Discussing Circumcision An Elephant in the Hospital

Name: Discussing Circumcision An Elephant in the Hospital
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Description: Discussing Circumcision An Elephant in the Hospital

Discussing Circumcision An Elephant in the Hospital
Circumcision.ppt Ryan McAllister Discussing Circumcision An Elephant in the Hospital Ryan McAllister, PhD Assistant Research Professor Physics & Oncology, Georgetown University Founding Coordinator, NotJustSkin.org This presentation may be freely distributed so long as it remains unmodified. Contact Ryan McAllister for updates or additional information

Wellbeing of Children and Parents

A Thorny Issue. Have You:
(You can opt out of participating) Performed a circumcision? Assisted? Given a parent information about circumcision? Had a child for whom you chose circumcision? Had a child for whom you didn’t choose circumcision? Assumed I was referring only to male children? Been circumcised? Not been circumcised? Had a circumcised lover, partner, spouse, brother, or parent? Conscientiously objected to performing or assisting? Opposed circumcision in some way? Been scolded for it? Come from a cultural or religious group that observes circumcision? Heard a circumcision joke? Heard that no men are bothered by being circumcised? Felt reluctant to talk about it in some settings? Felt that circumcision is fundamentally different than female genital cutting? Known any female who was genitally cut?

Hiding an elephant “It’s cleaner.” “It looks better.”
Poisoning the well “Everyone does it.” Appeal to majority “I’m circumcised and I’m fine.” Anecdotal “Little snip” “useless flap of skin” Minimizing “Babies don’t feel pain/remember.” Special pleading “Doctors do it. The AAP supports it.” Appeal to authority “I can’t imagine how it’s harmful.” Appeal to ignorance

Threshold for Child Surgery
Social conformity Parental preference Prevent potential, minor problem Prevent certain, grave problem Therapeutic Not allowed ever Imagine the consequences for each

Practitioner Responsibilities
Medical best interest Your patient Consent

The Genital Cutting Context
What if we don’t circumcise? The child’s experience Complications Survivor Parent Practitioner Child The adult experience Is there informed consent? How circumcision changes sex Why do practitioners perform it? Are practitioners informed?

Cyclic View of a Social Surgery
Could there be such a surgery?: Child Survivor Parent Practitioner Removes a healthy, unique organ part Not as a treatment Social surgery Significant complications Performed on minors Illegal on girls; Promoted for boys Lifelong function loss Tissue used commercially

Male Genital Cutting (MGC)
Circumcision.ppt Ryan McAllister Male Genital Cutting (MGC) While the U.S. is the only country in the world where infant genital cutting of any kind is routinely practiced, male genital cutting is approximately 7.5 times as frequent world-wide as female genital cutting. In general, where female genital mutilation is prevalent, male circumcision is also, though the reverse is not the case. Intact Male Populations: Virtually all: Chinese, Japanese, North Koreans, Vietnamese, Laotians, Cambodians, Burmese, Thais, Hindu, Sikh, Parsee and Christian Indians, Scandinavians, Zulus, Shona, certain other African nations, most Melanesian and some Western Polynesian (Rennell, Bellona) peoples, most Europeans, men of the former Soviet Union, Central and South Americans, New Zealand Maori, younger men of Britain and the Commonwealth. Genitally Cut Male Populations: About 500,000,000 Muslims, more than 100,000,000 U.S. Americans, about 25,000,000 Filipinos, some tens of millions of older men of Britain and the Commonwealth, some tens of millions of African tribesmen, about 14,000,000 South Koreans, 7,000,000 Jews, some hundreds of thousands of Central and Eastern Polynesians (Samoa, Tahiti, Tonga, Niue, Tokelau) and Melanesians (from Fiji, Vanuatu, parts of Solomon Islands and small parts of PNG), and some scores of thousands of aboriginal Australians. Female Genital Cutting is practiced predominantly in 28 countries in Africa.1,3 Eighteen African countries have prevalence rates of 50% or higher, but these estimates vary from country to country and within various ethnic groups.1,3 FGC also occurs in some Middle Eastern countries-Egypt, the Republic of Yemen, Oman, Saudi Arabia and Israel-and is found in some Muslim groups in Indonesia, Malaysia, Pakistan and India.4 Some immigrants practice various forms of FGC in other parts of the world, including Australia, Canada, New Zealand, the United States and in European nations.1,4 Toubia, N. (1999). Caring for Women with Circumcision. RAINBO: NY, NY. WHO. (Downloaded 8/9/01). Female Genital Information: Information Pack Rahman, A. & Toubia, N. (2000). Female Genital Mutilation: A Guide to Laws and Policies Worldwide. Zed Books Ltd: London, UK. Department of State. (March, 2001). Report on Female Genital Mutilation as Required by Conference Report (H. Rept ) to Public Law Circumcision legally questioned Circumcision always rare Circumcision now rare Tribal youth circumcision common Islamic youth circumcision common Baby circumcision common ca 2000

How Did We Get Here? Moral Hygiene Medical Claims
Circumcision.ppt Ryan McAllister How Did We Get Here? Moral Hygiene Medical Claims 1860’s–70’s, Circumcision “cures”: Epilepsy, phimosis, masturbation, paralysis, hip- joint disease, digestive disorders 1880’s–mid-1900’s, Circumcision “cures”: Spinal curvature, dementia, clumsiness, bed-wetting, rheumatic disorders, asthma, Bright’s disease, syphilis, incontinence, constipation, general nervousness, restlessness, irritability, insomnia, night terrors “In cases of masturbation we must … cause too much local suffering to allow the practice…” First quote from –Athol A. W. Johnson, On An Injurious Habit Occasionally Met with in Infancy and Early Childhood, The Lancet, vol. 1 (7 April 1860) Now I want to give you a context for circumcision in our medical history. The history of medical rationales for circumcision begins with a concern for “moral hygiene” rather than the kind of hygiene associated with personal cleanliness. Bright's disease (acute glomerulonephritis, acute nephritic syndrome, acute nephritis): A vague and obsolete term for disease of the kidneys - acute or chronic. Usually refers to nonsuppurative inflammatory or degenerative kidney diseases characterized by proteinuria and hematuria and sometimes by edema, hypertension, and nitrogen retention. Prevalent in males; onset at any age; highest incidence between 3 and 7 years of age. R. Bright: Cases and observation, illustrative of renal disease accompanied with the secretion of albuminous urine. Guy’s Hospital Reports, London, 1836, 1: Guy’s Hospital Reports, London, 1840, 5: –Athol A. W. Johnson, The Lancet vol 1 (1860)

Circumcision and the Child
Circumcision.ppt Ryan McAllister Circumcision and the Child The procedure Surgical complications Post-op complications Newborns and pain Care of the wound Consider Children’s rights Parent-child bonding Social view of boys Ownership of the body Organ trafficking Photo Credit: drmomma.org Graphic of Circumcised Baby Removed for Sensitive Viewers We can locate circumcision in the context of a large set of child body modification practices that includes foot binding, forehead flattening, neck extension, human genital modification, and scarification.

The Child’s Experience
“How can it be wrong to surgically alter the genitals of a baby girl … but okay to surgically alter the genitals of a baby boy?” - Soraya Miré, Survivor, FGC Activist

Consensus: Prevention and Management of Pain in the Newborn
Compared with older age groups, newborns experience greater sensitivity to pain pain has long-term consequences lack of crying does not indicate lack of pain Sets goal to “Prevent, reduce, or eliminate the stress and pain of neonates.” –Joint statement, American Academy of Pediatrics and Canadian Paediatric Society (2000)

Soraya Mire, Producer, Activist Female Genital Cutting Survivor Video Credit: James Loewen

The Circumcision Restraint
Circumcision.ppt Ryan McAllister The Circumcision Restraint In preparation for the procedure, the baby’s arms and legs are strapped to a board-like retaining device.

Circumcision.ppt Ryan McAllister “Any person who wants to subject a child to this should be required to witness one first” -Michelle Storms, MD, stopped performing circumcisions in 1988

Surgical Complications - Penile Structure
Circumcision.ppt Ryan McAllister Surgical Complications - Penile Structure Scarring always occurs Uneven circumcision is common 15% of examined circumcised males had penile adhesions [1] Lymphedema [2] Skin bridges [3-5] Urethral fistulas, hypospadius and epispadius (a) [6-14] Buried, concealed, and hidden penis (c) [15-27] Penile amputation (d) [28-44] (a) Urethral fistula at frenulum (note probe), probably the result of incisional trauma. (b) Three-year-old boy with an almost transected glans from circumcision at birth, but parents did not note the abnormality until age 3. Urethra had been completely transected (arrow). (c) Neonate referred immediately after Gomco clamp circumcision in which all the skin of the shaft had been amputated. Caused by pulling too much skin up into the clamp and amputating it. May require a free skin graft. (d) Six-month-old baby was referred after loss of the entire penis from cautery used during circumcision. Evidently both corpora had thrombosed and sloughed, so no phallus remained. From the textbook Pediatric Trauma, edited by Robert J. Touloukian, M.D., Yale University School of Medicine (John Wiley & Sons). Epispadias - A urinary tube anatomic variation where the opening of the urethra (urethral meatus) is somewhere on the top side (dorsal surface) of the penis. Hypospadias - A urinary tube anatomic variation where the opening of the urethra (urethral meatus) is located on the underside (ventral surface) of the penis. Hypospadias and Epispadias can be inadvertently produced during circumcision by splitting the glans penis at the time of dorsal or ventral split preparatory to actual excision of the prepuce. In addition, inadvertent laceration of the penile or scrotal skin has been recorded. On occasion, the tip of the glans has been excised.

