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Numerous medical studies have examined the effects of male circumcision with mixed opinions regarding the benefits and risks of the procedure. Opponents of circumcision say it is medically unnecessary, is unethical when performed on newborns, is painful even when performed with anesthetic, adversely affects sexual pleasure and performance, and is a practice defended by myths. Advocates for circumcision say it provides important health advantages which outweigh the risks, that it improves on sexual function, has a complication rate of less than 0.5% when carried out by an experienced physician, and is best performed during the neonatal period.

The Royal Dutch Medical Association stated in 2010: "There is currently not a single doctors' organisation that recommends routine circumcision for medical reasons."

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

Positions of major health organizations

Australasia

The Royal Australasian College of Physicians (RACP; 2009) state that "after extensive review of the literature" they " not recommend that routine circumcision in infancy be performed". They also state that "if the operation is to be performed, the medical attendant should ensure this is done by a competent surgeon, using appropriate anaesthesia and in a safe child-friendly environment." Additionally, the RACP state that there is an obligation to provide parents who request a circumcision for their child with accurate, up-to-date and unbiased information about the risks and benefits of circumcision, adding that "in the absence of evidence of substantial harm, parental choice should be respected."

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Circumcision: Information for Parents" in November 2004, and "Neonatal circumcision revisited" in 1996. The 1996 position statement says that "circumcision of newborns should not be routinely performed", and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many paediatricians no longer perform circumcisions."

Regarding the practice of routine infant circumcision, the College of Physicians and Surgeons of British Columbia states in its 'Professional Standards and Guidelines' (version September 2009) that "Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention."

Netherlands

The Royal Dutch Medical Association issued a new policy in May 2010: "The official viewpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children’s rights to autonomy and physical integrity. Contrary to popular belief, circumcision can cause complications – bleeding, infection, urethral stricture and panic attacks are particularly common. KNMG is therefore urging a strong policy of deterrence. KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications."

United Kingdom

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

United States

In a 2012 position statement, the American Academy of Pediatrics (AAP) stated that a systematic evaluation of the medical literature shows that the "preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure" and that the health benefits "are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns," but "are not great enough to recommend routine circumcision for all male newborns". The AAP takes the position that parents should make the final decision about circumcision, after appropriate information is gathered about the risks and benefits of the procedure. The 2012 statement shows a shift in the AAP's position from their 1999 statement in that the AAP says the health benefits of the procedure outweigh the risks, and supports having the procedure covered by insurance.

The AAP's 2012 position statement was also endorsed by the American College of Obstetricians and Gynecologists.

In 1999, the AMA stated that that circumcision "decreases the incidence of urinary tract infections in the first year of life, and also protects against the development of penile cancer later in life," but the low overall incidence of these conditions minimizes the benefits to risks. The AMA, in agreement with the AAP's 1999 position, stated that, although the medical benefits of circumcision do not outweigh the risks to the degree that routine infant circumcision can be recommended, parents should make their own, informed decision, and if the procedure is chosen, anesthetics should be used to block or minimize the pain. In 2011, American Medical Association president Peter W. Carmel stated, "There is strong evidence documenting the health benefits of male circumcision, and it is a low-risk procedure."

The American Academy of Family Physicians (AAFP), in their 2007 position paper on circumcision, states that the procedure has a reputation for being indicated for preventing UTIs and the contraction of some STDs, including HIV. The AAFP found the procedure to provide an absolute risk reduction of UTIs of 1%, of penile cancer of 0.2%, and that it is associated with a reduced risk of acquiring an STD, and of HIV transmission "in underdeveloped areas where the virus is highly prevalent." The complications of infection, bleeding, and failure to remove enough foreskin occur in less than 1% of procedures, and make up the vast majority of all complications; however, "more serious complications have also occurred," and that "evidence-based complications from circumcision include pain, bruising, and meatitis." The AAFP recommends that families make an informed choice about circumcision, and if so, anesthesia should be used.

The American Urological Association, in their 2007 policy statement on circumcision, said that "neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks," that it is "generally a safe procedure when performed by an experienced operator," and that although the possibility for serious complications exists, "when performed on healthy newborn infants as an elective procedure, the incidence of serious complications is extremely low." It described the specific benefits of circumcision as that it "prevents phimosis, paraphimosis and balanoposthitis, and is associated with a decreased incidence of cancer," but that its association with "reduced incidence of sexually transmitted diseases is conflicting." Regarding the 2005 and 2007 African HVI studes, the AUA stated that there is "convincing evidence that circumcision reduces by 50-60% the risk of transmitting the human immunodeficiency virus (HIV) to HIV negative men through sexual contact with HIV positive females," and that while "the results of studies in African nations may not necessarily be extrapolated to men in the United States at risk for HIV infection," the AUA "recommends that circumcision should be presented as an option for health benefits," but not the only strategy for reducing the spread of HIV. Like other organizations, the AUA states that the decision of whether to circumcise should be up to the informed consent of parents.

Costs and benefits

In June 2004 the College of Physicians and Surgeons of British Columbia said:

"Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention."

Several cost-benefit analyses of infant circumcision have been published:

• Cadman et al. (1984) concluded that the expense of circumcision outweighed any money that might be saved by reducing the risk of penile cancer. Therefore, they argued, public funds should not pay for it.

• Lawler et al. (1991) reported a net cost of $25.00 and a benefit of ten days of life. They concluded that there was no medical indication for or against circumcision.
• Ganiats et al. (1991) reported a net cost of $102 and a loss of 14 hours of healthy life. They found no medical reason to recommend for or against circumcision.

• Chessare (1992) weighed the risks of circumcision against the prevention of urinary tract infections. He concluded that non-circumcision produced the “highest expected utility”, provided that the probability of developing a UTI was less than 0.29%.
• Christakis et al. (2000) report that "Circumcision remains a relatively safe procedure. However, for some parents, the risks we report may outweigh the potential benefits."

• Van Howe (2004) reported that the overall effect of male neonatal non-therapeutic circumcision on health is more likely to be negative rather than positive.

• Singh-Grewal et al. (2005) compared reduction in risk of urinary tract infections with an estimated 2% complication rate, and concluded: "Haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%. Assuming equal utility of benefits and harms, net clinical benefit is likely only in boys at high risk of UTI." In an accompanying editorial, Schoen argued that the 2% complication rate used by Singh-Grewal et al. was high, noting that the American Academy of Pediatrics estimated the rate as 0.2% to 0.6%.

• Schoen et al. (2006) concluded: "Multiple lifetime medical benefits of neonatal circumcision can be achieved at little or no cost. Because postneonatal circumcision is so expensive, its rate is the most important factor determining future cost savings from newborn circumcision."

Some public and private health insurance providers have deleted coverage of elective non-therapeutic circumcision. In such cases, the cost falls on the person electing the procedure.

Circumcision procedures

Circumcision removes the foreskin from the penis. For infant circumcision, clamps, such as the Gomco clamp, the Plastibell, or the Mogen clamp are often used. Clamps cut the blood supply to the foreskin, stop bleeding and protect the glans. Before use of a clamp, the foreskin and the glans are separated with a blunt probe and/or curved hemostat.

• With the Plastibell, the foreskin and the clamp come away in three to seven days.

• With a Gomco clamp, a section of skin is first crushed with a hemostat then slit with scissors. The foreskin is drawn over the bell-shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is then tightened, "crushing the foreskin between the bell and the base plate." The crushing limits bleeding (provides hemostasis). While the flared bottom of the bell fits tightly against the hole of the base plate, the foreskin is then cut away with a scalpel from above the base plate. The bell protects the glans from the scalpel.

• With a Mogen clamp, the foreskin is grabbed dorsally with a straight hemostat, and lifted up. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result," according to Reynolds, than with Gomco or Plastibell circumcisions. The clamp is locked shut, and a scalpel is used to cut the foreskin from the flat (upper) side of the clamp.

The frenulum may be cut if frenular chordee is evident.

