Circumcision

Circumcision cuts or otherwise removes some or all of the foreskin (prepuce) from the penis. The frenulum may also be cut away at the same time, in a procedure called a frenectomy. The word "circumcision" comes from Latin circum (meaning "around") and caedere (meaning "to cut").

Circumcision predates recorded human history, with depictions found in stone-age cave drawings and Ancient Egyptian tombs. The origins of the practice are lost in antiquity. Theories include that circumcision is a form of ritual sacrifice or offering, a sign of submission to a deity, a rite of passage to adulthood, a mark of defeat or slavery, or an attempt to alter aesthetics or sexuality. Circumcision of males is a religious requirement of the Islamic and Jewish faiths. It is also practiced by the majority of South Koreans, Americans, and Filipinos.

Infant circumcision has come under increasing discussion in recent decades. The American Medical Association states that medical associations in the US, Australia, and Canada do not recommend routine “non-therapeutic” circumcision, which it defines as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. According to the AMA's 1999 literature review, in the US when parents choose elective circumcision for their child, it is largely because of social or cultural expectations, rather than medical concerns. However, a 2001 survey questionnaire found that 23.5% of parents listed 'health reasons'. Proponents of genital integrity condemn all elective infant circumcision, religious or secular, as a form of male genital mutilation that they consider comparable to female genital mutilation. Some argue that there are medical benefits in the procedure. Circumcision may be needed to treat chronic inflammation of the penis, and penile cancer. Some physicians recommend circumcision to treat phimosis, while others recommend the other effective treatments for this condition.

The procedures of circumcision

Circumcision removes the foreskin from the penis. For infant circumcision, clamps, such as the Gomco clamp, Plastibell, and Mogen are often used. These clamps are meant to protect the glans while they apply pressure to the foreskin to stop any bleeding. With the Plastibell clamp, the foreskin and the clamp come away in three to seven days. Before a Gomco clamp is used, a section of skin is 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 the bleeding (provides the hemostasis). With the flared bottom of the bell fit tightly against the hole of the base plate, the foreskin is cut away with a scalpel from above the base plate, while the bell covers the glans to prevent it being reached by the scalpel.

With a Mogen clamp, used by many physicians and some mohels (Jewish ritual circumcisers), the foreskin and the glans are separated with a blunt probe and/or curved hemostat (as with the first part of the Gomco procedure). The foreskin is then grabbed dorsally with a straight hemostat, and lifted up. The Mogen clamp is then slid between the glans and hemostat. The clamp is locked shut, and a scalpel used to cut the foreskin from the flat (upper) side of the clamp. A frenectomy may be performed if frenular chordee is evident.

According to a 1998 study, 45% of physicians used anaesthesia for infant circumcisions. Dorsal penile nerve block was the most commonly used form. Obstetricians had a significantly lower rate of anaesthesia use (25%) than pediatricians (71%) or family practitioners (56%). A 2004 Cochrane review concluded that dorsal penile nerve block was the most effective form of anaesthesia and EMLA (topical anaesthesia) was less effective. The authors noted that 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. 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.

Cultures and religions

Some cultures circumcise their males as a matter of tradition, either shortly after birth, in childhood or around puberty, when it may be (or form part of) a rite of passage. The practice is most notable among Jews and Muslims, and is more prevalent in the United States than in other Western nations.

Judaism

Circumcision is fundamental to Judaism. It is an essential component of Jewish practice and is a commandment obligatory under Jewish law (Halakha) for all Jewish males. It is usually performed in a ceremony called a Brit milah (or Bris milah, colloquially simply bris) (Hebrew for "Covenant of circumcision"). A mohel performs the ceremony on the eighth day after birth unless health reasons force a delay. According to the Torah (Genesis, chapter 17 verses 9-14), God commanded Abraham to circumcise himself, his offspring and his slaves as a sign of an everlasting covenant. According to Halakha, failure to follow the commandment carries the penalty of karet, or being cut off from the community by God. Brit milah is so important that should the eighth day fall on Shabbat, actions that would normally be forbidden because of the sanctity of the day are permitted in order to fulfill the requirement to circumcise. The expressly ritual element of circumcision in Judaism, as distinguished from its non-ritual requirement in Islam, is shown by the requirement that a child who either is born aposthetic (without a foreskin) or who has been circumcised without the ritual must nevertheless undergo a Brit Milah in which a drop of blood (hatafat-dam, הטפת דם) is drawn from the penis at the point where the foreskin would have been or was attached.

Less commonly practised, and at times the subject of controversy, is metzitzah b'peh, or oral suction. This is when after cutting off the foreskin, the mohel sucks blood from the wound to clean it, although today this is usually done with a glass tube.