Postoperative Complications (Child Data)
Circumcision.ppt Ryan McAllister Postoperative Complications (Child Data) Bleeding Difficulty Breastfeeding Meatitis Joshua Haskins died in Sept 2010 from circumcision blood loss Between 8% and 31% [48-51], usually later in the first year, but while the child is still in diapers Major Morbidity Infection Necrosis Necrotizing fasciitis, [56] scalded skin syndrome, [57] gangrene, [58] generalized sepsis, [59] meningitis. [60] Meatitis – inflammation of the meatus, the opening of the urethra. Meatitis and meatal ulcer are rarely, if ever, seen in the uncircumcised boy. Meatal stenosis is far more common in circumcised adult men than in uncircumcised adult men5 and is believed to result from meatitis in infancy. Caudal anesthesia is currently being employed in some centers,32 and its use, like the use of all regional anesthetics has its own inherent complications. Additional Complications of Plastibell: When the Plastibell is utilized, the ring of the bell may migrate and by pressure necrosis produce a set of problems unique to this technique. If the ring may migrate and by pressure necrosis produce a set of problems unique to this technique. If the ring is too large it may migrate proximally and produce a groove in the shaft itself.14,23,30,45,59,73 To avoid such complications, any retained Plastibell ring should be removed after several days if it has not fallen off spontaneously. Adopted from George W. Kaplan, M.D. Complications of Circumcision, UROLOGIC CLINICS OF NORTH AMERICA, 10, (1983). See also N. Williams and L. Kapila, Complications of Circumcision, BRITISH JOURNAL OF SURGERY, 80, (1993). Neonatal incidence 0.4% [46] Older boys as high as 10% [47] Necrosis and slough of the glans or entire penis.[52-54] Rates unknown, probably rare. LT Aggravated Response to Pain Permanent disability Death

Real Life Complications in DC
“In a two year period, I was referred >275 newborns and toddlers with complications of neonatal circumcision… 45% required corrective surgery” David M. Gibbons, Pediatric Urologist, Georgetown University Hospital

Circumcision and the Survivor
Circumcision.ppt Circumcision and the Survivor Ryan McAllister “I didn’t do what was right for my first son…. That wasn’t done right for me, either…. When does it stop?” “It has negatively impacted all of my relationships.” “I was just a baby—I couldn’t stop them.” Circumcised father, in tears, with one circumcised and one intact son “It's like I've been raped … sexual abuse” “This act of male genital mutilation—whether it's a culture and religious or personal choice—I think is nothing but a scar of betrayal.” You can watch the interview with the father quoted above at: “I can’t accept that someone did that to me.” Soyara Miré, Survivor FGC GC activist

The Foreskin Most erogenous tissue in male 12-15 square inches
Circumcision.ppt Ryan McAllister The Foreskin Most erogenous tissue in male 12-15 square inches 10,000-20,000 nerve endings Skin mobility Lubrication Specialized anatomy The surface are of the adult foreskin is between 12 and 15 square inches. It contains 10,000-20,000 nerve endings, the same kinds of fine touch receptors (Meissner’s corpuscles) found in the clitoris. These receptors are found in volar regions, such as the fingertips and lips, and are only sparsely located in the head of the penis. The foreskin contains part of the dartos muscle (sometimes referred to as the Peripenic muscle). This muscle lies just beneath the skin and is the same muscle responsible for contraction of the scrotal skin. The dartos muscle is also responsible for tightening the tip of the foreskin in a manner similar to that of a sphincter. [1,2] Credits for the picture showing the frenulum, frenular delta, and ridged band to John A. Erickson, Jefferson G. The peripenic muscle; some observations on the anatomy of phimosis. Surgery, Gynecology, and Obstetrics (Chicago) 1916; 23(2): Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44. Frenulum Ridged band (frenar band) Dartos muscle Photo credit: John A. Erickson 1994

Touch Sensitivity, Intact

Touch Sensitivity, Circumcised
Circumcision.ppt Ryan McAllister Touch Sensitivity, Circumcised “Only being able to see in black and white, rather than seeing in full color… There are feelings you'll just never have without the foreskin.” –Paul Tardiff, circumcised at 30.

Fine-Touch Sensitivity Comparison
Sorrels et al, BJU INTERNATIONAL 99, , 2007 “One of the biggest mistakes of my life….Sexual pleasure has been reduced by at least 70% both in intensity and range of sensations. –William E. Krueger, circumcised at 30

Touch Sensitivity Comparison
Circumcision.ppt Ryan McAllister Touch Sensitivity Comparison Intact Circumcised Alternative to slide 21 “One of the biggest mistakes of my life….Sexual pleasure has been reduced by at least 70% both in intensity and range of sensations. –William E. Krueger, circumcised at 30

“I've wondered what it's like to have a foreskin all my life.”
Circumcision.ppt Ryan McAllister The Foreskin Moves “The Three Zones of Penile Skin,” John A. Erickson 1994 “I've wondered what it's like to have a foreskin all my life.” –Survivor These photos and more can be examined at A) Penis slightly tumescent. The area between the upper and lower lines is the foreskin's outside fold. The foreskin's outside fold is almost as long as the skin covering the penile shaft. The foreskin's inside fold, equal in length to and covered by the foreskin's outside fold, is not visible. Well over half of the total penile skin is foreskin. B) The foreskin retracted (manually) about an inch. The area between the upper (blue) line and the lower (green) line is the foreskin's mostly retracted outside fold. The area below the lower line is the first half-inch or so of the foreskin's partially retracted inside fold C) The foreskin retracted. The area between the upper and lower lines is the foreskin's retracted outside fold. The area below the lower line is the foreskin's retracted inside fold, gathered behind the coronal sulcus. D) The foreskin retracted farther. Almost the entire penile shaft is now covered with foreskin. The area between the upper and lower lines is the foreskin's retracted outside fold. The area between the lower line and the glans is the foreskin's retracted inside fold. If the skin were released, it would return to its position in (C). E) The foreskin retracted as far as it will comfortably go. The area between the lower (green) line (the only line now visible) and the glans is the foreskin's fully retracted inside fold. (One of the fingers holding the foreskin back is partially visible.) The entire penile shaft is now covered with foreskin. Well over half of the shaft is covered with the foreskin's retracted inside fold. Veins, arteries, capillaries, and smooth glans texture clearly visible. F) A circumcised penis. The scar that now forms the junction between the mucosal and shaft tissue is uneven. G) Arrows point to the end of the mucosal membrane, above which is the circumcision scar. Credits to John A. Erickson Arrows indicate the scar

Dustin Marquardt; Video Credit: James Loewen

Circumcision and the Parent
Regret Poor consent process “I was shaking and I muttered ‘Oh God what have I done?’” –Lauren Stone, blogger, “Women Are Victims Too: A Letter to my Son” “After 63 hours of labor … the doctor asked me if I wanted him to go ahead and circumcise my baby … they didn't tell me about any pros or cons” –Claire Latham, “Circumcision Experience” "I will die hearing my baby's screams.” –Miriam Pollack, author, “Circumcision: A Jewish Feminist Perspective”

Video Credit: The Whole Network

Framing “Informed Consent”
Physicians want to be trusted, yet Don’t know complication incidence Trivialize complication severity Fail to state foreskin functions Omit ethical questions Perform unneeded surgery on minors

How Can Parents Know? No mention of foreskin sexual function
Circumcision.ppt Ryan McAllister How Can Parents Know? From GU Hospital Website: “Circumcision is considered a very safe procedure.” “The risks include: Bleeding Infection Localized redness Injury to the penis” Mission Vision ValuesIn June 2007, Georgetown University Hospital introduced a refreshed mission statement, along with revised vision and values statements from MedStar Health (the vision and values are shared by all MedStar organizations). The GUH mission statement was derived after a thorough process which included seeking input from focus groups with representation from nurses from all levels of the organization. Mission: To provide physical and spiritual comfort to our patients and families in the Jesuit tradition of cura personalis, caring for the whole personVisionTo be the trusted leader in caring for people and advancing healthValuesService We strive to anticipate and meet the needs of our patients, physicians and co-workers.   Patient First We strive to deliver the best to every patient every day. The patient is the first priority in everything we do.  Integrity We communicate openly and honestly, build trust and conduct ourselves according to the highest ethical standards.  Respect We treat each individual, those we serve and those with whom we work, with the highest professionalism and dignity.  Innovation We embrace change and work to improve all we do in a fiscally responsible manner.   Teamwork System effectiveness is built on the collective strength and cultural diversity of everyone, working with open communication and mutual respect No mention of foreskin sexual function

After the Circumcision
Circumcision.ppt Ryan McAllister After the Circumcision Painful 7-10 days Tip raw or yellowish Discharge up to a week Frequent bandage change Vit. A&D ointment to prevent adhesion Post-op complication signs No urination within 6-8 hours Persistent bleeding Swelling, foul-smelling drainage, or redness around tip, worse after 3 to 5 days From Circumcision: Frequently Asked Questions Published by the American Association of Pediatrics (AAP) in 2001

Care of the Unaltered Penis
Circumcision.ppt Ryan McAllister Care of the Unaltered Penis No harsh soaps or abrasives Do not use force to retract Foreskin becomes retractile on its own Fewer potential health problems A happier, healthier baby Care of the intact penis is simpler than care of the circumcised penis. Photo Credit: drmomma.org

Institutional Conflict of Interest
Circumcision.ppt Ryan McAllister Institutional Conflict of Interest Tissue use, (parents don’t know) Research $350-$500/vial Invitrogen Prod codes: C0205C, C0045C, C2025C, C0015C, …. “Magic Skin” treatment (Apligraf) Cosmetics ~ $1000/vial Valveta (Intercytex) Fees - $ /procedure One source for the Valveta story is Scientific American “A Cut above the Rest?: Wrinkle Treatment Uses Babies' Foreskins” Invitrogen sales include Fibroblasts, Keratocytes, and Melanocytes, differentiated by “donor” skin color And from GU website: Apligraf, a product produced by Organogenesis Inc. in Canton, Massachusetts, is a living skin graft created from foreskin removed from newborn babies during circumcision. By combining this living tissue with biological proteins and a basket weave of skin cells called keratinocytes, Apligraf helps to stimulate the natural healing process of the body that has been compromised because of lack of blood flow to the wounded skin area and other biologic wound failures. - 34

Presenting Circumcision
Circumcision.ppt Ryan McAllister Presenting Circumcision This is Dr. Lisa Masterson, Ob/Gyn from the show ‘”The Doctors” speaking with Craig Ferguson Notice her confidence in speaking Notice that the child’s pain and needs are nowhere in her presentation The benefits of having a foreskin are omitted Note that she tells her patients that “you really have to decide if you want your son to look like you.” This is how the circumcision decision is often portrayed to parents By physicians whose education has lead them here. Do parents really have to decide if they want their children to look like them?

