners of circumcised individuals".[76]

## Adverse effects

[edit]

Neonatal circumcision is generally a safe, low-risk procedure when done by an experienced practitioner.[80][81][82]

The most common acute complications are bleeding, infection and the removal of either too much or too little foreskin.[1][83] These complications occur in approximately 0.13% of procedures, with bleeding being the most common acute complication in the United States.[83] Minor complications are reported to occur in approximately 3.8%.[84] Severe complications are rare.[63] A specific complication rate is difficult to determine due to inconsistencies in classification.[1] Complication rates are greater when the procedure is performed by an inexperienced operator, in unsterile conditions, and older patient age.[15] In patients circumcised after the neonatal period and into adolescence, minor complication rates rise from approximately 1.5% in neonates to about 6% in adolescents. This increase is believed to be a result of increased foreskin vascularity.[85] Significant acute complications happen rarely,[1][15] occurring in about 1 in 500 newborn procedures in the United States.[1] Severe to catastrophic complications, including death, are so rare that they are reported only as individual case reports.[1][82] Where a Plastibell device is used, the most common complication is the retention of the device occurring in around 3.5% of procedures.[16] Other possible complications include buried penis, chordee, phimosis, skin bridges, urethral fistulas, and meatal stenosis.[82] These complications may be partly avoided with proper technique, and are often treatable without requiring surgical revision.[82] The most common long-term complication is meatal stenosis, this is almost exclusively seen in circumcised children, it is thought to be caused by ammonia producing bacteria coming into contact with the meatus in circumcised infants.[16] It can be treated by meatotomy.[16]

Effective pain management should be used during the procedure.[1] Inadequate pain relief may carry the risks of heightened pain response for newborns.[41] Newborns that experience pain due to being circumcised have different responses to vaccines given afterwards, with higher pain scores observed.[86] For adult men who have been circumcised, there is a risk that the circumcision scar may be tender.[87] There is no good evidence that circumcision affects cognitive abilities.[88]

## History

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Main article: History of circumcision

Circumcision knife from the Congo; wood, iron; late 19th/early 20th century

The word circumcision is from Latin circumcidere, meaning "to cut around".[2] Circumcision is the oldest known surgical procedure.[89] Depictions of circumcised penises are found in Paleolithic art,[90] predating the earliest signs of trepanation.[89][91]

The history of the migration and evolution of circumcision is known mainly from the cultures of two regions. In the lands south and east of the Mediterranean, starting with Central Sahara, Sudan and Ethiopia, the procedure was practiced by the ancient Egyptians and the Semites, and then by the Jews and Muslims. In Oceania, circumcision is practiced by the Australian Aboriginals and Polynesians.[92] There is also evidence that circumcision was practiced among the Aztec and Mayan civilizations in the Americas,[2] but little is known about that history.[27][28]

It has been speculated that circumcision originated as a substitute for castration of defeated enemies or as a religious sacrifice.[28] In many traditions, it acts as a rite of passage marking a boy's entrance into adulthood.[28]

### Middle East, Africa and Europe

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Further information: Circumcision in Africa

At Oued Djerat, in Algeria, engraved rock art with masked bowmen, which feature male circumcision and may be a scene involving ritual, have been dated to earlier than 6000 BP amid the Bubaline Period;[93] more specifically, while possibly dating much earlier than 10,000 BP, rock art walls from the Bubaline Period have been dated between 9200 BP and 5500 BP.[94] The cultural practice of circumcision may have spread from the Central Sahara, toward the south in Sub-Saharan Africa and toward the east in the region of the Nile.[93] Based on engraved evidence found on walls and evidence from mummies, circumcision has been dated to at least as early as 6000 BCE in ancient Egypt.[95] Some ancient Egyptian mummies, which have been dated as early as 4000 BCE, show evidence of circumcision.[92]: 2–3 [96]

Evidence suggests that circumcision was practiced in the Middle East by the fourth millennium BCE, when the Sumerians and the Semites moved into the area that is modern-day Iraq from the North and West.[27] The earliest historical record of circumcision comes from Egypt, in the form of an image of the circumcision of an adult carved into the tomb of Ankh-Mahor at Saqqara, dating to about 2400–2300 BCE. Circumcision was possibly done by the Egyptians for hygienic reasons, but also was part of their obsession with purity and was associated with spiritual and intellectual development. No well-accepted theory explains the significance of circumcision to the Egyptians, but it appears to have been endowed with great honor and importance as a rite of passage, performed in a public ceremony emphasizing the continuation of family generations and fertility. It may have been a mark of distinction for the elite: the Egyptian Book of the Dead describes the sun god Ra as having circumcised himself.[28][92]

Detail of the Artemision Bronze; the Greeks abhorred circumcision, making life difficult for circumcised Jews living among the Greeks.

Circumcision is prominent in the Hebrew Bible.[97] In addition to proposing that circumcision was adopted by the Israelites purely as a religious mandate, scholars have suggested that Judaism's patriarchs and their followers adopted circumcision to make penile hygiene easier in hot, sandy climates; as a rite of passage into adulthood; or as a form of blood sacrifice.[27][92][98]

Historical campaigns of ethnic, cultural, and religious persecution frequently included bans on circumcision as a means of forceful assimilation, conversion, and ethnocide.[99] Alexander the Great conquered the Middle East in the fourth century BCE, and in the following centuries ancient Greek cultures and values came to the Middle East. The Greeks abhorred circumcision, making life for circumcised Jews living among the Greeks and later the Romans very difficult.[99] Restrictions on the Jewish practice by European governments have occurred several times in world history, including the Seleucid Empire under Antiochus IV and the Roman Empire under Hadrian, where it was used as a means of forceful assimilation and conversion.[99] Antiochus IV's restriction on Jewish circumcision was a major factor in the Maccabean Revolt.[99] Hadrian's prohibition has also been considered by some to have been a contributing cause of the Bar Kokhba revolt.[99] According to Silverman (2006), these restrictions were part of a "broad campaign" by the Romans to "civilize" the Jewish people, viewing the practice as repulsive and analogous to castration.[99] His successor, Antoninus Pius, altered the edict to permit Brit Milah.[99] During this period in history, Jewish circumcision called for the removal of only a part of the prepuce, and Hellenized Jews often attempted to look uncircumcised and potentially restore their foreskins by stretching the extant parts of their foreskins with a specialized device called a pondus Judaeus. This was considered by the Jewish leaders to be a serious problem, and during the second century CE they changed the requirements of Jewish circumcision to call for the complete removal of the foreskin,[100] emphasizing the Jewish view of circumcision as intended to be not just the fulfillment of a Biblical commandment but also an essential and permanent mark of membership in a people.[92][98]

The Circumcision of Jesus Christ, by Ludovico Mazzolino

A narrative in the Christian Gospel of Luke makes a brief mention of the circumcision of Jesus, but physical circumcision is not part of the received teachings of Jesus. Circumcision has played an important role in Christian history and theology. Paul the Apostle reinterpreted circumcision as a spiritual concept, arguing literal circumcision to be unnecessary for Gentile converts to Christianity. The teaching that circumcision was unnecessary for membership in a divine covenant was instrumental to the separation of Christianity from Judaism.[101][102] While the circumcision of Jesus is celebrated as a feast day in the liturgical calendar of many Christian denominations.[102]

