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Circumcision is a procedure to remove the skin that covers the tip of the penis (the foreskin). This is the flap of skin that can usually be pulled back over the head of the penis.

Sometimes circumcision has to be carried out for medical reasons. This may be because the foreskin is damaged or infected and wont slide back over the head of the penis. Only around one in every 100 men need a circumcision for medical reasons, but the number of circumcisions carried out in the UK is roughly six times higher than this.

Sometimes circumcision is carried out for religious reasons. Other cultures practice circumcision because they think the foreskin is unhygienic, unnecessary, or causes health problems.

Many people have strong views on whether circumcision should be carried out or not. It isnt routinely performed in the UK because there is no clear clinical evidence that it is has medical benefit. Some studies suggest circumcision may help to prevent cancer of the penis and reduce the risk of sexually transmitted diseases (STIs). However, good personal hygiene, not smoking and practicing safe sex are more important.

Medical opinion is mixed as to whether circumcision has any health benefit.

Cancer of the penis:
Some studies suggest that circumcision can help to prevent cancer of the penis. This is an extremely rare type of cancer, and circumcision may only offer protection if done in childhood, not during puberty. However, poor personal hygiene, smoking, and catching a sexually transmitted infection (STI) called human papilloma virus (HPV) are more important reasons in the development of penile cancer. Countries with the highest rate of circumcision, such as America, also have the highest rate of penile cancer.

Sexually transmitted infections:
Some types of sexually transmitted infections are more common in uncircumcised than circumcised men. Men who arent circumcised may be less likely to notice the symptoms of STIs that cause warts or ulcers on the genitals such as herpes or syphilis. The symptoms of chlamydia can also be less obvious, making it more likely for men to pass on the infection without realising. However, infections such as penile warts and urethritis are more common in circumcised men, and yeast infections such as thrush affect circumcised and uncircumcised men equally.

The best and safest way to prevent the spread of sexually transmitted infections is to practice safe sex, use a condom and get yourself checked for any STIs before sleeping with a new partner or stopping using condoms.

Research into whether HIV is less likely in circumcised men has produced mixed evidence. In the UK, results in favour of circumcision do not outweigh the protection offered by practising safe sex and using condoms.

When should it be done?
In England, circumcision is occasionally carried out on the NHS for emergency medical reasons. Its usually considered a last resort if other types of treatment havent been successful.

Circumcision is a painful operation. Babies who are circumcised are usually given a local anaesthetic because a general anaesthetic is more dangerous. Local anaesthetic is a numbing medicine that can be injected at the base of the penis or in the shaft, or applied as a cream.

Older children and adults who are circumcised are normally given a full, general anaesthetic.

Non-therapeutic circumcision

Non-therapeutic or ritual circumcision is circumcision that is not carried out for a medical reason. Instead, it may be done for religious or cultural reasons.

The NHS does not fund ritual circumcision in England. However in some areas of the country where there is a high population of ethnic minority groups, ritual circumcision may be carried out on the NHS for a fee. At these clinics, only newborn babies between 6-12 weeks old are circumcised, and the child must be registered with a GP in the respective area. A referral to the clinic is made by either the GP, health visitor or nurse after consultation. The procedure will not usually be carried out without the consent of both parents and careful consideration of the childs best interests.

It is very important that parents considering having their son circumcised are fully aware of the issues and risks involved, including pain, bleeding, and the possibility of surgical error. Most doctors also urge parents to think about what is best for the child, and where possible consider the childs interests. If the boy is old enough, it is important that doctors and parents consider his feelings and ensure he is informed about what the procedure involves, the implications of not being circumcised and any other possible options.

The childs social and cultural circumstances must also be considered. In certain religions and cultures, circumcision may be required for all males. The decision not to circumcise may cause other problems such as social exclusion, or make it harder for the child to find their sense of identity. However, this must also be weighed up against the standard of medical care available.

