Marked titles link to the actual articles, in the
CIRP reference library
Adler, Sandra Ottaway and Stacey Gould
Circumcision: We Have Heard From the Experts; Now Let's Hear From the
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!
of female genital mutilation
Almroth, Vanja Almroth-Berggren, Osman Mahmoud Hassanein,
Said SalahEldin Al-Said, Sharif Siddiq Alamin Hasan, Ulla-Britt
Male complications of female genital mutilation
Social Science & Medicine 53 (2001) 1455–1460
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
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.
||Assmann 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]
Harrison SK, Hutton KA.
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.
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."
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.
Genital Cutting andWestern Discourses
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.
article explores dominant discourses surrounding male and female
genital cutting. Over a similar period of time, these genital
have separately been subjected to scrutiny and criticism. However,
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
of these practices. Rather, attitudes toward genital cutting reflect
historically and culturally specific understandings of the human body.
particular, I suggest that certain problematic understandings of male
female sexuality are deeply implicated in the dominant Western
on genital surgery.
||D. Berdeu, L. Sauze, P.
Ha-Vinh and C. Blum-Boisgard
analysis of treatments for phimosis: a comparison of surgical and
medicinal approaches and their economic effect
BJU International 87 (3), 239-244
"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."
||Birley 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.
|Blalock HJ, Vemulakonda V,
Ritchey ML, Ribbeck M.
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
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
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 -
PMID: 12771793 [PubMed - as supplied by publisher]
D., Van Howe, R. S
Alexithymia and Circumcision Trauma: A Preliminary Investigation
J Sex Med, 14 Apr 2011
This preliminary study investigates what role early trauma might have
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.
genital-cutting advocates Brian Morris and Jake Waskett (who claims to
advocate only "parental choice"- negating the penis-owner's
choice) have predictibly criticised the study, and Bollinger and Van Howe have replied.
||Gregory J. Boyle (Bond
Univeristy, Australia), Ronald
Goldman, J. Steven Svoboda and Ephrem
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.
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
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
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
the evidence on this issue and participate in the debate about the
advisability of this surgical procedure on unconsenting minors.
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]
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.
B, Wiebe N, Lander JA
Pain relief for neonatal circumcision
Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004217
The objective of this review was to
assess the effectiveness and safety of interventions for reducing pain
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
in newborns. None of the studied
interventions completely eliminated the
pain response to circumcision.
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.
avium causes disseminated infection in
patients with acquired immune deficieny syndrome. Mycobacterium
tuberculosis is a pathogen associated with the deaths of
people worldwide annually. Effective therapeutic regimens exist that
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
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
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.
Informed consent for neonatal circumcision: an ethical and legal
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
practice of circumcision and the legal and ethical duties of medical
specialists. This document is worth a read by all of us who perform
of Urology is the official journal of the American
Urological Association. This editorial comment seems to be a
quasi-official warning to urologists.
||FGC vs MGC, media
||Laura M. Carpenter &
Heather Hensman Kettrey
(Im)perishable Pleasure, (In)destructible
Desire: Sexual Themes in U.S. and English News Coverage of Male
Circumcision and Female Genital Cutting
The Journal of Sex Research, 52:8, 841-856,
what conditions do sexual pleasure and desire get addressed in news
coverage of sexual health issues like female genital cutting (FGC) and
male circumcision (MC)? In this study we employed an embodied
ethnosexuality approach to analyze sexual themes in 1,902 items
published from 1985 to 2009 in 13 U.S. and 8 English newspapers and
news magazines. Journalists’ discussions of sexual pleasure, desire,
control, problems, and practices differed in quantity and quality
depending on the practice and nation to which they pertained. News
coverage in both nations presented FGC as impeding female sexual
pleasure, desire, and activity in ways that reinforce (hetero)sexist
understandings of sexuality. The
English press depicted MC as diminishing male sexuality, whereas U.S.
papers showed it as enhancing male sexuality. These
patterns are influenced by, and serve to reinforce, cultural norms of
embodiment and ethnosexual boundaries based on gender, race, and
nationality. They may, in turn, shape public understandings of FGC and
MC as social problems.