Although it is not explicitly mentioned in the Quran (early seventh century CE), circumcision is considered essential to Islam, and it is nearly universally performed among Muslims. The practice of circumcision spread across the Middle East, North Africa, and Southern Europe with Islam.[103]

Genghis Khan and the following Yuan Emperors in China forbade Islamic practices such as halal butchering and circumcision.[104][105]

The practice of circumcision is thought to have been brought to the Bantu-speaking tribes of Africa by either the Jews after one of their many expulsions from European countries, or by Muslim Moors escaping after the 1492 reconquest of Spain. In the second half of the first millennium CE, inhabitants from the Northeast of Africa moved south and encountered groups from Arabia, the Middle East, and West Africa. These people moved south and formed what is known today as the Bantu. Bantu tribes were observed to be upholding what was described as Jewish law, including circumcision, in the 16th century. Circumcision and elements of Jewish dietary restrictions are still found among Bantu tribes.[27]

### Indigenous peoples of the Americas and Oceania

[edit]

Circumcision is practiced by some groups amongst Australian Aboriginal peoples, Polynesians, and Native Americans.[2][27]

For Aboriginal Australians and Polynesians, circumcision likely started as a blood sacrifice and a test of bravery and became an initiation rite with attendant instruction in manhood in more recent centuries. Often seashells were used to remove the foreskin, and the bleeding was stopped with eucalyptus smoke.[27][106]

Christopher Columbus reported circumcision being practiced by Native Americans.[28] It probably started among South American tribes as a blood sacrifice or ritual to test bravery and endurance, and later evolved into a rite of initiation.[27]

### Prophylactic circumcision

[edit]

#### Anglophonic adoption (1855–1918)

[edit]

The first medical professional to recommend circumcision as a prophylaxis against disease was the British physician Jonathan Hutchinson in 1855. By the late 19th century, the belief that circumcision acted as an effective prophylactic against disease was held by a majority of the core Anglosphere's medical communities and doctors, such as the prominent Lewis Sayre, president of the American Medical Association, subsequently leading to its widespread adoption.[21]

Circumcision began to be advocated as a means of prophylaxis in 1855, primarily as a means of preventing the transmission of sexually transmitted infections. At this time, British physician Jonathan Hutchinson published his findings that, among his venereal disease patients, Jews had a lower prevalence of syphilis.[107][108] Hutchinson suggested that circumcision lowers the risk of contracting syphilis.[108] Pursuing a successful career as a general practitioner, Hutchinson went on to advocate circumcision for health reasons for the next fifty years,[107] eventually earned a knighthood for his contributions to medicine. His viewpoint that circumcision was prophylactic against disease was adopted by other medical professionals.[109]

In 1870, orthopedic surgeon Lewis Sayre, a founder of the American Medical Association, introduced circumcision in the United States as a purported cure for several cases of young boys presenting with paralysis and other significant gross motor problems. He thought the procedure ameliorated such problems based on the then prominent "reflex neurosis" theory of disease, thinking that a tight foreskin inflamed the nerves and caused systemic problems.[110] The use of circumcision to promote good health also fit the germ theory of disease, which saw validation during the same period: the foreskin was thought to harbor infection-causing smegma.[111]: 106 Sayre published works on the subject and promoted it in speeches.[110] Many contemporary physicians also believed it could cure, reduce, or otherwise prevent a wide-ranging array of perceived medical problems and social ills. Its popularity spread with publications such as Peter Charles Remondino's History of Circumcision.[111][112][113] By the late 19th century, circumcision had become common throughout the Anglophonic world—Australia, Canada, the United States, and the United Kingdom—as well as the Union of South Africa. In the United Kingdom and United States, it was universally recommended.[21][111]

#### Interwar period and World War II (1918–1945)

[edit]

During the interwar period, medical organizations and doctors in mainland Europe experimented with the idea of routine circumcision for prophylactic reasons as well, alongside developments in the Anglophonic world. In France, the medical profession went so far as to recommend universal routine circumcision. However, prevalence in France and mainland Europe remained low.[19] There is a lack of consensus in the academic literature on why this occurred.[19]

Yosha & Bolnick & Koyle (2012) have suggested that a factor in its Anglophonic adoption and dismissal in mainland Europe relates to attitudes towards Judaism and Jewish practices. While many of these Anglophonic polities would not be considered tolerant by modern standards: the United Kingdom had Benjamin Disraeli—a Jew—as Prime Minister; Jews in the United States were prominent and generally well-respected; while in Australia "the racial issues of the time involved primarily Aborigines and Chinese immigration, and Jews were essentially below the radar". They argue that once "a substantial proportion of the male population [was] circumcised, the idea that it [was] a Jewish practice [became] no longer relevant. In Britain this was aided by the fact that circumcision was well known to be as much a practice of the nobility as a Jewish religious rite, so that the racial-religious nexus was broken." These factors were absent in continental Europe.[19]

Rates in the Anglophonic world began to sharply diverge after 1945.[28]

Pediatrician and political activist Benjamin Spock recommended circumcision in his influential work The Common Sense Book of Baby and Child Care, one of the best-selling books of the twentieth century.[114]

#### Mid-20th century (1945–1985)

[edit]

After the end of World War II, Britain implemented a National Health Service. Douglas Gairdner's 1949 article "The Fate of the Foreskin" argued that the evidence showed that the risks outweighed the benefits, leading to a significant reduction in circumcision incidence within the United Kingdom.[115]

In contrast to Gairdner, American pediatrician Benjamin Spock argued in favor of circumcision in his popular The Common Sense Book of Baby and Child Care which led to rates in the United States significantly rising. In the 1970s, national medical associations in Australia and Canada issued recommendations against routine infant circumcision, leading to drops in the rates of both of those countries. The United States made similar statements in the 1970s but stopped short of recommending against it.[28]

#### Modernity (since 1985)

[edit]

An association between circumcision and reduced heterosexual HIV infection rates was first suggested in 1986.[28]

Experimental evidence was needed to establish a causal relationship, so three randomized controlled trials were commissioned to exclude other confounding factors.[12] Trials took place in South Africa, Kenya and Uganda.[12] All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV contraction than the control group, so it was considered unethical to withhold the procedure, in light of strong evidence of prophylactic efficacy.[12][116] WHO assessed these as "gold standard" studies and found "strong and consistent" evidence from later studies that confirmed the results of the studies.[31] A scientific consensus subsequently developed that circumcision reduces heterosexual HIV infection rates in high-risk populations;[13][9][117] the WHO, along with other major medical organizations, have since promoted circumcision of high-risk populations as part of the program to reduce the spread of HIV.[31] The Male Circumcision Clearinghouse website was created in 2009 by WHO, UNAIDS, FHI and AVAC to provide evidence-based guidance, information, and resources to support the delivery of safe male circumcision services in countries that choose to scale up the procedure as one component of comprehensive HIV prevention services.[118][119] During the mid-2020s, misinformation about circumcision has been spread by U.S. President Donald Trump and many members of the Republican Party, who have falsely alleged that it is ineffective in reducing HIV transmission as a justification for USAID cuts.[120]

## Society and culture

[edit]

A circumcision being performed in Central Asia, c. 1865–1872

Circumcision is one of the oldest surgical procedures in human history, and remains as highly emotional and controversial issue.[121] Many societies hold a wide ranging perspectives and different cultural, ethical, or social views on circumcision.[19] In some cultures, males are generally required to be circumcised shortly after birth, during childhood or around puberty as part of a rite of passage.[122]

