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References

AuthorSubjectReferenceSummary
  
Marked titles link to the actual articles, in the CIRP reference library
 
Adler et al.parent
(not patient)
satisfaction
Robert Adler, Sandra Ottaway and Stacey Gould
Circumcision: We Have Heard From the Experts; Now Let's Hear From the Parents
PEDIATRICS Vol. 107 No. 2 February 2001, p. e20
A survey of parents in Southern California found poor Hispanic parents of intact babies were worse informed, felt disrespected and were less satisfied with their decision than well-off white parents of circumcised babies. Surprise!
Almroth, et alMale complications
of female genital mutilation
Lars Almroth, Vanja Almroth-Berggren, Osman Mahmoud Hassanein, Said SalahEldin Al-Said, Sharif Siddiq Alamin Hasan, Ulla-Britt Lithell, Staffan Bergstro
Male complications of female genital mutilation
Social Science & Medicine 53 (2001) 1455–1460
Abstract: Female genital mutilation (FGM) is known to cause a wide range of immediate and long-term complications for women subjected to the practice. Male complications due to FGM have, however, not been described before. The objectives of this study were to explore male complications and attitudes with regard to FGM. A village in the Gezira Scheme along the Blue Nile in Sudan constituted the basis of the study. Interviews were carried out according to a pretested questionnaire, using structured questions withopen-answer possibilities. Married men of the youngest parental generation and grandfathers were randomly selected from up-to-date election lists. All respondents except one agreed to be interviewed. A total of 59 men were interviewed, 29 young men and 30 grandfathers. Male complications resulting from FGM, such as difficulty in penetration, wounds/infections on the penis and psychological problems were described by a majority of the men. Most men were also aware of the female complications. More young than old respondents would have accepted a woman without FGM to become their daughter-in-law (p50.03). A majority of the young men would have preferred to marry a woman without FGM. This proportion was significantly higher than among the grandfathers (p50.01). Female genital mutilation can no longer be considered to be only an issue for women. The acknowledged male complications and attitudes described may open new possibilities to counteract the practice of FGM.
AnguloprehistoryAngulo JC, García-Díez M.
Male genital representation in paleolithic art: erection and circumcision before history
Urology. 2009 Jul;74(1):10-4.

OBJECTIVES: To report on the likely existing evidence about the practice of circumcision in prehistory, or at least a culture of foreskin retraction, and also the meaning of erection in Paleolithic minds. The origin of the ritual of circumcision has been lost in time. Similarly, the primitive anthropologic meaning of erection is undefined.

METHODS: We studied the archeologic and artistic evidence regarding human representations performed during the Upper Paleolithic period, 38,000 to 11,000 years BCE, in Europe, with a focus on genital male representations in portable and rock art.

RESULTS: Drawings, engravings, and sculptures displaying humans are relatively scarce, and <100 examples of male genitals are specifically represented. Some depict a circumcised penis and other represent urologic disorders such as phimosis, paraphimosis, discharge, priapism, or a scrotal mass. In addition, a small number of phalluses carved in horn, bone, or stone, with varying morphology, has survived to the present and also reveals a sustained cult for male erection and foreskin retraction not limited to a particular topographical territory. The very few noncoital human or humanoid figures with marked erection appear in a context of serious danger or death. Therefore, erection could be understood as a phenomenon related to the shamanic transit between life and death.

CONCLUSIONS: The erection in Paleolithic art is explicitly represented in almost all the figures defined as unequivocally male that have survived to the present and in many objects of portable art. Circumcision and/or foreskin retraction of the penis are present in most of the works.

Assman, et al.BXOAssmann T, Becker-Wegerich P, Grewe M, Megahed M, Ruzicka T.
Tacrolimus ointment for the treatment of vulvar lichen sclerosis
J Am Acad Dermatol. 2003 Jun;48(6):935-7
These doctors in Düsseldorf, Germany found that six weeks of treatment with tacrolimus ointment 0.1% (Protopic) twice daily, resolved signs and symptoms of lichen sclerosus in a 71 year old woman. Topical tacrolimus does not induce skin atrophy, unlike topical steroids.

PMID: 12789187 [PubMed - indexed for MEDLINE]

BabuballooningBabu R, Harrison SK, Hutton KA.
Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding?
BJU Int. 2004 Aug;94(3):384-7
Physiological phimosis with or without ballooning of the prepuce is not associated with noninvasive objective measures of obstructed voiding.
BeaugéphimosisBeaugé M.
Conservative Treatment of Primary Phimosis in Adolescents [Traitment Médical du Phimosis Congénital de L'Adolescent]
Saint-Antoine University, Paris VI, 1990-1991
This French doctor has devised some self-stretching exercises - which also give pleasure.
"We can be happy that manipulation of the tissues allows the avoidance of surgical intervention, and in other circumstances the limitation of the problems when surgery has unfortunately occurred."
Beaugé M.
The Causes of Adolescent Phimosis
British Journal of Sexual Medicine, September/October 1997
In this article, based on 300 cases, he argues that a major cause of phimosis in adolescents is if they do not retract their foreskins when masturbating. He prescribes the appropriate change in technique, which generally results in success within three weeks.
BellFGM,
anthropology
Kirsten Bell
Genital Cutting andWestern Discourses on Sexuality
Medical Anthropology Quarterly, Vol. 19, Issue 2, pp. 125–148
Don't be put off by the post-modern "discourse", this important article is in plain English. It analyses the failure of people in circumcising cultures to make the link between FGM and MGM in terms of our construction of gender.
Abstract: This article explores dominant discourses surrounding male and female genital cutting. Over a similar period of time, these genital operations have separately been subjected to scrutiny and criticism. However, although critiques of female circumcision have been widely taken up, general public opinion toward male circumcision remains indifferent. This difference cannot merely be explained by the natural attributes and effects of these practices. Rather, attitudes toward genital cutting reflect historically and culturally specific understandings of the human body. In particular, I suggest that certain problematic understandings of male and female sexuality are deeply implicated in the dominant Western discourses on genital surgery.
Berdeu et al.phimosisD. Berdeu, L. Sauze, P. Ha-Vinh and C. Blum-Boisgard
Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect
BJU International 87 (3), 239-244
(February 2001)

"Conclusion As topical pharmacological treatment avoids the disadvantages, trauma and potential complications of penile surgery, including anaesthesia-related risks, the use of topical steroids as a primary treatment appears to be justified in boys with clinically verifiable phimosis. This treatment could reduce costs by 75%, which represents a potential annual saving of F 150 million."

BirleybalanitisBirley HDL, Walker MM, Luzzi GA, Bell R, Taylor-Robinson D, Byrne M, Renton AM.
Clinical Features and Management of Recurrent Balanitis; Association with Atopy and Genital Washing.
Genitourin Med. 1993; 69:400-403.
Birley and colleagues found that balanitis was associated with more frequent daily washing of the genitals with soap and could be managed by restriction of washing.
Blalockiatrogenic
phimosis
Blalock HJ, Vemulakonda V, Ritchey ML, Ribbeck M.
Outpatient Management of Phimosis Following Newborn Circumcision
J Urol 2003 Jun;169(6):2332-2334
METHODS: A total of 521 pediatric patients underwent Gomco circumcision while under local anesthesia at our outpatient clinic between 1994 and 1999. Phimosis was noted in 15 patients (2.9%), and an additional 13 patients were referred to our clinic with phimosis after undergoing circumcision elsewhere. ...

RESULTS: Three patients had recurrence of the phimosis. ... Ten of the patients had obvious poor penile skin attachment with concealment of the penis even after resolution of the phimosis. Phimosis occurred more frequently in older patients undergoing circumcision - 15 patients were older than 1 month at circumcision. ...

CONCLUSIONS Phimosis with a trapped penis is an infrequent but important complication of circumcision. This condition is more likely to occur in older infants and those with poor attachment of the penile skin to the shaft. [This "poor attachment" is blaming the victim. Penile skin is not attached to the shaft in the intact male, but glides freely over it.] Early recognition allows outpatient treatment with excellent results, avoiding operative intervention with general anesthesia. [Leaving the baby intact would avoid the problem - one of the claimed reasons for circumcision - entirely.]

PMID: 12771793 [PubMed - as supplied by publisher]

BollingerpsychologyBollinger, D., Van Howe, R. S
Alexithymia and Circumcision Trauma: A Preliminary Investigation
J Sex Med, 14 Apr 2011

Abstract
This preliminary study investigates what role early trauma might have in alexithymia acquisition for adults by controlling for male circumcision. Three hundred self-selected men were administered the Toronto Twenty-Item Alexithymia Scale checklist and a personal history questionnaire. The circumcised men had age-adjusted alexithymia scores 19.9 percent higher than the intact men; were 1.57 times more likely to have high alexithymia scores; were 2.30 times less likely to have low alexithymia scores; had higher prevalence of two of the three alexithymia factors (difficulty identifying feelings and difficulty describing feelings); and were 4.53 times more likely to use an erectile dysfunction drug. Alexithymia in this population of adult men is statistically significant for having experienced circumcision trauma and for erectile dysfunction drug use.

Boyle et al.psychologyGregory J. Boyle (Bond Univeristy, Australia), Ronald Goldman, J. Steven Svoboda and Ephrem Fernandez
Male Circumcision: Pain, Trauma, and Psychosexual Sequelae
Journal of Health Psychology, May 2002, Vol 7 (No. 3), pp. 329-343
Believed to be the first academic article to be published which focuses on surveying the psychological harm caused by circumcision.
Abstract:
Infant male circumcision continues despite growing questions about its medical justification. As usually performed without analgesia or anaesthetic, circumcision is observably painful. It is likely that genital cutting has physical, sexual and psychological consequences too. Some studies link involuntary male circumcision with a range of negative emotions and even post- traumatic stress disorder (PTSD). Some circumcised men have described their current feelings in the language of violation, torture, mutilation and sexual assault. In view of the acute as well as long-term risks from circumcision and the legal liabilities that might arise, it is timely for health professionals and scientists to re-examine the evidence on this issue and participate in the debate about the advisability of this surgical procedure on unconsenting minors.
Boyle and HillHIVGregory J Boyle and George Hill
Sub-Saharan African randomised clinical trials into mail circumcision and HIV transmission: Methodological, ethical and legal concerns
Journal of Law and Medicine (Australia), December 2011 [(2011) 19 JLM 316]

Abstract

In 2007, WHO/UNAIDS recommended mail circumcision as an HIV-prevention measure based on three sub-Saharan African randomised clinical trials (RCTs) into female-to-male sexual transmsission. A related RCT investigated male-to-female transmission. However, the trials were compromised by inadequate equipoise; selection bias; inadequate blinding; problematic randomisation; trials stropped early with exaggerated treatment effects; and not investigating non-sexual transmission. Several questions remain unanswered. Why were the trials carried out in countries where more intact men were HIV-positive than in those where more circumcised men were HIV-positive? Why were men sampled from specific ethnic subgroups? Where were so many participants lost to follow-up? Why did men in the male circumcision group receive additional counselling on safe sex practices? While the absolute reduction associated with male circumcision across the three female-to-male trials was only about 1.3%, relative reduction was reported as 60%, but, after correction for lead-time bias, averaged 49%. In the Kenyan trial, male circumcision appears to have been associated with four new incident infections. In the Ugandan male-to-female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain.

Brady-FryerpainBrady-Fryer B, Wiebe N, Lander JA
Pain relief for neonatal circumcision
Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004217
OBJECTIVES: The objective of this review was to assess the effectiveness and safety of interventions for reducing pain at neonatal circumcision.
(DPNB) (EMLA)
REVIEWERS' CONCLUSIONS: DPNB [dorsal penile nerve block] was the most frequently studied intervention and was the most effective for circumcision pain. Compared to placebo, EMLA [eutectic mixture of analgesics] was also effective, but was not as effective as DPNB. Both interventions appear to be safe for use in newborns. None of the studied interventions completely eliminated the pain response to circumcision.
BroxmeyersmegmaLawrence Broxmeyer, Danuta Sosnowska, Elizabeth Miltner et al.
Killing of Mycobacterium avium and Mycobacterium tuberculosis by a Mycobacteriophage Delivered by a Nonvirulent Mycobacterium: A Model for Phage Therapy of Intracellular Bacterial Pathogens
The Journal of Infectious Diseases 2002;186:1155-1160
This suggests that a bacteriophage found in the "relatively benign" smegma bacterium is effective against tuberculosis.