This article is valuable is exposing the bias towards male genital
cutting in US media. Astonishingly, the authors fail to see
their own bias in choosing their terminology: "Recognizing that the
terms people use for these practices imply particular positions, we
employ what appear to be the least value-laden—FGC and MC—and use the
abbreviation ‘‘MC’’ to make the terms more parallel. The term MGM is
used chiefly by anti-MC activists; some anti-FGC activists prefer the
term FGM while others prefer FC, a term also used by practice
"MC" is also used by practise proponents, and the option of
"MGC" does not seem to have occured to them.
They also assume the distored media reportage of the Laumann
findings about MGC and sexual practice, rather than what the study
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
... 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
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
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.
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.
prepuceplasty with wound healing by second intention: An alternative
surgical approach in children's phimosis treatment.
BMC Urol. 2008 Mar 4;8(1):6
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]
and J.R. Taylor
British Journal of Urology,
Volume 83, Suppl. 1: Pages 34-44,
|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.
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, O. Shisana, L. Simbayi, M. Colvin
HIV and circumcision in South Africa
Conference on HIV/AIDS, Bankok, 2004
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.
Male Sexuality: Lallemand, Spermatorrhea, and the Rise of Circumcision
Journal of the History of Medicine and Allied Sciences 2005
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.
|Robert J L
Medical history and medical practice: persistent myths about the
2003 178 (4): 178-179
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, T. van Roode , P. Herbison, C. Paul.
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
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.
McRaven MD, Kelley Z, Penugonda S, Hope TJ.
Keratinization of the adult male foreskin and implications for male
AIDS. 2010 Jan 21. [Epub ahead of
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
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.
a larger sample size, Qin
et al. found inner foreskin to
be thicker than outer.]
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."
|| 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, D.M., Lawton, J.M.
and Shannon, F.T,
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
||Ch. Fischer-Klein and M.
Triple incision to treat phimosis in children: an alternative to
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, Paul M and Frederick
Circumcision Does Not Protect Against Cancer (letter),
British Medical Journal, (London) Vol. 312 no 7033 (March
23, 1996): pp. 779-780
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.
||M. Fox and
A covenant with the status quo? Male circumcision and the new BMA
J Med Eth. 2005; 31(8):463-9
This article offers a critique of the recently revised BMA guidance on
routine neonatal male circumcision and seeks to challenge the
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.
and Michael Thomson
HIV/AIDS and circumcision: lost in translation
J Med Ethics 2010;36:798-801
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, 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.
||John V. Geisheker
The Completely Unregulated Practice of Male Circumcision: Human Rights’
Abuse Enshrined in Law?
New Male Studies Journal 2:1 2013
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
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
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
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
||Matthew R. Giannetti
and the American Academy of Pediatrics: Should Scientific
Misconduct Result in Trade Association Liability?
IOWA LAW REVIEW, Vol 85, No 4, pp 1507-1568,
|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
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
"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.
S, Gregoriou S, Georgala C, Papaioannou D, Befon A, Kalogeromitros D,
1% cream in non-specific inflammatory recurrent balanitis
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]
|Gray J, Boston VE.
Glanular reconstruction and preputioplasty repair for distal
a unique day-case method to avoid urethral stenting and preserve the
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
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 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.
Rationalising circumcision: from tradition to fashion, from public
health to individual freedom-critical notes on cultural persistence of
the practice of genital mutilation
of Medical Ethics (U.K.), Volume 30: Pages 248-253, June 2004.
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
Circumcision and Human Behavior
|"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, Frederick M., Phimosis
World Journal of Urology, Volume 17, No. 3 : pp. 133-136, June 1999
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.
||Hodges, Frederick M.
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.
||Hoebeke PB, De Kuyper P, Van
of ventral skin in hypospadias repair, clue to aesthetic repair (point
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
penile shaft. Preserving the foreskin is taken for granted.
Conditions affecting the foreskin
Nursing Standard, 26,37, 35-9, February 2012
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
||Jorgenson, ET, Svensson A.
The treatment of Phimosis in Boys, with potent topical steroid cream.
Acta Dermato-Venereologica (Stockholm) 73:55-56, 1993
||J Pediatr Health Care 2001
of pain management interventions for neonatal circumcision
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.]
||HIV, risk compensation
||Kalichman S, Eaton L,
for HIV Prevention: Failure to Fully Account for Behavioral Risk
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
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.
||phimosis, frenulum breve
Li C-Y, Spillings A, Ralph D
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
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
Aim. To demonstrate the utility of
frenular grafting in patients with a
tight frenulum and concomitant phimosis who wish to retain their
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
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
Results. All men received an
interposition skin graft with 100% viability,
with no revision surgery required. Postoperatively, all men were
active and able to retract their foreskin.