Circumcision is commonly practiced in the Jewish,[122] Islamic,[123][124] and Druze faiths, and among the members of Coptic Church, the Ethiopian Orthodox Church and the Eritrean Orthodox Tewahedo Church.[125][126][127] In contrast, other religions, such as Mandaeism, Hinduism and Sikhism, strongly prohibit the practice of routine circumcision.[128][129][130]

### Religious views on circumcision

[edit]

See also: Religious male circumcision

#### Judaism

[edit]

Main article: Brit milah

Circumcision is near-universal among Jews.[131] The mitzvah of circumcision on the eighth day of life is considered among the most important commandments in Judaism. Barring extraordinary circumstances, failure to undergo the rite is seen by followers of Judaism as leading to a state of Kareth: the extinction of the soul and denial of a share in the world to come.[23][24][99] Reasons for biblical circumcision include to show off "patrilineal descent, sexual fertility, male initiation, cleansing of birth impurity, and dedication to God".[132]

Preparing for a Jewish ritual circumcision

The basis for its observance is found in the Torah of the Hebrew Bible, in Genesis chapter 17, in which a covenant of circumcision is made with Abraham household and his descendants. Jewish circumcision is part of the brit milah ritual, to be performed by a trained ritual circumciser, a mohel, on the eighth day of a newborn son's life, with certain exceptions for poor health. Jewish law requires that circumcision leaves the glans bare when the penis is flaccid. Mainstream Judaism foresees serious negative spiritual consequences if it is neglected.[122][133]

In Genesis 17:10-12 God specifies that even slaves must be circumcised. But Rabbinic judaism condemns forced conversion so Gentiles only required to get circumcised if they shows genuine interest in joining the Jewish nation. If an improper circumcision has already been performed it is required that a drop of blood be drawn as a symbolic circumcision.[134] Though there are certain exceptions for those with poor health.[135] The Reform and Reconstructionist movements generally do not require a circumcision as part of the conversion process.[134] According to traditional Jewish law, in the absence of an adult free Jewish male expert, a woman, a slave, or a child who has the required skills is also authorized to perform the circumcision, provided that they are Jewish.[136] However, most streams of non-Orthodox Judaism allow female mohels, called mohalot (Hebrew: מוֹהֲלוֹת, the plural of מוֹהֶלֶת mohelet, feminine of mohel), without restriction. In 1984 Deborah Cohen became the first certified Reform mohelet; she was certified by the Berit Mila program of Reform Judaism.[137] All major rabbinical organizations recommend that male infants should be circumcised. The issue of converts remains controversial in Reform and Reconstructionist Judaism.[138][139]

#### Alternative practice

[edit]

Brit shalom (Hebrew: ברית שלום; "Covenant of Peace"), also called alternative brit to the practice of brit milah, is the naming ceremony for Jews that does not involve circumcision. The first known ceremony is said to have been celebrated around 1970 by Rabbi Sherwin Wine, the founder of the Society for Humanistic Judaism.[140]

An increasing number of Jews in the United States have chosen not to circumcise their sons.[141]

#### Islam

[edit]

Main article: Khitan (circumcision)

Islamic scholars have diverse opinions on the obligatory nature of male circumcision, with some considering it mandatory (wājib), while others view it as only being recommended (sunnah).[142] According to historians of religion and scholars of religious studies, the Islamic tradition of circumcision was derived from the Pagan practices and rituals of pre-Islamic Arabia.[143] Although there is some debate within Islam over whether it is a religious requirement or mere recommendation, circumcision (called khitan) is practiced nearly universally by Muslim males. Islam bases its practice of circumcision on the Genesis 17 narrative, the same Biblical chapter referred to by Jews. The procedure is not explicitly mentioned in the Quran, however, it is a tradition established by Islam's prophet Muhammad directly (following Abraham), and so its practice is considered a sunnah (prophet's tradition) and is very important in Islam. For Muslims, circumcision is also a matter of cleanliness, purification and control over one's baser self (nafs).[123][124][144]

Children in Turkey wearing traditional circumcision costumes Boys in white clothing with bonnets at Tireli market, just after circumcision, Mali, 1990

There is no agreement across the many Islamic communities about the age at which circumcision should be performed. It may be done from soon after birth up to about age 15; most often it is performed at around six to seven years of age. The timing can correspond with the boy's completion of his recitation of the whole Quran, with a coming-of-age event such as taking on the responsibility of daily prayer or betrothal. Circumcision may be celebrated with an associated family or community event. Circumcision is recommended for, but is not required of, converts to Islam.[123][124][144]

#### Christianity

[edit]

Main article: Religious male circumcision § In Christianity

Traditionally, circumcision has not been practiced by Christians for religious reasons, the practice was viewed as succeeded by Baptism and the New Testament chapter Acts 15 recorded that Christianity did not require circumcision from new converts.[145] Christian denominations generally hold a neutral position on circumcision for prophylactic, cultural, and social reasons, while strongly opposing it for religious reasons. This includes the Catholic Church, which explicitly banned the practice of religious circumcision in the Council of Florence,[146] and maintains a neutral position on the practice of circumcision for other reasons.[147] A majority of other Christian denominations take a similar position on circumcision, prohibiting it for religious observance, but neither explicitly supporting or forbidding it for other reasons.[147]

Coptic Children wearing traditional circumcision costumes

Thus, circumcision rates of Christians are predominately determined by the surrounding cultures which they live in. In some African and Eastern Christian denominations circumcision is an established practice,[25][148] and generally boys undergo circumcision shortly after birth as part of a rite of passage.[25] Circumcision is near-universal among Coptic Christians,[149] and they practice circumcision as a rite of passage.[2][125][127][150] The Ethiopian Orthodox Church calls for circumcision, with near-universal prevalence among Orthodox men in Ethiopia.[2] Eritrean Orthodox practice circumcision as a rite of passage, and they circumcise their sons "anywhere from the first week of life to the first few year".[151] Some Christian churches in South Africa disapprove of the practice, while others require it of their members.[2]

Circumcision is practiced in many predominantly Christian countries.[152][153][154] Christian communities in Africa,[155][156] some Anglosphere countries, the Philippines, the Middle East,[157][158] South Korea and Oceania have high circumcision rates,[159][160] while Christian communities in Europe and South America have low circumcision rates, although none of these are performed out of perceived religious obligation.[25][161] Scholar Heather L. Armstrong writes that, as of 2021,[update] about half of Christian males worldwide are circumcised, with most of them being located in Africa, Anglosphere countries, and the Philippines.[162]

#### Druze faith

[edit]

Preparing for a ritual circumcision to a Druze child

Circumcision is widely practiced by the Druze;[163] Druze practice Druzism, an Abrahamic,[164][165] monotheistic, syncretic, and ethnic religion. The procedure is practiced as a cultural tradition, and has no religious significance in the Druze faith.[166][167] There is no special date for this act in the Druze faith: male Druze infants are usually circumcised shortly after birth,[168] however some remain uncircumcised until the age of ten or older.[168] Some Druses do not circumcise their male children and refuse to observe this "common Muslim practice".[169]

#### Samaritanism

[edit]

Like Judaism, the religion of Samaritanism requires ritual circumcision on the eighth day of life.[170]

#### Mandaeism

[edit]

Circumcision is forbidden in Mandaeism,[128][171] and the sign of the Jews given to Abraham by God, circumcision, is considered abhorrent by the Mandaeans.[172] According to Mandaean doctrine, a circumcised man cannot serve as a Mandaean priest.[173]