Circumcision and the Practitioner
Circumcision.ppt Ryan McAllister Circumcision and the Practitioner “…let out a scream I’d never heard come out of the mouth of a baby.” –Marilyn Milos, RN and founder, NOCIRC, after assisting a circumcision. Fired in 1985 for telling parents it was painful and unnecessary “I have been ridiculed, patronized, ostracized, … for my refusal to perform … circumcision.” –Michelle Storms, MD, stopped circumcising in 1988 “Medically, it doesn’t make sense… I don’t like doing the procedure. But I do it well. I’ve performed thousands of circumcisions.” –Helain Landy, MD, Head of Obstetrics, Georgetown University Hospital

Pathologizing a Healthy Organ
Circumcision.ppt Ryan McAllister Pathologizing a Healthy Organ Absent from most U.S. anatomy texts No education about function Taught only how to remove it Mistaught care – “retract and wash” Phimosis often misdiagnosed Foreskin gradually becomes retractile Cartoon represents roughly the timeline presented in Oster, and in Cold and Taylor

Practitioners Frame the Infant’s Experience
Dr. Phyllis Marx, OB/GYN, Mohel Documentary Writer/Director Eliyahu Ungar-Sargon Cut (2007)

OBs don’t see complications
OB sees baby as not their patient OBs neither follow-up nor handle complications Pedactric Urologists handle complications Obstetricians “can neither manage their complications (2-5% incidence) nor obtain proper informed consent” –David M. Gibbons, Pediatric Urologist Georgetown University Hospital

Justifications for Genital Cutting
Circumcision.ppt Ryan McAllister Justifications for Genital Cutting Parents say… Physicians say… Look “like others” or “like his Dad” (#1) “Looks better” “Easier to keep clean” Religion/Culture (Physician solicitation validates option) Reduce penile cancer Reduce UTI occurrence Reduce cervical cancer rate in female partner Reduce FM HIV transmission The incidence of penile cancer is 1 in 100,000. Urinary Tract Infections (UTIs) are more common in women than in intact or circumcised men. The myth that circumcision reduces the transmission rate of STIs is one of the most dangerous myths of all. The US aids epidemic occurred among men of whom almost 100% were circumcised. Worse, circumcision is associated with an increased resistance on the part of the male to use a condom. Condoms are effective at reducing STI transmission.

Documentary Writer/Director Eliyahu Ungar-Sargon Interviewing
Dr. Julian Ungar-Sargon MD PhD, Neurologist Orthodox Rabbi Hershy Worch Cut (2007)

Responses Appearance, Cleanliness Penile Cancer
Circumcision.ppt Ryan McAllister Responses Appearance, Cleanliness Penile Cancer Same argument used to support FGM ACS says no Irrelevant, rate ~ 1/100,000 Cervical Cancer UTIs Principally 2002 StudyB Husbands and wives had different HPV strainsC Surgery on baby for future partner? A: Wiswell, T.E, & Roscelli, J. D. (1986). Corroborative evidence for the decreased incidence of urinary tract infections in circumcised male infants. Pediatrics, 78 (1). B: Castellsagué X, Bosch FX, Muñoz, N, et al. Male Circumcision, Penile Human Papillomavirus Infection, and Cervical Cancer in Female Partners. New Engl J Med 2002; 346(15): C: Franceschi S, Castellsagué X, Dal Maso L, et al. Prevalence and determinants of human papillomavirus genital infection in men. Br J Cancer 2002;86: Landmark 1986 StudyA Instructions cause UTIs Lower rate than females in all cases

Circumcision as HIV prevention
Evidence for 3 Randomized Controlled Trials (RCTs) Volunteer men willing to be circumcised Randomly circumcise half Dubious methodology Claim ~ 60% reduced per exposure risk Evidence against Most other studies Geographic data U.S. high circumcision and high HIV rate

Circumcision as HIV prevention
Evidence For Evidence Against 3 Randomized Controlled Trials (RCTs) Volunteer men willing to be circumcised Randomly circumcise half Dubious methodology Claim ~ 60% reduced per exposure risk Most other studies Geographic data U.S. high circumcision and high HIV rate

Auvert Randomized Trial
Circumcision.ppt Ryan McAllister Auvert Randomized Trial [S6] Claims 60% per coitus HIV protection More safe sex counseling, condoms to circumcised group Methodological flaws in timing 4-6 weeks, too painful for intercourse post circumcision (AAFP) Circumcised group told “abstain at least 6 weeks” ELISA test ~3 month “window period” seroconversion Half the claimed protection appears in this window Corrected results insignificant Unusually high (4-5%) per coital transmission No control for blood exposures, dry sex, receptive anal intercourse Local clinic visits (strongest correlation with HIV infection) AAFP = American Academy of Family Practitioners [S6] Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial.Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A Nov;2(11):e298. Epub 2005 Oct 25. ELISA = Enzyme-Linked ImmunoSorbent Assay Critique 1 Their report also reveals several problems with the widely held assumption that penile-vaginal sex accounts for the overwhelming majority of HIV transmission in sub-Saharan Africa. The factor most strongly associated with incident HIV infection was attendance at a clinic for a health problem related to the genitals (rate ratio, 5.7) and is neither highlighted nor specifically discussed. Given evidence for increased risk of acquiring HIV from treatment for sexually transmitted diseases (STDs) in sub-Saharan Africa (relative to untreated STDs) [2], such a context for HIV acquisition should have been more assiduously explored, especially regarding nosocomial transmission.Regrettably, the authors did not control for blood exposures (e.g., other types of medical or dental care, including care from “street doctors” and village injectionists, injections with syringes kept at home, ritualistic procedures, and injection drug use). Nor did they assess anal intercourse, the variable most strongly associated with sexual transmission of HIV. Anal intercourse is not uncommon in sub-Saharan Africa [3]. The authors also did not ask participants to specify the sex of their nonspousal partners, despite much evidence for bisexual behavior on the part of many ﾒheterosexualﾓ men in sub-Saharan Africa [3].Furthermore, the authors did not report the relationship between level of condom use and HIV incidence. The need for more detailed investigation of sexual exposures is underlined by the negligible associations between such traditional measures of sexual riskﾑany type of unprotected sex, the number of sexual exposures (ﾒcontactsﾓ), and the number of nonspousal partnersﾑand HIV incidence [1]. Indeed, these results replicate the frequent lack of association between sexual behavior variables and HIV incidence or epidemic trajectories in sub-Saharan Africa [4]. (The authors should also report HIV incidence in persons reporting no sexual activity during specified study intervals.) Of concern as well is the high per coital actﾐHIV transmission probability implied by the data presented. A high transmission probability would suggest that the HIV prevalence in their participants should be greater than the 4%ﾐ5% observed at baseline.Until all modes of HIV transmissionﾑby sex and by puncturingﾑare comprehensively investigated [5,6], the most effective means of preventing HIV transmission will remain shrouded. In light of the anomalies and lacunae in Auvert and colleagues' study, the protective effect of male circumcision they observed amounts to a faith lift for the empirically beleaguered paradigm of heterosexual HIV transmission in sub-Saharan Africa Potterat JJ,ﾊBrewer DD,ﾊMuth SQ,ﾊBrody S (2006) The Protective Effect of Male Circumcision as a Faith Lift for the Troubled Paradigm of HIV Epidemiology in Sub-Saharan Africa. PLoS Med 3(1): e64 My Critique Used ELISA test… seroconversion is ~6 months. Half of the advantage appeared in the 1-3 month period, and the rest in the 4-12 month period. The benefit reduced in the month period Full recovery following circumcision generally requires four to six weeks of abstinence from all genital stimulation and sexual activity. -AAFP

Irresponsible Representation
Circumcision.ppt Irresponsible Representation Ryan McAllister “Male circumcision provides a degree of protection against HIV equivalent to what a vaccine of high efficacy would have achieved.” Measels vaccine: 99% recipients become immune –Auvert et al (2006), after showing 60% protection per exposure "I have heard that if you get circumcised, you cannot catch HIV/ Aids. I don't have to use a condom or worry about all those other ways of keeping safe...” Now recommended by WHO, UNAIDS, and USAID –37 year old Mukasa, from The Monitor (Kampala, Uganda), April 10, 2007, Jan Ajwang

Serious Concerns Is this good evidence? Preventative amputation?
Circumcision.ppt Ryan McAllister Serious Concerns Is this good evidence? Preventative amputation? Supports FGC Belief of immunity Decreased sensitivity Decreased condom use, increased risky behavior Increased M-t-F transmission rateA US: high circumcision, high HIV rates Condoms >95X more cost-effectiveB Circumcision is permanent amputation of healthy, sensitive, genital tissue 37- year old Mukasa: "I have heard that if you get circumcised, you cannot catch HIV/ Aids. I don't have to use a condom or worry about all those other ways of keeping safe. I finally get a method that suits me...” -The Monitor (Kampala), April 10, 2007, Jan Ajwang A: Chao A, Bulterys M, Musanganire F, et al. Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda-Johns Hopkins University AIDS Research Team. Int J Epidemiol 1994; 23: B: McAllister RG, Travis JW, Bollinger D, Rutiser C, Sundar V: The Cost to Circumcise Africa. Int. J, Men’s Health 2008;7(2):307–316.

Recap: Bias towards cutting infants
Not a treatment Unnecessary “Social surgery” Tissue used commercially Pains, risks Survivor Parent Practitioner Child Misinformed, wouldn’t want children hurt HURTS Sexual loss False choice, proxy consent inappropriate Indoctrinated into a harmful practice Ignorant about complications, other effects

“Not my responsibility”
Professional Organizations Protect practitioners, image Practitioners / Admins Business, avoid controversy OBs: “Child not my patient” Ethics Committee “Not appropriate venue” Neglecting parents and child

Yes, our responsibility
Reasons for change Care for children Care for parents Moral duty Professional responsibility While in your care, you are 100% responsible for what you do to a child.