Abstract: Mycobacterium avium causes disseminated infection in patients with acquired immune deficieny syndrome. Mycobacterium tuberculosis is a pathogen associated with the deaths of millions of people worldwide annually. Effective therapeutic regimens exist that are limited by the emergence of drug resistance and the inability of antibiotics to kill dormant organisms. The present study describes a system using Mycobacterium smegmatis, an avirulent mycobacterium, to deliver the lytic phage TM4 where both M. avium and M. tuberculosis reside within macrophages. These results showed that treatment of M. avium­ infected, as well as M. tuberculosis­ infected, RAW 264.7 macrophages, with M. smegmatis transiently infected with TM4, resulted in a significant time- and titer-dependent reduction in the number of viable intracellular bacilli. In addition, the M. smegmatis vacuole harboring TM4 fuses with the M. avium vacuole in macrophages. These results suggest a potentially novel concept to kill intracellular pathogenic bacteria and warrant future development.

Canningethics, lawCanning DA
Informed consent for neonatal circumcision: an ethical and legal conundrum
J Urol 2002 Oct 168(4 Pt 1): p. 1650-1
An editorial comment on Svoboda et al.'s paper, it puts doctors and parents on notice that their ethical and legal right to circumcise will be challenged:

"The authors carefully make the argument that circumcision, in the absence of a medical indication, may be unwise and may actually be illegal.
..."If circumcision becomes less commonly performed in North America, the legal system may no longer be able to ignore the conflict between the practice of circumcision and the legal and ethical duties of medical specialists. This document is worth a read by all of us who perform newborn circumcision."

The Journal of Urology is the official journal of the American Urological Association. This editorial comment seems to be a quasi-official warning to urologists.

Christakis et al.complications

Dimitri A. Christakis, Eric Harvey, Danielle M. Zerr, Chris Feudtner, Jeffrey A. Wright and Frederick A. Connell
A Trade-off Analysis of Routine Newborn Circumcision
PEDIATRICS Vol. 105 No. 1 Supplement January 2000, pp. 246-249

Abstract:
... This study attempted to determine the population-based rate of complications of newborn circumcision and to estimate the number needed to treat (NNT) based on this rate. The NNT is calculated from the reciprocal of the absolute risk reduction, that is, the number of children who would need to be circumcised to prevent one undesirable outcome. The number needed to harm (NNH), based on the absolute difference in complication rates between treatment and control groups, also was estimated. Finally, an attempt was made to establish the trade-off between complications and reported benefits from circumcision. Routine circumcisions done in Washington state in the years 1987 to 1996 were reviewed, excluding infants having other surgery.

Circumcision was performed in 130,475 infants, representing 37 percent of [352,635] male births in the period under review. Complications occurred in 0.2 percent of circumcised infants [or 261 infants] and 0.01 percent of [222,160] uncircumcised infants [or 22 infants, but how could any "uncircumcised" infants have complications of circumcision?]. Circumcised infants with any complication had significantly longer newborn stays than those without complications, but the only complication associated with a prolonged stay was "suture penile laceration." NNH [number Needed to Harm] estimates showed that some complication can be expected in 1 of every 476 circumcised children. Estimating the NNT [Number Needed to Treat] versus NNH trade-offs showed that 1.14 immediate circumcision-related complications are expected for every six urinary tract infections prevented and 1.9 are expected for every case of penile cancer prevented. [i.e. circumcising does more harm than good.]

The investigators believe that routine circumcision of newborn infants is relatively safe but not risk free. Some parents may be more impressed by the risk than by the potential benefits of circumcision, but in any case, viewing circumcision in terms of trade-offs should help parents make an informed decision.

Christakis et al. did not include complications that did not require medical treatment, such as unaesthetic outcomes, complications that appear many months or years later, like meatal stenosis, or complications that can be ignored until puberty, like removal of too much penile skin. These swing the balance right against infant circumcision, and even more when you attach any value (as Christakis et al. do not) to the possession of an intact foreskin.

ChristianakisphimosisChristianakis E.
Sutureless prepuceplasty with wound healing by second intention: An alternative surgical approach in children's phimosis treatment.
BMC Urol. 2008 Mar 4;8(1):6

ABSTRACT:
BACKGROUND: A new technique for the treatment of childrens phimosis is presented that minimizes the repairing time, the postoperative complications and maintains the physical foreskin appearance intact.
METHODS: Eightyseven children with phimosis were treated with this new developed technique, between 2003 and 2005. Sutureless prepuceplasty creates a permanent surgical extension of the close prepuce. Stretching and retraction of phimotic foreskin reveals a tight prepuce ring that is cutting in its dorsal surface longitudinally. Rarely triple symmetric incisions in the preputial outlet are necessary. The foreskin is loose and moves in bilateral courses absolutely free. The wounds are healing by second intention. Antisepsis, steroids and Elicina cream, (which contains allantoin, collagen, elastin, glycolic acid and vitamins A, D, and E) should apply daily, for twenty to thirty days.
RESULTS: The foreskin is moving in centripetal or efferent courses absolutely loosely, painless and bloodless. Mean time of follow-up was 27 months (one to four years). No complications were observed.
CONCLUSIONS: Sutureless prepuceplasty may present an acceptable alternative in children's phimosis reconstruction.

PMID: 18318903 [PubMed - as supplied by publisher]

Cold and TayloranatomyC.J. Cold and J.R. Taylor
The prepuce
British Journal of Urology,
Volume 83, Suppl. 1: Pages 34-44,
January 1999
A comprehensive survey of the anatomy, physiology and innervation of the prepuce, both female and male (foreskin). Using figures from Øster, it shows clearly that the foreskin is still attached to the glans in 50% of boys aged 10, in 10% of youths aged 15, so that efforts to separate it at an early age are misguided.
Overview
The prepuce is an integral, normal part of the external genitalia that forms the anatomical covering of the glans penis and clitoris. The outer epithelium has the protective function of internalising the glans (clitoris and penis), urethral meatus (in the male) and the inner preputial epithelium, thus decreasing external irritation or contamination. The prepuce is a specialized, junctional mucocutaneous tissue which marks the boundary between mucosa and skin; it is similar to the eyelids, labia minora, anus and lips. The male prepuce also provides adequate mucosa and skin to cover the entire penis during erection. The unique innervation of the prepuce establishes its function as an erogenous tissue ...
Connolly et al.HIVC.A. Connolly, O. Shisana, L. Simbayi, M. Colvin
HIV and circumcision in South Africa
Conference on HIV/AIDS, Bankok, 2004
[MoPeC3491]
Abstract:
Background: HIV infection remains highly prevalent in South Africa. Male circumcision has been shown to be protective for the acquisition of HIV in other African countries. It is important to determine if this association is evident in South Africa.
Methods: A cross-sectional, national household-based survey was conducted using second-generation surveillance procedures, weighted data adjusted for sample design was used. A total of 2585 males over the age of 15 were administered questionnaires and provided specimens for HIV testing. Results: Circumcision was reported by 916 (35.4%) of male participants. HIV prevalence among circumcised males was 10.7% and among uncircumcised males was 12.1%, p = 0.9. Blacks were less likely to be circumcised (28.8%) compared to other racial groups, 42.6%, p = 0.002. When the data was stratified by racial group, circumcised Blacks showed similar rates of HIV as uncircumcised Blacks, (OR: 0.8, p = 0.4) however other racial groups showed a strong protective effect [or rather, a negative correlation], (OR: 0.3, p = 0.01). The age of circumcision differed by racial group. Among Blacks, 37% were circumcised above the age of 12 compared to 6% among other racial groups. When the data are further stratified by age of circumcision, there is a slight protective effect between early circumcision and HIV among Blacks, OR: 0.7, p = 0.4.
Conclusion: In general, circumcision offers slight protection. The effect is much stronger in other racial groups than in blacks. [Yet it is among Black men that the circumcisionists are proposting to promote their favourite operation.] This racial difference cannot be explained by age of circumcision.
DarbyhistoryRob Darby
Pathologizing Male Sexuality: Lallemand, Spermatorrhea, and the Rise of Circumcision
Journal of the History of Medicine and Allied Sciences 2005 60(3):283-319
Abstract: Although spermatorrhea as a disease entity and an episode in nineteenth-century medical history has received significant scholarly attention over the past decade, many aspects of its nature, origins, and consequences remain obscure. The aim of this article is to indicate its origins in and links with medical anxiety about masturbation and to discuss the therapies devised to treat the condition. Particular attention is given to the work of Claude-François Lallemand and his influence on English doctors, especially William Acton, and the implications of their identification of the foreskin as the major risk factor for childhood masturbation and later spermatorrhea. It is further argued that fear of spermatorrhea was an important factor in the acceptance of circumcision as a valid medical intervention in the late nineteenth century.
history,
sexuality
Robert J L Darby
Medical history and medical practice: persistent myths about the foreskin
MJA 2003 178 (4): 178-179
Abstract: Although many 19th-century misconceptions about the foreskin have been dispelled since it was shown that infantile phimosis was not an abnormality, the ideas that ritual or religious circumcision arose as a hygiene measure, and that circumcision makes no difference to sexual response, have persisted. The first idea should be dismissed as a myth and the second has been seriously questioned by modern research.
Dickson, et al.STIs N. P. Dickson, T. van Roode , P. Herbison, C. Paul.
Circumcision and risk of sexually transmitted infections in a birth cohort
J Pediatr. 2008 Mar;152(3):383-7. Epub 2007 Oct 22.

OBJECTIVE: To determine the impact of early childhood circumcision on sexually transmitted infection (STI) acquisition to age 32 years.

STUDY DESIGN: The circumcision status of a cohort of children born in 1972 and 1973 in Dunedin, New Zealand was sought at age 3 years. Information about STIs was obtained at ages 21, 26, and 32 years. The incidence rates of STI acquisition were calculated, taking into account timing of first sex, and comparisons were made between the circumcised men and uncircumcised men. Adjustments were made for potential socioeconomic and sexual behavior confounding factors where appropriate.

RESULTS: Of the 499 men studied, 201 (40.3%) had been circumcised by age 3 years. The circumcised and uncircumcised groups differed little in socioeconomic characteristics and sexual behavior. Overall, up to age 32 years, the incidence rates for all STIs were not statistically significantly different - 23.4 and 24.4 per 1000 person-years for the uncircumcised and circumcised men, respectively. This was not affected by adjusting for any of the socioeconomic or sexual behavior characteristics.

CONCLUSIONS: These findings are consistent with recent population-based cross-sectional studies in developed countries [unlike the widely publicised Fergusson study], which found that early childhood circumcision does not markedly reduce the risk of the common STIs in the general population in such countries.

DinhkeratinisationDinh MH, McRaven MD, Kelley Z, Penugonda S, Hope TJ.
Keratinization of the adult male foreskin and implications for male circumcision
AIDS. 2010 Jan 21. [Epub ahead of print]

OBJECTIVE:: The theory that a more thinly keratinized inner foreskin leads to increased HIV-1 susceptibility has been based on relatively little published data. We sought to quantify the keratin thicknesses of the inner and outer foreskin to determine the plausibility of this hypothesis.

DESIGN:: We took repeated measurements of the keratin layer of 16 adult male foreskins to determine whether differences existed between the inner and outer foreskin.

METHODS:: Adult foreskins were collected from consenting donors undergoing elective male circumcision for unknown medical indications in Chicago, Illinois, USA. Specimens were processed, sectioned and stained for keratin using antifilaggrin fluorescent antibodies. Slides stained with hematoxylin and eosin were used as controls and compared with results from previously published studies using this method. Keratin layers were measured in a standardized fashion for each specimen.

RESULTS:: Comparing our fluorescence-based analysis with previously published immunohistochemical methods revealed that our method was highly accurate for measuring foreskin keratin thickness. There was significant heterogeneity in the keratin thickness of the inner and outer aspects of the male foreskin within and between the different donors. There was no significant difference between the inner and outer foreskin keratin thickness (25.37 +/- 12.51 and 20.54 +/- 12.51 mum, respectively; P = 0.451).