Complications

After reviewing the literature, the American Academy of Pediatrics (2012) found that acute complications "most commonly involve bleeding, infection, or an imperfect amount of tissue removed," and that "significant acute complications are rare," occurring in about 1 in 500 newborn procedures; severe to catastrophic complications were so rare that they were only reported as case reports. The AAP also found it difficult to report an overall complication rate due to scant data on complications, and inconsistencies in how a "complication" was classified across the literature reviewed. In their review of the medical literature, the American Academy of Family Physicians (2007) found that the complications of infection, bleeding, and failure to remove enough foreskin occur in less than 1% of procedures, and make up the vast majority of all complications. They also found "more serious complications have also occurred," and that "evidence-based complications from circumcision include pain, bruising, and meatitis." The American Urological Association (2007) stated that neonatal circumcision is "generally a safe procedure when performed by an experienced operator," and that although the possibility for serious complications exists, "when performed on healthy newborn infants as an elective procedure, the incidence of serious complications is extremely low."

Immediate complications

Male circumcision is a cutting operation and like other cutting operations, surgical mishaps, infection, and hemorrhage occur. Williams & Kapila (1993) report an "enormous variety of complications" and estimate a complication rate of 2-10 percent but say deaths are rare.

According to the AMA, blood loss and infection are the most common complications, but most bleeding is minor and can be stopped by applying pressure. These complications are less likely with a skilled and experienced circumciser. Kaplan identified other complications, including urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias, impotence and removal of too much tissue, sometimes causing secondary phimosis. He stated, “Virtually all of these complications are preventable with only a modicum of care" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.”

Infection

Infections are usually minor and local, but sometimes they have led to urinary tract infection, life-threatening systemic infections, meningitis or death.

Hemorrhage

Bleeding after circumcision is usually minor and easily controlled, but on rare occasions it has led to shock from blood loss (hypovolemic shock) or death (exsanguination).

Coagulation disorders affect from 2 to 4 per cent of the population and the condition is underdiagnosed. Severe bleeding following circumcision may be a sign of hemophilia.

Surgical mishap

Mistakes can happen with any surgery. Surgical mistakes from circumcision include documented cases of penile denudation, cutting off part or all of the glans penis, urethral fistula, several types of injury associated with certain types of circumcision clamps used and penile necrosis which results in loss of the entire penis. The RACP (2004) states that the penis is lost in 1 in 1,000,000 circumcisions.

Anesthetic risk

Anesthetic risk includes Methemoglobinemia, because of the immaturity of the methaemoglobin reductase pathway.

Death

Although deaths have been reported, the American Academy of Family Physicians (2007) states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision.

Delayed complications

• Meatal stenosis may be a common longer-term complication from circumcision. Recent publications give a frequency of occurrence between 0.9% and 9% to 10%. The opening to the urethra (meatus) may also be affected, leading to inflammation and meatal ulceration.
• Urinary retention
• Venous stasis, the slowing down of venous blood flow
• Concealed penis
• Adhesions
• Skin bridges, when the cut skin attaches to the glans penis. Skin bridges do not commonly require surgical correction; rather, a brief, simple office procedure may be performed.
• Painful erections.

Psychological and emotional consequences

Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, and cite a longitudinal study which did not find any difference in developmental and behavioural indices. A literature review by Gerharz and Haarmann (2000) reached a similar conclusion. Goldman (1999) discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure. Boyle et al. (2002) state that circumcision may result in psychological harm, including post-traumatic stress disorder (PTSD), citing a study that shows an incidence rate of PTSD (measured according to DSM-IV) of almost 70% among Filipino boys subjected to ritual circumcision, and 51% among boys subjected to medical circumcision (with local anaesthetic). Hirji et al. (2005) state that "Reports of psychological trauma are not borne out in studies but remain as an anecdotal cause for concern." The British Medical Association (2006) stated that the "medical harms or benefits have not been unequivocally proven," and that " it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks."

Some organizations have formed support groups for men who are resentful about being circumcised.

Pain

The American Academy of Pediatrics' policy states:

Some common painful minor procedures, such as circumcision, do not always receive the warranted attention to comfort issues. Available research indicates that newborn circumcisions are a significant source of pain during the procedure and are associated with irritability and feeding disturbances during the days afterward. Opportunities for alleviating pain exist before, during, and after the procedure, and many interventions are effective.

-- The Assessment and Management of Acute Pain in Infants, Children and Adolescents, 2001.

Many studies have examined adverse effects of the procedure; some employing various forms of pain relief. A few of these findings are summarised in the following table.

Studies investigating several forms of pain relief have one entry for each form.

Many other studies have investigated the pain caused by circumcision, and the effectiveness of different forms of analgesia and anaesthesia.

Taddio et al. reported behavioural changes (heightened pain responses) during vaccinations in children circumcised with EMLA cream and with no anaethesia at the 99.9+% statistical confidence level (p<0.001) four to six months after their circumcision, suggesting a persistent effect on pain response. The researchers commented:

"Study of the vaccination pain response of infants who had received more effective circumcision pain management (i.e., dorsal penile nerve block and adequate postoperative pain management) would be interesting."

Kirya and Werthmann investigated the effect of dorsal penile nerve block (DPNB), describing it as "painless". However, Lander et al. found that DPNB is less effective than ring block.

Breastfeeding

Some advocates have hypothesized that circumcision may negatively impact breastfeeding. The most current research does not support the belief that neonatal circumcision disrupts breastfeeding.

Earlier studies exploring this phenomenon include the Howard study, reporting that neonatal circumcision without anaesthesia and using acetaminophen (Tylenol) results in deteriorated feeding immediately after circumcision. They commented:

Numerous studies have shown that circumcision causes severe pain. This is shown by measures of crying, heart rate, respiratory rate, transcutaneous PO₂, and cortisol levels…… Neonatal circumcision are often performed on the day of discharge with many neonates leaving the hospital 3 to 6 hours postoperatively. Thus the observed deterioration in ability to breast-feed may potentially contribute to breast-feeding failure. Furthermore some neonates in this study required formula supplementation because of maternal frustration with attempts at breast-feeding, or because the neonate was judged unable to breast-feed postoperatively. This finding is disconcerting because early formula supplementation is associated with decreased breast-feeding duration.

Howard et al. concluded that:

Acetaminophen was not found to ameliorate either the intra-operative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the postoperative period.

Fergusson et al. found no evidence in their study of an association between neonatal circumcision and breastfeeding outcomes. They concluded that "the findings do not support the view that neonatal circumcision disrupts breastfeeding."

Long Term Costs and Benefits

Conditions affecting the prostate

Ross et al. (1987) reported on two case-control studies in Southern California. Both studies included 142 cases and in each study the risk was lower in circumcised men (relative risk of 0.5 in whites and 0.6 in blacks). Mandel & Schuman (1987) reported on a case-control study with 250 cases. Compared with controls drawn from their neighborhood, circumcised men were less likely to develop prostate cancer (odds ratio 0.82). Ewings & Bowie (1996) performed a case-control study of 159 cases of prostate cancer, and found a reduced rate among circumcised men (odds ratio 0.62). The authors noted: "...some statistically significant associations were found, although these can only be viewed as hypothesis generating in this context."

McCredie et al. (2001) studied 1,216 men aged 40–69 years using the International Prostate Symptom Score, and found that being circumcised was associated with a higher prevalence of moderate-to-severe urinary symptoms.

In September 2010, the Royal Australasian College of Physicians stated that "Circumcision has not been demonstrated to decrease the risks of prostate cancer."

Human Papilloma Virus (HPV)

A meta-analysis by Van Howe in 2006 found no significant association between circumcision status and HPV infection and that "the medical literature does not support the claim that circumcision reduces the risk for genital HPV infection". However, Castellsagué et al. maintain that this meta-analysis was flawed, and further note that a re-analysis of the same data "... clearly shows, no matter how the studies are grouped, a moderate to strong protective effect of circumcision on penile HPV and related lesions."

In several studies, uncircumcised men were found to have a greater incidence of human papilloma virus (HPV) infection than circumcised men. One of these studies has been criticized on methodological grounds. One study found no statistically significant difference in the incidence of HPV infection between circumcised and uncircumcised men.