Steps Stop performing Recommend against Medical student education
Physician reeducation Parent education Revise informed consent Cease tissue use

Circumcision.ppt Ryan McAllister The following slides contain supplementary material and references. Additional Material

Consensus: Prevention and Management of Pain in the Newborn
Circumcision.ppt Ryan McAllister Consensus: Prevention and Management of Pain in the Newborn Compared with older age groups newborns experience greater sensitivity to pain pain has long-term consequences lack of crying does not indicate lack of pain Sets goal to “Prevent, reduce, or eliminate the stress and pain of neonates.” –Joint statement, American Academy of Pediatrics and Canadian Paediatric Society Both statements agree on all these issues. What we should ask ourselves is “Surgery on infants or no surgery on infants?” Rather than “Anesthetic or No Anesthetic?” American Academy of Pediatrics and Canadian Paediatric Society. Prevention and management of pain and stress in the neonate. Pediatrics 2000 Feb;105: Anand KJS. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med Feb;155:

Circumcision significantly increases risk of serious infection
Methicillin-Resistant Staphylococcus Aureus Initial presentation post-circumcision staphylococcal necrotizing fasciitis After surgical debridement of infected tissue

Circumcision Kills Boys
Circumcision.ppt Ryan McAllister Circumcision Kills Boys “The summer [male] circumcision season death toll in the Eastern Cape has risen to 14…” –EC circumcision deaths: 14 South Africa’s Dispatch Online 17 Dec 2010 “39 young men died in the last month after undergoing the rite of passage into manhood” –S. Africa sees rise in post-circumcision deaths MSNBC 29 July 2010

Touch Sensitivity Results
Circumcision.ppt Ryan McAllister Touch Sensitivity Results Amputated Amputated Scar Sorrels et al, BJU INTERNATIONAL 99, (2007)

Foreskin Protective Functions
Circumcision.ppt Ryan McAllister Foreskin Protective Functions Anatomical Lysozyme (antibacterial) Immunoglobulins (antibodies) Langerhans cells (immune system) Sebaceous glands (moisturizing) That serve to Prevent over-keratinization Protect from contamination, meatal stenosis, and UTIs The skin covering protects Protects from injury Protects the nerves Protects against sunburn, frostbite, and other environmental hazards` Protection: Just as the eyelids protect the eyes, the foreskin protects the glans and keeps its surface soft, moist, and sensitive. It also maintains optimal warmth, pH balance, and cleanliness. The glans itself contains no sebaceous glands -- glands that produce the sebum, or oil, that moisturizes our skin.11 The foreskin produces the sebum that maintains proper health for the surface of the glans. Immunological Defense: The mucous membranes that line all body orifices are the body's first line of immunological defense. Glands in the foreskin produce antibacterial and antiviral proteins such as lysozyme.12 Lysozyme is also found in tears and mother's milk. Specialized epithelial Langerhans cells, an immune system component, abound in the foreskin's outer surface.13 Plasma cells in the foreskin's mucosal lining secrete immunoglobulins, antibodies that defend against infection.14 11. A. B. Hyman and M. H. Brownstein, "Tyson's 'Glands': Ectopic Sebaceous Glands and Papillomatosis Penis," Archives of Dermatology 99 (1969): A. Ahmed and A. W. Jones, "Apocrine Cystadenoma: A Report of Two Cases Occurring on the Prepuce," British Journal of Dermatology 81 (1969): G. N. Weiss et al., "The Distribution and Density of Langerhans Cells in the Human Prepuce: Site of a Diminished immune Response?" Israel Journal of Medical Sciences 29 (1993): P. J. Flower et al, "An immunopathologic Study of the Bovine Prepuce," Veterinary Pathology 20 (1983):

Foreskin Sexual Functions
Circumcision.ppt Ryan McAllister Foreskin Sexual Functions Erotic pleasure [63-71] Most of the specialized fine-touch nerve endings (Meissner's corpuscles) in the penis [63-71] Release phermones on arousal Release natural lubricants Make the glans a visual signal of sexual arousal Provide play of skin in erection Mechanically reduce friction Prevent painful intercourse Stimulate partner Retain lubrication Erogenous Sensitivity: The foreskin is as sensitive as the fingertips or the lips of the mouth. It contains a richer variety and greater concentration of specialized nerve receptors than any other part of the penis.63 These specialized nerve endings can discern motion, subtle changes in temperature, and fine gradations of texture.64-71 Coverage during Erection: As it becomes erect, the penile shaft becomes thicker and longer. The double-layered foreskin provides the skin necessary to accommodate the expanded organ and to allow the penile skin to glide freely, smoothly, and pleasurably over the shaft and glans. Self-stimulating Sexual Functions: The foreskin's double-layered sheath enables the penile shaft skin to glide back and forth over the penile shaft. The foreskin can normally be slipped all the way, or almost all the way, back to the base of the penis, and also slipped forward beyond the glans. This wide range of motion is the mechanism by which the penis and the orgasmic triggers in the foreskin, frenulum, and glans are stimulated. Sexual Functions in Intercourse: One of the foreskin's functions is to facilitate smooth, gentle movement between the mucosal surfaces of the two partners during intercourse. The foreskin enables the penis to slip in and out of the vagina nonabrasively inside its own slick sheath of self-lubricating, movable skin. The female is thus stimulated by moving pressure rather than by friction only, as when the male's foreskin is missing. See also K. Ohara, “The effect of male circumcision on the sexual enjoyment of the female partner” BJU INTERNATIONAL 83 Supplement 1 (1999):

Comparing Anatomy During Erection
Circumcision.ppt Ryan McAllister Comparing Anatomy During Erection

Studies on HIV and circumcision (before the ones in the news)
Circumcision.ppt Ryan McAllister Studies on HIV and circumcision (before the ones in the news) 1994 Circumcision increases risk of Male to Female transmission [S1] 1995 Tanzania no protective effect [S2] 1999 Meta analysis finds circumcised men at greater risk for acquiring HIV [S3] 2001 Heterosexual monogamous couples in Uganda: HIV transmission not related to circumcision status [S4] 2005 Female circumcision correlated with 50% lower AIDS seropositivity in Tanzania [S5] 2007 Langerin in Langerhans cells in the foreskin helps to prevent HIV transmission to immune cells [S7] Refs for this slide: S1 Chao A, Bulterys M, Musanganire F, et al. Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda-Johns Hopkins University AIDS Research Team. Int J Epidemiol 1994; 23: S2 Grosskurth H., Mosha F, Todd J, et al. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS 1995;9(8): S3 Van Howe RS. Circumcision and HIV-infection: meta-analysis and review of the medical literature. Int J STD AIDS 1999; 10: 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)= ). [S4] Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet 2001; 357: S5 FEMALE CIRCUMCISION AND HIV INFECTION IN TANZANIA: FOR BETTER OR FOR WORSE?IAS Conf HIV Pathog Treat 2005 Jul 24-27;3rd: Abstract No. TuOa0401 Stallings R.Y.1, Karugendo E.2 1ORC Macro, Calverton Maryland, United States of America, 2National Bureau of Statistics, Dar es Salaam, United Republic of Tanzania TORONTO, CANADA -- August 17, HIV prevalence is not necessarily lower in populations that have higher male circumcision rates, according to findings from a study of African countries presented here at the 16th International AIDS Conference (AIDS 2006).  The study, which examined the association between male circumcision and HIV infection in 8 Sub-Saharan African countries, contradicts the findings of previous research and the opinion of several prominent personalities active in the fight against AIDS, such as former US President Bill Clinton.  While several studies have indicated that male circumcision has a protective effect against sexually transmitted infections (STI), including HIV infection, the evidence is inconclusive, said investigator Vinod Mishra, MD, director of research, ORC Macro, Calverton, Maryland. "We're just questioning that push," he said of the optimism displayed by Clinton and others.  The study used demographic findings from recent demographic and health surveys in Burkina Faso, Cameroon, Ghana, Kenya, Lesotho, and Malawi, and AIDS indicator surveys from Tanzania and Uganda. The surveys were conducted from 2003 to 2005 and sample sizes ranged from 3,300 men in Lesotho to 10,000 men in Uganda.  In survey fieldwork in each country, men aged 15 to 59 gave blood for anonymous HIV testing. Information on circumcision status and on STI/STI symptoms was based on men's responses to questions in survey interviews.  Prevalence of male circumcision ranged from a high of 96% in Ghana to a low of 21% in Malawi. Among the other countries, circumcision rates were 84% in Kenya, 89% in Burkina Faso, and 25% in Uganda.  HIV prevalence was markedly lower among circumcised than uncircumcised men only in Kenya (11.5% among uncircumcised men vs 3.1% among circumcised men). A small protective effect of male circumcision was also seen in Burkina Faso (2.9% vs 1.7%, respectively) and Uganda (5.5% vs 3.7%).  In the other countries, there was either no difference in HIV rates between circumcised and uncircumcised men or circumcised men were more likely to be HIV-positive than uncircumcised men. For example, in Lesotho, HIV was seen in 23.4% of circumcised men compared with 15.4% of uncircumcised men.  "If anything, the correlation [between circumcision and HIV infection] goes the other way," in most of the countries studied, Dr. Mishra said during his presentation on August 15th.  When adjusted for sociodemographic and behavioral factors, a small protective effect was observed in 6 of the 8 countries, but it was not statistically significant in any country, Dr. Mishra said.  In Kenya, and to a lesser extent, in Ghana, Malawi, Tanzania, and Uganda, circumcised men were less likely than uncircumcised men to report having had an STI or STI symptoms in the 12-month period prior to the survey (2.1% vs 5.4%, respectively). The relationship was reversed in Cameroon (8.0% vs 2.5%) and Lesotho (12.1% vs 7.5%).  With other factors controlled, male circumcision had some protective effect in 5 of the 8 countries, but the effect was statistically significant only in Tanzania.  In addition, "circumcised men tend to have more lifetime sex partners, so there's some [high-risk] behaviors that go with circumcision status," he said.  A study limitation is that it was based on self-reported information on circumcision status and STI/STI symptoms. It also lacks data on age at circumcision and degree of circumcision, which might influence susceptibility to HIV infection.  However, Dr. Mishra said the study is consistent with other research that has failed to find a protective effect of male circumcision on HIV and STIs.   [Presentation title: Is Male Circumcision Protective of HIV Infection? Abstract TUPE0401]