CONCLUSION:: We found no difference between the keratinization of the inner and outer aspects of the adult male foreskin. Keratin layers alone are unlikely to explain why uncircumcised men are at higher risk for HIV infection.

[With a larger sample size, Qin et al. found inner foreskin to be thicker than outer.]

DowsettHIV Gary W Dowsett, Murray Couch
Male Circumcision and HIV Prevention: Is There Really Enough of the Right Kind of Evidence?
Reproductive Health Matters 2007;15(29):33–44

From the conclusion:
"We believe we need to know much more about male circumcision for HIV prevention before adopting it as a population health measure. The WHO/UNAIDS Statement is cautious in noting the existence of caveats and gaps, but it argues that it is time to go ahead. We would argue that there is still much work to do before national authorities and the global HIV/AIDS community can feel confident about proceeding."

More

Dunn
phimosis Dunn HP.
Non-surgical management of phimosis.
Aust N Z J Surg 1989;59(12):963.

A 22 year old man in a Royal New Zealand Navy cruiser during World War II complained of penile pain and discharge ... his problem was ... phimosis with recurrent balanitis.... The patient reported to the Sick Bay daily and for 2-3 min. the preputial orifice was put on stretch with a small artery forceps. ... For a week no obvious improvement was noted but then the resistance at the margin of the orifice was suddenly overcome and by the end of the second week its diameter had increased to about 2.5 cm. ... With daily washing the balanitis soon cleared up.

Fergusson (1988)
general Fergusson, D.M., Lawton, J.M. and Shannon, F.T,
Neonatal Circumcision and Penile Problems: An 8-Year Longitudianl Study
Pediatrics Vol. 81 No 4, April 1988, pp 537-541
This long-term cohort study seemed to show a marginal benefit of circumcision.

Abstract: The prevalence of penile problems was examined in a birth cohort of more than 500 New Zealand children studied from birth to 8 years of age. By 8 years, circumcised children had a rate of 11.1 problems per 100 children, and uncircumcised children had a rate of 18.8 per 100. The majority of these problems were for penile inflammation including balanitis, meatitis, and inflammation of the prepuce. However, the relationship between risks of penile problems and circumcision status varied with the child's age. During infancy, circumcised children had a significantly higher risk of problems than uncircumcised children, but after infancy the rate of penile problems was significantly higher among the uncircumcised. These associations were not changed when the results were adjusted statistically for the effects of a series of potentially confounding social and perinatal factors.

But boys left intact at birth were counted as intact throughout, and problems of delayed circumcisions counted as problems of intactness. Three percent of the "intact" cohort suffered "postcircumcision infection".
Fisher-Klein & Rauchenwaldphimosis Ch. Fischer-Klein and M. Rauchenwald
Triple incision to treat phimosis in children: an alternative to circumcision?
BJU International Volume 92 Issue 4 September 2003 p459
A survey of 197 boys (3 months - 18yrs) treated for phimosis with triple incision instead of circumcision. Satisfaction with the result was high. Of 128 parents or older children responding, 108 (84%) were satisfied with the function and 102 (80%) reported a good cosmetic outcome. 119 (93%) would recommend it to other parents. Doctors found excellent functional and cosmetic outcome in 71 (77%).
The surgeons still appear to be scalpel-happy: they operated to please parents who wanted a quick result when spontaneous resolution is the norm - if the boys had true phimosis at all.
Fleiss

penile cancer

Fleiss, Paul M and Frederick Hodges, Neonatal Circumcision Does Not Protect Against Cancer (letter),
British Medical Journal, (London) Vol. 312 no 7033 (March 23, 1996): pp. 779-780
Dr Paul Fleiss
Dr Paul Fleiss

immunology

P M Fleiss, F M Hodges, R S Van Howe Immunological functions of the human prepuce,
Sexually Transmitted Infections (London), Vol. 74 No. 5, Pages 364-367. October 1998.

 
FoxethicsM. Fox and M. Thomson
A covenant with the status quo? Male circumcision and the new BMA guidance to doctors
J Med Eth. 2005; 31(8):463-9
ABSTRACT
This article offers a critique of the recently revised BMA guidance on routine neonatal male circumcision and seeks to challenge the assumptions underpinning the guidance which construe this procedure as a matter of parental choice. Our aim is to problematise continued professional willingness to tolerate the non-therapeutic, non-consensual excision of healthy tissue, arguing that in this context both professional guidance and law are uncharacteristically tolerant of risks inflicted on young children, given the absence of clear medical benefits. By interrogating historical medical explanations for this practice, which continue to surface in contemporary justifications of non-consensual male circumcision, we demonstrate how circumcision has long existed as a procedure in need of a justification. We conclude that it is ethically inappropriate to subject children - male or female - to the acknowledged risks of circumcision and contend that there is no compelling legal authority for the common view that male circumcision is lawful.
HIV policyMarie Fox and Michael Thomson
HIV/AIDS and circumcision: lost in translation
J Med Ethics 2010;36:798-801
doi:10.1136/jme.2010.038695

Abstract
In April 2009 a Cochrane review was published assessing the effectiveness of male circumcision in preventing acquisition of HIV. It concluded that there was strong evidence that male circumcision, performed in a medical setting, reduces the acquisition of HIV by men engaging in heterosexual sex. Yet, importantly, the review noted that further research was required to assess the feasibility, desirability and cost-effectiveness of implementation within local contexts. This paper endorses the need for such research and suggests that, in its absence, it is premature to promote circumcision as a reliable strategy for combating HIV. Since articles in leading medical journals as well as the popular press continue to do so, scientific researchers should think carefully about how their conclusions may be translated both to policy makers and to a more general audience. The importance of addressing ethico-legal concerns that such trials may raise is highlighted. The understandable haste to find a solution to the HIV pandemic means that the promise offered by preliminary and specific research studies may be overstated. This may mean that ethical concerns are marginalised. Such haste may also obscure the need to be attentive to local cultural sensitivities, which vary from one African region to another, in formulating policy concerning circumcision.

Gairdner general Gairdner, D., The Fate Of The Foreskin, A Study Of Circumcision,
British Medical Journal, Dec. 24, 1949, Volume 2, 1433-1437
This landmark paper was a nail in the coffin of circumcision in the UK. Especially convincing was the high death-rate.
Geishekerlaw, ethics John V. Geisheker
The Completely Unregulated Practice of Male Circumcision: Human Rights’ Abuse Enshrined in Law?
New Male Studies Journal 2:1 2013
Conclusion

The sheer antiquity of “ritual” circumcision (and now after 140 years, Anglophone medicalized, male circumcision) has allowed it to escape legal scrutiny, though there is much musing in the academic literature. Without legal incentive or bioethical rigor, medical authorities have created - indeed, established by conscious omission – a regulatory vacuum which suits their needs.

... Anglo-American law and bioethics has simply failed to consider the human rights of infant boys. Little attention has been paid to the lifetime physical effects imposed by a religion the boy hasn’t yet chosen– or the losses incurred to humor an adult, secular, cosmetic, whim born of anti-sexual instincts, one which fee-for-service medical practitioners have nurtured for decades.

By contrast, the U.S. federal law forbidding even the mildest, even merely symbolic, female genital cutting, expressly disavowed any exception for ritual motivation or “custom.” ... A gender-neutral law, forbidding the genital cutting of minors, could equally have noted that male circumcision is also a “custom,” especially in the U.S. There has been no successful challenge, however, to the U.S. federal anti-FGM law on either Free Exercise or Equal Protection grounds, nor, I suspect, is there likely to be one any time soon.

Hundreds of years of cutting the genitals of boys is not easy to challenge – or even to question, it seems – despite glaring, minimal, institutional protections for the boy’s safety, or observance of his fundamental human right to bodily integrity. Recent laws that “enshrine” male circumcision, and forbid inquiry into safety regulation, are worse – a huge step backwards for the historical rights of boys.

GianettilawMatthew R. Giannetti
Circumcision and the American Academy of Pediatrics: Should Scientific Misconduct Result in Trade Association Liability?
IOWA LAW REVIEW, Vol 85, No 4, pp 1507-1568, May 2000
This law student at University of Iowa argues in detail that it should:
"The 1999 Task Force on Circumcision policy statement ... has flaws and may ... be culpable for failing to adhere to the generally accepted scientific and professional preference for valuing methodology in assessing the soundness of existing information. The responsible course of action for the AAP would be to admit that the evidence does not now support, and never has supported the continued routine performing of circumcision on infant males."
GoertzelstatisticsGoertzel, Ted
Myths of Murder and Multiple Regression
Skeptical Inquirer, Vol 26, No. 1, January/February 2002
Using claims of statistical proof that the death penalty reduces murder rates, licencing of concealed weapons reduces murders, and abortion reduces crime, argues that
  "When presented with an econometric model, consumers should insist on evidence that it can predict trends in data other than the data used to create it. Models that fail this test are junk science, no matter how complex the analysis."
  His argument is equally applicable to claims that circumcision prevents urinary tract infections or HIV.
GorgalabalanitisGeorgala S, Gregoriou S, Georgala C, Papaioannou D, Befon A, Kalogeromitros D, Rigopoulos D
Pimecrolimus 1% cream in non-specific inflammatory recurrent balanitis
Dermatology. 2007;215(3):209-12
BACKGROUND: Non-specific balanitis is a common inflammatory dermatosis with frequent relapses and considerable impact on male sexual life.
OBJECTIVE: To evaluate the efficacy and safety of pimecrolimus 1% cream in recurrent non-specific balanitis.
METHODS: Twenty-six patients with recurrent flares of non-specific balanitis were randomly assigned to 1 group applying pimecrolimus cream 1% and 1 group applying placebo on the glans twice daily for 7 days. The patients were assessed on day 14. They were instructed to continue applying the agent whenever symptoms initialized for the following 90 days and take account of the cumulative days with symptoms. Results: Seven out of the 11 (63.6%) patients in the pimecrolimus group and 1 out of 11 (9%) in the control group were free of all symptoms and lesions after 14 days, 3 (27.3%) in both groups reported improvement, while 1 (9.1%) in the pimecrolimus and 7 (63.6%) in the control group remained unaffected. (chi(2) = 9.0, d.f. = 2, p = 0.011). Days with symptoms during the 90-day follow-up period were 7.50 +/- 3.02 for the pimecrolimus and 17.62 +/- 4.40 for the control group (p = 0.000064).
CONCLUSIONS: Pimecrolimus 1% cream is promising in relieving symptoms and signs of non-specific balanitis during flares and controlling the disease during long-term follow-up.

PMID: 17823517 [PubMed - indexed for MEDLINE]

Greyhypospadias
repair
Gray J, Boston VE.
Glanular reconstruction and preputioplasty repair for distal hypospadias: a unique day-case method to avoid urethral stenting and preserve the prepuce.
BJU Int 2003 Feb;91(3):268-70
The GRAP (glanular reconstruction and preputioplasty) repair is a novel method for the day-case reconstruction of distal hypospadias, and uniquely allows the reconstruction of the prepuce. The case notes of 205 boys who had had GRAP repairs were reviewed, and 63 of them who had had GRAP repairs 10 or more years earlier were surveyed, and compared with controls.

CONCLUSION: The complication rate and patient satisfaction with GRAP is comparable with those of other techniques. GRAP is a simple day-case procedure with few complications.... Importantly, the prepuce can be preserved and refashioned to give a good cosmetic result, with no phimosis, which is increasingly important as circumcision becomes less acceptable to both the general public and the medical profession [in the UK].

GrossmanmethodsGrossman E.
The Evolution of Circumcision Technique.
In: Circumcision: A Pictorial Atlas of its History, Instrument Development and Operating Techniques.
Great Neck: Todd & Honeywell 1982:17-34.
A critical survey of circumcision methods up to its date of publication. Not critical of circumcision itself, but finds fault with most methods. Invaluable in sourcing this site's methods page.
HellstenethicsS K Hellsten
Rationalising circumcision: from tradition to fashion, from public health to individual freedom-critical notes on cultural persistence of the practice of genital mutilation
Journal of Medical Ethics (U.K.), Volume 30: Pages 248-253, June 2004.
Important: one of the first articles to be critical of the ethical issues underlying both male and female genital modification, pointing out the contradictions in other articles in the same journal defending MGM. Points out the universal nature of genital mutilation and the irrelevance of the claimed reasons. Analyses individual vs customary rights.
HillbehaviourGeorge Hill
Circumcision and Human Behavior
Google Knol.
"Psychologists now recognize that male circumcision affects emotions and behavior. This article discusses the impact of male circumcision on human behavior. ...