Christianity

Catholic, Protestant, Eastern and Oriental Orthodox Christianity do not prescribe circumcision. The first Church Council in Jerusalem decided that circumcision was not a requirement (Acts 15), and St. Paul warned gentile Christians against adopting the practice (Galatians 6:12-16, Philippians 3:2-3). However, individual Christians and Christian traditions may have different customs. For example, circumcision is customary among members of the Coptic Orthodox, Ethiopian Orthodox, and Eritrean Orthodox churches in their home countries. On 1 January, the Catholic Church used to celebrate the Circumcision of Christ. This has been superseded by the Solemnity of Mary, Mother of God. Anglican and Lutheran churches have other feast days at this time such as the Holy Name of Jesus.

Islam

The origin of circumcision in Islam is a matter of religious and scholarly debate. It is mentioned in some parts of the Hadith, but not in the Qur'an. Fiqh scholars have different opinions about circumcision in Shariah, depending on which Hadith are accepted and how they are interpreted. According to some it is recommended (Sunnah); according to others, it is obligatory. Some have quoted the Hadith to argue that the requirement of circumcision is based on the covenant with Abraham.

The timing of Muslim circumcision varies. Turkish, Balkan, rural Egyptians and Central and South Asian Muslims typically circumcise boys between the ages of six and eleven and traditionally the event may be a joyous occasion and celebrated with sweets and feasting. However, in the middle class it is more usually done in infancy and is largely unremarked upon. In Turkey the celebratory feast is called "Sünnet Düğünü" and is considered a very important celebration in man's life as a passage to a manhood. In Pakistan, Muslims usually circumscise their boys on the 7th day of life. The birth celebration, Aqiqa takes place with the sacrifice of goat or two on behalf of the new-born child.. While circumcision may be performed at all ages from newborn period to adulthood, the medical profession has encouraged medical circumcisions in the first week after birth to reduce complications "Circumcision is performed by barbers, medical technicians, quacks and doctors including paediatric surgeon[s] [and as] yet there is no consensus for the best age and method." In Iran, Dr. Paula Drew states that “circumcision, which formerly celebrated the onset of manhood, has for many years now been more customarily performed at the age of 5 or 6 for children born at home, and at two days old for those born in a medical setting.…By puberty, all Muslim Iranian boys must be circumcised if they are to participate fully in religious activities.” Kamyar et al describe it as an "obligatory custom" and note that it is not necessary for the circumciser to be a Muslim.

Baha'i

"Bahá'ís are not advised on a particular course of action in respect to circumcision of males; circumcision of females is considered mutilation." .

Druze

The Druze do not practice male circumcision .

Hinduism

There is no specific reference to male circumcision in the Hindu holy books, and Hindus in India generally do not practice circumcision.

Sikhism

"Circumcision holds no relevance to a Sikh." All rituals which do not hold relevance are strictly forbidden. For Sikhs, "acceptance of Nature's beautiful body is an important component of the Sikh value system."

Secular tradition

Routine circumcision practices in South Korea are largely the result of American cultural and military influence following the Korean War. The origin of the practice in the Philippines is uncertain according to one newspaper article, although it speculatively attributes it to the influence of western colonizers. That the origin is uncertain is supported by the seventeenth century text of Antonio de Morga's History of the Philippine Islands, which equally speculatively attributes circumcision to Islamic influence. 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.

Non-Western initiatory traditions

Circumcision can be part of an initiation rite in some African, Pacific Islander, and certain isolated Australian aboriginal traditions, such as in 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, including subincision for 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 practised 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, it is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males. Although in many West African traditional societies circumcision has become medicalised and is simply performed in infancy without ado or any particular conscious cultural significance, among the Urhobo people 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

Circumcising infants as a public health measure is controversial. Circumcision advocates assert that circumcision is a significant public health measure, preventing infections, and slowing down the spread of AIDS. The genital integrity movement, however, asserts that infant circumcision is a human rights violation and a sexual assault, and that the practice of circumcising infants or children should be discouraged or banned.

Consent

Debate often focuses on what limits, if any, should be placed on a caregiver's ability to have a child circumcised. The procedure is hard to reverse , the immediate medical value is disputed and the result may not be in accordance with the child's wishes when he is an adult. Some believe that male circumcision is ethically identical to female genital cutting and question the apparent inconsistency in prohibiting one but not the other. Some assert that circumcision causes sexual harm and emotional scarring later in life, or urge that the procedure should be left until the boy is mature enough to make the choice for himself. Others assert that circumcision is less traumatic when performed in infancy and that there is no evidence of sexual or emotional harm. They point out that restrictions on circumcision would be highly intrusive on the religious or cultural rites and practices of various communities and would interfere with the traditional right of parents to make this decision on behalf of their child. A number of medical associations accept that the parents should determine what is in the best interest of the infant or child, though the RACP and the BMA observe that controversy exists on this issue and the BMA insists that a circumcision must not go ahead without the consent of both parents.