HIV in Africa Circumcision.ppt Ryan McAllister

Published vs Corrected Results

PEPFAR 2011: “Aggressive Scale up”
Circumcision.ppt Ryan McAllister PEPFAR 2011: “Aggressive Scale up” Funding mass circumcision 14 countries Kenya “36,000 in 30 days” Tanzania: “105,000” in months Bad interpretation of bad science Claims “by 153,000 male circumcisions you avert 88,000 new infections” An effect 50 times that seen in any study Imperialism, paternalism, racism? Caroline Ryan, MD, MPH, Dir., Technical leadership Information from Caroline Ryan, MD, MPH, director of technical leadership at PEPFAR (President's Emergency Plan for AIDS Relief) in an interview with John Donnelly

Early “Benefits” of Circumcision
Circumcision.ppt Ryan McAllister Early “Benefits” of Circumcision Clumsiness and bed-wetting 1887 “[His] Hip trouble is from falling down, an accident that children with tight foreskins are specially liable to, owing to the weakening of the muscles produced by the condition of the genitals.” Lewis L. Sayer, MD, “Circumcision for the Cure of Enuresis,” Journal of the American Medical Association, Vol. 7, pp Neurological disorders 1895 “In all cases in which male children are suffering nerve tension, confirmed derangement of the digestive organs, restlessness, irritability, and other disturbances of the nervous system, even to chorea, convulsions, and paralysis, or where through nerve waste the nutritive facilities of the general system are below par and structural diseases are occurring, circumcision should be considered as among the lines of treatment to be pursued.” Charles E. Fisher, Circumcision, in A Hand-Book On the Diseases of Children and Their Homeopathic Treatment. Chicago: Medical Century Co., p.875. Following its introduction, circumcision was purported to cure a variety of illnesses. Epilepsy, paralysis, idiocy, and almost any illness in a young male who had not already been circumcised might apparently be cured by circumcision. See “From Ritual to Science: The Medical Transformation of Circumcision in America”, David L. Gollaher, Journal of Social History Vol. 28 No. 1, pp. 5 – 36, Fall This article is available online at

Circumcision.ppt Ryan McAllister The Trend Continues “Measures more radical than circumcision would, if public opinion permitted their adoption, be a true kindness to patients of both sexes.” Jonathan Hutchinson, On Circumcision as Preventative of Masturbation, Archives of Surgery, vol. 2 (1891): pp 1902 “I have repeatedly seen such cases as convulsions, constant crying in infants, simulated hip joint diseases, backwardness in studies, enuresis, marasmus, muscular incoordination, paralysis, masturbation, neurasthenia, and even epilepsy, cured or greatly benefited by the proper performance of circumcision." W.G.Steele, MD. “Importance of Circumcision.” Medical World,Vol. 20 (1902): pp Another quote: 1935 “all male children should be circumcised. … Nature intends that the adolescent male shall copulate as often and as promiscuously as possible, and to that end covers the sensitive glans so that it shall be ever ready to receive stimuli. … the glans of the circumcised rapidly assumes a leathery texture less sensitive than skin.” R.W. Cockshut. Circumcision. British Medical Journal, Vol.2 (1935): p.764.

Circumcision.ppt Ryan McAllister Abnormal bonding of penile skin as a result of circumcision May result in physical and psychological discomfort Skin Bridges

Circumcision is Associated with
Circumcision.ppt Ryan McAllister Circumcision is Associated with Decreased pleasurable sensation for the man [72-74] Increased erectile problems [75-76] Increased sexual problems for female partners [77] Psychological problems, including anger, grief, difficulty with trust, inhibited intimacy, communication challenges [78] Increased diversity of sexual behaviors [79,80] Increased resistance to condom use [80] No difference in STD transmission rate [79] Increased risk of UTIs [81-83] No difference in cervical cancer rates for sexual partners [84] “Circumcision is not considered to be beneficial in preventing or reducing the risk of penile cancer,” –American Cancer Society (1999)

Legislation Female circumcision Male circumcision
Circumcision.ppt Ryan McAllister Legislation Female circumcision U.S. – Illegal to perform on a minor since 1996 [17 below] Legislation criminalizing FC/FGM has been adopted in 16 countries, including 9 in Africa. [15 below] Male circumcision Sweden – On June 1, 2001, the Swedish Parliament passed a law restricting circumcision to licensed practitioners, except for religious circumcision in the first two months of life. Finland – The consent of both parents is now required. Involuntary intersex gender assignment No legislation. More on Finland - Late in 1999, the Juridic Ombudsman of the Finnish Parliament, Riitta-Leena Paunio, noted that infant circumcision is not recommended without a medical reason and recommended that children should be consulted and should give their permission. She said the Finnish Parliament should weigh up the parents' religious rights over their children against the obligation of society to protect its children from ritualistic operations without immediate benefit to them. This decision is believed to be the first of its kind in any country. As an immediate result, the consent of both parents is now required. Countries that have adopted legislation criminalizing FC/FGM: Australia (six of eight states), Burkina Faso, Canada, Central African Republic, Côte d'Ivoire, Djibouti, Ghana, Guinea, New Zealand, Norway, Senegal, Sweden, Tanzania, Togo, the United Kingdom, and the United States. In addition, three states in Nigeria have criminalized the practice. [15] U.S. Law: On September 30, 1996, Congress enacted a provision criminalizing the practice of FC/FGM as part of the Illegal Immigration Reform and Immigrant Responsibility Act of [17] With two exceptions, it provides that "whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years shall be fined under this title or imprisoned not more than 5 years, or both." [18] The statute exempts a surgical operation if such operation is "necessary to the health of the person on whom it is performed, and is performed by a person licensed in the place of its performance as a medical practitioner." [19] The term "health" in this exemption is to be interpreted narrowly. The statute states that "no account shall be taken of the effect on the person on whom the operation is to be performed of any belief on the part of that person, or any other person, that the operation is required as a matter of custom or ritual." [20] The statute also exempts an operation if it is "performed on a person in labor or who has just given birth and is performed for medical purposes connected with that labor or birth by a person licensed as a medical practitioner, midwife, or person in training to become such a practitioner or midwife." [21] 15 The Center for Reproductive Rights, Female Circumcision/Female Genital Mutilation (FC/FGM): Global Laws and Policies Towards Elimination (2000). 17 See Illegal Immigration Reform and Immigrant Responsibility Act of 1996, Pub. L , § 645, 110 Stat (1996). WOMEN'S POLICY, INC., THE RECORD: GAINS AND LOSSES FOR WOMEN AND FAMILIES IN THE 104TH CONGRESS (1997). 18 U.S.C.A. at § 116(a). 19 Id. at § 116(b)(1). 20 Id. at 116(c). 21Id. at § 116(b)(2). See Legislation on Female Circumcision/ Female Genital Mutilation in the United States for more information

Male and Female Circumcision
Circumcision.ppt Ryan McAllister Male and Female Circumcision Clitoridectomy and Infibulation in Africa "She loses only a little piece of the clitoris, just the part that protrudes. The girl does not miss it. She can still feel, after all. There is hardly any pain. Women's pain thresholds are so much higher than men's." "The parts that are cut away are disgusting and hideous to look at. It is done for the beauty of the suture." "Female circumcision protects the health of a woman. Infibulation prevents the uterus from falling out [uterine prolapse]. It keeps her smelling so sweet that her husband will be pleased. If it is not done, she will stink and get worms in her vagina." "Leaving a girl uncircumcised endangers both her husband and her baby. If the baby's head touches the uncut clitoris during birth, the baby will be born hydrocephalic [excess cranial fluid]. The milk of the mother will become poisonous. If a man's penis touches a woman's clitoris he will become impotent." "A circumcised woman is sexually more pleasing to her husband. The tighter she is sewn, the more pleasure he has." "Doctors do it, so it must be a good thing." 35 year old Sudanese woman: "Yes, I have suffered from chronic pelvic infections and terrible pain for years now. You say that all if this is the result of my circumcision? But I was circumcised over 30 years ago! How can something that was done for me when I was four years old have anything to do with my health now?" Infant Male Circumcision in North America "It's only a little piece of skin. The baby does not feel any pain because his nervous system is not developed yet.“ "An uncircumcised penis is a real turn-off. Its disgusting. It looks like the penis of an animal." "An uncircumcised penis causes urinary infections and penile cancer. It generates smegma and smegma stinks. A circumcised penis is more hygienic and oral sex with an uncircumcised penis is disgusting to women." "Men have an obligation to their wives to give up their foreskin. An uncircumcised penis will cause cervical cancer in women. It also spreads disease." "Circumcised men make better lovers because they have more staying power than uncircumcised men." "Doctors do it, so it must be a good thing." 35 years old American male: "I have lost nearly all interest in sex. You might say that I'm becoming impotent. I don't seem to have much sensation in my penis anymore, and it is becoming more and more difficult for me to reach orgasm. You say that this is the result of my circumcision? That doesn't make any sense. I was circumcised 35 years ago, when I was a little boy. How can that affect me in any way now?" Compiled by Hanny Lightfoot-Klein, M.A. Some of her research is reprinted at Hanny Lightfoot-Klein, The Sexual Experience and Marital Adjustment of Genitally Circumcised and Infibulated Females in The Sudan, The Journal of Sex Research 26, (1989). Hanny Lightfoot-Klein, PRISONERS OF RITUAL: SOME CONTEMPORARY DEVELOPMENTS IN THE HISTORY OF FEMALE GENITAL MUTILATION , presented at the Second International Symposium on Circumcision in San Francisco, April-30 - May 3, 1991. Additional quotes she reports about female circumcision "All the women in the world are circumcised. It is something that must be done. If there is pain, then that is part of a woman's lot in life." "An uncircumcised vulva is unclean and only the lowest prostitute would leave her daughter uncircumcised. No man would dream of marrying an unclean woman. He would be laughed at by everyone." Sudanese grandmother: "In some countries they only cut out the clitoris, but here we do it properly. We scrape our girls clean. If it is properly done, nothing is left, other than a scar. Everything has to be cut away." Additional quotes she reports about male circumcision "Men in all the 'civilized' world are circumcised.“ "An uncircumcised penis is dirty and only the lowest class of people with no concept of hygiene leave their boys uncircumcised." My own father, a physician, speaking of ritual circumcision inflicted upon my son: "It is a good thing that I was here to preside. He had quite a long foreskin. I made sure that we gave him a good tight circumcision."