#### Yazidism

[edit]

Circumcision is not required in Yazidism, but is practised by some Yazidis due to regional customs.[174] The ritual is usually performed soon after birth; it takes place on the knees of the kerîf (approximately "godfather"), with whom the child will have a life-long formal relationship.[175]

### Indian religions

[edit]

See also: Indian religions

#### Hinduism

[edit]

Sculptural representation of lingam, male sex organ-placed on yoni, female sex organ. In Hinduism, lingam and yoni represent the masculine and the feminine creative principles respectively.[176]

In Hinduism, the major scriptures Upanishads state that the nature of the higher self (Brahman), in essence, is bliss (ānanda), which the self in each being (Atman) experiences during dreamless deep sleep, but remains unconscious of it, and experience it in a conscious state during sensual activity.[177]: 48 The upanishads propound that in humans, just as eyes correspond to the experience of sight, nose with smell, ears with sound, and tongue with taste, the genitals correspond to "bliss, delight and procreation".[177] One of the principal upanishads, Brihadaranyaka Upanishad, states that in humans, genitals are the "single locus of pleasure (ānanda)".[178] In Sanskrit literature, the male genitalia is called Upastha ("that which stands up") and is traditionally considered to be a "source of great power or vitality (ojas)."[179] In Yoga physiology, the penis corresponds with svadhishthana chakra, and channels the flow of nadis, which enable higher sensations and consciousness.[180] Consequently, circumcision, or even an interference with a tight foreskin, is strictly forbidden in Hindu traditions.[181]

#### Sikhism

[edit]

Sikhism does not require the elective circumcision of its followers and strongly criticizes the practice.[130][182] The Guru Granth Sahib criticizes circumcision in a hymn.[183] The holy book of Sikhs, dating to 1708, specifically bans circumcision as an Islamic custom, saying: "If God wished me to be a Muslim, it would be cut off by itself."[184]

#### Buddhism

[edit]

In Buddhism, the number 10 of the overall 32 attributes of the enlightened individual is possibly a reference to circumcision, which says: "His sexual organs are concealed in a sheath and exude a pleasant odor similar to vanilla." Due to the ambivalent nature of this scriptural reference, Buddhists do not circumcise, however Buddhist men often retract their foreskins permanently.[184]

### Cultural views on circumcision

[edit]

Main article: Cultural views on circumcision

#### African cultures

[edit]

This section is an excerpt from Circumcision in Africa.[edit]

Circumcision in Africa, and the rites of initiation in Africa, as well as "the frequent resemblance between details of ceremonial procedure in areas thousands of kilometres apart, indicate that the circumcision ritual has an old tradition behind it and in its present form is the result of a long process of development."[185]

#### Australian cultures

[edit]

Some Australian Aborigines use circumcision as a test of bravery and self-control as a part of a rite of passage into manhood, which results in full societal and ceremonial membership. It may be accompanied by body scarification and the removal of teeth, and may be followed later by penile subincision. Circumcision is one of many trials and ceremonies required before a youth is considered to have become knowledgeable enough to maintain and pass on the cultural traditions. During these trials, the maturing youth bonds in solidarity with the men. Circumcision is also strongly associated with a man's family, and it is part of the process required to prepare a man to take a wife and produce his own family.[126]

#### Filipino culture

[edit]

Main article: Tuli (rite)

In the Philippines, circumcision is known as "tuli" and is generally viewed as a rite of passage.[186] An overwhelming majority of Filipino men are circumcised.[186][a] Often this occurs, in April and May, when Filipino boys are taken by their parents. The practice dates back to the arrival of Islam in 1450. Pressure to be circumcised is even in the language: one Tagalog profanity for 'uncircumcised' is supot, meaning 'coward' literally. A circumcised eight or ten year-old is no longer considered a boy and is given more adult roles in the family and society.[188]

### Regulations

[edit]

Worldwide, the large majority of polities do not have specific laws concerning the circumcision of males,[2] with religious infant circumcision being legal in every country.[131][189] A few countries have passed legislation on the procedure: Germany allows routine circumcision,[190] while non-religious routine circumcision is illegal in South Africa and Sweden.[2][189] No major medical organization recommends circumcising all males, and no major medical organization recommends banning the procedure.[19][191][131]

In the academic literature, there is general agreement among both supporters and opponents of the practice that an outright ban would be predominately ineffective and "harmful".[19][131][192][191] A consensus to keep the procedure within the purview of medical professionals is found across all major medical organizations, who advise medical professionals to yield to some degree to parental preferences in their decision to agree to circumcise.[19][131] The Royal Dutch Medical Association, which expresses some of the strongest opposition to routine neonatal circumcision, argues that while there are valid reasons for banning it, doing so could lead parents who insist on the procedure to turn to poorly trained practitioners instead of medical professionals.[19][189]

During the 2010s, several right-wing nationalist parties prominently called for the banning of circumcision.[193] Gressgård argued that politicians that supported Norway's proposed circumcision ban debated circumcision in a manner which constituted "ethnocentrism".[194]

### Economic considerations

[edit]

The cost-effectiveness of circumcision has been studied to determine whether a policy of circumcising all newborns or a policy of promoting and providing inexpensive or free access to circumcision for all adult men who choose it would result in lower overall societal healthcare costs. As HIV/AIDS is an incurable disease that is expensive to manage, significant effort has been spent studying the cost-effectiveness of circumcision to reduce its spread in parts of Africa that have a relatively high infection rate and low circumcision prevalence.[195] Several analyses have concluded that circumcision programs for adult men in Africa are cost-effective and in some cases are cost-saving.[196][197] In Rwanda, circumcision has been found to be cost-effective across a wide range of age groups from newborn to adult,[53][198] with the greatest savings achieved when the procedure is performed in the newborn period due to the lower cost per procedure and greater timeframe for HIV infection protection.[199][198] Circumcision for the prevention of HIV transmission in adults has also been found to be cost-effective in South Africa, Kenya, and Uganda, with cost savings estimated in the billions of US dollars over 20 years.[195] Hankins et al. (2011) estimated that a $1.5 billion investment in circumcision for adults in 13 high-priority African countries would yield $16.5 billion in savings.[200]

The overall cost-effectiveness of neonatal circumcision has also been studied in the United States, which has a different cost setting from Africa in areas such as public health infrastructure, availability of medications, and medical technology and the willingness to use it.[201] A study by the CDC suggests that newborn circumcision would be societally cost-effective in the United States based on circumcision's efficacy against the transmission of HIV alone during coitus, without considering any other cost benefits.[1] The American Academy of Pediatrics (2012) recommends that neonatal circumcision in the United States be covered by third-party payers such as Medicaid and insurance.[1] A 2014 review that considered reported benefits of circumcision such as reduced risks from HIV, HPV, and HSV-2 stated that circumcision is cost-effective in both the United States and Africa and may result in health care savings.[202] A 2014 literature review found that there are significant gaps in the current literature on male and female sexual health that need to be addressed for the literature to be applicable to North American populations.[78]

## References

[edit]