Two studies have shown that circumcised men report, or were found to have, a higher prevalence of genital warts than uncircumcised men.

The Medical College of Georgia studied the impact of a new (as of 2004) vaccine against "HPV types 16 and 18, the two most common causes of cervical and penile cancer".

Circumcision has been associated with a lower incidence of Human Papilloma Virus infection in males in several studies. HPV infection is a known risk factor in the development of penile cancer. Other studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer. "In weighing the risks and benefits of circumcision, doctors consider the fact that penile cancer is one of the least common forms of cancer in the United States" and "Ultimately, decisions about circumcision are highly personal and depend more on social and religious factors than on medical evidence". They state that it is important to concentrate on the main risk factors: poor hygiene, having unprotected sex with multiple partners, and cigarette smoking. They also state that the current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer.

HPV and cervical cancer

Some medical researchers have found evidence of a link between a higher incidence of cervical cancer in female partners of uncircumcised men and a higher incidence of penile human papillomavirus (HPV) in uncircumcised men.

Stern and Neely (1962) observed no protective effect of male circumcision in female partners. Punyaratabandhu et al. (1982) reported a protective effect in Thai women. Kjaer et al. (1991) reported an apparently protective effect in Dutch women, that failed to achieve statistical significance. Agarwal et al. (1993) observed a significantly protective effect among Indian women.

The role of male circumcision in female infection with HPV remains controversial. As Castellsagué (2002) said, "…it would not make sense to promote circumcision as a way to control cervical cancer in the United States, where Pap smears usually detect it at a treatable stage."

Penile cancer

Penile cancer is very rare in North America and Europe; it accounts for about 0.2% of cancers in men and 0.1% of cancer deaths in men in the United States. Annually, there is one case in 100,000 men in the United States. However, penile cancer is much more common in some parts of Africa and South America, where it accounts for up to 10% of cancers in men.Penile cancer is a rare form of cancer, mostly occurring in men over the age of 60. Frisch et al. evaluated penile cancer rates in Denmark and found that Danish men (who are predominantly not circumcised) had an incidence of 0.9-1.0 per 100,000 in 1975.

Kochen and McCurdy performed a life table analysis on penile cancer rates, and estimated that penile cancer affected uncircumcised males at a rate of 1 in 600. However, Poland has criticised the assumptions used in their analysis.

Burkitt (1973) states that the geographical distribution of penile cancer is strongly influenced by circumcision status. However, he notes wide differences in penile cancer rates between African tribes who do not practice circumcision, and suggests that additional etiological factors may be responsible.

The Canadian Paediatric Society (1982) assert that there could be genetic or environmental factors that influence the incidence of carcinoma and that the association with circumcision could be coincidental.

Childhood circumcision has been associated with a reduced incidence of penile cancer in numerous studies. Boczko and Freed (1979) stated that since Wolbarst's 1932 review, "there have been only eight documented cases of penile carcinoma in an individual circumcised in infancy." They described the ninth reported case, concluding that "performing it in infancy continues to be the most effective prophylactic measure against penile carcinoma." The AMA remarked that in six case series published from 1932 and 1986, "all penile cancers occurred in uncircumcised individuals."

Maden et al. (1993) reported that the risk of penile cancer was greater in men who were never circumcised (OR 3.2; 95% CI 1.8-5.7) and among those who were circumcised after the neonatal period (OR 3.0; 95% CI 1.4-6.6). An editorial by Holly and Palefsky complimented the study for noting other risk factors for penile cancer, and also for providing corroborating evidence as to the association between a lack of neonatal circumcision and the development of penile cancer. However, they criticised the study for combining data from invasive and in situ cancers. They concluded that as Maden reported that 20% of the men with penile cancer were circumcised at birth, the recommendation of circumcision for medical indications remained somewhat controversial and the risks and benefits must be weighed. The American Academy of Pediatrics made similar criticism, also noting the possibly inaccurate use of self-report to determine circumcision status.

Schoen et al. (2000) studied the association between neonatal circumcision and invasive penile cancer, reporting that the relative risk for uncircumcised men was 22 times that of circumcised men.

Tseng et al. (2001) studied the association between neonatal circumcision and both invasive penile cancer and carcinoma in situ. The authors reported that neonatal circumcision was associated with reduced risk of invasive penile cancer (OR 0.41; 95% CI 0.13–1.1) but not carcinoma in situ. The association was reduced when only subjects with no history of phimosis were included, and the authors concluded that the protective effect of circumcision may be mediated in large part by phimosis.

Daling et al. (2005) examined the association between circumcision during childhood and invasive penile cancer and carcinoma in situ. Absence of circumcision in childhood was associated with increased risk of invasive penile cancer (OR 2.3; 95% CI 1.3-4.1), but not carcinoma in situ. When men with phimosis were excluded, no significant increase in risk of invasive penile cancer was observed.

Fleiss and Hodges, together with Cold, Storms and Van Howe, suggest that the idea that neonatal circumcision renders the subject immune to penile cancer can be traced back to an opinion article in 1932 by the American circumcisionist Abraham L. Wolbarst as a scare tactic to increase the rate of neonatal circumcision.

Fleiss and Hodges state that epidemiological studies have failed to prove Wolbarst's assertion. Stanton, however, notes that Fleiss and Hodges cited only a single such study, 'that of Maden et al., and, curiously, omit its main conclusion—that "absence of neonatal circumcision and potential resulting complications are associated with penile cancer."'

Cadman et al.'s (1984) study said that using routine infant circumcision to prevent penile cancer would not be cost-effective; the costs of circumcising everyone would be over a hundred times the savings achieved.

Christakis DA, Harvey E, Zerr DM, et al. (2000) found that it would take 909 infant circumcisions to prevent 1 case of invasive penile cancer.

Positions of medical organisations

The American Academy of Pediatrics (1999) stated that studies suggest that neonatal circumcision confers some protection from penile cancer, but circumcision at a later age does not seem to confer the same level of protection. They stated further that penile cancer is a rare disease in developed countries and that the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low. Similarly, the American Medical Association states that although neonatal circumcision seems to lower the risk of contracting penile cancer, because it is rare and occurs later in life, the use of circumcision as a preventive practice is not justified.

The Royal Australasian College of Physicians stated that the use of infant circumcision to prevent penile cancer alone in adulthood is not justified.

The American Cancer Society stated:

Circumcision seems to protect against penile cancer when it is done shortly after birth. Men who were circumcised as babies have less than half the chance of getting penile cancer than those who were not. The reasons for this are not entirely clear, but may be related to other known risk factors. For example, men who are circumcised cannot develop a condition called phimosis. Men with phimosis have an increased risk of penile cancer (see below). Also, circumcised men seem to be less likely to be infected with HPV, even after adjusting for differences in sexual behavior.

In weighing the risks and benefits of circumcision, doctors consider the fact that penile cancer is one of the least common forms of cancer in the United States. Neither the American Academy of Pediatrics nor the Canadian Academy of Pediatrics recommends routine circumcision of newborns (for medical reasons). In the end, decisions about circumcision are highly personal and depend more on social and religious factors than on medical evidence.

HIV/AIDS

Van Howe conducted a meta-analysis in 1999 and found circumcised men at a greater risk for HIV infection. He further speculated that circumcision may be responsible for the increased number of partners, and therefore, the increased risk. Van Howe's work was reviewed by O'Farrell and Egger (2000) who said Van Howe used an inappropriate method for combining studies, stating that re-analysis of the same data revealed that the presence of the foreskin was associated with increased risk of HIV infection (fixed effects OR 1.43, 95%CI 1.32 to 1.54; random effects OR 1.67, 1.25 to 2.24). Moses et al. (1999) also criticised Van Howe's paper, stating that his results were a case of "Simpson's paradox, which is a type of confounding that can occur in epidemiological analyses when data from different strata with widely divergent exposure levels are combined, resulting in a combined measure of association that is not consistent with the results for each of the individual strata." They concluded that, contrary to Van Howe's assertion, the evidence that lack of circumcision increases the risk of HIV "appears compelling".