"All of the behavioral changes described in this paper are negative, unfavorable, or detrimental in nature. No positive, favorable, or beneficial behavioral changes have been found."

Hodges phimosis Hodges, Frederick M., Phimosis in antiquity,
World Journal of Urology, Volume 17, No. 3 : pp. 133-136, June 1999
Dr Frederick Hodges
Dr Frederick Hodges
This article shows how the Greeks and Romans understood the rare condition of phimosis, not as is commonly believed today, pathological in itself, and not confused with a merely copious foreskin.
aesthetics Hodges, Frederick M.
The Ideal Prepuce in Ancient Greece and Rome: Male Genital Aesthetics and Their Relation to Lipodermos, Circumcision, Foreskin Restoration, and the Kynodesme
Bulletin of the History of Medicine, Vol 75: pp 375 - 405, Fall 2001.
This article shows how the Greeks valued the foreskin, considering its absence (lipodermos) an obscenity to be prevented by the use of a kynodesme.
Hoebekehypospadias repairHoebeke PB, De Kuyper P, Van Laecke E.
'Batman Excision' of ventral skin in hypospadias repair, clue to aesthetic repair (point of technique).
Eur Urol 2002 Nov;42(5):520-2
These Belgian paediatric urologists refine the "classical Byars' flaps" technique of using excess dorsal skin to cover the ventral penile shaft. Preserving the foreskin is taken for granted.

Hunter

nursing, general

Hunter, David
Conditions affecting the foreskin
Nursing Standard, 26,37, 35-9, February 2012

Abstract
This article aims to provide an update on the anatomy of, and some of the conditions affecting, the foreskin. The cultural and religious significance of the foreskin will be expored as well as nursing care and health promotion needs of men. The possible link between circumcision status and human immunodeficiency virus will be briefly discussed. Maintaining the cleanliness of the genitals is advocated to reduce the incidence of inflammatory conditions.

Full text: 1 2 3 4 5

JorgensonphimosisJorgenson, ET, Svensson A.
The treatment of Phimosis in Boys, with potent topical steroid cream.
Acta Dermato-Venereologica (Stockholm) 73:55-56, 1993

 

JoycepainJ Pediatr Health Care 2001 May-Jun;15(3):105-14
Evaluation of pain management interventions for neonatal circumcision pain.
Joyce BA, Keck JF, Gerkensmeyer J.
This study ("randomized, double-blind" but using only 23 babies) compared pain response during circumcision with EMLA and with music. As usual, no control group of babies was left intact. "Neonates deserve interventions that will provide them with a less painful start in life." [Correction: neonates deserve protection from unnecessary interventions.]
KalichmanHIV, risk compensationKalichman S, Eaton L, Pinkerton S
Circumcision for HIV Prevention: Failure to Fully Account for Behavioral Risk Compensation
PLoS Med 4(3): e138 doi:10.1371/journal.pmed.0040138 (2007)

... It is difficult to imagine a convincing public health message that effectively influences men to undergo circumcision and continue to consistently use condoms.

Circumcised men in the ANRS 1265 trial reported 18% more sexual contacts at follow-up than did uncircumcised men, but no other sexual behavior differences were obtained. However, for ethical reasons all men in MC RCTs receive ongoing risk-reduction counseling and free condoms, which reduces the utility of these trials for estimating the potential behavioral impact of MC when implemented in a natural setting. ... Based on the 18% difference in sexual contacts for circumcised and uncircumcised men in the ANRS 1265 trial and the assumption that “risk compensation might be higher in a nonresearch program scale-up,” Kahn et al. adjusted the 60% effectiveness estimate obtained in this RCT downward to 50% to reflect a 25% increase in sexual risk behaviors among circumcised men. Although Kahn et al.'s model explicitly incorporated the increased risk of HIV acquisition associated with risk compensation, it did not consider the impact of risk compensation on the HIV transmission risk of HIV-infected circumcised men, or on circumcised men's risk for non-HIV sexually transmitted infections (STIs). ...

There is no evidence that circumcision increases or decreases the risk of HIV transmission by HIV-infected men. However, risk compensation by HIV-infected circumcised men will substantially increase the risk of transmission to their sex partners. This suggests that, in the short term at least, circumcision would reduce the incidence of HIV among men, but increase the incidence among women, translating to increased prevalence among women, which in turn translates to greater risk to men. Epidemiological models of MC should take this dynamic into account.

Kayesphimosis, frenulum breveKayes O, Li C-Y, Spillings A, Ralph D
Frenular Grafting: An Alternative to Circumcision in Men with a Combination of Tight Frenulum and Phimosis
The Journal of Sexual Medicine Volume 4 Issue 4i Page 1070-1073, July 2007

ABSTRACT
Introduction. Men suffering from frenular scarring and stricturing with associated phimosis are traditionally treated with circumcision. In men wishing to retain their foreskin, the treatment options are limited by this dual pathology. Frenuloplasty alone is contraindicated in this clinical setting.
Aim. To demonstrate the utility of frenular grafting in patients with a tight frenulum and concomitant phimosis who wish to retain their foreskin.
Methods. Six men were included in the study. Presenting symptoms included bleeding (N = 2) and pain/phimosis (N = 6). Median age is 27 years (25-34 years). All men were healthy and sexually active. We describe a refined technique involving the excision of scarred and redundant frenular tissue and the insertion of a skin graft to the area.
Main Outcome Measures. All patients were assessed for graft viability, functional/symptom improvement, time to penetrative intercourse, and overall satisfaction.
Results. All men received an interposition skin graft with 100% viability, with no revision surgery required. Postoperatively, all men were sexually active and able to retract their foreskin.
Conclusions. Cosmetic outcomes are encouraging and painless sexual intercourse is attainable in this difficult group of patients.

KimsexDaiSik Kim and Myung-Geol Pang
The effect of male circumcision on sexuality
British Journal of Urology (excerpt) Abstract BJU International Online Early doi:10.1111/j.1464-410X.2006.06646.x Volume 0 Issue 0

Objective
To prospectively study, using a questionnaire, the sexuality of men circumcised as adults compared to uncircumcised men, and to compare their sex lives before and after circumcision.

Subjects and Methods
The study included 373 sexually active men, of whom 255 were circumcised and 118 were not. Of the 255 circumcised men, 138 had been sexually active before circumcision, and all were circumcised at >20 years of age. As the Brief Male Sexual Function Inventory does not specifically address the quality of sex life, questions were added to compare sexual and masturbatory pleasure before and after circumcision.

Results
There were no significant differences in sexual drive, erection, ejaculation, and ejaculation latency time between circumcised and uncircumcised men. Masturbatory pleasure decreased after circumcision in 48% of the respondents, while 8% reported increased pleasure. Masturbatory difficulty increased after circumcision in 63% of the respondents but was easier in 37%. About 6% answered that their sex lives improved, while 20% reported a worse sex life after circumcision.

Conclusion
There was a decrease in masturbatory pleasure and sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings.

Lander pain Lander, Janice PhD; Barbara Brady-Freyer, MN; James B. Metcalfe, MD, FRCSC; Shermin Nazerali, MPharm; Sarah Muttit, MD, FRCPC. Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision A Randomized Controlled Trial
Journal of the American Medical Association, Volume 278 No. 24, Pages 2157-2162, December 24/31, 1997.
This paper, designed to compare different anaesthetics, is remarkable because the control group (NB circumcised without anaesthetic - there was no intact control group) was discontinued for ethical reasons.
LanephimosisT.M. LANE and L.M. SOUTH
Lateral preputioplasty for phimosis
J.R.Coll.Surg.Edinb., 44, October 1999, 310-12
ABSTRACT: There exists a lack of understanding of normal preputial development which is reflected in the large numbers of inappropriate referrals for circumcision. While the scarred prepuce invariably responds best to formal cicumcision a more conservative approach is recommended in those symptomatic patients with non-retractile foreskins. In this study, patients referred to the out-patient department with a phimosis were assessed. Those with a phimosis and secondary preputial scarring were listed for circumcision. Those with a narrowed foreskin and a history of recurrent balanitis or local symptoms such as fissuration, thought suitable for a more conservative approach, were listed for preputioplasty. Those with a phimosis but without local symptoms were reassured and discharged. Thirty patients were referred for preputioplasty. One patient developed a post-operative wound infection which settled with oral antibiotics prescribed by his general practitioner. This left him with further preputial adhesions and he later underwent circumcision. The remaining patients reported no post-operative problems at follow-up. Cosmesis was good with high levels of patient satisfaction expressed. All had easily retractile foreskins at follow-up. Large numbers of patients might reasonably benefit from a lateral preputioplasty when presenting with a symptomatic phimosis in the absence of significant scarring of the prepuce. It avoids the needless loss of the foreskin, the importance of which is only now beginning to emerge.
LangphimosisLang, K.
[Conservative therapy of phimosis]
Monatsschr Kinderheilkd 1986 Nov;134(11):824-5
[in German]

Abstract:"...In 56 cases of boys before puberty with severe phimosis 53 could be completely cured by combined parenteral HCG [Human Chorionic Gonadotropin] and local Corticoid treatment within 4-6 weeks. The longtime follow up study did not show any later side effect. The therapeutic scheme is given."

LaumannSTDs,
sexual
performance
Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice.
JAMA 1997;277:1052-7
Based on the National Health and Social Life Survey of 1410 USAmerican men aged 18 to 59, this study seemed to find that circumcised men have more varied sexual practices, and are less likely to experience sexual dysfunction in old age. Its flaws include relying on self-reporting to determine circumcision status. Some of its findings about practices apply only to white men, suggesting they are culturally determined, not direct consequences of circumcision

The sexual dysfunction data was not corrected for ethnicity and factors that flow from it, such as tendency towards hypertension, which causes erectile dysfunction.

This study found significantly more circumcised men contracted chlamydia (in fact none of the 353 intact men did), and the differences for other sexually transmitted diseases (though mainly favouring intactness) were not significant.

It is widely and falsely quoted as saying circumcised men practice anal sex more than intact men, and that they are less likely to lose interest in sex in old age.
sexual dysfunctionLaumann, Edward O., PhD; Anthony Paik, MA; Raymond C. Rosen, PhD
Sexual Dysfunction in the United States: Prevalence and Predictors
JAMA Vol. 281 No. 6, February 10, 1999
Using the same data as before, Laumann now concludes that "...circumcision generally do[es] not result in increased odds of experiencing sexual dysfunction."
LeibowitzsubjectArleen A. Leibowitz, Katherine Desmond, Thomas Belin
Determinants and Policy Implications of Male Circumcision in the United States
American Journal of Public Health, 10.2105/AJPH.2008.134403

Abstract
Objective. We sought to determine whether lack of state Medicaid coverage for infant male circumcision correlates with lower circumcision rates. [Oddly negative, meaning whether Medicaid coverage correlates with higher circumcision rates, and biased, "lack" suggesting there should be Medicaid coverage.]

Methods. We used data from the Nationwide Inpatient Sample on 417282 male newborns to calculate hospital-level circumcision rates. We used weighted multiple regression to correlate hospital circumcision rates with hospital-level predictors and state Medicaid coverage of circumcision.

Results. The mean neonatal male circumcision rate was 55.9%. When we controlled for other factors, hospitals in states in which Medicaid covers routine male circumcision had circumcision rates that were 24 percentage points higher than did hospitals in states without such coverage (P<.001). Hospitals serving greater proportions of Hispanic patients had lower circumcision rates; this was not true of hospitals serving more African Americans. Medicaid coverage had a smaller effect on circumcision rates when a hospital had a greater percentage of Hispanic births.

Conclusions. Lack of Medicaid coverage for neonatal male circumcision correlated with lower rates of circumcision. Because uncircumcised males face greater risk of HIV and other sexually transmitted infections, lack of Medicaid coverage for circumcision may translate into future health disparities for children born to poor families covered by Medicaid.

[This study, posing as scientific, is just a Trojan horse for strident advocacy. It shows that parents are not strongly motivated to circumcise and will leave their sons alone if they have to pay for the operation. It has been widely quoted in the service of this advocacy. Two letters to the American Journal of Public Health answer it.]

