Circumcision

Circumcision is the removal of some or all of the foreskin (prepuce) from the penis. The word "circumcision" comes from Latin circum (meaning "around") and cædere (meaning "to cut").

The earliest depictions of circumcision are from cave drawings of Ancient Egyptian tombs, though some pictures may be open to interpretation. Male circumcision is a religious commandment in Judaism and is recommended or obligatory in Islam. It is also customary in some Christian churches in Africa including some Oriental Orthodox Churches.

According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, mostly in the Middle East and Africa.

Neonatal circumcision advocates claim circumcision provides important health advantages which outweigh the risks, has no substantial effects on sexual function, has a complication rate of less than 0.5% when carried out by an experienced physician, and is best performed on newborns. Opponents of neonatal circumcision claim it violates the individual's bodily rights, is medically unnecessary, adversely affects sexual pleasure and performance, and is largely supported by myths.

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

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

However, this is in complete contrast to the studies conducted by the University of Chicago that concluded that circumcision has no significant effect on the prevention of HIV/AIDS.

Circumcision procedures
For infant circumcision, clamps, such as the Gomco clamp, Plastibell, and Mogen are often used. Clamps cut the blood supply to the foreskin, limit any bleeding and protect the glans. Before using a clamp, the foreskin and the glans are separated with a blunt probe and/or curved hemostat.
 * With the Plastibell, the adhesions between glans and foreskin are first cut with a probe. The foreskin is cut longitudinally, the Plastibell is placed over the glans and the foreskin is covered over the Plastibell. A ligature is then tied firmly around the foreskin. This crushes the skin against the groove in the Plastibell. The skin protruding beyond the ring is then cut away. The remaining foreskin and the clamp come off in three to seven days.
 * With a Gomco clamp, a section of skin is first crushed with a hemostat then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is then tightened, "crushing the foreskin between the bell and the base plate." The crushing limits bleeding (provides hemostasis). While the flared bottom of the bell fits tightly against the hole of the base plate, the foreskin is then cut away with a scalpel from above the base plate. The bell prevents the glans being reached by the scalpel.
 * With a Mogen clamp, the foreskin is grabbed dorsally with a straight hemostat, and lifted up. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result," than with Gomco or Plastibell circumcisions. The clamp is locked shut, and a scalpel is used to cut the foreskin from the flat (upper) side of the clamp.

Cultures and religions
Circumcising cultures may circumcise their males either shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is most prevalent in the Muslim world, Israel, the United States, the Philippines, South Korea and Africa. It is less common in Europe, Latin America, China and India. It is commonly practiced in the Jewish and Islamic faiths.

Under Jewish law circumcision is a mitzva aseh ("positive commandment" to perform an act) and is obligatory for Jewish males. It is only postponed or abrogated in the case of threat to the life or health of the child. It is usually performed by a mohel on the eighth day after birth in a ceremony called a Brit milah (or Bris milah, colloquially simply bris), which means "Covenant of circumcision" in Hebrew. It is considered of such religious importance that the body of an uncircumcised Jewish male is circumcised before burial: the only modification to bodily remains performed under halakha (Jewish religious law), which demands that corpses be treated with absolute respect and dignity. Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches. Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ.

In Islam, circumcision is mentioned in some hadith, but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended (Sunnah); others that it is obligatory. Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham. While endorsing circumcision for males, scholars note that it is not a requirement for converting to Islam.

Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War. In West Africa infant circumcision may have had tribal significance as a rite of passage or otherwise in the past; today in some non-Muslim Nigerian societies it is medicalised and is simply a cultural norm.

Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land, where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago. Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature: subincision is practised amongst some aboriginal peoples in the Western Desert. In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu; participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.

Circumcision is also commonly practiced in the Polynesian islands of Samoa, Tonga, Niue, and Tikopia. In Samoa it is accompanied by a celebration.