Weiss, Quigley and Hayes carried a meta-analysis on circumcision and HIV in 2000 and found as follows: "Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised."

A review by Szabo and Short (2000) hypothesizes that circumcision is effective against the transmission of HIV because "the inner surface of the foreskin contains Langerhans' cells with HIV receptors; these cells are likely to be the primary point of viral entry into the penis of an uncircumcised man."

Siegried et al. (2003) surveyed 35 observational studies relating to HIV and circumcision: 16 conducted in the general population and 19 in high-risk populations.

We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV.

In 2005, Siegfried et al. published a review in which 37 observational studies were included. Most studies indicated an association between lack of circumcision and increased risk of HIV, but the quality of evidence was judged insufficient to warrant implementation of circumcision as a public health measure. The authors stated that the results of the three randomised controlled trials then underway would therefore provide essential evidence about the effects of circumcision as an HIV intervention.

The report on a 2008 meta-analysis of 15 observational studies, including 53,567 gay and bisexual men from the United States, Britain, Canada, Australia, India, Taiwan, Peru and the Netherlands (52% circumcised), stated that the rate of HIV infection was non-significantly lower among men who were circumcised compared with those who were uncircumcised. For men who engaged primarily in insertive anal sex, a protective association was reported, but it too was not statistically significant. Observational studies included in the meta-analysis that were conducted prior to the introduction of highly active antiretroviral therapy in 1996 demonstrated a statistically significant protective effect for circumcised men who have sex with men against HIV infection.

Three randomised control trials were commissioned to investigate whether circumcision could lower the rate of HIV contraction.

On Wednesday, March 28, 2007, the World Health Organisation (WHO) and UNAIDS issued joint recommendations concerning male circumcision and HIV/AIDS. These recommendations are:

• Male circumcision should now be recognized as an efficacious intervention for HIV prevention.
• Promoting male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men.

Published meta-analyses, using data from the RCTs, have estimated the summary relative risk at 0.42 (95% CI 0.31-0.57), 0.44 (0.33-0.60) and 0.43 (0.32-0.59). (rate of HIV infection in circumcised divided by rate in uncircumcised men). Weiss et al. report that meta-analysis of "as-treated" figures from RCTs reveals a stronger protective effect (0.35; 95% CI 0.24-0.54) than if "intention-to-treat" figures are used. Byakika-Tusiime also estimated a summary relative risk of 0.39 (0.27-0.56) for observational studies, and 0.42 (0.33-0.53) overall (including both observational and RCT data). Weiss et al. report that the estimated relative risk using RCT data was "identical" to that found in observational studies (0.42). Byakika-Tusiime states that available evidence satisfies six of Hill's criteria, and concludes that the results of her analysis "provide unequivocal evidence that circumcision plays a causal role in reducing the risk of HIV infection among men." Mills et al. conclude that circumcision is an "effective strategy for reducing new male HIV infections", but caution that consistently safe sexual practices will be required to maintain the protective effect at the population level. Weiss et al. conclude that the evidence from the trials is conclusive, but that challenges to implementation remain, and will need to be faced.

Other Sexually transmitted infections

A recent systematic review has suggested that there is strong evidence for a protective effect of circumcision against Syphilis or Chancroid infection, but only weak evidence for a protective effect against Herpes Simplex.

Epididymitis

Epididymitis is inflammation of the epididymis. It can be very painful, and become a chronic condition, but medical treatment is well accepted and effective. One 1998 study found the rate of epididymitis in boys with foreskins was significantly higher than in those without; that an intact foreskin is an important etiological factor in boys with epididymitis.

Hygiene

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

The Royal Australasian College of Physicians emphasizes that the penis of an uncircumcised infant requires no special care and should be left alone. It states that attempts to forcibly retract the foreskin, e.g. to clean it, are painful, often injure the foreskin, and can lead to scarring, infections and pathologic phimosis. Non-circumcised men are told not to wash with soap as it can inflame the penis.

Smegma is a combination of exfoliated epithelial cells, transudated skin oils, and moisture that can accumulate under the foreskin of males and within the female vulva area. It is common to all mammals—male and female. In rare cases, accumulating smegma may be a factor in causing balanitis.

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

Lerman and Liao (2001) state that apart from its effects on UTI rates, "Most of the other medical benefits of circumcision probably can be realized without circumcision as long as access to clean water and proper penile hygiene are achieved."

Local infection and inflammation

A 1988 New Zealand study of penile problems by Fergusson et al., in a birth cohort of more than 500 children from birth to 8 years of age found that:

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.

The authors of this study acknowledged certain problem with the data:

It is important to recognize that the data on medical attendance for penile problems was collected as part of a much larger longitudinal study of child health and development in which the primary concern was not with the issue of the longterm consequences of circumcision. This feature of the data collection process places a number of restrictions on the quality of the collected data. Specifically, data relating to immediate postcircumcision problems and penile problems that were treated at home without medical attention were not available. Also, diagnostic details of medical attendances for penile problems were limited. The net result of these imprecisions in the data collection process is that the incidence and prevalence of penile problems probably underestimated and the problems can only be described in terms of broad diagnostic categories. Nonetheless, we believe that the trends that emerge from the analysis are likely to reflect general differences in the medical histories of circumcised and uncircumcised children.

Van Howe observed that Fergusson et al. used parental complaints rather than direct examination in their retrospective study, so the study may have understated the number of boys with penile problems.

Studies have found that boys with foreskins tend to have higher rates of various infections and inflammations of the penis than those who are circumcised. The reasons are unclear, but several hypotheses have been suggested:

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

Some mothers believe that circumcision will relieve them and the child of the bother of cleanliness, however Patel (1966) insists this is incorrect.

Balanitis

Balanitis, an inflammation of the glans penis, has several causes. Some of these, such as anaerobic infection, occur more frequently in uncircumcised men. Balanitis involving the foreskin is called balanoposthitis. The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. One study found more than five times the rate of balanitis in the uncircumcised men in the study group. The most common complication of balanitis is phimosis, or inability to retract the foreskin from the glans penis.

EMedicine says: "Uncircumcised men with poor personal hygiene are most affected by balanitis. Lack of aeration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema. Adherence of the foreskin to the inflamed and edematous glans penis causes phimosis." O'Farrell et al. noted inferior hygiene among uncircumcised men attending a sexually transmitted infections (STI) clinic at Ealing Hospital, London. The researchers also reported an association between balanitis and inferior hygiene.

Balanitis has many causes, including irritation by environmental substances, physical trauma, and infection by a wide variety of pathogens, including bacteria, virus, yeast, or fungus — each of which require a particular treatment. Good medical practice includes careful diagnosis with the aid of a good patient history, swabs and cultures, and pathologic examination of a biopsy. Only then can the proper treatment be prescribed. Many studies of balanitis do not examine the subjects' genital washing habits. A 1993 study by Birley et al. did so and found that excessive genital washing with soap may be a strong contributing factor to balanitis.

In a birth cohort of 500 boys studied from birth to 8 years of age, Fergusson et al. reported that the rate of penile inflammation problems per 100 boys at risk was 7.6 among circumcised boys and 14.4 among uncircumcised boys. In a retrospective study of 545 boys, Herzog and Alverez found that balanitis occurred in 5.9% of the uncircumcised and 2.9% of the circumcised children; the difference was not statistically significant. In a cross-sectional study of 398 patients, Fakjian et al. reported that balanitis was diagnosed in 12.5% of the uncircumcised men and 2.3% of the circumcised men. In a study of 225 men, O'Farrell et al. found that circumcised men were less likely to be diagnosed with balanitis than uncircumcised men. Van Howe found that circumcised penes required more care in the first 3 months of life. He found that circumcised boys were more likely to develop balanitis.