Lempert and ShahethicsAntony Lempert and Anish Shah
Male circumcision and child safeguarding
British Association for Community Child Health (BACCH) Newsletter, June 2012

Ritual circumcision or non-therapeutic excision of the foreskin (NTEF) is increasingly under the spotlight. We explore some of the reasons why the medical profession, the public, and even some religious organisations are increasingly turning away from this traditional religious operation, and why it should now be considered a child safeguarding issue.

McCredieurinaryMcCredie M, Staples M, Johnson W, English DR, Giles GG
Prevalence of urinary symptoms in urban Australian men aged 40-69
J Epidemiol Biostat. 2001;6(2):211-8

BACKGROUND: This study was devised to determine the prevalence of urinary symptoms among men living in the Australian cities of Melbourne, Sydney or Perth, and to identify factors associated with the presence of moderate-to-severe urinary symptoms.

METHODS: The study comprised a population-based sample of 1,216 men, aged 40-69 years, whose names were obtained through electoral rolls and who participated as controls in a case-control study of risk factors for prostate cancer. As part of a structured face-to-face interview, the men completed the International Prostate Symptom Score (IPSS). Men with moderate (IPSS = 8-19) or severe (IPSS > or = 20) urinary symptoms were compared with those with mild or no symptoms (IPSS < 8) using unconditional logistic regression. RESULTS: The age-specific prevalence of moderate-to-severe urinary symptoms (IPSS > or = 8) in men aged 40-49, 50-59, 60-69 years was 16%, 23% and 28%, respectively. Compared with men with no or mild urinary symptoms (IPSS < 8), men with moderate-to-severe symptoms were more likely to report not currently living as married [odds ratio (OR) = 1.5; 95% confidence interval (CI) 1.1-2.0] and being circumcised (O[dds ]R[atio] = 1.5; 95% C[onfidence ]l[nterval] 1.2-2.0) [i.e. they are 1 ½ times as likely - 19 out of 20 similar surveys would show that that they are from 1.2 times to twice as likely]. The increased likelihood associated with drinking an average of > 60 g day(-1) of alcohol in the 2 years before interview was of marginal statistical significance (OR = 1.6; 1.0-2.6). There were no significant differences between men with IPSS > or = 8 and those with IPSS < 8 with respect to body mass index, education level, having had a vasectomy, or cigarette smoking.

CONCLUSION: Among Australian men, being circumcised, or not currently living as married, were associated with increased prevalence of urinary symptoms.

PMID: 11434500 [PubMed - indexed for MEDLINE]

McGrathanatomyMcGrath,Ken
The Frenular Delta: a New Preputial Structure
Understanding Circumcision
ed. Denniston et al. Kluwer Academic/Plenum Publishers, New York, 2001, pp199-206
describes the frenular delta, a sensitive area under the intact penis, distinct from the ridged band.
Machmouchi et al.age, complicationsM. Machmouchi, A. Alkhotani
Is Neonatal Circumcision Judicious?
Eur J Pediatr Surg 2007; 17: 266-269
Abstract
Background: Circumcision is the most frequently performed procedure in male children.
Aim: The aim of the study was to compare the outcome of circumcision performed in the early neonatal period and circumcision performed at 5 months of age. Setting of the study was the King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.
Methods: The study was performed as a prospective cohort study.
Results: A total of 350 infants were enrolled. 250 neonates were circumcised at the age of 1 to 4 days (early group) and 100 infants underwent circumcision at the age of 5 months (late group). A bone cutter was used for 50 neonates, a Gomco clamp in another 50 neonates, and a Plastibell in the remaining 250 cases (150 in the early group and 100 in the late group). Complications including meatal deformities, meatal stenosis, adhesions and infection were more frequent and more significant in the neonatal circumcision group.
Conclusions: From our study, circumcision at 5 months results in significantly fewer serious complications than circumcision in the neonatal period, irrespective of the method used. Therefore, neonatal circumcision should not be recommended.

[All 100 of the 5-months circumcisions were done by Plastibell™. Therefore it is not possible to say "irrespective of the method used". In effect they performed two studies. One compared methods for neonatal circumcisions. The other compared 150 neonatal and 100 5-month circumcisions, all using Plastibell™. But since they did not circumcise any babies using other methods at five months, they can not draw any valid conclusions about how circumcisions using other methods would have gone at five months. It is unclear from this abstract whether they did indeed compare like with like, only the Plastibell™ circumcisions at birth with those at five months. If they compared the other methods with Plastibell at five months, the difference in method could be entirely responsible for the difference in outcome, and the age at circumcision have nothing to do with it. Unsurprisingly, there was no control group of babies not circumcised at all.]

MadencancerMaden, Christopher, et al., History of Circumcision, Medical Conditions, and Sexual Activity and Risk of Penile Cancer,
Journal of the National Cancer Institute 1993;85:19-24
Maden found a correlation between intactness and penile cancer, but he failed to correct for age: his men with penile cancer were older than those without, and hence born before circumcision was fashionable. He found 41 circumcised men with penile cancer in a sample of 110, and 22 of those were circumcised in infancy, disproving the commonly repeated claim that "men circumcised in infancy never contract penile cancer."
Menczercervical cancerJoseph Menczer, The Low Incidence of Cervical Cancer in Jewish Women: Has the Puzzle Finally Been Solved? ,
IMAJ 2003;5:120-123 (Israel Medical Association Journal)
Extensive review of claims about circumcision, concluding: "Although the dispute over the association of circumcision and cervical cancer in various populations is still ongoing [23,24], there seems to be no hard evidence that circumcision prevents its occurrence in Jewish women, and it is no longer considered to play a protective role."

23. Brinton LA, Reeves WC, Brenes MM, et al. The male factor in the etiology of cervical cancer among sexually monogamous women. Int J Cancer 1989;44:199±203.
24. Agarwal SS, Sehgal A, Sardana S, Kumar A, Luthra UK. Role of male behavior in cervical carcinogenesis among women with one lifetime partner. Cancer 1993;72:1666±9.

Meuller, et al.UTIsMueller ER, Steinhardt, G, Naseer S, et al.
The incidence of genitourinary abnormalities in circumcised and uncircumcised boys presenting with an initial urinary tract infection by 6 months of age
Pediatrics. 1997; 100(suppl):580
Published in abstract only, but shows that the rate of UTIs is associated with the presence of UT abnormalities but not with circumcision.
MorgangeneralWilliam Keith C. Morgan, MD
The Rape of the Phallus
Journal of the American Medical Association
Volume 193 No 3
Pages 123-124
July 19, 1965.

Reprinted for a wider audience in The Realist, April 1966.

Morgan's witty and comprehensive survey of circumcision was the first to undermine its medical pretentions and expose its murky psychological underpinnings, as well as putting a useful term into the language.
NadlerinnervationNadler RD
Proximate and ultimate influences on the regulation of mating in the great apes
Am J Primatol 1995;37:93-102
"The human prepuce has an evolutionary advancement over the prepuce of other primates. This is most clearly seen in the evolutionary increase in corpuscular innervation of the human prepuce and the concomitant decrease in corpuscular receptors of the human glans relative to the innervation of the prepuce and glans of lower primates."

A riposte to the claim that the foreskin is "just a mammalian sheath for the penis".

Ng'ayoherpesNg'ayo MO, Bukusi E, Morrow RA, Rowhani-Rahbar A, Obare BA, Friedrich D, Holmes KK.
Sexual and Demographic Determinants for Herpes Simplex Virus Type 2 among Fishermen along Lake Victoria, Kenya.
Sex Transm Infect. 2007 Dec 20
OBJECTIVES: To determine the prevalence and correlates of herpes simplex virus type two (HSV-2) seropositivity among fishermen along Lake Victoria shores in Kisumu district, Kenya.
METHODS: Sera from a random sample of 250 fishermen from 18 beaches were collected following a detailed sociodemographic interview. HSV-2 infection was tested by Kalon HSV-2 ELISA.
RESULTS: The HSV-2 seroprevalence was 63.9%. In multivariate analysis, fishermen were more likely to be infected with HSV-2 if they were HIV-positive (prevalence ratio (PR): 1.27; 95% confidence interval (CI): 1.06, 1.52) as compared to those testing HIV-negative, were 18-20 (PR: 0.49; 95% CI: 0.24, 0.99) and older than 40 (PR: 1.66; 95% CI: 1.30, 2.14) years of age as compared with those 21-25 years of age, perceived their last two sexual partners to have an sexually transmitted infection (STI) (PR: 1.27; 95% CI: 1.06, 1.52) as compared with those who did not; and were circumcised (PR: 1.49; 95% CI: 1.19, 1.86) as compared with those who were not circumcised.
CONCLUSIONS: HSV-2 seroprevalence is high among this population and is associated with HIV serostatus, age, perception about partner's STI status, and circumcision.

... since few men were circumcised in this study [18, vs 232 intact], ... this association may have arisen by chance.

O'HarasexualityO'Hara K, O'Hara J.
The effect of male circumcision on the sexual enjoyment of the female partner
BJU, Vol. 83, Supplement 1, Jan. 1999, 79-84
This write-in survey has been criticised because an anti-circumcision source was among those used to recruit respondents, but what is striking is their agreement as to how sex is better with intact men, descriptions that are in accord with the neurological facts. They maintain the correlations remain when the (45%) subjects who may be predisposed to Intactivism are removed.
Ozdoganmethoglobinemia, anaestheticHatice Ozdogan, Selcan Osma, Gozde B Aydin, Avni Dinc, Gulten Ozgun
Methemoglobinemia presenting in a circumcised baby following application of prilocaine: a case report,
Journal of Medical Case Reports 2010, 4:49
Abstract
Introduction: Local anesthesia with prilocaine has become a routine part of ambulatory circumcision procedures. Methemoglobinemia is a rare but potentially lethal complication of local anesthetics.
Case presentation: We report the case of a 40-day-old Turkish boy who presented with cyanosis after receiving local anesthesia with prilocaine. His methemoglobin level revealed severe methemoglobinemia (methemoglobin = 44%). His cyanosis resolved after intravenous administration of methylene blue.
Conclusion: Although the association between prilocaine use and methemoglobinemia has generally restricted the use of prilocaine in babies, it is still widely used in ambulatory procedures, especially during circumcision in the neonatal period. Prilocaine should not be used in babies who are less than 3 months old because of the risk of methemoglobinemia; other local anesthetics may be used for this age group. Furthermore, general anesthesia by mask ventilation may be favored for babies less than 3 months of age instead of local anesthetics.
PatelcomplicationsPatel H.
The problem of routine infant circumcision,
Can Med Assoc J 1996;95:576-581
Patel found a high incidence of complications, mainly minor, (35 haemorrhages, 31 meatal ulcers, 8 infections, 8 meatal stenoses, 1 phimosis) among 100 babies circumcised at one hospital in Kingston, Ontario.
PieretticomplicationsRafael V. Pieretti, Allan M. Goldstein and Rafael Pieretti-Vanmarcke
Late complications of newborn circumcision: a common and avoidable problem,
Ped. Surg. Int. DOI 10.1007/s00383-010-2566-9

Abstract
Purpose The purpose of this paper is to study the types of operative and post-operative late complications resulting from newborn circumcisions and to make recommendations to prevent them.
Methods After obtaining IRB approval, a retrospective review of the late complications resulting from newborn circumcisions treated at the MassGeneral Hospital for Children from January 2003 to December 2007 was undertaken. [So "late" means within seven years - no reference to complications affecting sexual function] The source used was the consultation notes and operative reports of affected patients. Additionally, cases seen in the outpatient Pediatric Urology Clinic from April 2007 to April 2008 were reviewed.
Results A total of 8,967 children were operated during the study period, of which 424 (4.7%) were for complications resulting from previous neonatal circumcision. Penile adhesions, skin bridges, meatal stenosis, redundant foreskin (incomplete circumcision with uncircumcised appearance), recurrent phimosis, buried penis and penile rotation were the most frequent complications. At the outpatient clinic of the Section of Pediatric Urology, 127 boys with concerns following newborn circumcision were evaluated, representing 7.4% of the total volume of cases seen in this clinic.
Conclusions Our results indicate the need to undertake a collaborative study to define the incidence of complications following newborn circumcisions, which should be performed by practitioners with adequate training in the technique of their choice and its post-operative care.