Among some West African animist groups, such as the Dogon and Dowayo, circumcision is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males. Among the Urhobo of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te Oshare ("the boy is now man"), constitutes a rite of passage from one age set to another. For Nilotic peoples, such as the Kalenjin and Maasai, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set.

Ethical issues
The American Medical Association defines “non-therapeutic” circumcision as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. It states that medical associations in the US, Australia, and Canada do not recommend the routine non-therapeutic circumcision of newborns.

Circumcision advocates argue that circumcision prevents infections and slows down the spread of AIDS. Opponents of circumcision question the ethical validity of removing healthy, functioning genital tissue from a minor, arguing that infant circumcision infringes upon individual autonomy and represents a human rights violation.

Consent
Views differ on whether limits should be placed on caregivers having a child circumcised.

Some medical associations take the position that the parents should determine what is in the best interest of the infant or child, but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue. The BMA state that in general, "the parents should determine how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices." They state that because the parents' interests and the child's interests sometimes differ, there are "limits on parents' rights to choose and parents are not entitled to demand medical procedures contrary to their child's best interests." They state that competent children may decide for themselves.

Some argue that the medical problems that have their risk reduced by circumcision are already rare, can be avoided, and, if they occur, can usually be treated in less invasive ways than circumcision. Somerville states that the removal of healthy genital tissue from a minor should not be subject to parental discretion and that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient. Denniston contends that circumcision is harmful and asserts that in the absence of the individual's consent, non-therapeutic child circumcision violates several ethical principles that govern medicine.

Others believe neonatal circumcision is permissible, if parents should so choose. Viens argues that, in a cultural or religious context, circumcision is of significant enough importance that parental consent is sufficient and that there is "an absence of sufficient evidence or persuasive argumentation" to support changing the present policy. Benatar and Benatar argue that circumcision can be beneficial to a male before he would be able to otherwise provide consent, that "it is far from obvious that circumcision reduces sexual pleasure," and that "it is far from clear that non-circumcision leaves open a future person’s options in every regard."

Emotional consequences
Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, and cite a longitudinal study finding no difference in developmental and behavioural indices. Goldman (1999) discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure. Milos asserts the existence of "excruciating pain, perinatal encoding of the brain with violence, interruption of maternal-infant bonding, betrayal of infant trust..." among other consequences, and points to support groups providing information to Jewish parents "who are grappling with this difficult issue" as well as men "who perceive themselves as victims of a sexual assault."

Legality
In 2001, Sweden allowed only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anaesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the law, and in 2001, the World Jewish Congress stated that it was “the first legal restriction on Jewish religious practice in Europe since the Nazi era.” In 2005, the Swedish National Board of Health and Welfare reviewed the law and recommended that it be maintained. In 2006, the United States State Department's report on Sweden stated that most Jewish mohels had been certified under the law and 3000 Muslim and 40–50 Jewish boys were circumcised each year.

In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised were illegal. The prosecutor claimed that, "part of healthy genitalia is removed without medical foundation, or competent consent". No punishment was assigned by the court.

Pain and pain relief during circumcision
According to the American Academy of Pediatrics' 1999 Circumcision Policy Statement, “There is considerable evidence that newborns who are circumcised without analgesia experience pain and psychologic stress.” It therefore recommended using pain relief for circumcision. One of the supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response during vaccination months later. While acknowledging that there may be "other factors" besides circumcision to account for different levels of pain response, they stated that they did not find evidence of such. They concluded "pretreatment and postoperative management of neonatal circumcision pain is recommended based on these results." Other medical associations also cite evidence that circumcision without anesthetic is painful.

Stang, 1998, found 45% of physicians used anaesthesia – most commonly a dorsal penile nerve block – for infant circumcisions. Obstetricians used anaesthesia significantly less often (25%) than family practitioners (56%) or pediatricians (71%).