Treatments that are less invasive than circumcision are effective in treating most mild cases of balanitis. Birley, et al., found that in 90% of their cases of chronic or recurring balanitis "use of emollient creams and restriction of soap washing alone controlled symptoms satisfactorily". They also state that circumcision “might be of benefit in a patient whose balanitis relapses despite these measures, and remains the principal treatment for specific conditions such as lichen sclerosus and plasma cell balanitis.” The less invasive procedures are not as successful in treating balanitis xerotica obliterans, or BXO, which is much less common but harder to treat. Balanitis xerotica obliterans is a skin condition causing white, atrophic patches on the glans or foreskin. It is much more common among uncircumcised males. Circumcision is believed to reliably reduce the threat of BXO.

Balanitis in childhood. Balanitis afflicts young boys generally only where a difficult to retract tight foreskin is present. Two studies found that uncircumcised boys were at approximately twice the risk of developing balanitis Escala and Rickwood, in a 1989 examination of 100 cases of balanitis in childhood, concluded: "he risk in any individual, uncircumcised boy appears to be no greater than 4%." They recommend circumcision as a last resort only in cases of recurrent balanitis.

Images of balanitis

Urinary tract infection (UTI)

Infections of the urinary tract (kidneys, ureters, bladder and urethra) can generally be treated effectively with antibiotics, though in rare cases they can lead to more serious conditions.

Singh-Grewal (2005) performed a meta-analysis of 12 studies (one randomised controlled trial, four cohort studies, and seven case–control studies) looking at the effect of circumcision on the risk of urinary tract infection (UTI) in boys. Circumcision was associated with a reduced risk of UTI (OR = 0.13; 95% CI, 0.08 to 0.20; p<0.001). The authors found that the number of circumcisions (number needed to treat) to prevent one infection was 111.

Some of the studies done to investigate the effect circumcision has on incidence of UTI have been extensively criticized for their methodology. The American Academy of Pediatrics noted in its 1999 circumcision policy statement:

Few of the studies that have evaluated the association between UTI in male infants and circumcision status have looked at potential confounders (such as prematurity, breastfeeding, and method of urine collection) in a rigorous way. For example, because premature infants appear to be at increased risk for UTI, the inclusion of hospitalized premature infants in a study population may act as a confounder by suggesting an increased risk of UTI in uncircumcised infants. Premature infants usually are not circumcised because of their fragile health status. In another example, breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status.

A 1998 Canadian population based cohort study by To et al. reported a relative risk of 3.7. The overall incidence of UTIs in infants was low, 1.88 and 7.02 per 1000 respectively. Based upon their data, To et al. estimate that 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life.

The American Medical Association cites evidence that the incidence of UTIs is “small (0.4%–1%)” in uncircumcised infants, and “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI…One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition.” According to the American Medical Association, "There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI)."

Jakobsson et al. (1999) found that the mean diagnostic rate of the first UTI in children under 2 years of age was 1.5%; the mean incidence was 1.0%; and the cumulative incidence at 2 years of age was estimated at 2.2%.

Nayir (2001) conducted a study in Turkey to contrast the effects of circumcision and antibiotics on bacteriuria. He split 70 uncircumcised boys into 2 equal groups. One group was circumcised immediately, the other treated with antibiotics. The circumcised group were found to have a lower rate of bacteriuria per patient. Newman (2002) found that lack of circumcision was associated with a UTI. Cason et al. (2000) investigated the effect of circumcision on recurrent UTI. Of 744 male infants admitted to the hospital's neonatal intensive care unit, 38 had UTI's. None of the premature infants in the study had a recurrent UTI once a circumcision was performed. Schoen et al. (2000) found that of the 14,893 male infants born during 1996 in 12 KPNC (Kaiser Permanente Medical Care Program of Northern California) hospitals, 154 cases of UTI occurred in boys under 1 year of age. Of these, 138 were uncircumcised. The most prominent organism found was E. coli. They concluded that in the first year of life non-circumcised boys have a higher incidence of UTI.

Mueller et al. (1997) investigated the contribution of underlying genitourinary (GU) structural abnormalities to UTI. They found that regardless of circumcision status, infants who present with a UTI in the first 6 months of life are more likely to have an underlying genitourinary (GU) structural abnormality. In the remaining patients with normal underlying anatomy and UTI there were as many circumcised infants as those who retained their foreskin.

Glennon et al. examined periurethral carriage of Proteus mirabilis (a common cause of UTI in boys) in 60 circumcised and 124 uncircumcised boys. The researchers grew P mirabilis from swabs taken from 22.6% of the uncircumcised boys and 1.7% of the circumcised boys, concluding that their results support the idea that the prepuce may be the source of UTI infection. Serour et al. swabbed the periurethral areas of 46 circumcised and 125 uncircumcised males, reporting that facultative Gram-negative rods were more common among uncircumcised males. The authors stated that their findings were "in accordance with a previous finding of increased risk of urinary tract infection in uncircumcised young men." Wiswell et al. obtained intraurethral and circumferential glans cultures from a total of 300 boys, concluding that the foreskin was associated with a "greater quantity of periurethral bacteria and a greater likelihood for the presence of, as well as higher concentrations of, potentially uropathogenic organisms." Wijesinha et al. conducted a prospective study of periurethral bacterial flora among 25 boys undergoing circumcision. Before circumcision, uropathogens were observed in 52% of boys. After circumcision, none were observed. Gunsar et al. reported on a prospective study of 50 boys. The periurethral and glanular sulcus flora were evaluated before and after circumcision. Pathogenic bacteria were identified in periurethral swabs taken from 64% of patients before circumcision and 10% after. From the glanular sulcus area, pathogenic bacteria were identified in 68% of boys before circumcision, and 8% afterwards. Fussell et al. reported that pathogenic bacteria adhere to the mucosal surface of the foreskin, commenting that this finding would appear to be related to the higher incidence of UTI in uncircumcised males.

The Canadian Paediatric Society questions whether increased UTI and balanitis rates in uncircumcised male infants may be caused by forced premature retraction. Cunningham also mentioned this in response to an early study by Wiswell, Smith and Bass. Hodges and Fleiss claim that "it has been proven that retraction and washing of the infant foreskin can cause urinary tract infections by irritating the mucous membranes and destroying the naturally occurring beneficial flora which protects against pathogens." Some contend that fewer pathogens are present in circumcised males.

A 2008 retrospective analysis by Roth et al. found no statistically significant difference between circumcision status and the incidence of UTI in boys who had upper urinary tract obstructions.

Skin conditions

Researchers from the Imperial College School of Medicine, Chelsea & Westminster Hospital, London, England reported the results of their study of 357 patients referred for genital skin disease:

Most cases of inflammatory dermatoses were diagnosed in uncircumcised men, suggesting that circumcision protects against inflammatory dermatoses. The presence of the foreskin may promote inflammation by a koebnerization phenomenon, or the presence of infectious agents, as yet unidentified, may induce inflammation. The data suggest that circumcision prevents or protects against common infective penile dermatoses.

Some American military doctors have recommended prophylactic circumcision because of the difficult conditions during wartime. For example, a United States Army report regarding World War II noted that in case of penile lesions, the foreskin may "invite secondary infection". The sexually transmitted disease chancroid, now very uncommon, was also associated with phimosis, which could hardly occur in circumcised males, and "soldiers in combat were seldom able to practice personal hygiene".

There are a few cases of skin diseases such as staphyloccal scalded skin syndrome or impetigo following circumcision. One study found a difference in infection rates between circumcised and uncircumcised boys (p < 0.10) that was not statistically significant, "perhaps due to the relatively small number.." .

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

Zoon's Balanitis, illustrated here, also known as Balanitis Circumscripta Plasmacellularis or plasma cell balanitis (PCB) is an idiopathic, rare, benign penile dermatosis, usually of a middle-aged or older man. Circumcision is the usual treatment of choice but fusidic acid cream 2% has been curative in some cases.