Emotional consequences

An article discussed the extent to which circumcision may cause emotional harm to males. Some organizations have been founded as support groups for circumcised men who are upset with their status. Several studies suggest that circumcised infants do not forget the pain during circumcision easily, as a correlation between circumcision with ineffective anaesthesia and intensity of pain response during vaccination months later has been noted.

Legality

The mainstream medical organizations do not consider male infant circumcision to be a legal issue as long as the decision for circumcision was made by the legal guardians, and that they have given their informed consent.

In 2001, Sweden passed a law restricting the performance of neo-natal circumcisions to persons certified by the National Board of Health. This law requires that a medical doctor or an anesthesia nurse accompany the circumcisor, and that anaesthetic is applied prior to the procedure. Most Jewish mohels have been so certified. Muslims and Jews in Sweden objected to the law, and the World Jewish Congress stated that it was “the first legal restriction on Jewish religious practice in Europe since the Nazi era.”

Medical aspects

The direct medical benefits of neonatal circumcision are still under debate, with various studies reaching different opinions. The studies have been conducted using cost-benefit analyses. The complication morbidity is compared to the potential gain in expected longevity, and the medical costs of circumcision are compared to the expected reduction in lifetime health costs. In the words of the BMA, “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.” Biases notwithstanding, some studies decided that circumcision has a net benefit, some decided that it has a net decrement, and others decided that the benefits and risks balance each other out and that other factors must be taken into consideration.

The American Medical Association, American Academy of Pediatrics, and the Royal Australasian College of Physicians all suggest that anasthesia be used if performing circumcision.

Risks of circumcision

Circumcision is a surgical procedure. While the risks of circumcision-related complications are very low, the complications resulting from a poorly carried out circumcision, post-operative bleeding, or infection can be catastrophic. Bleeding and infection are the most common complications of the procedure, according to the AMA, although in the majority of cases, bleeding is minor and hemostasis can be achieved by pressure application. Kaplan identified longer term complications, including urinary fistulas, 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. Unfortunately, most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.” Infant circumcision may cause problems such as skin bridges, when the cut skin does not heal neatly but attaches to the glans penis instead. This does not commonly require surgical correction; rather, a brief, simple office procedure may be performed. Meatal stenosis may be a common longer-term complication from circumcision. Recent publications give a frequency of occurrence between 0.9% in Iran and 9% to 10% in the U.S. Loss of the penis itself has been documented. The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.

The American Medical Association quotes a complication rate of 0.2%–0.6%, based on the studies of Gee and Harkavy. These same studies are quoted by the American Academy of Pediatrics. The American Academy of Family Physicians quotes a range of anywhere between 0.1% and 35%. The Royal Australasian College of Physicians and the Canadian Paediatric Society bring the AMA results together with other studies with results ranging anywhere between 0.06% to 55%, and bring Williams & Kapila citing that a 2%–10% seems reasonable.

Fatal complications have been reported. The American Academy of Family Physicians states that death is rare, and cites an estimated death rate with circumcisions of infants of 1 in 500,000. Gairdner's 1949 study reported that during the 1940s an average of 16 children per year, out of an estimated 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 guessed that such deaths were more likely due to the circumcision operation.

Metzitzah b'peh without a sterile glass tube or pipette was implicated in the transfer of HSV from mohels to eight Israeli infants, one of which suffered brain damage. When three New York City infants contracted herpes after metzizah b'peh by one mohel and one of them died, New York authorities took out a restraining order against the mohel. However, the mohel's attorney argued that the New York Department of Health had not supplied conclusive medical evidence linking his client with the disease. In September 2005, the city withdrew a restraining order against the mohel and turned the matter over to a chasidic rabbinical court. In February 2006, Dr. Thomas Frieden, the Health Commissioner of New York City, wrote, “There exists no reasonable doubt that ‘metzitzah b'peh’ can and has caused neonatal herpes infection.…The Health Department recommends that infants being circumcised not undergo metzitzah b'peh”. In May 2006, the Department of Health for New York State issued a protocol for the performance of metzitzah b'peh. Dr. Antonia C. Novello, Commissioner of Health for New York State, together with a board of rabbis and doctors, worked, she said, to “allow the practice of metzizah b'peh to continue while still meeting the Department of Health's responsibility to protect the public health.”