1. ^ a b c d e f g h i j k l m n o p q r s t u v w American Academy of Pediatrics Task Force on Circumcision (September 2012). "Male circumcision". Pediatrics. 130 (3): e756 – e785. doi:10.1542/peds.2012-1990. PMID 22926175.
2. ^ a b c d e f g h i j k l m n Weiss H, Polonsky J, Bailey R, Hankins C, Halperin D, Schmid G (2007). Male circumcision: global trends and determinants of prevalence, safety, and acceptability (PDF). Geneva: World Health Organization. ISBN 978-92-4-159616-9. OCLC 425961131. Archived (PDF) from the original on 22 December 2015.
3. ^ a b c d Lissauer T, Clayden G (October 2011). Illustrated Textbook of Paediatrics, Fourth edition. Elsevier. pp. 352–353\. ISBN 978-0-7234-3565-5.
4. ^ a b c d e f g h i j Hay W, Levin M (25 June 2012). Current Diagnosis and Treatment Pediatrics 21/E. McGraw Hill Professional. pp. 18–19\. ISBN 978-0-07-177971-5. Archived from the original on 18 January 2016.
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6. ^ a b Yuan T, Fitzpatrick T, Ko NY, Cai Y, Chen Y, Zhao J, et al. (April 2019). "Circumcision to prevent HIV and other sexually transmitted infections in men who have sex with men: a systematic review and meta-analysis of global data". The Lancet. Global Health (Mata-analysis). 7 (4): e436 – e447. doi:10.1016/S2214-109X(18)30567-9. PMC 7779827. PMID 30879508.
7. ^ a b c d e f Rehmeyer CJ (March 2011). "Male circumcision and human papillomavirus studies reviewed by infection stage and virus type". The Journal of the American Osteopathic Association. 111 (3 Suppl 2): S11 – S18. PMID 21415373.
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9. ^ a b c For sources on this, see:
* Bell K (2016). Health and Other Unassailable Values: Reconfigurations of Health, Evidence and Ethics. Taylor & Francis. p. 106\. ISBN 978-1-317-48203-1. "...defending the casual relation between male circumcision and reduced HIV transmission has become essentially hegemonic in the academic literature."
* Merson M, Inrig S (2017). The AIDS Pandemic: Searching for a Global Response. Springer International Publishing. p. 379\. ISBN 978-3-319-47133-4.
10. ^ Sharma AL, Hokello J, Tyagi M (25 June 2021). "Circumcision as an Intervening Strategy against HIV Acquisition in the Male Genital Tract". Pathogens. 10 (7): 806. doi:10.3390/pathogens10070806. ISSN 2076-0817. PMC 8308621. PMID 34201976.
11. ^ Manual for early infant male circumcision under local anaesthesia. Geneva: World Health Organization. 2010. Archived from the original on 14 April 2022. Retrieved 14 April 2022. "There are significant benefits in performing male circumcision in early infancy, and programmes that promote early infant male circumcision are likely to have lower morbidity rates and lower costs than programmes targeting adolescent boys and men."
12. ^ a b c d e Siegfried N, Muller M, Deeks JJ, Volmink J (April 2009). Siegfried N (ed.). "Male circumcision for prevention of heterosexual acquisition of HIV in men". The Cochrane Database of Systematic Reviews. 2013 (2): CD003362. doi:10.1002/14651858.CD003362.pub2. PMC 11666075. PMID 19370585.
13. ^ a b Merson M, Inrig S (2017). The AIDS Pandemic: Searching for a Global Response. Springer Publishing. p. 379\. ISBN 978-3-319-47133-4. "This led to a [medical] consensus that male circumcision should be a priority for HIV prevention in countries and regions with heterosexual epidemics and high HIV and low male circumcision prevalence."
14. ^ a b c Thomas A, Necchi A, Muneer A, Tobias-Machado M, Tran AT, Van Rompuy AS, et al. (February 2021). "Penile cancer". Nature Reviews. Disease Primers (Review). 7 (1) 11. doi:10.1038/s41572-021-00246-5. PMID 33574340. S2CID 231877615.
15. ^ a b c Weiss HA, Larke N, Halperin D, Schenker I (February 2010). "Complications of circumcision in male neonates, infants and children: a systematic review". BMC Urology. 10 2\. doi:10.1186/1471-2490-10-2. PMC 2835667. PMID 20158883.
16. ^ a b c d Selekman R, Copp H (2020). "Urologic Evaluation of the Child". In Partin A (ed.). Campbell Walsh Wein Urology (12th ed.). Elsevier. pp. 388–402\. ISBN 978-0-323-67227-6.
17. ^ a b Gable L, Gamharter K, Gostin L, Hodge Jr J, Puymbroeck R (2007). "1.12 Male Circumcision". Legal Aspects of HIV/AIDS: A Guide for Policy and Law Reform. World Bank Publications. pp. 38–39\. ISBN 978-0-8213-7105-3.
18. ^ a b c d e f Manual for early infant male circumcision under local anaesthesia. Geneva: World Health Organization. 2010. Archived from the original on 14 April 2022. Retrieved 14 April 2022. "There are significant benefits in performing male circumcision in early infancy, and programmes that promote early infant male circumcision are likely to have lower morbidity rates and lower costs than programmes targeting adolescent boys and men."
19. ^ a b c d e f g h i j k l Jacobs M, Grady R, Bolnick DA (2012). "Current Circumcision Trends and Guidelines". In Bolnick DA, Koyle M, Yosha A (eds.). Surgical Guide to Circumcision. London: Springer. pp. 3–8, 255–257\. doi:10.1007/978-1-4471-2858-8_1. ISBN 978-1-4471-2857-1. "Outside of strategic regions in sub-Saharan Africa, no call for routine circumcision has been made by any established medical organizations or governmental bodies. Positions on circumcision include "some medical benefit/parental choice" in the United States, "no medical benefit/parental choice" in Great Britain, and "no medical benefit/physical and psychological trauma/parental choice" in the Netherlands."
20. ^ a b c Caga-anan EC, Thomas AJ, Diekema DS, Mercurio MR, Adam MR (8 September 2011). Clinical Ethics in Pediatrics: A Case-Based Textbook. Cambridge University Press. p. 43\. ISBN 978-0-521-17361-2. Archived from the original on 18 January 2016.
21. ^ a b c Al-Salem A (2016). An Illustrated Guide to Pediatric Urology. Springer Publishing. p. 481\. ISBN 978-3-319-44182-5.
22. ^ Afshar K, Kazemi B, MacNeily A (2018). "The Role of Circumcision in Preventing Sexually Transmitted Infections". In Singh S (ed.). Diagnostics to Pathogenomics of Sexually Transmitted Infections. Wiley. pp. 28–34\. ISBN 978-1-119-38084-9.
23. ^ a b Mark E (2003). "Frojmovic/Travelers to the Circumcision". The Covenant of Circumcision: New Perspectives on an Ancient Jewish Rite. Brandeis University Press. p. 141\. ISBN 978-1-58465-307-3. "Circumcision became the single most important commandment... the one without which... no Jew could attain the world to come."
24. ^ a b Hamilton V (1990). The Book of Genesis, Chapters 1-17. Eerdmans Publishing Company. p. 473\. ISBN 978-0-8028-2521-6. "In fact, circumcision is only one of two performative commands, the neglect of which bring the kareth penalty. (The other is the failure to be cleansed from corpse contamination, umb. 19:11-22.)"
25. ^ a b c d Stearns PN (2008). The Oxford Encyclopedia of the Modern World. Oxford University Press. p. 179\. ISBN 978-0-19-517632-2. "Uniformly practiced by Jews, Muslims, and the members of Coptic, Ethiopian, and Eritrean Orthodox Churches, male circumcision remains prevalent in many regions of the world, particularly Africa, South and East Asia, Oceania, and Anglosphere countries."