Conclusions. Cosmetic outcomes are
encouraging and painless sexual
intercourse is attainable in this difficult group of patients.
||DaiSik Kim and Myung-Geol Pang
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
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
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.
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, 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.
and L.M. SOUTH
Lateral preputioplasty for phimosis
44, October 1999, 310-12
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
cicumcision a more conservative approach is recommended in those
patients with non-retractile foreskins. In this study, patients
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
symptoms such as fissuration, thought suitable for a more conservative
approach, were listed for preputioplasty. Those with a phimosis but
local symptoms were reassured and discharged. Thirty patients were
for preputioplasty. One patient developed a post-operative wound
which settled with oral antibiotics prescribed by his general
This left him with further preputial adhesions and he later underwent
circumcision. The remaining patients reported no post-operative
follow-up. Cosmesis was good with high levels of patient satisfaction
expressed. All had easily retractile foreskins at follow-up. Large
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,
importance of which is only now beginning to emerge.
[Conservative therapy of phimosis]
Monatsschr Kinderheilkd 1986 Nov;134(11):824-5
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."
|Laumann EO, Masi CM,
Zuckerman EW. Circumcision
in the United States: prevalence, prophylactic effects, and sexual
|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
The sexual dysfunction data was not corrected for ethnicity and factors
that flow from it, such as tendency towards hypertension, which causes
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.
||Laumann, Edward O., PhD; Anthony Paik, MA;
Raymond C. Rosen, PhD
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."
Leibowitz, Katherine Desmond, Thomas Belin
Determinants and Policy Implications of Male Circumcision in the United
American Journal of Public Health, 10.2105/AJPH.2008.134403
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
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
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 Anish Shah
Male circumcision and child safeguarding
British Association for Community Child Health (BACCH) Newsletter, June
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
organisations are increasingly turning away from this traditional
religious operation, and why it should now be considered a child
||McCredie 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
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
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
(IPSS > or = 20) urinary symptoms were compared with those with
mild or no
symptoms (IPSS < 8) using unconditional logistic regression.
age-specific prevalence of moderate-to-severe urinary symptoms (IPSS
= 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
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]
The Frenular Delta: a New Preputial Structure
ed. Denniston et al. Kluwer Academic/Plenum Publishers, New York, 2001,
|describes the frenular delta, a
sensitive area under the intact penis, distinct from the ridged band.
Machmouchi, A. Alkhotani
Is Neonatal Circumcision Judicious?
J Pediatr Surg 2007; 17: 266-269
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
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
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.]
||Maden, Christopher, et al., History
of Circumcision, Medical Conditions, and Sexual Activity and Risk of
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."
||Joseph 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],
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
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.
||Mueller 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
||William Keith C. Morgan, MD
Rape of the Phallus
Journal of the American Medical Association
Volume 193 No 3
July 19, 1965.
Reprinted for a wider audience in The Realist,
|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.
Proximate and ultimate influences on the regulation of mating in the
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".
Naimer, K. Zega, W.F. Silverman
Anatomy of the cutaneous surface of the male genitalia, with
elaboration upon the inner preputial coronal-shaft junction
J. Ped. Urol (2015), http://dx.doi.org/10.1016/j.jpurol.2015.06.022
Descriptions of the penile prepuce in anatomical and clinical texts
either omit details or contain a small, yet potentially serious, error
with regard to the manner of its attachment to the penis.
This study sought to cast light on a ubiquitous but poorly understood
and under-appreciated structure, while correcting a long-standing
mistake in the medical literature.
The foreskins of five male
stillborn babies were dissected and carefully examined.
Tissue from the apposing surfaces of the various regions of the inner
and outer prepuce surfaces and the transition zone itself were
collected, embedded in paraffin, sectioned, stained, examined and
photographed under microscopy.
Contradicting the prevailing descriptions in the literature that the
inner prepuce is a single, uniform sheath, this study's observations
and histological findings demonstrated that it actually splits into
separate laminae that connect distally to the shaft at the base of the
corona and proximally with the shaft fascia, respectively.