HIV

The most recent data indicate that circumcision is correlated with significantly reduced risks of HIV transfer during heterosexual intercourse (a between 48% and 53% reduction, although the topic remains the subject of ongoing research and debate in the medical community. There are also fears that some may mistakenly believe they will be protected against HIV through circumcision and see circumcision as a safe alternative to other forms of protection, such as condoms.)

Research by the World Health Organization published in the US Public Library of Science Medicine journal in July, 2006, showed that men who had been circumcised had a significantly lower risk of infection with the AIDS virus, and calculated that if all men were circumcised over the next 10 years, some two million new infections could be avoided.

In March 2005, a Cochrane review of the medical evidence concluded that, “Although the positive results of these observational studies suggest that circumcision is an intervention worth evaluating in randomised controlled trials, the current quality of evidence is insufficient to consider implementation of circumcision as a public-health intervention.” Initial population based studies suggesting that circumcision might play a protective role were criticised because confounding factors such as religion may have skewed the results; the reviewers therefore commented that the results of randomised controlled trials then underway would be critical.

The results of the first randomised controlled trial was published in November 2005. It found a 60% reduction in the rate of new HIV infection (from 2.1 per 100 to 0.85 per 100 in the intervention group and claimed that male circumcision provided a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa.

Two further randomised trials of the effect of circumcision on HIV infections conducted in Uganda and Kenya were originally scheduled to be concluded in 2007. However, the US National Institutes of Health (NIH) stated on December 13, 2006 that they had stopped the trials early citing that circumcision was so effective that it would be unethical to continue the experiment and not offer circumcision in the uncircumcised men who were acting as controls. The results showed that circumcised males in Uganda were 53% less likely to get infected and circumcised males in Kenya were 48% less likely to get infected.

A possible mechanism relates to Langerhans cells, a part of the human immune system. Szabo and Short suggest that Langerhans cells in the foreskin may provide an entry point for viral infection. Three studies identified high concentrations of Langerhans and other HIV target cells in the human prepuce. Additionally, McCoombe, Cameron, and Short found that the keratin is thinnest on the foreskin and frenulum. Conversely, some authors believe that the prepuce has an important immunological function, and that its removal increases the chances of infections. This hypothesis has been criticised on technical grounds.

HPV

Several studies have shown that uncircumcised men are at greater risk of human papilloma virus (HPV) infection. While most genital HPV strains are considered harmless, some can cause genital warts or cancer althought there is a vaccine against most cancer causing strains of HPV. One study found no statistically significant difference between men with foreskins for HPV infection than those who are circumcised, but did note a significantly higher incidence of HPV lesions and urethritis in uncircumcised men.

Hygiene

The American Academy of Pediatrics observes “Circumcision has been suggested as an effective method of maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene.” It states that the "relationship among hygiene, phimosis, and penile cancer is uncertain" and further remarks that "genital hygiene needs to be emphasized as a preventive health topic throughout a patient's lifetime."

The Royal Australasian College of Physicians emphasizes that a non-circumcised infant's penis requires no special care and should be left alone, stating that attempts to forcibly retract the foreskin, e.g. to clean it, are painful, often injure the foreskin, and can lead to scarring, infections and pathologic phimosis. It is recommended that, while there is no special age where the foreskin should be retractable, once the foreskin becomes retractable, the child should gently wash it with soap and water. It has been suggested, however, that excessive washing of the foreskin and the glans will make infections such as balanitis more likely.

Circumcision reduces the amount of smegma produced by the male. Smegma is a combination of exfoliated epithelial cells, transudated skin oils, and moisture that can accumulate under the foreskin of males and within the female vulva area. It has a characteristic strong odor and taste, and is common to all mammals—male and female. While smegma is generally not believed to be harmful to health, the strong odour may be considered to be a nuisance or give the impression of a lack of hygiene. In rare cases, accumulating smegma may help cause balanitis.

It has been suggested that circumcision arose in peoples living in arid and sandy regions as a public health measure intended to prevent recurring irritation and infection caused by sand accumulating under the foreskin. Darby, after checking the official war histories of Britain, Australia and New Zealand and other records, and finding no mention of ‘balanitis’ or ‘foreskin’ or ‘circumcision’ dismissed this idea as a “medical urban myth,” concluding that “‘sand under the foreskin,’ balanitis, and circumcision were not significant problems during either of the World Wars.”

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 reasons are unclear, but several hypotheses have been suggested:

• The foreskin may harbor bacteria and become infected if it is not cleaned properly.
• The foreskin may become inflamed if it is cleaned too often with soap.
• The forcible retraction of the foreskin in boys can lead to infections.