[Their results indicate yet again that circumcision should not be performed in the absence of pressing medical need.]

Qinkeratinisation, Langerhans cellsQin Q, Zheng XY, Wang YY, Shen HF, Sun F, Ding W.
Langerhans' cell density and degree of keratinization in foreskins of Chinese preschool boys and adults
Int Urol Nephrol. 2009 Jan 30. [Epub ahead of print]

BACKGROUND: Recent epidemiological studies have proposed that male circumcision reduces the relative risk of acquiring HIV-1. Here, we evaluated the density of Langerhans' cell and degree of keratinization in the foreskins of Chinese preschool boys and adults.

METHODS: Sixty preschool boys and 20 healthy men without infectious history following male circumcisions were included. The keratin thickness and Langerhans' cells were quantified by using keratin staining, immunohistochemistry, and image analysis.

RESULTS: The extent of keratinization was much greater in the inner foreskin than in the outer foreskin in adults and boys with infectious history. It was likely to be less keratinized in boys' foreskins compared with those of adults. The density of Langerhans' cells was higher in the outer foreskin than in the inner foreskin of adults and healthy boys. [And the outer foreskin is just a continuation of the shaft skin. This undermines claims that circumcision significantly reduces the exposure of the Langerhans cells to HIV.] Furthermore, an increased density of Langerhans' cells of inner foreskin was also found in boys with infectious history compared with healthy boys. There was much higher Langerhans' cell density in boys' foreskin compared with those of adults.

CONCLUSIONS: These findings suggest that Chinese men may have a different feature of keratin in the foreskin, and a higher Langerhans' cells density in boys' foreskin may be due to it being less keratinized.

PMID: 19184514

RajanfrenuloplastyPrabhakar Rajan, S Alan McNeill, and Kevin J Turner
Is Frenuloplasty Worthwhile? A 12-Year Experience
Ann R Coll Surg Engl. 2006 October; 88(6): 583–584
The authors surveyed 209 of their 213 frenuloplasty patients since 1992. 48 (23% responded. Median satisfaction was 8/10. 34 would recommend it. 23 of 209 (11%) were circumcised by the same doctors after frenuloplasty. A few more may have been circumcised elsewhere.
Ramos and BoylestressSamuel Ramos, Gregory J. Boyle
Ritual and Medical Circumcision among Filipino boys: Evidence of Post-traumatic Stress Disorder
ePublications@Bond University.
... investigated the psychological consequences of partial penile amputation, involving both medical and ritual circumcision procedures in the Philippines. Boys aged from 11 to 16 years were recruited from five different schools of the Batangas province.... The boys completed a two-part questionnaire. The preliminary part requested biographical information, including any history of other traumatic events, and perception of the circumcision experience. The second part assessed the presence of post traumatic stress disorder (PTSD) symptoms. ... Among ... previously non-traumatized boys, 1072 boys were circumcised under medical procedures and 505 were subjected to ritual circumcision. Almost 70% of the boys subjected to ritual circumcision (Tuli), and 51% of those subjected to medical circumcision fulfilled the DSM-IV criteria for a diagnosis of PTSD
ReddyphimosisReddy S, Jain V, Dubey M, Deshpande P, Singal AK. (Mumbai, India)
Local steroid therapy as the first-line treatment for boys with symptomatic phimosis - a long-term prospective study.
Acta Paediatr. 2011 Nov 21. doi: 10.1111/j.1651-2227.2011.02534.x. [Epub ahead of print]

Aim: Phimosis is a common paediatric urological disorder and often necessitates circumcision. We prospectively evaluated local steroid therapy (LST) as the first choice therapy for such children.

Methods: Two hundred and sixty symptomatic boys up to 15 years of age (mean 34 months) with phimosis were started on betamethasone dipropionate (0.05%) application on gently stretched prepuce twice a day. Follow-up visits were arranged at the end of weeks 1, 2 and 4 and 6 months. Grade of phimosis was objectively graded.

Results: Ninety one percent of the boys showed a successful outcome at the end of 4 weeks; 72% responded in first week, further 16% responded in week 2, and only 2.6% achieved alleviation of phimosis on further application of LST beyond 2 weeks. Fourty two (17.8%) boys had a recurrence of phimosis on a long-term follow-up (mean - 25.4 months, range 6-48 months); thus, the long-term success rate was 77%, while 60 (23%) boys underwent surgery.

Conclusion: Local steroid therapy is safe and successful in alleviating symptomatic tight foreskin in a large majority of children. The response can be seen as early as 1 week; most of the children respond by week 2 and continuing therapy further may not be very effective.

RedigermotivationChris Rediger and Andries J. Muller, MB ChB MPraxMed CCFP
Parents' rationale for male circumcision
Canadian Family Physician, February 2013 vol. 59 no. 2 e110-e115

Abstract

Objective To determine which factors parents consider to be most important when pursuing elective circumcision procedures in newborn male children.

Design Prospective survey.

Setting Saskatoon, Sask.

Participants A total of 230 participants attending prenatal classes in the Saskatoon Health Region over a 3-month period.

Main outcome measures Parents' plans to pursue circumcision, personal and family circumcision status, and factors influencing parents' decision making on the subject of elective circumcision.

Results The reasons that parents most often gave for supporting male circumcision were hygiene (61.9%), prevention of infection or cancer (44.8%), and the father being circumcised (40.9%). The reasons most commonly reported by parents for not supporting circumcision were it not being medically necessary (32.0%), the father being uncircumcised (18.8%), and concerns about bleeding or infection (15.5%). Of all parents responding who were expecting children, 56.4% indicated they would consider pursuing elective circumcision if they had a son; 24.3% said they would not. In instances in which the father of the expected baby was circumcised, 81.9% of respondents were in favour of pursuing elective circumcision. When the father of the expected child was not circumcised, 14.9% were in favour of pursuing elective circumcision. Regression analysis showed that the relationship between the circumcision status of the father and support of elective circumcision was statistically significant (P < .001).

Father's status and circumcision preference - Rediger

Among couples in which the father was circumcised, 82.2% stated that circumcision by an experienced medical practitioner was a safe procedure for all boys, in contrast to 64.1% of couples in which the father of the expected child was not circumcised. When the expecting father was circumcised, no one responded that circumcision was an unsafe procedure, compared with 7.8% when the expecting father was not circumcised (P = .003).

Conclusion Despite new medical information and updated stances from various medical associations, newborn male circumcision rates continue to be heavily influenced by the circumcision status of the child's father.

[So the father's circumcision status is an independent variable, directly affecting what they do, regardless of what they say.]

RichtersgeneralJ Richters, AM Smith, RO de Visser, AE Grulich, and CE Rissel
Circumcision in Australia: prevalence and effects on sexual health,
Int J STD AIDS, August 1, 2006; 17(8): 547-54
ABSTRACT: The results from a telephone survey in 2001-02 of a probability sample of Australian households including 10,173 men aged 16-59 (response rate 69.4%) are used to assess the prevalence of circumcision across social groups in Australia and examine lifetime history of sexually transmissible infection (STI), sexual difficulties in the last year, sexual practices including masturbation, and sexual attitudes.More than half (59%) of the men were circumcised. Circumcision was less common among younger men (32% aged <20) and more common among the Australian born (69%). After correction for age, circumcision was unrelated to reporting STI, but appeared to protect against penile candidiasis [or rather, showed a negative correlation with candidiasis]. Circumcision was unrelated to most sexual difficulties, but circumcised men were less likely to report physical pain during intercourse or trouble keeping an erection; reasons for this are unknown. There were no significant differences in practices at last sexual encounter with a female partner or in masturbation alone. Circumcised men had somewhat more liberal sexual attitudes. Neonatal circumcision was routine in Australia until the 1970s. It appears not to be associated with significant protective or harmful sexual health outcomes. This study provides no evidence about the effects on sexual sensitivity. PMID: 16925903
sexualityJuliet Richters
Circumcision and the Socially Imagined Sexual BodySubject
Health Sociology Review Volume 15 Issue 3 - 2006

Abstract

In a generation, Australia has changed from a country where most boys are circumcised in infancy to one where circumcision is the minority experience.

Proponents argue that routine circumcision is desirable because it protects against a number of conditions. Yet circumcision can be seen rather as a sociocultural intervention with post hoc medical justification. As a form of body modification, it serves to exaggerate the visual difference between male and female. Reducing the ambiguity and untidiness of the penis turns it into a neat phallus more specifically fitted for what is seen as its purpose in a gendered sexual culture focused on coitus. Does circumcision reduce penile sensitivity?

Applying the methods of evidence-based medicine to this question has problems, centrally that of how 'sensitivity' is to be measured. The nature of the loss is in a sense 'unspeakable' and for many people unimaginable, because the reception of delicate sensation is not part of their notion of masculine sexuality.

sizeJuliet Richters, John Gerofi, Basil Donovan
Are condoms the right sizes? A method for self-measurement of the erect penis
Venereology Volume 8, Number 2, May 1995, pp 77-
"One hundred and two were circumcised, 43 were not, and two men did not answer. The uncircumcised penises had slightly larger circumferences, but the difference was not significant (2mm behind the coronal ridge and 4mm at the glans). There was a significant difference in length, with the uncircumcised men haing a mean length 8 mm greater than the circumcised (t=2.06, p<0.05). Insufficient residual foreskin in some circumcised men may have tethered their erections."
Risserstatus-
ignorance
Risser JM, Risser WL, Eissa MA, Cromwell PF, Barratt MS, Bortot A.
Self-assessment of circumcision status by adolescents.
Am J Epidemiol. 2004 Jun 1;159(11):1095-7
Adolescents in Houston were asked their circumcision status and then examined. Of the 1,508 subjects (mean age 15 years), 64% were Black, 29% Hispanic, and 7% White. Of the 738 circumcised subjects, 69% considered themselves circumcised, 7% considered themselves intact, and 23% did not know. Of the 751 intact youths, 65% described themselves as intact, 4% reported being circumcised, and 31% did not know.
Robinsonconsent Consent for non-therapeutic male circumcision on religious grounds
Robinson R, Makin E, Wheeler R
Ann R Coll Surg Engl 2009; 91: 152–154

ABSTRACT
INTRODUCTION
The aim of this study was to assess whether surgeons are conforming to guidance laid down by professional organisations and the courts in obtaining dual parental consent for non-therapeutic circumcision.

PATIENTS AND METHODS
A retrospective case-note review over a 12-month period (April 2005 to April 2006) of circumcisions in boys under the age of 16 years in a tertiary paediatric surgical unit was undertaken.

RESULTS
A total of 62 boys aged 1–14 years (median age, 4 years) underwent non-therapeutic circumcision. Written consent from both parents was obtained in only 4 cases (6.4%). In no case was written consent obtained from the patient or their views documented. In 58 cases, the written consent was provided by only one parent; the mother in 34 (55%), the father in 24 (45%). Of these 58 cases, in 25 (43%) both parents attended with the child on the day of surgery.

CONCLUSIONS
The data reveal a consistent non-conformity with recommended practice and the common law. It seems unlikely that the doctors involved are deliberate and inveterate law-breakers. The reason for this non-compliance may be ignorance of the rules, or due to the impracticality of their implementation. There is evidence that doctors are ignorant of the legal rules pertaining to their patients, and the results may reflect this ignorance. However, there are also practical difficulties in obtaining dual consent that may be partially responsible for the variance. Inevitably, investment will be required to overcome these difficulties. Cost may tempt service providers to abandon the provision, leaving parents to their own devices.

Rubelsupercision,
anthropology
Arthur Rubel et al.
Genital mutilation and adult role behavior among Lowland Christian Filipinos of Cebu
American Anthropologist, Vol. 73,1971, pp. 806-10
Boys age about 9-11 undergo supercision, and some intact adult men request the procedure. "College girls" are said to prefer them for sex and marriage. One young woman told interviewer that she would consider her fiance a "real coward" and "effeminate" (local language term) if he was intact and refused supercision. Reasons offered by "coeds" for preferring supercised men: Christian custom, makes man complete, healthy, protects against cancer, promotes physical growth and strength, intact men smell bad, more pleasure because supercised penis is "bigger and fuller," intact men are unnatural.
Schoengeneral, cancerSchoen EJ, Anderson G, Bohon C, et al: Report of the American Academy of Pediatrics Task Force on Circumcision.
Pediatrics 84:388-391,1989.