26. ^ Pitts-Taylor V (2008). Cultural Encyclopedia of the Body [2 volumes]. ABC-CLIO. p. 394\. ISBN 9781567206913. "For most part, Christianity does not require circumcision of its followers. Yet, some Orthodox and African Christian groups do require circumcision. These circumcisions take place at any point between birth and puberty."
27. ^ a b c d e f g h Doyle D (October 2005). "Ritual male circumcision: a brief history" (PDF). The Journal of the Royal College of Physicians of Edinburgh. 35 (3): 279–285\. doi:10.1177/1478271520053503005. PMID 16402509. Archived (PDF) from the original on 14 March 2023. Retrieved 16 January 2023.
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29. ^ Morris BJ, Wamai RG, Henebeng EB, Tobian AA, Klausner JD, Banerjee J, et al. (1 March 2016). "Estimation of country-specific and global prevalence of male circumcision". Population Health Metrics. 14 (1) 4: 1–13\. doi:10.1186/s12963-016-0073-5. ISSN 1478-7954. PMC 4772313. PMID 26933388.
30. ^ Seeth A (1 June 2018). "'It's hassle-free,' says actor Melusi Yeni about his medical circumcision". News24. Archived from the original on 5 May 2022. Retrieved 5 May 2022. "Actor Melusi Yeni was the millionth man to undergo voluntary male medical circumcision at the Sivananda Clinic in KwaZulu-Natal."
31. ^ a b c d e "Preventing HIV Through Safe Voluntary Medical Male Circumcision For Adolescent Boys And Men In Generalized HIV Epidemics". World Health Organization. 2020. Archived from the original on 22 November 2021. Retrieved 24 May 2021.
32. ^ Marrazzo JM, del Rio C, Holtgrave DR, Cohen MS, Kalichman SC, Mayer KH, et al. (23–30 July 2014). "HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society-USA Panel". JAMA. 312 (4): 390–409\. doi:10.1001/jama.2014.7999. PMC 6309682. PMID 25038358.
33. ^ a b Pinto K (August 2012). "Circumcision controversies". Pediatric Clinics of North America. 59 (4): 977–986\. doi:10.1016/j.pcl.2012.05.015. PMID 22857844.
34. ^ Wapner J (24 February 2015). "The Troubled History of Foreskin". Mosaic Science. Archived from the original on 26 December 2021. Retrieved 3 February 2022. "In the decades since, medical practice has come to rely increasingly on evidence from large research studies, which, as many American doctors see it, have supported the existing rationale... How can experts who have undergone similar training evaluate the same studies and come to opposing conclusions? I've spent months scrutinising the medical literature in an attempt to decide which side is right. The task turned out to be nearly impossible. That's partly because there is so much confused thinking around the risks and benefits of circumcision, even among trained practitioners."
35. ^ Morris BJ (November 2007). "Why circumcision is a biomedical imperative for the 21(st) century". BioEssays. 29 (11): 1147–1158\. doi:10.1002/bies.20654. PMID 17935209.
36. ^ Press B, Jalfon M, Solomon D, Hittelman AB (July 2024). "Clinical and environmental considerations for neonatal, office-based circumcisions compared with operative circumcisions". Frontiers in Urology. 4 1380154\. doi:10.3389/fruro.2024.1380154. ISSN 2673-9828. PMC 12327250. PMID 40777091. "Neonatal circumcision is supported by both the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) due to the belief that the health benefits outweigh the minimal risk of the procedure."
37. ^ "Background, Methods, and Synthesis of Scientific Information Used to Inform "Information for Providers to Share with Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV Infection, Sexually Transmitted Infections, and other Health Outcomes"". stacks.cdc.gov. 22 August 2018. Archived from the original on 22 October 2023. Retrieved 12 October 2023.
38. ^ a b c d e f World Health Organization, UNAIDS, Jhpiego (Johns Hopkins Program for International Education in Gynecology and Obstetrics) (December 2009). "Manual for Male Circumcision Under Local Anaesthesia" (PDF). Archived from the original (PDF) on 15 January 2012. "...there are many myths about male circumcision that circulate. For example, some people think that circumcision can cause impotence (failure of erection) or reduce sexual pleasure. Others think that circumcision will cure impotence. Let me assure you that none of these is true." Alt URL Archived 30 March 2023 at the Wayback Machine
39. ^ "What to Expect After Circumcision: "Most of the swelling will be gone within a month but it takes up to 6 months for all of the swelling to go away."". University of Mississippi Medical Center. Retrieved 14 May 2025.
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129. ^ Clarence-Smith WG (2008). "Islam and Female Genital Cutting in Southeast Asia: The Weight of the Past" (PDF). Finnish Journal of Ethnicity and Migration. 3 (2: Special Issue: Female Genital Cutting in the Past and Today): 14–22\. Archived from the original (PDF) on 6 March 2009.
130. ^ a b Cherry M (2013). Religious Perspectives on Bioethics. Taylor & Francis. p. 213\. ISBN 978-90-265-1967-3.
131. ^ a b c d e Cohen-Almagor R (9 November 2020). "Should liberal government regulate male circumcision performed in the name of Jewish tradition?". SN Social Sciences. 1 (1) 8. doi:10.1007/s43545-020-00011-7. ISSN 2662-9283. S2CID 228911544. "Protagonists and critics of male circumcision agree on some things and disagree on many others... They also do not underestimate the importance of male circumcision for the relevant communities.... Even the most critical voices of male circumcision do not suggest putting a blanket ban on the practice as they understand that such a ban, very much like the 1920–1933 prohibition laws in the United States, would not be effective... Protagonists and critics of male circumcision debate whether the practice is morally acceptable... They assign different weights to harm as well as to medical risks and to non-medical benefits. The different weights to risks and benefits conform to their underlying views about the practices... Protagonists and critics disagree about the significance of medical reasons for circumcision..."
132. ^ Hendel R (2005). Remembering Abraham: Culture, Memory, and History in the Hebrew Bible. Oxford University Press. pp. 3–30\. ISBN 9780199784622.
133. ^ Bolnick DA, Katz KE (2012). "Jewish Ritual Circumcision". In Bolnick DA, Koyle M, Yosha A (eds.). Surgical Guide to Circumcision. London: Springer. pp. 265–274\. doi:10.1007/978-1-4471-2858-8_23. ISBN 978-1-4471-2857-1.
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135. ^ Levine A, Zvi Brettler M (2017). The Jewish Annotated New Testament. Oxford University Press. p. 673\. "With rare exceptions (e.g. matters of health), Judaism requires circumcision for all male children on their eighth day of birth."
136. ^ Talmud Avodah Zarah 26b; Menachot 42a; Maimonides' Mishneh Torah, Milah, ii. 1; Shulkhan Arukh, Yoreh De'ah, l.c.