Why is it necessary?
In the UK, circumcision is generally only carried out for emergency medical conditions. Doctors often disagree on when circumcision should be carried out at all, and many view it as a last resort treatment. It may be recommended in the following cases:

Phimosis is when the foreskin is very tight cant be pulled back over the head (glans) of the penis. It is normal for the foreskin to be attached to the head of the penis in boys up to about the age of 5, and parents shouldnt try to pull it back because this can cause pain or injury. Usually by the age of 6 the foreskin has separated by itself and can be pulled back.

In some boys, phimosis can continue up to the age of 10, and sometimes into adulthood. Circumcision isnt needed for phimosis under the age of 6, but may be considered after this if the foreskin is damaged. This is usually happens as a result of severe or repeated infections. However, watchful waiting is often enough, as the majority of foreskins loosen themselves naturally, and true phimosis (see below) only accounts for about 1% of cases.

Some boys have a rare form of phimosis called true phimosis. This is usually a congenital condition (present from birth), which stops the foreskin being pulled back at all. It can also develop after lots of infections of the foreskin and head of the penis. True phimosis is normally treated with circumcision, although parents may not recognise the condition when their son is a baby.

Paraphimosis is a tight foreskin that can't be pulled back and squeezes the penis painfully. It forms a ring around the penis, cutting off some of the blood flow to the glans and causing it to swell up. Doctors can sometimes treat paraphimosis by gently squeezing the trapped glans until the foreskin can slide over it again. If this isnt possible, circumcision may be needed.

Balanitis and balanoposthitis:
Balanitis and balanoposthitis are infections and swelling of the penis. Balanitis affects the foreskin and balanoposthitis affects the head of the penis. Both conditions are more common in men and boys with diabetes - after going to the toilet, drops of urine containing sugar may remain on the foreskin, providing the perfect conditions for bacteria to multiply in and cause an infection.Balanitis that keeps coming back can lead to scarring and phimosis, and may eventually make circumcision necessary.

Penile cancer affecting the foreskin:
Cancer of the penis is very rare there are about 350 new cases in the UK each year. It often starts on the foreskin, and circumcision is sometimes considered to stop it spreading.

Painful sex:
Circumcision is occasionally carried out in men if a tight foreskin is making sex painful.

In babies, the foreskin takes around seven to ten days to heal up after circumcision. It can take up to three weeks in older boys and men.

Stitches that dissolve by themselves are normally used to close up the wound, and dont need to be removed. Circumcision is painful and painkillers such as paracetamol or ibuprofen will need to be taken for at least the first three days.

Circumcision exposes the sensitive skin of the glans. In babies, nappies can rub against it and make it sore, so make sure you tuck down your babys penis before putting the nappy in place. The penis will be red and swollen for a few days after circumcision and children and adults may find it more comfortable to wear lose clothing for a while. Petroleum ointment put directly on the area can reduce the irritation.

After a child has been circumcised, it is important to make sure the child does not ride a bike or use other sit-on toys until the swelling has completely gone down. They should be able to return to school about a week after being circumcised, and you should tell your childs teacher about the operation.

Consult your GP if:

there is bleeding from your childs penis,
your childs penis stays swollen after two weeks, or
your child still finds passing urine painful a few days after the operation.
Older boys and men should also see their GP if they have any problems after the operation.

As with all types of surgical operation, circumcision has some risks. The rate of complications for circumcision carried out for medical reasons in this country is low, but problems with religious or cultural circumcisions may not always be reported.

The most common problem is bleeding and infection in the area that has been circumcised. Other complications include:

decrease in sensation (feeling) in the penis particularly during sex;
damage to the urethra (urine tube in the penis) causing the urine tube to become narrow and making it hard to pass urine;
accidental amputation of the glans (head of the penis) (this is very rare); and
blood infection or blood poisoning (septicaemia).

© Queen's Printer and Controller of HMSO, 2005

Crown copyright material is reproduced with the permission of the controller of HMSO and the Queens Printer for Scotland.



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