The penile prepuce is a discrete and deceptively complex part of the
male anatomy, yet key details of its interposing surfaces are
inaccurately described or entirely omitted in the literature.
Understanding the normal anatomy of the prepuce is critically relevant,
particularly for urologists and
others involved in the performance of circumcision. For
example, avoiding potentially catastrophic avulsion of the inner
preputial remnant beyond the coronal sulcus during circumcision and
accurate assessment of tissue positioning prior to penile
reconstruction in cases of hypospadias.
The findings of this study correct a misunderstanding in the anatomy of
Over the proximal border of the corona the inner
prepuce spits into two laminae each of a separate orientation.
This astonishing study, by three Israeli doctors, is like a study of
the anatomy of the neck performed by Elizabethan executioners. No
consideration is given to the complex structure or many functions of
the prepuce in the adult man. From that point of view, the attachment of
the very thin shaft mucosa when it ends at the base of the preputial
sac is made doubly secure by the two laminae. The prepuce is still not
a distinct (and hence easily removable) structure. There is still no
||Ng'ayo MO, Bukusi E, Morrow
RA, Rowhani-Rahbar A, Obare BA, Friedrich D, Holmes KK.
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
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
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'Hara K, O'Hara J.
effect of male circumcision on the sexual enjoyment of the female
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.
||Hatice Ozdogan, Selcan Osma,
Gozde B Aydin, Avni Dinc, Gulten Ozgun
presenting in a circumcised
baby following application of prilocaine: a case
Journal of Medical Case Reports 2010, 4:49
Introduction: Local anesthesia with
prilocaine has become a routine part of ambulatory circumcision
Methemoglobinemia is a rare but potentially lethal complication of
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
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
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
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.
||Rafael V. Pieretti, Allan M.
Goldstein and Rafael Pieretti-Vanmarcke
complications of newborn circumcision: a common and avoidable problem,
Ped. Surg. Int. DOI 10.1007/s00383-010-2566-9
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
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
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.
results indicate yet again that circumcision should not be performed in
the absence of pressing medical need.]
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]
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
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
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
Rajan, S Alan McNeill, and Kevin J Turner
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, Gregory J. Boyle
Ritual and Medical Circumcision among
Filipino boys: Evidence of Post-traumatic Stress Disorder
|... 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
information, including any history of other traumatic events, and
perception of the
circumcision experience. The second part assessed the presence of post
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
circumcision (Tuli), and 51% of those subjected to medical circumcision
DSM-IV criteria for a diagnosis of PTSD
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
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.
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
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
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 <
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
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.
the father's circumcision status is an independent variable, directly
affecting what they do, regardless of what they say.]
||J Richters, AM Smith, RO de
Visser, AE Grulich, and CE Rissel
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
Circumcision and the Socially Imagined Sexual BodySubject
Sociology Review Volume 15 Issue 3 - 2006
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
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.
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."
Eissa MA, Cromwell PF, Barratt MS, Bortot A.
circumcision status by adolescents.
Am J Epidemiol. 2004 Jun
|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.
||Consent for non-therapeutic
male circumcision on
Robinson R, Makin E, Wheeler R
Ann R Coll Surg Engl 2009; 91: 152–154
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.
A total of 62 boys aged 1–14 years (median age, 4 years) underwent
non-therapeutic circumcision. Written
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.
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.
|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
adult men request the procedure. "College girls" are said to prefer
for sex and marriage. One young woman told interviewer that she would
consider her fiance a "real coward" and "effeminate" (local language
if he was intact and refused supercision. Reasons offered by "coeds"
preferring supercised men: Christian custom, makes man complete,
protects against cancer, promotes physical growth and strength, intact
smell bad, more pleasure because supercised penis is "bigger and
intact men are unnatural.
||Schoen EJ, Anderson G, Bohon
C, et al: Report of the American Academy of Pediatrics Task Force on
Schoen, E.J.: Benefits of Newborn Circumcision: Is Europe Ignoring
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.
||Schwartz, William M., MD;
Charney, Edward B., MD; Curry, Thomas A., MD;
Ludwig, Stephen., MD
PEDIATRIC PRIMARY CARE: A Problem-solving
2nd Edition, Year Book Medical Publishers, Inc., 1990, pp.
|Discusses the real rate of
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 ).
||Urinary Tract Infections
D, Macdessi J, Craig J.