Phimosis

Phimosis is the inability to retract the prepuce over the glans penis after separation from the glans has occurred. The foreskin is joined to the glans, and is naturally unretractable when a baby is born. but there are differences of opinion about how long this should continue, and how the foreskin should be treated if it remains too tight for too long. Gairdner published data regarding the age of first foreskin retraction in 1949 that is now thought by some to be incorrect. However, these data are still presented in medical textbooks and taught in medical schools. According to these newer publications, many doctors, therefore, are misinformed about the natural development of the foreskin, and this contributes to the mis-diagnosis of the normal non-retractile foreskin of childhood as pathological disease. Rickwood and Walker (1989) raised concern that phimosis is frequently misdiagnosed by physicians who confuse it with the developmentally non-retractable foreskin, and Rickwood et al. write in their 2000 paper "Towards evidence based circumcision of English boys" in the British Medical Journal:

Too many English boys, especially those under 5 years of age, are still being circumcised because of misdiagnosis of phimosis. What is phimosis? At birth, the foreskin is almost invariably non-retractable, but this state is transient and resolves in nearly all boys as they mature through puberty. Such normality, with an unscarred and pliant preputial orifice, is clearly distinguishable from pathological phimosis, a condition unambiguously characterised by secondary cicatrisation of the orifice, usually due to balanitis xerotica obliterans. This problem, the only absolute indication for circumcision, affects some 0.6% of boys, peaks in incidence at 11 years of age, and is rarely encountered before the age of 5. (…) Strictly, only some 0.6% of boys with pathological phimosis need to be circumcised, although more relaxed criteria would allow for a similar proportion affected by recurrent balanoposthitis.

A 1968 Danish study of 9,545 boys, which distinguished between phimosis and preputial adhesion, found that both conditions steadily declined with age. Phimosis was 8% among 6-7 year olds but only 1% among 16-17 year olds. Similarly, preputial adhesion was 63% among 6-7 year olds but only 3% among 16-17 year olds. The author, Jakob Øster, concluded:

Phimosis is seen to be uncommon in schoolboys, and the indications for operation even rarer if the normal development of the prepuce is patiently awaited. When this policy is pursued, in the majority of cases of phimosis, it is seen to be a physiological condition which gradually disappears as the tissues develop.

It has been observed that Øster's study may not be representative of wider populations. The true incidence of phimosis is controversial. Osmond found that 14% of British soldiers had phimosis, and Schoeberlein noted that 9.2% of uncircumcised German men had phimosis. Reporting on a New Zealand study, Fergusson et al. found that 3.7% of boys had phimosis, while Herzog and Alvarez found it in 2.6%. Dawson and Whitfield say "True phimosis is rare but may cause appreciable problems in either childhood or adolescence." The AAP state that the true frequency of problems such as phimosis is unknown.

Several researchers have described less invasive treatments for phimosis than circumcision, and recommend that they be tried first. Several studies have identified phimosis as a risk factor for penile cancer.

Phimosis is also a complication of circumcision, which can occur when too little foreskin is removed.

Images of phimosis.

Paraphimosis

The American Academy of Family Physicians says:

"Paraphimosis is a urologic emergency, occurring in uncircumcised males, in which the foreskin becomes trapped behind the corona and forms a tight band of constricting tissue. Often iatrogenically induced, paraphimosis can be prevented by returning the prepuce to cover the glans following penile manipulation. Treatment often begins with reduction of edema, followed by a variety of options, including mechanical compression, pharmacologic therapy, puncture technique and dorsal slit. Prevention and early intervention are key elements in the management of paraphimosis."

The article goes on to say that the cause is most often iatrogenic (caused by doctors). It further stated:

"Rare causes of paraphimosis include self-inflicted injury to the penis (such as piercing a penile ring into the glans) and paraphimosis secondary to penile erections."

Several techniques to treat paraphimosis are listed in an article in the American Family Physician and on the Circumcision Information and Resource Pages (CIRP). One procedure is minor surgery to make a small slit in the foreskin without removing any tissue. Another is called the "Dundee technique." An article in the American Family Physician says that paraphimosis is one of the medical indications for circumcision. The Royal Children's Hospital in Melbourne, Australia, says, "Once reduced, a single episode of paraphimosis is not an indication for circumcision."

Images of paraphimosis: Figure 1 in Choe, 2000; and Circlist.com

See also

• Bioethics of neonatal circumcision
• Circumcision controversies
• Circumcision and law
• Female circumcision
• Foreskin
• Foreskin restoration
• Genital modification and mutilation
• Male circumcision

References

1. ^ Milos, M; MacRis, D (1992). "Circumcision A medical or a human rights issue?". Journal of Nurse-Midwifery. 37 (2 Suppl): S87. doi:10.1016/0091-2182(92)90012-R. PMID 1573462.
2. Krieger, John N.; Mehta, Supriya D.; Bailey, Robert C.; Agot, Kawango; Ndinya-Achola, Jeckoniah O.; Parker, Corette; Moses, Stephen (2008). "Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya". Journal of Sexual Medicine. 5 (11): 2610–22. doi:10.1111/j.1743-6109.2008.00979.x. PMC 3042320. PMID 18761593.
3. Schoen (2007). "Should newborns be circumcised? Yes". Canadian Family Physician. 53 (12): 2096–8, 2100–2. PMC 2231533. PMID 18077736.
4. ^ "Non-therapeutic circumcision of male minors (2010)". KNMG. 12 June 2010.
5. ^ "New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications" (PDF). World Health Organization. March 28, 2007. Retrieved 2007-08-13. {{cite journal}}: Cite journal requires |journal= (help)
6. "Male Circumcision and Risk for HIV Transmission and Other Health Conditions: Implications for the United States". Centers for Disease Control and Prevention. 2008.
7. "Current College Position on Circumcision". Royal Australasian College of Physicians. 2009-08-27.
8. "Circumcision: Information for parents". Caring for kids. Canadian Paediatric Society. 2004. Archived from the original on 2005-12-19. Retrieved 2006-10-24. Circumcision is a "non-therapeutic" procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social or cultural reasons. To help make the decision about circumcision, parents should have information about risks and benefits. It is helpful to speak with your baby's doctor. After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions. {{cite web}}: Unknown parameter |month= ignored (help)
9. Fetus and Newborn Committee (1996). "Neonatal circumcision revisited". Canadian Medical Association Journal. 154 (6): 769–780. PMC 1487803. PMID 8634956. Retrieved 2006-07-02. {{cite journal}}: Unknown parameter |month= ignored (help) “We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors.
10. College of Physicians and Surgeons of British Columbia: Professional Standards and Guidelines: Circumcision (Infant Male) The College of Physicians and Surgeons of British Columbia] (pdf)
11. ^ Medical Ethics Committee (2006). "The law and ethics of male circumcision - guidance for doctors". British Medical Association. Retrieved 2009-07-23. Circumcision for medical purposes
    Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. Male circumcision in cases where there is a clear clinical need is not normally controversial. Nevertheless, normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal. The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. Doctors should be aware of this and reassure parents accordingly.
    
    Non-therapeutic circumcision
    Male circumcision that is performed for any reason other than physical clinical need is termed non-therapeutic (or sometimes "ritual") circumcision. Some people ask for non-therapeutic circumcision for religious reasons, some to incorporate a child into a community, and some want their sons to be like their fathers. Circumcision is a defining feature of some faiths.
    