Anesthetic or No Anesthetic?
Circumcision.ppt Ryan McAllister Anesthetic or No Anesthetic? Anesthetic risks General anesthesia has led to deaths Local anesthetic agents injected into the corpora cavernosa can produce impotence; the rate is unknown Idiosyncratic reactions and overdosage Epinephrine may produce local tissue problems or systemic toxicity Without anesthesia Decreased pO2 Increased serum cortisol Increased withdrawal Has precipitated a pneumothorax Greater long-term increased response to painful stimuli [45]

Further Resources cirp.org – Medical journal articles
Circumcision.ppt Ryan McAllister Further Resources cirp.org – Medical journal articles DoctorsOpposingCircumcision.org icgi.org – International Coalition for Genital Integrity nocirc.org – General information, international symposia norm.org – National Organization of Restoring Men notjustskin.org – Children, Parents, Community A few relevant organizations: Nurses for the Rights of the Child (NRC) Conscientious Objector Information for Nurses Betty Katz Sperlich, R.N., and Mary Conant, R.N. 369 Montezuma #354, Santa Fe, NM Tel: Website: Intersex Society of North America th Avenue NE Suite 300, Seattle, WA Website: Lightfoot-Associates Information on Female Genital Mutilation Hanny Lightfoot-Klein, M.A N. Calle Bosque, Tucson, AZ Tel: , Fax: Circumcision Resource Center (CRC) Information and Resources Ronald Goldman, Ph.D. 232, Boston, MA Tel/Fax: Website:

Two Position Statements
Circumcision.ppt Ryan McAllister Two Position Statements “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.” – American Academy of Pediatrics 1999 “There is no medical indication for routine male circumcision…. The foreskin requires no special care during infancy. It should be left alone.” – The Royal Australasian College of Physicians 2002 Policy Statement: American Academy of Pediatrics Task Force on Circumcision, (1999) Position Statement: Routine Circumcision of Normal Male Infants and Boys. Australian College of Paediatrics, (1996) An older statement from Australia “Neonatal male circumcision has no medical indication. It is a traumatic procedure performed without anaesthesia to remove a normal and healthy prepuce.” -- Australian College of Paediatrics 1996

“Circumcision is a personal choice
“Circumcision is a personal choice. You really have to decide, do you want your son to look like you?” –Lisa Masterson, MD, OB/GYN on “The Doctors” TV Show Adults don’t have to decide Amputation to make children look like parents is unethical

Female Genital Cutting
Circumcision.ppt Ryan McAllister Female Genital Cutting Approximately 2% of women are circumcised worldwide Benefits asserted by practitioners include Hygienic benefits for the woman Safety benefits for her children Esthetic or pleasurable benefits for her mate WHO defines female genital mutilation (FGM): FGM - all procedures involving partial or total removal of or other injury to female genital organs whether for cultural, religious or other non-therapeutic reasons. Type I (~80%) – excision of prepuce or part or all of clitoral tip Type II - Type I + part or total excision of labia minora Type III (~15%, infibulation or pharaonic circumcision) – excision of part or all of external genitalia and narrowing of vaginal opening Type IV – other alteration to the female genital organs Many case studies of Female circumcision have been recorded by Hanny-Lightfoot Klein, who wrote Prisoners of Ritual: An Odyssey into Female Genital Circumcision in Africa after several years spent studying the practice and the people in Africa, with particular emphasis on the Sudan. Some of her publications are available at The World Health Organization statement comes from its Fact Sheet No 241 June 2000 FEMALE GENITAL MUTILATION What is Female Genital Mutilation? Female genital mutilation (FGM), often referred to as ‘female circumcision’, comprises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons. There are different types of female genital mutilation known to be practiced today. They include: Type I - excision of the prepuce, with or without excision of part or all of the clitoris; Type II - excision of the clitoris with partial or total excision of the labia minora; Type III - excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation); Type IV - pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and any other procedure that falls under the definition given above. The most common type of female genital mutilation is excision of the clitoris and the labia minora, accounting for up to 80% of all cases; the most extreme form is infibulation, which constitutes about 15% of all procedures. Health Consequences of FGM The immediate and long-term health consequences of female genital mutilation vary according to the type and severity of the procedure performed. Immediate complications include severe pain, shock, hemorrhage, urine retention, ulceration of the genital region and injury to adjacent tissue. Hemorrhage and infection can cause death. More recently, concern has arisen about possible transmission of the human immunodeficiency virus (HIV) due to the use of one instrument in multiple operations, but this has not been the subject of detailed research. Long-term consequences include cysts and abscesses, keloid scar formation, damage to the urethra resulting in urinary incontinence, dyspareunia (painful sexual intercourse) and sexual dysfunction and difficulties with childbirth. Psychosexual and psychological health: Genital mutilation may leave a lasting mark on the life and mind of the woman who has undergone it. In the longer term, women may suffer feelings of incompleteness, anxiety and depression. Who Performs FGM, at What Age and for What Reasons? In cultures where it is an accepted norm, female genital mutilation is practiced by followers of all religious beliefs as well as animists and non believers. FGM is usually performed by a traditional practitioner with crude instruments and without anaesthetic. Among the more affluent in society it may be performed in a health care facility by qualified health personnel. WHO is opposed to medicalization of all the types of female genital mutilation. The age at which female genital mutilation is performed varies from area to area. It is performed on infants a few days old, female children and adolescents and, occasionally, on mature women. The reasons given by families for having FGM performed include: psychosexual reasons: reduction or elimination of the sensitive tissue of the outer genitalia, particularly the clitoris, in order to attenuate sexual desire in the female, maintain chastity and virginity before marriage and fidelity during marriage, and increase male sexual pleasure; sociological reasons: identification with the cultural heritage, initiation of girls into womanhood, social integration and the maintenance of social cohesion; hygiene and aesthetic reasons: the external female genitalia are considered dirty and unsightly and are to be removed to promote hygiene and provide aesthetic appeal; myths: enhancement of fertility and promotion of child survival; religious reasons: Some Muslim communities, however, practice FGM in the belief that it is demanded by the Islamic faith. The practice, however, predates Islam. Prevalence and Distribution of FGM Most of the girls and women who have undergone genital mutilation live in 28 African countries, although some live in Asia and the Middle East. They are also increasingly found in Europe, Australia, Canada and the USA, primarily among immigrants from these countries. Today, the number of girls and women who have been undergone female genital mutilation is estimated at between 100 and 140 million. It is estimated that each year, a further 2 million girls are at risk of undergoing FGM. Current WHO activities related to FGM : Advocacy and Policy Development A joint WHO/UNICEF/UNFPA policy statement on FGM and a Regional Plan to Accelerate the Elimination of FGM were published to promote policy development and action at the global, regional, and national level. Several countries where FGM is a traditional practice are now developing national plans of action based on the FGM prevention strategy proposed by WHO. Research and Development A major objective of WHO’s work on FGM is to generate knowledge, test interventions to promote the elimination of FGM. Research protocols on FGM have been developed with a network of collaborating research institutions as well as biomedical and social science researchers with linkages to appropriate communities. WHO has reviewed programming approaches for the prevention of FGM in countries and has organized training for community workers to strengthen their effectiveness in promoting prevention of FGM at the grassroots level. Development of training materials and training for health care providers WHO has developed training materials for integrating the prevention of FGM into nursing, midwifery and medical curricula as well as for in-service training of health workers. Evidence based training workshops, to raise the awareness of health workers and to solicit their active involvement as advocates against FGM, have also been developed for nurses and midwives in the African and Eastern Mediterranean region. For further information, journalists can contact : WHO Press Spokesperson and Coordinator, Spokesperson's Office, WHO HQ, Geneva, Switzerland / Tel /2599 / Fax /

Genital Cutting (GC) Geography
Circumcision.ppt Ryan McAllister Genital Cutting (GC) Geography Female GC (2%) Male GC (15%) While the U.S. is the only country in the world where infant genital cutting of any kind is routinely practiced, male genital cutting is approximately 7.5 times as frequent world-wide as female genital cutting. In general, where female genital mutilation is prevalent, male circumcision is also, though the reverse is not the case. Intact Male Populations: Virtually all: Chinese, Japanese, North Koreans, Vietnamese, Laotians, Cambodians, Burmese, Thais, Hindu, Sikh, Parsee and Christian Indians, Scandinavians, Zulus, Shona, certain other African nations, most Melanesian and some Western Polynesian (Rennell, Bellona) peoples, most Europeans, men of the former Soviet Union, Central and South Americans, New Zealand Maori, younger men of Britain and the Commonwealth. Genitally Cut Male Populations: About 500,000,000 Muslims, more than 100,000,000 U.S. Americans, about 25,000,000 Filipinos, some tens of millions of older men of Britain and the Commonwealth, some tens of millions of African tribesmen, about 14,000,000 South Koreans, 7,000,000 Jews, some hundreds of thousands of Central and Eastern Polynesians (Samoa, Tahiti, Tonga, Niue, Tokelau) and Melanesians (from Fiji, Vanuatu, parts of Solomon Islands and small parts of PNG), and some scores of thousands of aboriginal Australians. Female Genital Cutting is practiced predominantly in 28 countries in Africa.1,3 Eighteen African countries have prevalence rates of 50% or higher, but these estimates vary from country to country and within various ethnic groups.1,3 FGC also occurs in some Middle Eastern countries-Egypt, the Republic of Yemen, Oman, Saudi Arabia and Israel-and is found in some Muslim groups in Indonesia, Malaysia, Pakistan and India.4 Some immigrants practice various forms of FGC in other parts of the world, including Australia, Canada, New Zealand, the United States and in European nations.1,4 Toubia, N. (1999). Caring for Women with Circumcision. RAINBO: NY, NY. WHO. (Downloaded 8/9/01). Female Genital Information: Information Pack Rahman, A. & Toubia, N. (2000). Female Genital Mutilation: A Guide to Laws and Policies Worldwide. Zed Books Ltd: London, UK. Department of State. (March, 2001). Report on Female Genital Mutilation as Required by Conference Report (H. Rept ) to Public Law