137. ^ "Berit Mila Program of Reform Judaism". 7 October 2013. Archived from the original on 7 October 2013. Retrieved 20 July 2022.
138. ^ Glickman M (12 November 2005). "B'rit Milah: A Jewish Answer to Modernity". Reform Judaism. Archived from the original on 12 March 2017. Retrieved 11 March 2017.
139. ^ Cohen H (20 May 2002). "Bo: Defining Boundaries". Jewish Reconstructionist Federation. Archived from the original on 9 October 2007. Retrieved 3 November 2007.
140. ^ Lowenfeld J (2 August 2011). "Little-known non-cutting ritual appeals to some who oppose circumcision". The Jewish Journal of Greater Los Angeles. LA. Archived from the original on 25 August 2018. Retrieved 11 March 2020. "According to Gottfried, the earliest known brit shalom ceremony was performed around 1970 by her mentor, Rabbi Sherwin Wine, the founder of the Society for Humanistic Judaism."
141. ^ Chernikoff H (3 October 2007). "Jewish "intactivists" in U.S. stop circumcising". Reuters. Archived from the original on 27 December 2008. Retrieved 3 November 2007.
142. ^ Dabbagh H (December 2022). "Is Circumcision "Necessary" in Islam? A Philosophical Argument Based on Peer Disagreement". Journal of Religion and Health. 61 (6): 4871–4886\. doi:10.1007/s10943-022-01635-0. PMC 9569283. PMID 36006531.
143. ^ Abu-Sahlieh SA (1994). "To mutilate in the name of Jehovah or Allah: legitimization of male and female circumcision". Medicine and Law. 13 (7–8). World Association for Medical Law: 575–622\. PMID 7731348.7–8&rft.pages=575-622&rft.date=1994&rft_id=info:pmid/7731348&rft.aulast=Abu-Sahlieh&rft.aufirst=SA&rfr_id=info:sid/en.wikipedia.org:Circumcision" class="Z3988">; Aldeeb Abu-Sahlieh SA (1995). "Islamic Law and the Issue of Male and Female Circumcision". Third World Legal Studies. 13. Valparaiso University School of Law: 73–101\. Archived from the original on 12 November 2019. Retrieved 13 February 2020.
144. ^ a b El-Sheemy MS, Ziada AM (2012). "Islam and Circumcision". In Bolnick DA, Koyle M, Yosha A (eds.). Surgical Guide to Circumcision. London: Springer. pp. 275–280\. doi:10.1007/978-1-4471-2858-8_24. ISBN 978-1-4471-2857-1.
145. ^ Mark E (2003). The Covenant of Circumcision: New Perspectives on an Ancient Jewish Rite. Brandeis University Press. pp. xxiii. ISBN 978-1-58465-307-3.
146. ^ Pope Eugenius IV (1990) [1442]. "Ecumenical Council of Florence (1438–1445): Session 11—4 February 1442; Bull of union with the Copts". In Tanner NP (ed.). Decrees of the ecumenical councils. 2 volumes (in Greek and Latin). Washington, D.C.: Georgetown University Press. ISBN 978-0-87840-490-2. LCCN 90003209. Archived from the original on 25 April 2009. Retrieved 25 April 2007. "it denounces all who after that time observe circumcision"
147. ^ a b Slosar JP, O'Brien D (2003). "The ethics of neonatal male circumcision: a Catholic perspective". The American Journal of Bioethics. 3 (2): 62–64\. doi:10.1162/152651603766436306. PMID 12859824. S2CID 38064474.
148. ^ Pitts-Taylor V (2008). Cultural Encyclopedia of the Body [2 volumes]. ABC-CLIO. p. 394\. ISBN 978-1-56720-691-3. "For most part, Christianity does not require circumcision of its followers. Yet, some Orthodox and African Christian groups do require circumcision. These circumcisions take place at any point between birth and puberty."
149. ^ Sharkey HJ (2015). American Evangelicals in Egypt: Missionary Encounters in an Age of Empire. Princeton University Press. p. 30\. ISBN 978-0-691-16810-4.
150. ^ Adams G, Adams K (2012). "Circumcision in the Early Christian Church: The Controversy That Shaped a Continent". In Bolnick DA, Koyle M, Yosha A (eds.). Surgical Guide to Circumcision. London: Springer. pp. 291–298\. doi:10.1007/978-1-4471-2858-8_26. ISBN 978-1-4471-2857-1.
151. ^ DeMello M (2007). Encyclopedia of Body Adornment. ABC-Clio. p. 66\. ISBN 978-0-313-33695-9. "Coptic Christians, Ethiopian Orthodox, and Eritrean Orthodox churches on the other hand, do observe the ordainment, and circumcise their sons anywhere from the first week of life to the first few years."
152. ^ Gruenbaum E (2015). The Female Circumcision Controversy: An Anthropological Perspective. University of Pennsylvania Press. p. 61\. ISBN 978-0-8122-9251-0. "Christian theology generally interprets male circumcision to be an Old Testament rule that is no longer an obligation ... though in many countries (especially the United States and Sub-Saharan Africa, but not so much in Europe) it is widely practiced among Christians"
153. ^ Hunting K (2012). Essential Case Studies in Public Health: Putting Public Health Into Practice. Jones & Bartlett Publishers. pp. 23–24\. ISBN 978-1-4496-4875-6. "Neonatal circumcision is the general practice among Jews, Christians, and many, but not all Muslims."
154. ^ Wylie KR (2015). ABC of Sexual Health. John Wiley & Sons. p. 101\. ISBN 978-1-118-66569-5. "Although it is mostly common and required in male newborns with Moslem or Jewish backgrounds, certain Christian-dominant countries such as the United States also practice it commonly."
155. ^ Creighton S, Liao LM (2019). Female Genital Cosmetic Surgery: Solution to What Problem?. Cambridge University Press. p. 63\. ISBN 978-1-108-43552-9. "Christians in Africa, for instance, often practise infant male circumcision."
156. ^ Nga A (30 December 2019). "The Ritual of Circumcision in Africa: The Case of South Africa". Africanews. Archived from the original on 6 December 2022. Retrieved 8 November 2022. "This practice is old and widespread among African Christians with very close links to their beliefs. It can be executed traditionally or in hospital."
157. ^ Bakos GT (2011). On Faith, Rationality, and the Other in the Late Middle Ages:: A Study of Nicholas of Cusa's Manuductive Approach to Islam. Wipf and Stock Publishers. p. 228\. ISBN 978-1-60608-342-0. "Although it is stated that circumcision is not a sacrament necessary for salvation, this rite is accepted for the Ethiopian Jacobites and other Middle Eastern Christians."
158. ^ Sharkey HJ (2017). A History of Muslims, Christians, and Jews in the Middle East. Cambridge University Press. p. 63\. ISBN 978-0-521-76937-2. "On the Coptic Christian practice of male circumcision in Egypt, and on its practice by other Christians in western Asia."
159. ^ "Circumcision protest brought to Florence". Associated Press. 30 March 2008. Archived from the original on 26 March 2023. Retrieved 2 August 2022. "However, the practice is still common among Christians in the United States, Oceania, South Korea, the Philippines, the Middle East and Africa. Some Middle Eastern Christians actually view the procedure as a rite of passage."
160. ^ Ross JI (2015). Religion and Violence: An Encyclopedia of Faith and Conflict from Antiquity to the Present. Routledge. p. 169\. ISBN 978-1-317-46109-8. "For instance, the majority of South Koreans, Americans, and Filipinos, as well as African Christians, practice circumcision."