    There is a spectrum of views within the BMA's membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly. The Association has no policy on these issues. Indeed, it would be difficult to formulate a policy in the absence of unambiguously clear and consistent medical data on the implications of the intervention. As a general rule, however, the BMA believes that parents should be entitled to make choices about how best to promote their children's interests, and it is for society to decide what limits should be imposed on parental choices. {{cite web}}: Unknown parameter |month= ignored (help)
12. ^ "Circumcision Policy Statement". PEDIATRICS. 130 (3): 585–586. 27 August 2012. doi:10.1542/peds.2012-1989.
13. Rabin, Roni (August 27, 2012). "Benefits of Circumcision Are Said to Outweigh Risks". NY Times. Retrieved August 31, 2012.
14. Brown, Eryn (August 26, 2012). "Pediatricians' group shifts in favor of circumcision". LA Times. Retrieved August 31, 2012.
15. AP (August 27, 2012). "Circumcision benefits outweigh risks and insurers should pay; pediatricians revise stance". Washington Post. Retrieved August 31, 2012.
16. Council on Scientific Affairs. Report 10: Neonatal circumcision. ChIcago: American Medical Association, 1999.
17. "AMA Adopts New Policies During Final Day of Semi-Annual Meeting". AMA. Nov 15, 2011. Retrieved September 03, 2012. {{cite web}}: Check date values in: |accessdate= (help)
18. ^ "Circumcision: Position Paper on Neonatal Circumcision". American Academy of Family Physicians. 2007. Retrieved 2012-09-04.
19. ^ American Urological Association. "Circumcision". About AUA - Policy Statements. Retrieved 2007-08-26.
20. "Circumcision (Infant Male)" (PDF). Resource manual. College of Physicians and Surgeons of British Columbia. 2004. Retrieved 2009-08-16.
21. Cadman, D.; Gafni, A; McNamee, J (1984). "Newborn circumcision: an economic perspective". Canadian Medical Association Journal. 131 (11): 1353–5. PMC 1483656. PMID 6437656.
22. Lawler; Bisonni, RS; Holtgrave, DR (1991). "Circumcision: a decision analysis of its medical value". Family medicine. 23 (8): 587–93. PMID 1794670.
23. Ganiats; Humphrey, JB; Taras, HL; Kaplan, RM (1991). "Routine neonatal circumcision: a cost-utility analysis". Medical decision making. 11 (4): 282–93. doi:10.1177/0272989X9101100406. PMID 1766331.
24. CIRP.org
25. Circs.org
26. Van Howe (2004). "A cost-utility analysis of neonatal circumcision". Medical decision making. 24 (6): 584–601. doi:10.1177/0272989X04271039. PMID 15534340.
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118. Boczko, S (1979). "Penile carcinoma in circumcised males". N Y State J Med. 79 (12): 1903–4. PMID 292845. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
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121. ^ "Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision". Pediatrics. 103 (3): 686–93. 1999. doi:10.1542/peds.103.3.686. PMID 10049981.
122. Schoen, EJ (2000). "The highly protective effect of newborn circumcision against invasive penile cancer". Pediatrics. 105 (3): e36. doi:10.1542/peds.105.3.e36. PMID 10699138. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
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124. Cold, J. (1997). "Carcinoma in Situ of the Penis in a 76-Year-Old Circumcised Man". The Journal of family practice. 44 (4): 407–409. PMID 9108839. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
125. ^ Paul M., Fleiss (1996). "Neonatal circumcision does not protect against cancer". British Medical Journal. 312 (7033): 779–780. doi:10.1016/j.cognition.2004.12.006. PMC 1479854. PMID 15913592. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
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128. A trade-off analysis of routine newborn circumcision Pediatrics 105 (1 Pt 3): 246-9, 2000
129. "Policy Statement On Circumcision" (PDF). Royal Australasian College of Physicians. 2004. Retrieved 2007-02-28. The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision. Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It remains an important ritual in some religious and cultural groups.…In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis.…The complication rate of neonatal circumcision is reported to be around 1% to 5% and includes local infection, bleeding and damage to the penis. Serious complications such as bleeding, septicaemia and meningitis may occasionally cause death. The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law. If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate. {{cite web}}: Unknown parameter |month= ignored (help)
130. "What Are the Risk Factors for Penile Cancer?". American Cancer Society. 2008-07-11.
131. Van Howe, R.S. (1999). "Circumcision and HIV infection: review of the literature and meta-analysis". International Journal of STD's and AIDS. 10: 8–16. doi:10.1258/0956462991913015. Retrieved 2008-09-23. Thirty-five articles and a number of abstracts have been published in the medical literature looking at the relationship between male circumcision and HIV infection. Study designs have included geographical analysis, studies of high-risk patients, partner studies and random population surveys. Most of the studies have been conducted in Africa. A meta-analysis was performed on the 29 published articles where data were available. When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis (odds ratio (OR)=1.06, 95% confidence interval (CI)=1.01-1.12). Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded. {{cite journal}}: Unknown parameter |month= ignored (help)
132. O'Farrell N, Egger M (2000). "Circumcision in men and the prevention of HIV infection: a 'meta-analysis' revisited". Int J STD AIDS. 11 (3): 137–42. doi:10.1258/0956462001915480. PMID 10726934. The results from this re-analysis thus support the contention that male circumcision may offer protection against HIV infection, particularly in high-risk groups where genital ulcers and other STDs 'drive' the HIV epidemic. A systematic review is required to clarify this issue. Such a review should be based on an extensive search for relevant studies, published and unpublished, and should include a careful assessment of the design and methodological quality of studies. Much emphasis should be given to the exploration of possible sources of heterogeneity. In view of the continued high prevalence and incidence of HIV in many countries in sub-Saharan Africa, the question of whether circumcision could contribute to prevent infections is of great importance, and a sound systematic review of the available evidence should be performed without delay.
133. Moses S, Nagelkerke NJ, Blanchard J (1999). "Analysis of the scientific literature on male circumcision and risk for HIV infection" (PDF). International journal of STD & AIDS. 10 (9): 626–8. doi:10.1258/0956462991914681. PMID 10492434. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
134. Weiss, H.A. (2000). "Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis" (PDF). AIDS. 14 (15): 2361–70. doi:10.1097/00002030-200010200-00018. PMID 11089625. Retrieved 2008-09-25. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
135. "How does male circumcision protect against HIV infection?". Retrieved 2007-11-30.
136. Siegfried N, Muller M, Volmink J; et al. (2003). Siegfried, Nandi (ed.). "The Cochrane Database of Systematic Reviews". Cochrane database of systematic reviews (Online) (3): CD003362. doi:10.1002/14651858.CD003362. PMID 12917962. {{cite journal}}: |chapter= ignored (help); Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
137. Siegfried N, Muller M, Deeks J; et al. (2005). "HIV and male circumcision--a systematic review with assessment of the quality of studies". The Lancet infectious diseases. 5 (3): 165–73. doi:10.1016/S1473-3099(05)01309-5. PMID 15766651. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
138. ^ Millett GA, Flores SA, Marks G, Reed JB, Herbst JH (2008). "Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis". JAMA. 300 (14): 1674–84. doi:10.1001/jama.300.14.1674. PMID 18840841. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
139. "WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention". World Health Organisation. 2007. {{cite web}}: Unknown parameter |month= ignored (help)
140. ^ Weiss HA, Halperin D, Bailey RC, Hayes RJ, Schmid G, Hankins CA (2008). "Male circumcision for HIV prevention: from evidence to action?" (PDF). AIDS. 22 (5): 567–74. doi:10.1097/QAD.0b013e3282f3f406. PMID 18316997. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
141. ^ Mills E, Cooper C, Anema A, Guyatt G (2008). "Male circumcision for the prevention of heterosexually acquired HIV infection: a meta-analysis of randomized trials involving 11,050 men". HIV Med. 9 (6): 332–5. doi:10.1111/j.1468-1293.2008.00596.x. PMID 18705758. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
142. ^ Byakika-Tusiime J (2008). "Circumcision and HIV Infection: Assessment of Causality". AIDS Behav. 12 (6): 835–41. doi:10.1007/s10461-008-9453-6. PMID 18800244. {{cite journal}}: Unknown parameter |month= ignored (help)
143. Weiss HA, Thomas SL, Munabi SK, Hayes RJ (2006). "Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis". Sexually Transmitted Infections. 82 (2): 101–9, discussion 110. doi:10.1136/sti.2005.017442. PMC 2653870. PMID 16581731. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