J.M. Glass, 1999, stated that Jewish ritual circumcision is so quick that "most mohelim do not routinely use any anaesthesia as they feel there is probably no need in the neonate. However, there is no Talmudic objection and should the parents wish for local anaesthetic cream to be applied there is no reason why this cannot be done." Tannenbaum and Shechet, 2000, stated that an “authentic, traditional bris performed by a mohel does not use clamps, so there is no pain associated with crushing tissue.” They also asserted that due to the speed of the procedure and rarity of complication, it is “more humane not to subject the infant to a local anesthetic.”

Lander et al., found that babies circumcised without pain relief "exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the circumcision and following. Two newborns ... became ill following circumcision (choking and apnea)." A 2004 Cochrane review, which compared the dorsal penile nerve block and EMLA (topical anaesthesia) found both anaesthetics appear safe, but neither of them completely eliminated pain. Razmus et al. reported that newborns circumcised with the dorsal block and the ring block in combination with the concentrated oral sucrose had the lowest pain scores. Ng et al. found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.

Sexual effects
The American Academy of Pediatrics (1999) stated "a survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men. There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males. Masters and Johnson noted no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men." In January 2007, The American Academy of Family Physicians (AAFP) stated "The effect of circumcision on penile sensation or sexual satisfaction is unknown. Because the epithelium of a circumcised glans becomes cornified, and because some feel nerve over-stimulation leads to desensitization, many believe that the glans of a circumcised penis is less sensitive. [...] No valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction."

Boyle et al. (2002) stated that "the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings&mdash;many of which are lost to circumcision." They concluded, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well."

Medical aspects
The British Medical Association, states “there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.” Cost-benefit analyses have varied. Some found a small net benefit of circumcision,  some found a small net decrement,  and one found that the benefits and risks balanced each other out and suggested that the decision could "most reasonably be made on nonmedical factors."

Risks of circumcision
While the risk in a competently performed medical circumcision is very low, complications from bleeding, infection and poorly carried out circumcisions can be catastrophic. According to the American Medical Association (AMA), blood loss and infection are the most common complications, but most bleeding is minor and can be stopped by applying pressure. Kaplan identified other complications, including urinary fistulas, meatal stenosis, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias, impotence and removal of too much tissue, sometimes causing secondary phimosis. He stated “Virtually all of these complications are preventable with only a modicum of care" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.”

Complication rates ranging from 0.06% to 55% have been cited. Infant circumcision may result in skin bridges, and meatal stenosis may be a common longer-term complication from circumcision. The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.

Deaths have been reported. The American Academy of Family Physicians states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision. Gairdner's 1949 study reported that an average of 16 children per year out of about 90,000 died following circumcision in the UK. He found that most deaths had occurred suddenly under anaesthesia and could not be explained further, but hemorrhage and infection had also proven fatal. Deaths attributed to phimosis and circumcision were grouped together, but Gairdner argued that such deaths were probably due to the circumcision operation.

Adult circumcisions are often performed without clamps, and require 4 to 6 weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.

HIV and other sexually transmitted diseases
In March 2007, WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an effective intervention for HIV prevention, but also noted that male circumcision only provides partial protection and should not replace other interventions to prevent the heterosexual transmission of HIV. The Centers for Disease Control and Prevention (CDC) state that several types of research have documented that male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex. Both the WHO and CDC indicate that it may not reduce HIV transmission from men to women, and that data is lacking for the transmission rate of men who engage in anal sex with either a female or male partner, as either the insertive or receptive partner.

The World Health Organization (WHO) stated that studies of three trials provide compelling evidence that male circumcision provides a 50–60% reduction in HIV transmission from female to male. All three trials were stopped early by their monitoring boards, because it was judged that the significant reductions in HIV incidence made it unethical to continue following control group participants without offering circumcision. In 2007, WHO and UNAIDS recommended that male circumcision should now be recognized as an efficacious intervention for HIV prevention, but emphasised that it does not provide complete protection against HIV infection. They have stated that scientific findings regarding the role of male circumcision in preventing heterosexual HIV infection are particularly relevant in regions where the incidence of heterosexually acquired HIV infection is high, such as Sub-Saharan Africa, and stressed that the procedure must be carried out safely and under conditions of informed consent. Before there were any results from randomized controlled trials, reviews of observational data differed as to whether there was sufficient evidence for an intervention effect of circumcision against HIV.