Schoen, E.J.: Benefits of Newborn Circumcision: Is Europe Ignoring Medical Evidence?
Arch Dis Child 1997, 77, 358-60
Schoen is a rampant circumcisor. He chaired the AAP Task force on circumcision and pushed his own opinion ahead of the evidence.

He advocates universal male circumcision.

He has published verses mocking intactness and restoration in medical journals.
SchwartzComplicationsSchwartz, William M., MD; Charney, Edward B., MD; Curry, Thomas A., MD; Ludwig, Stephen., MD
PEDIATRIC PRIMARY CARE: A Problem-solving Approach
2nd Edition, Year Book Medical Publishers, Inc., 1990, pp. 861-862
Discusses the real rate of circumcision complications.
ShawethicsDavid Shaw
Cutting through red tape: non-therapeutic circumcision and unethical guidelines
Clin Ethics 2009;4:181-186
ABSTRACT: Current General Medical Council (GMC) guidelines state that any doctor who does not wish to carry out a non-therapeutic circumcision (NTC) on a boy must invoke conscientious objection. This paper argues that this is illogical, as it is clear that an ethical doctor will object to conducting a clinically unnecessary operation on a child who cannot consent simply because of the parents’ religious beliefs. Comparison of the GMC guidelines with the more sensible British Medical Association guidance reveals that both are biased in favour of NTC and subvert standard consent procedures. It is further argued that any doctor who does participate in NTC of a minor may be guilty of negligence and in breach of the Human Rights Act. In fact, the GMC guidance implies that doctors must claim conscientious objection if they do not wish to be negligent. Both sets of guidelines should be changed to ensure an objective consent process and avoid confusion over the ethics of NTC.

The complete paper (requires Adobe Acrobat Reader ).

Get Acrobat Reader

Singh-Grewal et al.Urinary Tract InfectionsSingh-Grewal D, Macdessi J, Craig J.
Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomized trials and observational studies
Arch Dis Child. 2005 May 12; [Epub ahead of print]
"Given a risk of UTI in normal boys of about 1%, the number-needed-to treat to prevent one urinary tract infection is 111. In boys with recurrent urinary tract infection or high-grade vesicoureteric reflux , the risk of urinary tract infection recurrence is 10% and 30% and the numbers needed-to-treat are 11 and 4 respectively [i.e. 10 boys or three boys being circumcised to no purpose.]. ... assuming equal utility of benefits and harms [an assumption they were forced to make because of the lack of data about the harms of circumcision], net clinical benefit is only likely in boys at high risk of urinary tract infection."

PMID: 15890696 [PubMed - as supplied by publisher]

This is a meta-analysis of earlier work, not a new study.

SomervilleethicsSomerville, Margaret, Letter to C. Robin Walker, 10 November 1997.Somerville, Professor of Law in McGill University's centre for ethics, medicine and law, suggests that infant circumcision is unethical. Her book "The Ethical Canary" includes a chapter on the subject.
Sorrells, et alsensitivityMorris L. Sorrells, James L. Snyder, Mark D. Reiss, Christopher Eden, Marilyn F. Milos, Norma Wilcox, Robert S. Van Howe
Fine-touch pressure thresholds in the adult penis
BJU International 99 (4), 864-869
(British Journal of Urology International,
Volume 99 Issue 4 Page 864 - April 2007)
OBJECTIVE: To map the fine-touch pressure thresholds of the adult penis in circumcised and uncircumcised men, and to compare the two populations.

SUBJECTS AND METHODS: Adult male volunteers with no history of penile pathology or diabetes were evaluated with a Semmes-Weinstein monofilament touch-test to map the fine-touch pressure thresholds of the penis. Circumcised and uncircumcised men were compared using mixed models for repeated data, controlling for age, type of underwear worn, time since last ejaculation, ethnicity, country of birth, and level of education.

RESULTS: The glans of the uncircumcised men had significantly lower mean (sem) pressure thresholds than that of the circumcised men, at 0.161 (0.078) g (P = 0.040) when controlled for age, location of measurement, type of underwear worn, and ethnicity. There were significant differences in pressure thresholds by location on the penis (P < 0.001). The most sensitive location on the circumcised penis was the circumcision scar on the ventral surface. Five locations on the uncircumcised penis that are routinely removed at circumcision had lower pressure thresholds than the ventral scar of the circumcised penis.

CONCLUSIONS: The glans of the circumcised penis is less sensitive to fine touch than the glans of the uncircumcised penis. The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates the most sensitive parts of the penis.

SpillsburyUnnecessary circumcisionKatrina Spilsbury, James B Semmens, Z Stan Wisniewski and C D'Arcy J Holman
Circumcision for phimosis and other medical indications in Western Australian boys
MJA 2003 178 (4): 155-158
Objective: To investigate the incidence rate of circumcision for phimosis and other medically indicated reasons in Western Australian boys from 1 January 1981 to 31 December 1999.
Results: The rate of medically indicated circumcisions increased in boys aged less than 15 years during the study period. [A small increase was to be expected, corresponding to the decline in routine circumcision over that period.] ...
Conclusion: The rate of circumcision to treat phimosis in boys aged less than 15 years is seven times the expected incidence rate for phimosis. Many boys are circumcised before reaching five years of age, despite phimosis being rare in this age group.

The article has an associated editorial: "Treating phimosis" by Paddy A Dewan, MJA 2003 178 (4): 148-150, including photographs of true and false phimosis.

Svobodaethics, lawJ. S. Svoboda, R. S. Van Howe and J. G. Dwyer
Informed Consent for Neonatal Circumcision: an Ethical and Legal Conundrum
J Contemp Health Law Policy, 17: 61-133, 2000
This important paper challenges the right of doctors and parents to authorise RIC. It has been noticed by the American Urological Association.
ethics, FGMJ. S. Svoboda, and R. Darby
A Rose by any other Name: Rethinking the Similarities and Differences between Male and Female Genital Cutting
Medical Anthropology Quarterly, Volume 21, Number 3 (September 2007), pp. 301-323.
ABSTRACT: This paper offers a critical examination of the tendency to segregate discussion of surgical alterations to the male and female genitals into separate compartments - the first known as circumcision, the second as genital mutilation. It is argued that this fundamental problem of definition underlies the considerable controversy surrounding these procedures when carried out on minors, and that it hinders objective discussion of the alleged benefits, harms and risks. The variable effects of male and female genital surgeries are explored, and a scale of damage for male circumcision to complement the World Health Organization's categorisation of female genital mutilation is proposed. The origins of the double standard identified are placed in historical perspective, and a brief conclusion makes a plea for greater gender neutrality in the approach to this contentious issue.
SzaszhistorySzasz, T.
Remembering masturbatory insanity
Ideas on Liberty, 50: 35-36 (May), 2000
"In this column, I shall briefly retell the story of what, until relatively recently, had been the most commonly diagnosed and most enthusiastically treated mental disease in the history of medicine, namely, masturbation."

Circumcision is mentioned as one of its "cures".
Taddio 1995 pain Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys.
Lancet 1995; 345: 291-2.
Taddio et al's first paper showed that circumcised babies reacted more strongly to the pain of being vaccinated than intact ones, months after their circumcisions.
Taddio 1997 painTaddio A, Katz J, Ilersich AL, Koren G.
Effect of neonatal circumcision on pain response during subsequent routine vaccination.
Lancet 1997;349(9052):599-603.
This pain study had a control group of boys left intact, and - surprise! - they felt the least pain of all.

Circumcised boys showed stronger pain responses to vaccination than intact boys (and those who hadn't had pain relief, more than those who'd been given it).

The logical conclusion is of course that babies should not be circumcised if it is not necessary, but of course the researchers conclude that pain relief should be used.

This experiment immediately calls its own ethics into question, since by definition it involves deliberately inflicting pain on unanaesthetised neonates.

Taddio 2000pain Taddio A, Pollock N, Gilbert-MacLeod C, Ohlsson K, Koren G
Combined analgesia and local anesthesia to minimize pain during circumcision.
Arch Pediatr Adolesc Med 2000 Jun;154(6):620-3
Their third paper is fatally flawed, attempting to test two variables, circumcision method and pain-relief method at the same time.
Taddio 2002painTaddio A, Shah V, Gilbert-MacLeod C, Katz J.
Conditioning and hyperalgesia in newborns exposed to repeated heel lances.
JAMA 2002 Aug 21;288(7):857-61
Prospective cohort study of 21 full-term newborns born to mothers with diabetes and 21 controls. CONCLUSIONS: Newborns who had diabetic mothers and were exposed to repeated heel lances in the first 24 to 36 hours of life learned to anticipate pain and exhibited more intense pain responses during venipuncture than normal infants.

In brief: newborn babies DO feel pain.

TayloranatomyTaylor, J.P., A.P. Lockwood and A.J.Taylor
The prepuce: Specialized mucosa of the penis and its loss to circumcision
Journal of Urology (1996), 77, 291-295
Taylor details the innervation of the ridged band of the prepuce, suggesting its great importance in sexual functioning. He also calculates the size of the prepuce as much greater than is commonly believed.
TiffanypsychologyTiffany, Leone-Vespa
Understanding the relationship between circumcision and emotional development in young boys: Measuring aggressiveness and emotional expressiveness
Dissertation for Psy.D, Alliant International University, Fresno, Californai, 2011, 148 pages; 3467063
Abstract:

The purpose of this study was to determine whether the circumcision surgery produced a higher incidence of aggressiveness and a lower incidence of emotional expressiveness in circumcised children versus uncircumcised or intact children. This study was conducted using a cross-sectional design in which data were collected through four self-report questionnaires: demographic questionnaire, circumcision questionnaire, Self-Expressiveness in the Family Questionnaire (SEFQ), and Infant-Toddler Social and Emotional Assessment (ITSEA). When applicable, the SEFQ was completed by both parents for a total of 66 parent participants. There were 40 male children participants (20 circumcised; 20 intact) [A small sample. Whether the findings can be generalised would depend very much on how randomly the sample was selected from the general population.] .

Data were analyzed using an independent t test. Of the six hypotheses, five were confirmed.

The first significant finding of this study was that circumcised boys compared to intact boys scored higher on the ITSEA-EX subscale of the ITSEA, which measures activity/impulsivity, aggression/defiance, and peer aggression.
The second significant finding of this study was that circumcised boys compared to intact boys scored higher on the ITSEA-IN subscale of the ITSEA, which measures depression/withdrawal, general anxiety, separation distress, and inhibition to novelty.
The third significant finding of this study was that circumcised boys compared to intact boys scored higher on the ITSEA-DYS subscale of the ITSEA, which measures negative emotionality, sleep, eating, and sensory sensitivity.
The fourth significant finding of this study was that circumcised boys compared to intact boys scored lower on the ITSEA-COMP subscale of the ITSEA, which measures compliance, attention, mastery, motivation, imitation/play, empathy, and prosocial peer relations.
The fifth finding of this study was that parents of circumcised boys compared to parents of intact boys scored lower on the SEFQ-Positive scale, which measures positive emotions.
The sixth finding was that there were no differences between the parents of circumcised boys compared to the parents of intact boys on the SEFQ-Negative scale, which measures negative emotions.

[These findings are certainly interesting, but a much larger sample is needed before we can conclude that circumcision actually has these effects.]

To et alUTIsTo T., Agha M., Dick P.T. et al. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection.
Lancet 1998;352:1813-16.
Found a significant but small effect of circumcision. It would take 195 circumcisions to prevent one UTI. You can see a graphic illustration of that figure.
WilkinsonBXOWilkinson DJ, Lansdale N, Everitt LH, Marven SS, Walker J, Shawis RN, Roberts JP, Mackinnon AE, Godbole PP.
Foreskin preputioplasty and intralesional triamcinolone: a valid alternative to circumcision for balanitis xerotica obliterans.
J Pediatr Surg. 2012 Apr;47(4):756-9

Abstract

BACKGROUND:
We previously reported our short-term experience of foreskin preputioplasty as an alternative to circumcision for the treatment of foreskin balanitis xerotica obliterans (BXO). In this study, we aimed to compare this technique with circumcision over a longer period.