Female Genital Cutting in the U.S.
Circumcision.ppt Ryan McAllister Female Genital Cutting in the U.S. Female circumcision has also been practiced in the U.S. The pictures displayed here are taken from an article in General Practitioner titled “Female Circumcision: Indications and a New Technique”. The amount and locations of tissue removed are clearly visible. A host of additional articles proposed female circumcision, though predominantly of adult females who consent to the surgery, including: Circumcision in the Female: Its Necessity and How to Perform It Benjamin E. Dawson, A.M., M.D. - Kansas City, Missouri President, Eclectic Medical University American Journal of Clinical Medicine, vol. 22, no. 6, p , June 1915 Circumcision of the Female C.F. McDonald, M.D. - Milwaukee, Wisconsin GP, Vol. XVIII No. 3, p , September, 1958 Female Circumcision: Indications and a New Technique W.G. Rathmann, M.D. GP, vol. 20, no. 3, pp , September, 1959

Female Genital Cutting (FGC)

Female Genital Cutting Bans
Circumcision.ppt Ryan McAllister Figure from “Ending a Brutal Practice” The Economist June 10, 2010

Genital Cutting “America, why don't you get up and say
Circumcision.ppt Ryan McAllister Genital Cutting 15% of males 2% of females worldwide Amputates sexual tissue Alters sexuality Painful Surgical complications Lifelong detriments Parental regret Does not promote health “America, why don't you get up and say ‘We're not going to do this to our boys!’” –Soraya Miré, Survivor, FGC Activist

Circumcision.ppt Ryan McAllister Informed Consent Law Physician must disclose personal interests unrelated to patient’s health, whether research or economic (L1) Case Law Synthesis Buyer beware does not apply to medicine What would a reasonable patient want to know? Disclose all material risks Potential disability Alternatives and results of no treatment Childbirth may eviscerate consent Undisclosed profit may eviscerate consent L1 Moore v. Regents of the Univ. of Cal., 793 P.2d 479, 483 (Cal. 1990) Synthesis of Case Law Requirements “Buyer beware” standard does not apply due to the medical and trusting nature of the relationship.108 Some courts use patient-centered approach, “what would the reasonable patient want to know?” & requires that a doctor disclose all “material” risks & dangers. A risk is material if a doctor knows or should know that a reasonable patient would attach significance to it.110 A potential disability caused by the proposed therapy is a “material” risk.1 1 1 disclose alternatives to the proposed treatment, including the likely results of not pursuing treatment.112 Doctors are required to disclose facts if they know (or should know) that patients are in the dark about or mistaken about these facts.113 The trauma of childbirth may eviscerate a woman’s ability to consent.114 bias due to financial profit, if not disclosed, may eviscerate informed consent.115

You may have heard these
“It’s so common, how could it be harmful?” Bandwagon fallacy “Doctors do it.” “The AAP supports it.” Appeal to authority “Babies don’t feel pain/remember” Special pleading “I’m circumcised and I’m fine” Anecdotal evidence “I can’t imagine how it could be harmful” Appeal to ignorance “Parents must choose for their child” Excluded middle “Little snip” or “useless flap of skin” Minimizing “weasel words” “It’s cleaner” “It looks better” “fanatics” Poisoning the well / ad hominem “There’s no evidence that…” Observational selection

References 1 Circumcision.ppt Ryan McAllister Penile Adhesions
Katharine A. Gracely-Kilgore, R.N., M.S.N., C.P.N.P., “Penile Adhesion: The Hidden Complication of Circumcision” NURSE PRACTITIONER, Volume 5 Number 9: Pages 22-4, May 1984. Lymphedema. Penile lymphedema may occur following circumcision especially if the wound separates or becomes infected. Skin grafting may be required for resolution. Shulman, J. Ben-Hur, N., and Neuman, Z.: Surgical complications of circumcision. Am. J. Dis. Child., 127:149; 1964. Skin Bridges Klauber GT, Boyle J. Preputial skin-bridging. Complication of circumcision. Urology 1974; 3: Sathaye VU, Goswami AK, Sharma SK. Skin bridge - a complication of paediatric circumcision. Br J Urol 1990; 66: 214. Ritchey ML, Bloom DA. Re: Skin bridge--a complication of paediatric circumcision. Br J Urol 1991; 68: 331. Urethral Fistula Johnson S. Persistent urethral fistula following circumcision: report of a case. US Naval Med Bull 1949; 49: Limaye RD, Hancock RA. Penile urethral fistula as a complication of circumcision. J Pediatr 1968; 72: Lackey JT, Mannion RA, Kerr JE. Urethral fistula following circumcision. JAMA 1968; 206: 2318. Lackey JT, Mannion RA, Kerr JE. Subglanular urethral fistula from infant circumcision. J Indiana State Med Assoc 1969; 62: Shiraki, IW. Congenital megalourethra with urethracutaneous fistula following circumcision: a case report. J Urol 1973: 109: 723. Lau, JTK, Ong GB. Subglandular urethral fistula following circumcision: repair by the advancement method. J Urol 1981; 126: Benchekroun A, Lakrissa A, Tazi A, Hafa D, Ouazzani N. Fistules urethrales apres circoncision: a propos de 15 cas. [Urethral fistulas after circumcision: apropos of 15 cases] Maroc Med 1981; 3: Palmer SY, Colodny AH. Congenital urethrocutaneous fistulas. Urology. 1994; 44: Baskin LS. Canning DA. Snyder III HM. Duckett JW Jr. Surgical repair of urethral circumcision injuries. Journal d'Urologie 1997;158(6): Concatenation of references in reference slides Penile Adhesions 1.Katharine A. Gracely-Kilgore, R.N., M.S.N., C.P.N.P., “Penile Adhesion: The Hidden Complication of Circumcision” NURSE PRACTITIONER, Volume 5 Number 9: Pages 22-4, May 1984. Lymphedema. Penile lymphedema may occur following circumcision especially if the wound separates or becomes infected. Skin grafting may be required for resolution. 2.Shulman, J. Ben-Hur, N., and Neuman, Z.: Surgical complications of circumcision. Am. J. Dis. Child., 127:149; 1964. Skin Bridges Klauber GT, Boyle J. Preputial skin-bridging. Complication of circumcision. Urology 1974; 3: Sathaye VU, Goswami AK, Sharma SK. Skin bridge - a complication of paediatric circumcision. Br J Urol 1990; 66: 214. Ritchey ML, Bloom DA. Re: Skin bridge--a complication of paediatric circumcision. Br J Urol 1991; 68: 331. Urethral Fistula Johnson S. Persistent urethral fistula following circumcision: report of a case. US Naval Med Bull 1949; 49: Limaye RD, Hancock RA. Penile urethral fistula as a complication of circumcision. J Pediatr 1968; 72: Lackey JT, Mannion RA, Kerr JE. Urethral fistula following circumcision. JAMA 1968; 206: 2318. Lackey JT, Mannion RA, Kerr JE. Subglanular urethral fistula from infant circumcision. J Indiana State Med Assoc 1969; 62: Shiraki, IW. Congenital megalourethra with urethracutaneous fistula following circumcision: a case report. J Urol 1973: 109: 723. Lau, JTK, Ong GB. Subglandular urethral fistula following circumcision: repair by the advancement method. J Urol 1981; 126: Benchekroun A, Lakrissa A, Tazi A, Hafa D, Ouazzani N. Fistules urethrales apres circoncision: a propos de 15 cas. [Urethral fistulas after circumcision: apropos of 15 cases] Maroc Med 1981; 3: Palmer SY, Colodny AH. Congenital urethrocutaneous fistulas. Urology. 1994; 44: Baskin LS. Canning DA. Snyder III HM. Duckett JW Jr. Surgical repair of urethral circumcision injuries. Journal d'Urologie 1997;158(6): Buried, Concealed, and Hidden Penis Stewart DH. The toad in the hole circumcision -- a surgical bugbear. Boston Med Surg J 1924; 191: Talarico RD, Jasaitis JE. Concealed penis: a complication of neonatal circumcision. J Urol 1973; 110: Trier WC, Drach GW. Concealed penis. Another complication of circumcision. Am J Dis Child 1973; 125: Radhakrishnan J, Reyes HM. Penoplasty for buried penis secondary to "radical" circumcision. J Pediatr Surg 1984; 19: Kon M. A rare complication following circumcision: the concealed penis. J Urol 1983; 130: Donahoe PK, Keating MA. Preputial unfurling to correct the buried penis. J Pediatr Surg 1986; 21: Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF. Surgical correction of the buried penis: description of a classification system and a technique to correct the disorder. J Urol 1986; 136: Shapiro SR. Surgical treatment of the "buried" penis. Urology 1987; 30: Horton CE, Vorstman B, Teasley D, Winslow B. Hidden penis release: adjunctive suprapubic lipectomy. Ann Plast Surg 1987; 19: van-der Zee JA, Hage JJ, Groen JM, Bouman FG. Een ernstige complicatie ten gevolge van rituele circumcisie van een 'begraven' penis. [A serious complication of ritual circumcision of a 'buried' penis] Ned Tijdschr Geneeskd 1991; 135: Bergeson PS. et al. The Inconspicuous Penis. Department of General Pediatrics and Urology, Phoenix Children's Hospital. Pediatrics 1993; 92: Alter GJ, Horton CE Jr; Horton CE Jr. Buried penis as a contraindication for circumcision. J Am Coll Surg 1994; 178: Alter G. Buried Penis. (link to Penile Amputation Brimhall JB. Amputation of the penis following a unique method of preventing hemorrhage after circumcision. St Paul Med J 1902; 4: 490. Lerner BL. Amputation of the penis as a complication of circumcision. Med Rec Ann 1952;46: Levitt SB, Smith RB, Ship AG. Iatrogenic microphallus secondary to circumcision. Urology 1976; 8: Izzidien AY. Successful replantation of a traumatically amputated penis in a neonate. Journal of Pediatric Surgery April 1981,16(2): Hanash KA. Plastic reconstruction of partially amputated penis at circumcision. Urology 1981; 18(3): Azmy A, Boddy SA, Ransley PG. Successful reconstruction following circumcision with diathermy. Br J Urol 1985; 57: Yilmaz AF, Sarikaya S, Yildiz S, et al. Rare complication of circumcision: penile amputation and reattachment. European Urology (Basel) 1993; 23(3): Audry G, Buis J, Vazquez MP, Gruner M. Amputation of penis after circumcision--penoplasty using expandable prosthesis. Eur J Pediatr Surg 1994; 4: 44-5. Hanukoglu A, Danielli L, Katzir Z, Gorenstein A, Fried D. Serious complications of routine ritual circumcision in a neonate: hydro ureteronephrosis, amputation of glans penis, and hyponatraemia. Eur J Pediatr 1995; 154: Gluckman GR et al. Newborn Penile Glans Amputation During Circumcision and Successful Reattachment. Journal of Urology (Baltimore), vol. 153 no. 3 Part 1 March 1995 pp Strimling BS. Partial amputation of glans penis during Mogen clamp circumcision. Pediatrics 1996; 97: Neulander E, Walfisch S. Kaneti J. Amputation of distal penile glans during neonatal ritual circumcision -- a rare complication. Br J Urol 1996; 77: Sherman J, Borer JG, Horowitz M, Glassberg KI. Circumcision: successful glanular reconstruction and survival following amputation. J Urol 1996; 156: 842. Van Howe RS. Re: circumcision: successful glanular reconstruction and survival following traumatic amputation (Letter). J Urol. 1997;158:550. Coskunfirat OK, Sayiklkan S, Velidedeoglu H.. Glans and penile skin amputation as a complication of circumcision (letter). Ann Plast Surg 1999;43(4):457. Siegel-Itzkovich J. Baby's penis reattached after botched circumcision. BMJ 2000;321:529. Park JK, Min JK, Kim HJ. Reimplantation of an amputated penis in prepubertal boys. J Urol 2001;165:586-7. Pain Response 45.Taddio A, Koren G et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet, Vol. 349: Pages (March 1, 1997). Infection Gee, W. F., and Ansell, J. S.: Neonatal circumcision: A ten-year overview with comparison of the Gomco clamp and the Plastibell device. Pediatrics, 55:524, 1976. Fraser, I. A., Allen, M. J., Bagshaw, P. F., et al.: A randomized trial to assess childhood circumcision with the Plastibell device compared with a conventional dissection technique. Br. J. Surg., 68: , 1968. Meatitis Daley, M. C.: Circumcision. J.A.M.A., 214:2195, 1970. Lairdner, D. [sic, should be Gairdner]: The fate of the foreskin. A study of circumcision. Br. Med. J., 2:1433, 1949. Mackenzie, A. R.: Meatal ulceration following neonatal circumcision. Obstet Gynecol., 28:221, 1966. Patel, H.: The problem of routine circumcision. Can. Med. Assoc. J., 95:576, 1966. Necrosis Davidson, F.: Yeasts and circumcision in the male. Br. J. Ven. Dis., 53: , 1977. Money, J.: Ablatio penis: normal male infant reassigned as a girl. Arch Sex. Behav., 4: Sterenberg. N., Golan, J., and Ben-Hur, N.: Necrosis of the glans penis following neonatal circumcision. Plast. Reconstr. Surg., 68: , 1981. Major Morbidity Thorek, P., and Egel, P.: Reconstruction of the penis with split-thickness skin graft. Plast. Reconstruc. Surg., 4: 469, 1969. Woodside, J. R. Necrotizing fascitis after circumcision. Am. J. Dis. Child., 134:301, 1980. Annunziato, D. and Goldman, L. M.: Staphylococcal scalded skin syndrome. A complication of circumcision. Am. J. Dis. Child 132: ; 1978. Sussman, S. J., Schiller, R. P., and Shaskikumar, V. L.: Fournier's syndrome and review of the literature. Am. J. Dis. Child. Kirkpatrick, B. V., and Eitzman, D. V.: Neonatal septicemia after circumcision. Clin. Pediatr., 13: , 1974. Procopis, P. G., and Kewley, G. D. Complication of circumcision. Med. J. Aust., 1:15, 1982. Death Cleary, T. G., and Kohl, S.: Overwhelming infection with group B beta-hemolytic streptococcus associated with circumcision. Pediatrics, 64: , 1979. Scurlock, J. M. and Pemberton, P. J.: Neonatal meningitis and circumcision. Med. J. Aust., 1: Innervation of the Foreskin Z. Halata and B. L. Munger, "The Neuroanatomical Basis for the Protopathic Sensibility of the Human Glans Penis," Brain Research 371 (1986): J. R. Taylor et al, "The Prepuce: Specialized Mucosa of the Penis and its Loss to Circumcision," British Journal of Urology 77 (1996): H. C. Bazett et al, "Depth, Distribution and Probable Identification in the Prepuce of Sensory End-Organs Concerned in Sensations of Temperature and Touch, Thermometric Conductivity," Archives of Neurology and Psychiatry 27 (1932): D. Ohmori, "Uber die Entwicklung der Innervation der Genitalapparate als Peripheren Aufnahmeapparat der Genitalen Reflexe," Zeitschrift fur Anotomie und Entwicklungsgeschichte 70 (1924): A. De Girolamo and A. Cecio, "Contributo alla Conoscenza dell'innervazione Sensitiva del Prepuzio Nell'uomo,' Bollettino della Societa Italiona de Biologia Sperimentale 44 (1968): A. S. Dogiel, "Die Nervenendigungen in der Haut der ausseren Genitalorgane des Menschen," Archiv fur Mikroskopische Anotomie 41 (1893): A. Bourlond and R. K. Winkelmann, "Linnervation du Prepuce chez le Nouveau-ne", Archives Belges de Dermatologie et de Syphiligraphie 21 (1965): R. K. Winkelmann, "The Erogenous Zones: Their Nerve Supply and its Significance," Proceedings of the Staff Meetings of the Mayo Clinic 34 (1959): R. K. Winkelmann, "The Cutaneous innervation of Human Newborn Prepuce," Journal of Investigative Dermatology 26 (1956): 53-67 Decreased sensation Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychological Reports 2001;88: Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5): Zwang G. Functional and erotic consequences of sexual mutilations. In: GC Denniston and MF Milos, eds. Sexual Mutilations: A Human Tragedy New York and London: Plenum Press, 1997 (ISBN ). Erectile problems Stinson JM. Impotence and adult circumcision. J Nat Med Assoc 1973;65:161. Sexual problems for female partner 77.O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1, Negative feelings 78.Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychological Reports 2001;88: Wider set of sexual behaviors and increased resistance to condom use 79.Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13): No difference in STD rate 80.Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13): Urinary Tract Infection 81.Bollgren I, Winberg J. Letter. [Rebuttal of Edgar J. Schoen] Acta Paediatrica Scandinavia 1991; 80:575-7. 82.Amato D, Garduno-Espinosa J. Circumcision of the newborn male and the risk of urinary tract infection during the first year: A meta-analysis. Bol Med Infant Mex Volume 49, Number 10, October 1992, 83.Craig JC et al. Effect of circumcision on incidence of urinary tract infection in preschool boys. From the Department of Nephrology, Royal Alexandra Hospital for Children, Sydney, Australia. Cervical Cancer 84.Elizabeth Stern; Peter M. Neely. "Cancer of the Cervix in Reference to Circumcision and Marital History," Journal of the American Medical Women's Association, vol. 17, no. 9 (September 1962): pp