Circumcision for the prevention of urinary tract infection in boys: A
review of randomized trials and observational studies
Arch Dis Child. 2005 May 12; [Epub ahead of print]
|"Given a risk of UTI in
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
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
PMID: 15890696 [PubMed - as supplied by publisher]
This is a meta-analysis of earlier work, not a new
||Somerville, 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, James L. Snyder, Mark D. Reiss, Christopher Eden, Marilyn F.
Milos, Norma Wilcox, Robert S. Van Howe
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)
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.
||Katrina Spilsbury, James B
Semmens, Z Stan Wisniewski and C D'Arcy J Holman
for phimosis and other medical indications in Western Australian boys
MJA 2003 178 (4): 155-158
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.
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.
||J. S. Svoboda, R. S. Van Howe
and J. G. Dwyer
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
||J. S. Svoboda, and R. Darby
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),
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
of male and female genital surgeries are explored, and a scale of
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,
brief conclusion makes a plea for greater gender neutrality in the
approach to this contentious issue.
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 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 A, Katz J, Ilersich
AL, Koren G.
of neonatal circumcision on pain response during subsequent routine
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
||Taddio A, Pollock N, Gilbert-MacLeod C, Ohlsson
K, Koren G
Combined analgesia and local anesthesia to minimize pain during
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 A, Shah V,
Gilbert-MacLeod C, Katz J.
Conditioning and hyperalgesia in newborns exposed to repeated heel
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
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.
||Taylor, J.P., A.P. Lockwood
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.
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
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
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.
findings are certainly interesting, but a much larger sample is needed
before we can conclude that circumcision actually has these effects.]
||To T., Agha M., Dick P.T. et
study on circumcision of newborn boys and subsequent risk of
|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.
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
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.
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
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
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%)
32 had no macroscopic evidence of BXO. The incidence of meatal
stenosis was significantly less in the foreskin preputioplasty group, 6
104 vs 6 (19%) of 32 (P = .034).
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
consent: moral authority misconceived
Journal of Medical Ethics
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.
||R. S. Van
A Cost-Utility Analysis of Neonatal Circumcision
Med Decis Making, December 1, 2004; 24(6): 584 - 601
|A Cost-Utility Analysis of
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
circumcised was undertaken using the Quality of Well-being Scale, a
analysis, the standard reference case, and a societal perspective.
Neonatal circumcision increased incremental costs by $828.42 per
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.
||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
examinations and age younger than 3 years, exact logistic regression
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
Direct Link: http://www.ncbi.nlm.nih.gov/entrez/q...ubmed_docsu m
||A. Way, V.
Mishra, R. Hong, K. Johnson
male circumcision protective of HIV infection?
AIDS 2006 - XVI International AIDS Conference
Abstract no. TUPE0401
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.
Werker, Amrita Ahuja, and Brian Wendell
Male Circumcision and AIDS: The Macroeconomic Impact of a
Working paper, Harvard Business School, October 2006 - unpublished but widely
Theories abound on the potential macroeconomic impact of AIDS in
there have been surprisingly few empirical studies to test the mixed
predictions. In this paper, we examine the impact of the AIDS epidemic
African nations through 2002 using the male circumcision rate to
plausibly exogenous variation in HIV prevalence. Medical researchers
found significant evidence that male circumcision can reduce the risk
contracting HIV. We find that national male circumcision rates for
countries are both a strong predictor of HIV/AIDS prevalence and
with other determinants of economic outcomes. Two-stage least squares
regressions do not support the hypotheses that AIDS has had any
impact on economic growth, savings, or fertility behavior in African
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,
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 Kapila, Complications
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.
||Winberg, Jan, Ingela
Bollgreg, Leif Gothefors, Maria Herthelius, Kjell Tullus,
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.
TE Prepuce presence portends prevalence of potentially perilous
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.
Wiswell TE, Smith FR, Bass JW Decreased incidence of urinary tract
infections in circumcised male infants.
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
He is on record
as seeing financial benefit to doctors from circumcision.
||Wolbarst Abraham L. Universal
circumcision as a sanitary measure.
JAMA 1914; 62:92-7
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.)
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
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.
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.]
||Erdal 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,
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
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.
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.