METHODS:
Between 2002 and 2007, boys requiring surgery for BXO were offered either foreskin preputioplasty or primary circumcision. The preputioplasty technique involved triradiate preputial incisions and injection of triamcinolone intralesionally. Retrospective case-note analysis was performed to identify patient demographics, symptoms, and outcomes.

RESULTS:
One hundred thirty-six boys underwent primary surgery for histologically confirmed BXO. One hundred four boys opted for foreskin preputioplasty, and 32, for circumcision. At a median follow-up of 14 months (interquartile range, 2.5-17.8), 84 (81%) of 104 in the preputioplasty group had a fully retractile and no macroscopic evidence of BXO. Of 104, 14 (13%) developed recurrent symptoms/BXO requiring circumcision or repeat foreskin preputioplasty. In the circumcision group, 23 (72%) of 32 had no macroscopic evidence of BXO. The incidence of meatal stenosis was significantly less in the foreskin preputioplasty group, 6 (6%) of 104 vs 6 (19%) of 32 (P = .034).

CONCLUSION:
Our results show a good outcome for most boys undergoing foreskin preputioplasty and intralesional triamcinolone for BXO. There is a small risk of recurrent BXO, but rates of meatal stenosis may be reduced.

Wrigleyconsent, ethicsAnthony Wrigley
Proxy consent: moral authority misconceived
Journal of Medical Ethics
2007;33:527-531

ABSTRACT
The Mental Capacity Act 2005 has provided unified scope in the British medical system for proxy consent with regard to medical decisions, in the form of a lasting power of attorney. While the intentions are to increase the autonomous decision making powers of those unable to consent, the author of this paper argues that the whole notion of proxy consent collapses into a paternalistic judgement regarding the other person’s best interests and that the new legislation introduces only an advisor, not a proxy with the moral authority to make treatment decisions on behalf of another. The criticism is threefold. First, there is good empirical evidence that people are poor proxy decision makers as regards accurately representing other people’s desires and wishes, and this is therefore a pragmatically inadequate method of gaining consent. Second, philosophical theory explaining how we represent other people’s thought processes indicates that we are unlikely ever to achieve accurate simulations of others’ wishes in making a proxy decision. Third, even if we could accurately simulate other people’s beliefs and wishes, the current construction of proxy consent in the Mental Capacity Act means that it has no significant ethical authority to match that of autonomous decision making. Instead, it is governed by a professional, paternalistic, best-interests judgement that undermines the intended role of a proxy decision maker. The author argues in favour of clearly adopting the paternalistic best-interests option and viewing the proxy as solely an advisor to the professional medical team in helping make best-interests judgements.

Van Howecost/benefitR. S. Van Howe
A Cost-Utility Analysis of Neonatal Circumcision
Med Decis Making, December 1, 2004; 24(6): 584 - 601
A Cost-Utility Analysis of Neonatal Circumcision
Robert S. Van Howe, MD, MS, FAAP
Department of Pediatrics, Michigan State University College of Human Medicine, Marquette, Michigan
A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically.
In the same issue:
D. T. Gray Neonatal Circumcision: Cost-Effective Preventive Measure or "the Unkindest Cut of All"?
(Med Decis Making, December 1, 2004; 24(6): 688 - 692)
- a critical review of the above.
inflammation Van Howe RS
Neonatal circumcision and penile inflammation in young boys
Clin Pediatr (Phila). 2007 May;46(4):329-33.
"This study prospectively documents the incidence of penile inflammation in a consecutive sample of boys according to circumcision status whose visit with the physician included a genital examination in a private primary care pediatric practice in rural northern Wisconsin. Penile inflammation was more common in circumcised than noncircumcised boys, especially in the first 3 years of life (exact odds ratio, 8.01, 95% confidence interval, 31-329.15). When adjusted for the number of genital examinations and age younger than 3 years, exact logistic regression found an adjusted exact odds ratio of 7.91 (95% confidence interval, 1.76-77.66). The study found that rather than protecting against penile inflammation, neonatal circumcision increases the risk of penile inflammation, particularly in boys younger than 3 years old." From the NIH PubMed database of scientific publications(http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed) Direct Link: http://www.ncbi.nlm.nih.gov/entrez/q...ubmed_docsu m http://cpj.sagepub.com/cgi/content/abstract/46/4/329
WayHIVA. Way, V. Mishra, R. Hong, K. Johnson
Is male circumcision protective of HIV infection?
AIDS 2006 - XVI International AIDS Conference Abstract no. TUPE0401
Abstract
Background: There is a large body of literature indicating that male circumcision has a protective effect against HIV infection; however, not all studies find this effect. This study examines the association between male circumcision and HIV serostatus across sub-Saharan African countries.

Methods: Data are from recent Demographic and Health Surveys in Burkina Faso, Cameroon, Ghana, Kenya, Lesotho, and Malawi and from AIDS Indicator Surveys in Tanzania and Uganda. During survey fieldwork in each of these countries, men age 15-59 (15-54 in Kenya and 15-49 in Tanzania) gave blood for anonymous HIV testing. HIV serostatus data for men were analyzed for their relationship to reported circumcision status using bivariate and multivariate statistical methods, after controlling for key demographic, social, and behavioral characteristics. Results: National HIV prevalence ranged from 2% in Ghana and Burkina Faso to 24% in Lesotho. The proportion of uncircumcised men was highest in Lesotho (52%), and lowest in Ghana (5%). In bivariate analysis, circumcised men had lower HIV prevalence in only two of the eight countries. With age, education, wealth status, and a number of sexual and other behavioral risk factors controlled statistically, in only one of the eight countries were circumcised men at a significant advantage. In the other seven countries, the association between circumcision and HIV status was not statistically significant for the male population as a whole.

Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs.

WerkerHIVEric Werker, Amrita Ahuja, and Brian Wendell
Male Circumcision and AIDS: The Macroeconomic Impact of a Health Crisis
Working paper, Harvard Business School, October 2006 - unpublished but widely circulated
Abstract: Theories abound on the potential macroeconomic impact of AIDS in Africa, yet there have been surprisingly few empirical studies to test the mixed theoretical predictions. In this paper, we examine the impact of the AIDS epidemic on African nations through 2002 using the male circumcision rate to identify plausibly exogenous variation in HIV prevalence. Medical researchers have found significant evidence that male circumcision can reduce the risk of contracting HIV. We find that national male circumcision rates for African countries are both a strong predictor of HIV/AIDS prevalence and uncorrelated with other determinants of economic outcomes. Two-stage least squares regressions do not support the hypotheses that AIDS has had any measurable impact on economic growth, savings, or fertility behavior in African nations. However we do find weak evidence that AIDS has lead to a slow-down in education gains, as measured by youth literacy, and a rise in poverty, as measured by malnutrition.
Their argument is circular. They assume that circumcision protects against HIV infection, and use it inversely as a measure of HIV incidence. Circumcisionists use this paper to prove that circumcision protects, but the figures in which they find correlations are highly selective. In Lesotho, for example, circumcision and HIV are both prevalent.
Williams and KapilacomplicationsWilliams and Kapila, Complications of Circumcision.
Br. J. Surg 1993, Vol 80, Oct, 1231-1236
Estimates the rate of complication at 2-10%, but that of meatal stenosis at 8-20%. Enumerates many grotesque mishaps.
WinbergUTIsWinberg, Jan, Ingela Bollgreg, Leif Gothefors, Maria Herthelius, Kjell Tullus,
THE PREPUCE: A MISTAKE OF NATURE?
The Lancet, Vol 1: pages 598-599.(March 18, 1989)
The conclusion of this misleadingly-titled paper is a resounding "NO!" The authors argue that by colonising the baby's foreskin with the mother's benign bacteria, breast-feeding is a better protection against UTI than circumcision.
WiswellUTIsWiswell
TE Prepuce presence portends prevalence of potentially perilous periurethral pathogens
The Journal of Urology, 1992; 148: 739-42

Wiswell TE, Hachey WE. Urinary tract infections (UTIs) and the uncircumcised state: an update
Ped Res, 1992; 31:103A, abstract 603

Wiswell TE, Roscelli JD Corroborative evidence for the decreased incidence of urinary tract infections in circumcised male infants.
Pediatrics, 1986; 78(1): 96-9

Wiswell TE: Further evidence for the decreased incidence of urinary tract infections in circumcised male infants.
Pediatrics 1986;78:96-99.

Wiswell TE, Smith FR, Bass JW Decreased incidence of urinary tract infections in circumcised male infants.
Pediatrics 1985;75:901-903.

Wiswell TE, Smith FR. Decreased incidence of urinary tract infections in circumcised male infants
Experience and Reason, 1985; 75(5)

Wiswell is an enthusiastic circumcisor (with a sick sense of humour). His various studies all correlate intactness and UTIs, using huge samples, but with faulty methodology. For example, all the babies concerned were born in military hospitals, intact ones were more likely to be hospitalised for UTI because they were to be circumcised. He stresses the (apparent) large reduction in UTIs to the complete disregard of the very low baseline rate.
He is on record as seeing financial benefit to doctors from circumcision.
Wolbarstpenile cancerWolbarst Abraham L. Universal circumcision as a sanitary measure.
JAMA 1914; 62:92-7

and

Wolbarst, AL. Circumcision and penile cancer. Lancet 1932; 150-3.

(Note the great age of these studies) Wolbarst correlated penile cancer with intactness and concluded that circumcision was prophylactic. When his figures are corrected for age, the correlation disappears (penile cancer is a disease of old men.)
YangsensitivityYang DM, Lin H, Zhang B, Guo W.
[Circumcision affects glans penis vibration perception threshold]
[Article in Chinese]
Zhonghua Nan Ke Xue. 2008 Apr;14(4):328-30
PMID: 18481425 [PubMed - in process]

OBJECTIVE: To evaluate the effect of circumcision on the glans penis sensitivity by comparing the changes of the glans penis vibrotactile threshold between normal men and patients with simple redundant prepuce and among the patients before and after the operation.
METHODS: The vibrotactile thresholds were measured at the forefinger and glans penis in 73 normal volunteer controls and 96 patients with simple redundant prepuce before and after circumcision by biological vibration measurement instrument, and the changes in the perception sensitivity of the body surface were analyzed.
RESULTS: The G/F (glans/finger) indexes in the control and the test group were respectively 2.39 +/- 1.72 and 1.97 +/- 0.71, with no significant difference in between (P > 0.05). And those of the test group were 1.97 +/- 0.71, 2.64 +/- 1.38, 3.09 +/-1.46 and 2.97 +/- 1.20 respectively before and 1, 2 and 3 months after circumcision, with significant difference between pre- and post-operation (P < 0.05).
CONCLUSION: There is a statistic difference in the glans penis vibration perception threshold between normal men and patients with simple redundant prepuce. The glans penis perception sensitivity decreases after circumcision.

[The term "redundant prepuce" is not defined - there is nothing to suggest the men were not normal, and the circumcisions, medically unnecessary. This result is comparable to that of Sorrells et al, without the measurements at the foreskin.]

Yilmazpsychological traumaErdal Yilmaz, Ertan Batislam, Mehmet Murad Bsar and Halil Basar,
Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids
International Journal of Urology, Volume 10 Number 12: Pages 651-656, December 2003.
Objective: The objective of our study was to assess the efficacy of topical steroids in the treatment of phimosis and evaluate patients using the Diagnostic and Statistical Manual-III-Revised (DSM-III- R) test with the aim of eliminating castration anxiety of circumcision in the phallic period.

Circumcision is the most frequently practiced surgery in Turkey for religious and traditional purposes. Most of the operations are performed in neonates and primary school children. It has been pointed out that between the ages of 3 and 6 years - the 'phallic period' of childhood development - circumcision may affect the psychological status of the child and eventually cause psychological and behavioral disturbances.

...the rate of anxiety disorders such as multiple anxieties, overanxious disorder, simple and social phobias and separation anxiety were remarkably higher in the circumcision group.

Conclusion
The application of topical steroids is an easy, effective and low-cost treatment for phimosis. Circumcision is a traumatic experience and anxiety scores in a child tested by DSM-III-R increase preoperatively and perioperatively. In populations where circumcision is a cultural necessity, medical therapy for phimosis with topical steroids can be justified, particularly during the phallic period.

 

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