McCoombe et al. stated that a layer of keratin could provide protection from viral entry, and found that the keratin is thinner on the foreskin than the glans penis, and thinnest on the inner surface of the foreskin.

A meta-analysis found that circumcision is associated with lower rates of syphilis, chancroid and possibly genital herpes.

Hygiene, and infectious and chronic conditions
Studies have found that boys with foreskins tend to have higher rates of various infections and inflammations of the penis than those who are circumcised. The foreskin may harbor bacteria and become infected if it is not cleaned properly, but may become inflamed if it is cleaned too often with soap. Also, the forcible retraction of the foreskin in boys can lead to infections.

Circumcision is one treatment for balanitis. The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams.

Several studies have shown that uncircumcised men are at greater risk of human papilloma virus (HPV) infection. One study found no statistically significant difference in the incidence of HPV infection between circumcised and uncircumcised men, but did note a higher prevalence of urethritis in the uncircumcised. Results of the 1999 to 2004 United States National Health and Nutrition Examination Survey demonstrated that more circumcised men reported having been diagnosed with genital warts compared with uncircumcised men (4.5% and 2.4%, respectively).

Twelve studies have indicated that neonatal circumcision reduces the rate of Urinary tract infections (UTI's) in male infants by a factor of about 10. Some UTI studies have been criticized for not taking into account a high rate of UTI's among premature infants, who are usually not circumcised because of their fragile health status. The AMA stated that “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI," and noted one decision analysis model that concluded that circumcision was not justified as a preventative measure against UTI.

Penile cancer
Penile cancer affects from 0.82 per 100,000 in Denmark to 10.5 per 100,000 men per year in parts of India (0.9 to 1 per 100,000 in the United States). Studies have reported a rate of penile cancer from 3 to 22 times higher in uncircumcised than circumcised men.

The American Academy of Pediatrics (1999) stated that studies suggest that neonatal circumcision confers some protection from penile cancer, but circumcision at a later age does not seem to confer the same level of protection. Further, because penile cancer is a rare disease, the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low.

The American Cancer Society (2006) stated, "The current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer."

United States
The American Academy of Family Physicians (2007) recommends that physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering circumcision for newborn boys.

The American Academy of Pediatrics (1999) do not recommend that all infant boys be circumcised, and state that parents should choose what is best for their child by looking at the benefits and risks. The AAP also recommended using analgesia as a safe and effective method for reducing pain associated with circumcision, and that circumcision only be performed on newborns who are stable and healthy.

The American Medical Association supports the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics.

The American Urological Association (2007) believes that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. In the context of HIV studies carried out in Africa, the AUA states that while "the results of studies in African nations may not necessarily be extrapolated to men in the United States at risk for HIV infection," the AUA "recommends that circumcision should be presented as an option for health benefits."

Canada
The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Circumcision: Information for Parents" in November 2004, and "Neonatal circumcision revisited" in 1996. The 1996 position statement says that "circumcision of newborns should not be routinely performed," (a statement with which the Royal Australasian College of Physicians concurs,) and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many pediatricians no longer perform circumcisions."

“We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors.

United Kingdom
The British Medical Association's position (June 2006) was that male circumcision for medical purposes should only be used where less invasive procedures are either unavailable or not as effective. The BMA specifically refrained from issuing a policy regarding “non-therapeutic circumcision,” stating that as a general rule, it “believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.”