161. ^ Peteet JR (2017). Spirituality and Religion Within the Culture of Medicine: From Evidence to Practice. Oxford University Press. pp. 97–101\. ISBN 978-0-19-027243-2. "male circumcision is still observed among Ethiopian and Coptic Christians, and circumcision rates are also high today in the Philippines and the US."
162. ^ Armstrong HL (2021). Encyclopedia of Sex and Sexuality: Understanding Biology, Psychology, and Culture [2 volumes]. ABC-CLIO. pp. 115–117\. ISBN 978-1-61069-875-7.
163. ^ Ubayd A (2006). The Druze and Their Faith in Tawhid. Syracuse University Press. p. 150\. ISBN 978-0-8156-3097-5. "Male circumcision is standard practice, by tradition, among the Druze"
164. ^ Abulafia AS (23 September 2019). "The Abrahamic religions". www.bl.uk. London: British Library. Archived from the original on 12 July 2020. Retrieved 9 March 2021.
165. ^ Obeid A (2006). The Druze & Their Faith in Tawhid. Syracuse University Press. p. 1\. ISBN 978-0-8156-5257-1.
166. ^ Jacobs D (1998). Israel and the Palestinian Territories: The Rough Guide. Rough Guides. p. 147\. ISBN 978-1-85828-248-0. "Circumcision is not compulsory and has no religious significance."
167. ^ Silver MM (2022). The History of Galilee, 1538–1949: Mysticism, Modernization, and War. Rowman & Littlefield. p. 97\. ISBN 978-1-7936-4943-0. "Muslim men are circumcised, whereas this is not a religious obligation among the Druze"
168. ^ a b Dana N (2003). The Druze in the Middle East: Their Faith, Leadership, Identity and Status. University of Michigan Press. p. 56\. ISBN 978-1-903900-36-9.
169. ^ Brenton RB (2013). The Sunni-Shi'a Divide: Islam's Internal Divisions and Their Global Consequences. Potomac Books, Inc. p. 56\. ISBN 978-1-61234-523-9. "There are many references to the Druze refusal to observe this common Muslim practice, one of the earliest being the rediscoverer of the ruins of Petra, John Burckhardt. "The Druses do not circumcise their children"
170. ^ Mark E (2003). The Covenant of Circumcision: New Perspectives on an Ancient Jewish Rite. University Press of New England. pp. 94–95\. ISBN 978-1-58465-307-3.
171. ^ Lupieri E (2001). The Mandaeans: The Last Gnostics. Wm. B. Eerdmans Publishing. p. 60\. ISBN 978-0-8028-3350-1. Archived from the original on 14 September 2023. Retrieved 6 August 2022.
172. ^ Schmidinger T (2019). Beyond ISIS: History and Future of Religious Minorities in Iraq. Transnational Press London. p. 82\. ISBN 978-1-912997-15-2.
173. ^ Deutsch N (1999). Guardians of the Gate: Angelic Vice-regency in the Late Antiquity. BRILL. p. 105\. ISBN 978-90-04-10909-4.
174. ^ Parry OH (1895). "Six months in a Syrian monastery; being the record of a visit to the head quarters of the Syrian church in Mesopotamia, with some account of the Yazidis or devil worshippers of Mosul and El Jilwah, their sacred book". London : H. Cox.
175. ^ Kreyenbroek PG (2009). Yezidism in Europe: Different Generations Speak about Their Religion. Otto Harrassowitz Verlag. ISBN 978-3-447-06060-8.
176. ^ Narayanan V, Urban HB (2006). "Hinduism - Shaivism". In Riggs T (ed.). Worldmark Encyclopedia of Religious Practices, Volume 1. Thomson Gale. pp. 316, 334. ISBN 9780787666125.
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178. ^ Feuerstein G (1998). Tantra : the path of ecstasy. Random House. p. 230\. ISBN 157062304X.
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180. ^ Motoyama H (2003). Theories of the Chakras : bridge to higher consciousness. New Age Books. pp. 136–137, 164, 187. ISBN 9788178220239.
181. ^ Cox G, Morris BJ (2012). "Why Circumcision: From Prehistory to the Twenty-First Century". In Bolnick DA, Koyle M, Yosha A (eds.). Surgical Guide to Circumcision. Springer Science & Business Media. p. 251\. ISBN 978-1-4471-2857-1. "The traditions of Hinduism prohibit circumcision, and even any interference with a tight foreskin."
182. ^ Cole WO, Sambhi PS (1995). The Sikhs: Their Religious Beliefs and Practices. Sussex Academic Press. pp. 155–156\. ISBN 978-1-898723-13-4.
183. ^ "Sri Granth: Sri Guru Granth Sahib". www.srigranth.org.
184. ^ a b Cox G, Morris BJ (2012). "Why Circumcision: From Prehistory to the Twenty-First Century". In Bolnick DA, Koyle M, Yosha A (eds.). Surgical Guide to Circumcision. Springer Science & Business Media. p. 251\. ISBN 978-1-4471-2857-1.
185. ^ Wagner G (1949). "Circumcision And Initiation Rites" (PDF). The Bantu of North Kavirondo: Volume 1. Oxford University Press. p. 335\. doi:10.4324/9780429485817. ISBN 9780429485817. `{{cite book}}`: ISBN / Date incompatibility (help)
186. ^ a b "Tuli a rite of passage for Filipino boys". 6 May 2011. Archived from the original on 8 December 2015. Retrieved 6 December 2015.
187. ^ Zirkumzision nach Dieffenbach. Archived 2 September 2022 at the Wayback Machine (vgl. Schumpelick u. a., S. 434 ff.)
188. ^ "'Circumcision season': Philippine rite puts boys under pressure". Channel News Asia. Agence France-Presse. 19 June 2019. Archived from the original on 20 June 2019. Retrieved 20 June 2019.
189. ^ a b c "Circumcision of Infant Males" (PDF). The Royal Australasian College of Physicians. September 2010. Archived (PDF) from the original on 12 August 2015. Retrieved 11 September 2013.
190. ^ "Circumcision remains legal in Germany". Deutsche Welle. 12 December 2012. Archived from the original on 26 October 2013. Retrieved 11 September 2013.
191. ^ a b Basaran O (2023). Circumcision and Medicine in Modern Turkey. University of Texas Press. pp. 156–157\. ISBN 978-1-4773-2702-9. "Regardless of their ethical stances, scholars of both camps tend to agree that a blanket criminalization of male circumcision would be unhelpful and harmful to boys..."
192. ^ "Non-therapeutic circumcision of male minors". KNMG Viewpoint. Utrecht, The Netherlands: Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst (KNMG) (Royal Dutch Society for the Promotion of Medicine). May 2010. Archived from the original on 8 March 2018. Retrieved 7 March 2018.
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195. ^ a b Doyle SM, Kahn JG, Hosang N, Carroll PR (January 2010). "The impact of male circumcision on HIV transmission". The Journal of Urology. 183 (1): 21–26\. doi:10.1016/j.juro.2009.09.030. PMID 19913816.
196. ^ Uthman OA, Popoola TA, Uthman MM, Aremu O (March 2010). Van Baal PH (ed.). "Economic evaluations of adult male circumcision for prevention of heterosexual acquisition of HIV in men in sub-Saharan Africa: a systematic review". PLOS ONE. 5 (3): e9628. Bibcode:2010PLoSO...5.9628U. doi:10.1371/journal.pone.0009628. PMC 2835757. PMID 20224784.
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## Notes

[edit]

1. ^ The most commonly-done procedure is in actuality not a circumcision but a dorsal slit, where no foreskin is actually removed. When the foreskin is removed, it is commonly known locally as a "German cut" in reference to the introduction of the modern surgical technique by the founder of plastic and reconstructive surgery, Johann Friedrich Dieffenbach.[187]

## External links

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