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147. Although the Academy's 1975 statement asserted that "A program of education leading to continuing good personal hygiene would offer all the advantages of circumcision without the attendant surgical risk," the 1999 statement cites a study which found that "appropriate hygiene decreased significantly the incidence of phimosis, adhesions, and inflammation, but did not eliminate all problems."
148. "Care Of The Foreskin". Paediatric Policy - Circumcision. The Royal Australasian College of Physicians. 2004. Archived from the original on 2007-01-11. Retrieved 2006-07-13. {{cite web}}: Unknown parameter |month= ignored (help)
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150. Sonnex, C (1997). "Balanoposthitis associated with the presence of subpreputial "smegma stones"". Genitourin Med. 73 (6): 567. PMC 1195951. PMID 9582487. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
151. Hutson, J.M. (2004). "Circumcision: a surgeon's perspective" (PDF). Journal of Medical Ethics. 30 (3): 238–240. doi:10.1136/jme.2002.001313. PMC 1733864. PMID 15173354. Retrieved 2006-07-09. {{cite journal}}: Unknown parameter |month= ignored (help)
152. Darby, Robert (2005). "The riddle of the sands: circumcision, history, and myth" (PDF). The New Zealand Medical Journal. 118 (1218): 76–82. PMID 16027753. Retrieved 2006-07-09.
153. Lerman, SE; Liao, JC (2001). "Neonatal circumcision". Pediatric clinics of North America. 48 (6): 1539–57. doi:10.1016/S0031-3955(05)70390-4. PMID 11732129. {{cite journal}}: Cite has empty unknown parameter: |author-name-separator= (help); Unknown parameter |author-separator= ignored (help); Unknown parameter |month= ignored (help)
154. Fergusson DM, Lawton JM, Shannon FT (1988). "Neonatal circumcision and penile problems: an 8-year longitudinal study". Pediatrics. 81 (4): 537–41. PMID 3353186. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
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157. ^ Fergusson, DM (1988). "Neonatal circumcision and penile problems: an 8-year longitudinal study". Pediatrics. 81 (4): 537–541. PMID 3353186. Retrieved 2007-07-18. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help) Cite error: The named reference "Ferg" was defined multiple times with different content (see the help page).
158. ^ Fakjian, N (1990). "An argument for circumcision. Prevention of balanitis in the adult". Arch Dermatol. 126 (8): 1046–7. doi:10.1001/archderm.126.8.1046. PMID 2383029. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
159. ^ Herzog, LW (1986). "The frequency of foreskin problems in uncircumcised children". Am J Dis Child. 140 (3): 254–6. PMID 3946358. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
160. O’Farrel, Nigel (2005). "Association between the intact foreskin and inferior standards of male genital hygiene behaviour: a cross-sectional study". International Journal of STD & AIDS. 16 (8): 556–588(4). doi:10.1258/0956462054679151. PMID 16105191. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help) Editor’s note: I cannot confirm that the article substantiates the claim as I cannot access the full article.
161. ^ Fetus and Newborn Committee (1996). "Neonatal circumcision revisited". Canadian Medical Association Journal. 154 (6): 769–780. PMC 1487803. PMID 8634956. Retrieved 2006-07-02. {{cite journal}}: Unknown parameter |month= ignored (help)
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163. ^ Au, T.S. (2003). "Balanitis, Bacterial Vaginosis and Other Genital Conditions". In Pedro Sá Cabral, Luís Leite, and José Pinto (eds.) (ed.). Handbook of Dermatology & Venereology (2nd ed.). Lisbon, Portugal: Department of Dermatology—Hospital Pulido Valente. ISBN 978-962-334-030-4. Retrieved 2006-09-04. {{cite book}}: |editor= has generic name (help); External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help); Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |isbn-status= ignored (help)CS1 maint: multiple names: editors list (link)
164. Edwards, Sarah (1996). "Balanitis and balanoposthitis: a review". Genitourinary Medicine. 72 (3): 155–159. PMC 1195642. PMID 8707315. Retrieved 2006-09-04.
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166. Fakjian N, Hunter S, Cole GW, Miller J (1990). "An argument for circumcision. Prevention of balanitis in the adult". Archives of Dermatology. 126 (8): 1046–7. doi:10.1001/archderm.126.8.1046. PMID 2383029. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
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170. O’Farrel, Nigel (2005). "Association between the intact foreskin and inferior standards of male genital hygiene behaviour: a cross-sectional study" (Abstract). International Journal of STD & AIDS. 16 (8): 556–588(4). doi:10.1258/0956462054679151. PMID 16105191. Retrieved 2008-09-06. Overall, circumcised men were less likely to be diagnosed with a STI/balanitis (51% and 35%, P = 0.021) than those non-circumcised. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
171. Van Howe RS (2007). "Neonatal circumcision and penile inflammation in young boys". Clinical pediatrics. 46 (4): 329–33. doi:10.1177/0009922806295708. PMID 17475991.
172. Vincent, Michelle Valerie (2005). "The response of clinical balanitis xerotica obliterans to the application of topical steroid-based creams" (Abstract). Journal of Pediatric Surgery. 40 (4): 709–712. doi:10.1016/j.jpedsurg.2004.12.001. PMID 15852285. Retrieved 2006-09-21. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
173. Wright, J.E. (1994). "The treatment of childhood phimosis with topical steroid". The Australian and New Zealand journal of surgery. 64 (5): 327–328. doi:10.1111/j.1445-2197.1994.tb02220.x. PMID 8179528. Retrieved 2006-09-21. {{cite journal}}: Unknown parameter |month= ignored (help)
174. Webster, T.M. (2002). "Topical steroid therapy for phimosis". The Canadian journal of urology. 9 (2): 1492–1495. PMID 12010594. {{cite journal}}: |access-date= requires |url= (help); |format= requires |url= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
175. Scheinfeld, Noah S. (January 11, 2006). "http://www.emedicine.com/derm/topic46.htm". Diseases Of The Dermis. EMedicine. Retrieved 2006-09-21. {{cite web}}: External link in |title= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
176. Mattioli, G. (2002). "Lichen sclerosus et atrophicus in children with phimosis and hypospadias" (Abstract). Pediatric Surgery International. 18 (4): 273–275. doi:10.1007/s003830100699. PMID 12021978. Retrieved 2006-09-21. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
177. Herzog, L.W. (1986). "The Frequency of Foreskin Problems in Uncircumcised Children". Am J Dis Child. 140 (3): 254–256. PMID 3946358. {{cite journal}}: Cite has empty unknown parameter: |month= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
178. Fergusson, D.M. (1988). "Neonatal Circumcision and Penile Problems: An 8-Year Longitudinal Survey". Pediatrics. 81 (4): 537–41. PMID 3353186. {{cite journal}}: Cite has empty unknown parameter: |month= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
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184. Jakobsson, B. (1999). "Minimum incidence and diagnostic rate of first urinary tract infection". Pediatrics. 104 (2 (part 1)): 222–226. doi:10.1542/peds.104.2.222. PMID 10428998. Retrieved 2008-10-06. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
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187. Cason, Dana L. (2000). "Can circumcision prevent recurrent urinary tract infections in hospitalized infants?". Clinical Pediatrics. 39 (12): 699–703. doi:10.1177/000992280003901203. PMID 11156067. Retrieved 2008-10-05. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
188. Schoen, Edgar J. (2000). "Newborn Circumcision Decreases Incidence and Costs of Urinary Tract Infections During the First Year of Life". Pediatrics. 105 (4): 789–793. doi:10.1542/peds.105.4.789. PMID 10742321. Retrieved 2008-10-05. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
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225. Holman, John R. (1999). "Adult Circumcision". American Family Physician. 59 (6): 1514–8. PMID 10193593. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
226. "Paraphimosis". Clinical Practice Guidelines. Royal Children's Hospital Melbourne.
227. Circlist.com

Further reading

• Apt (1965). "Circumcision and prostatic cancer". Acta medica Scandinavica. 178 (4): 493–504. doi:10.1111/j.0954-6820.1965.tb04294.x. PMID 5891277.
• Bailis, Stefan A.; Halperin, Daniel T. (2006). "Male circumcision: time to re-examine the evidence". StudentBMJ. 14: 179–180.

External links

• American Academy of Pediatrics. Circumcision Policy Statement (RE9850). March 1999.
• American Medical Association. Report 10 of the Council on Scientific Affairs (I-99), Neonatal Circumcision. Dec 1999.
• British Medical Association. The Law & Ethics of Male Circumcision - Guidance for Doctors. March 2003.
• Canadian Paediatric Society. Neonatal Circumcision Revisited. 1996 (reaffirmed March 2002)
• The Royal Australasian College of Physicians. Policy Statement On Circumcision (PDF), September 2004.

• Circumcision debate