Australasia
The Royal Australasian College of Physicians states "there is no medical indication for routine neonatal circumcision". It states, "If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment"

History of circumcision
It has been variously proposed that circumcision began as a religious sacrifice, as a rite of passage marking a boy's entrance into adulthood, as a form of sympathetic magic to ensure virility, as a means of suppressing (or enhancing) sexual pleasure or to increase a man's attractiveness to women, or as an aid to hygiene where regular bathing was impractical, among other possibilities. Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practicing circumcision, leading to its spread regardless of whether the people understood this. It is possible that circumcision arose independently in different cultures for different reasons.



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

Medical circumcision in the 19th century and early 20th century
There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The germ theory of disease elicited an image of the human body as a conveyance for many dangerous germs, making the public "germ phobic" and suspicious of dirt and bodily secretions. Because of its function, the penis became "dirty" by association, and from this premise circumcision was seen as preventative medicine to be practiced universally. In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation. It was also said to protect against syphilis, phimosis, paraphimosis, balanitis, and "excessive venery" (which was believed to produce paralysis). Gollaher states that physicians advocating circumcision in the late nineteenth century expected public skepticism, and refined their arguments to overcome it.

Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada, South Africa and to a lesser extent in the United Kingdom and New Zealand. Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 30% of newborn American boys were being circumcised in 1900, 55% in 1925, and 72% in 1950.

Circumcision since 1945
In 1949, the United Kingdom's newly-formed National Health Service removed infant circumcision from its list of covered services. Since then, circumcision has been an out-of-pocket cost to parents, and the proportion of newborns circumcised in England and Wales has fallen to less than one percent. In Canada, individual provincial health services began delisting circumcision in the 1980s.

In South Korea, circumcision grew in popularity following the establishment of the United States trusteeship in 1945 and the spread of American influence. More than 90% of South Korean high school boys are now circumcised, but the average age of circumcision is 12 years.

In some South African ethnic groups, circumcision has roots in several belief systems, and is mostly performed on teenage boys.

A study in 1987 found that the prominent reasons for parents choosing circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns. A 2005 study speculated that increased recognition of the potential benefits may be responsible for an observed increase in the rate of neonatal circumcision in the USA between 1988 and 2000.

Prevalence of circumcision
Estimates of the proportion of males that are circumcised worldwide vary from one-sixth to a third. WHO has estimated that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), with almost 70% of these being Muslim. Prevalence is near universal in the Middle East and Central Asia. WHO states that "there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines". WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe, and Klavs et al. report findings that "support the notion that the prevalence is low in Europe". In Latin America, prevalence is universally low. Estimates for individual countries include Spain, Columbia and Denmark less than 2%, Finland and Brazil 7%, Taiwan 9% and Thailand 13%.

WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively. Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa. The circumcision rate has declined sharply in Australia since the 1970s, leading to an age-graded fall in prevalence, with a 2000-01 survey finding 32% of those aged 16-19 years circumcised, 50% for 20-29 years and 64% for those aged 30-39 years. Prevalence in the UK is also age-graded, with 12% of those aged 16-19 years circumcised and 20% of those aged 40-44 years.

Circumcision opposition

 * The Circumcision Information and Resource Pages by Geoffrey T. Falk
 * Doctors Opposing Circumcision presided by George C. Denniston, MD, MPH
 * National Organization of Circumcision Information Resource Centers by Marilyn Milos, RN
 * Sex as Nature Intended It by Kristen O'Hara.

Circumcision promotion

 * Jewish Circumcision – Brit Milah Chabad.org
 * Benefits of circumcision: medical, health and sexual by Professor Brian Morris
 * Circumcision: a lifetime of medical benefits by Edgar Schoen, BSc., M.D.

Circumcision techniques

 * Description of an adult circumcision from the American Academy of Family Physicians.
 * Visualisation of amount of skin removed, showing 'styles' of circumcision.
 * Circumcision by bone cutting method. Retrieved 13 February 2007.
 * Circumcision child: Operation Script on Wikisurgery.
 * Circumcision child: Information for patients on Wikisurgery
 * Circumcision adult daycase: Information for patients on Wikisurgery