The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. There are less invasive treatments than circumcision for posthitis.

Balanitis

Balanitis, an inflammation of the glans penis, has a variety of causes. Some of these, such as anaerobic infection, occur more frequently in uncircumcised men, while others, such as fungal infection, have no statistically significant differences in frequency of occurrence between circumcised and uncircumcised men. There are less invasive treatments than circumcision that have been shown effective in treating most mild cases of balanitis. Birley, et al, also agrees that for many mild forms of balanitis there are less invasive procedures, but does state that there are times when circumcision “might be of benefit in a patient whose balanitis relapses despite these measures, and remains the principal treatment for specific conditions such as lichen sclerosus and plasma cell balanitis.” Also, less invasive procedures are not as successful in treating balanitis xerotica obliterans, or BXO, which is harder to treat.

Lichen sclerosus et atrophicus (LSA) produces a whitish-yellowish patch on the skin, and is not believed to be always harmful or painful, and may sometimes disappear without intervention. Some consider balanitis xerotica obliterans to be a form of LSA that happens to be on the foreskin, where it may cause pathological phimosis. Circumcision is believed to reliably reduce the threat of BXO.

Penile cancer

Penile cancer is cancer of the penis, i.e. on the glans or the foreskin. Most cases have been found to occur in men over the age of 70. Kochen and McCurdy performed a life table analysis on penile cancer rates. Their basic assumptions were that these cancers occur exclusively in uncircumcised males and that age-specific rates calculated from older groups were applicable to the 1971 birth cohort. Their overall analysis finds an estimated occurrence rate in uncircumcised males of 1 in 600, or 0.167%, with a median age of occurrence of 67 years old. However, they close their predictions section with the following “Since the uncircumcised male is uniquely susceptible, virtually all of these cancers are preventable by neo-natal circumcision. The number of lifetime incident cancers that could be prevented annually by circumcision can be estimated with birth statistics available for 1971. In that year, there were 1,822,910 recorded live male births. If none had been neonatally circumcised, our analysis predicts that one in 600, or more than 3,000 would have penile cancer in their lifetimes.”

However, a small risk is associated with non-classic vigorous circumcisions that leave scarring.

In 2005, the American Cancer Society said that while studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer, it is important to concentrate on the main risk factors: poor hygiene, having unprotected sex with multiple partners, and cigarette smoking. They further state that the current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer.

The American Academy of Pediatrics states 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, penile cancer is a rare disease and the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low.

The American Medical Association states similarly that although neonatal circumcision seems to lower the risk of contracting penile cancer, because it is rare and occurs later in life, the use of circumcision as a preventive practice is not justified.

Phimosis and paraphimosis

It is normal for an infant's foreskin to be attached to the glans. Pathological phimosis is a condition when the foreskin remains so tight that retraction over the glans is painful or impossible. Rickwood suggested that the term 'phimosis' should be restricted to cases in which the prepuce loses suppleness and becomes scarred. The AAP state that the true frequency of problems such as phimosis is unknown. Fergusson et al found phimosis in 16% of non-circumcised boys, while Herzog and Alvarez found it in 2.6%. Rickwood and Walker raised concern that phimosis is frequently misdiagnosed by physicians confusing it with the developmentally non-retractible foreskin. Several researchers have described less invasive treatments for phimosis, and recommend that they be tried first.

Several studies have identified phimosis as a risk factor for penile cancer. The British Medical Journal published one letter that stated it would be irresponsible to expose a patient to risk for longer than necessary. .

Paraphimosis is an acute condition where a tight foreskin is stuck behind the glans and cannot be returned to its original position, curbing the blood flow to the glans. In children, it is sometimes caused by a caregiver trying to forcibly retract the infant foreskin.

Urinary tract infections

Twelve studies have indicated that neonatal circumcision reduces the occurrence rate of Urinary tract infections in male infants by a factor of about 10. The March 1999 AAP statement notes that premature infants are usually not circumcised because of their fragile health status. Studies have found that 1 in 10 premature infants will have a urinary tract infection during the first month of life. Some of the UTI studies have been criticised for not taking these and other factors into account. A Swedish study found that the cumulative incidence of UTIs in boys under 2 years of age was 2.2%. The AMA cites evidence that the incidence of UTI’s is “small (0.4%–1%)” in uncircumcised infants, and “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI…One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition.”

The Canadian Paediatric Society poses the question of whether increased UTI and balanitis rates in non-circumcised male infants may be caused by forced premature retraction. According to the Lerman and Liao, aside from its effects on UTI infection rates, "Most of the other medical benefits of circumcision probably can be realized without circumcision as long as access to clean water and proper penile hygiene are achieved."