References 2 Circumcision.ppt Ryan McAllister
Buried, Concealed, and Hidden Penis Stewart DH. The toad in the hole circumcision -- a surgical bugbear. Boston Med Surg J 1924; 191: Talarico RD, Jasaitis JE. Concealed penis: a complication of neonatal circumcision. J Urol 1973; 110: Trier WC, Drach GW. Concealed penis. Another complication of circumcision. Am J Dis Child 1973; 125: Radhakrishnan J, Reyes HM. Penoplasty for buried penis secondary to "radical" circumcision. J Pediatr Surg 1984; 19: Kon M. A rare complication following circumcision: the concealed penis. J Urol 1983; 130: Donahoe PK, Keating MA. Preputial unfurling to correct the buried penis. J Pediatr Surg 1986; 21: Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF. Surgical correction of the buried penis: description of a classification system and a technique to correct the disorder. J Urol 1986; 136: Shapiro SR. Surgical treatment of the "buried" penis. Urology 1987; 30: Horton CE, Vorstman B, Teasley D, Winslow B. Hidden penis release: adjunctive suprapubic lipectomy. Ann Plast Surg 1987; 19: van-der Zee JA, Hage JJ, Groen JM, Bouman FG. Een ernstige complicatie ten gevolge van rituele circumcisie van een 'begraven' penis. [A serious complication of ritual circumcision of a 'buried' penis] Ned Tijdschr Geneeskd 1991; 135: Bergeson PS. et al. The Inconspicuous Penis. Department of General Pediatrics and Urology, Phoenix Children's Hospital. Pediatrics 1993; 92: Alter GJ, Horton CE Jr; Horton CE Jr. Buried penis as a contraindication for circumcision. J Am Coll Surg 1994; 178: Alter G. Buried Penis. (link to Penile Amputation Brimhall JB. Amputation of the penis following a unique method of preventing hemorrhage after circumcision. St Paul Med J 1902; 4: 490. Lerner BL. Amputation of the penis as a complication of circumcision. Med Rec Ann 1952;46:

Penile Amputation Continued Levitt SB, Smith RB, Ship AG. Iatrogenic microphallus secondary to circumcision. Urology 1976; 8: Izzidien AY. Successful replantation of a traumatically amputated penis in a neonate. Journal of Pediatric Surgery April 1981,16(2): Hanash KA. Plastic reconstruction of partially amputated penis at circumcision. Urology 1981; 18(3): Azmy A, Boddy SA, Ransley PG. Successful reconstruction following circumcision with diathermy. Br J Urol 1985; 57: Yilmaz AF, Sarikaya S, Yildiz S, et al. Rare complication of circumcision: penile amputation and reattachment. European Urology (Basel) 1993; 23(3): Audry G, Buis J, Vazquez MP, Gruner M. Amputation of penis after circumcision--penoplasty using expandable prosthesis. Eur J Pediatr Surg 1994; 4: 44-5. Hanukoglu A, Danielli L, Katzir Z, Gorenstein A, Fried D. Serious complications of routine ritual circumcision in a neonate: hydro ureteronephrosis, amputation of glans penis, and hyponatraemia. Eur J Pediatr 1995; 154: Gluckman GR et al. Newborn Penile Glans Amputation During Circumcision and Successful Reattachment. Journal of Urology (Baltimore), vol. 153 no. 3 Part 1 March 1995 pp Strimling BS. Partial amputation of glans penis during Mogen clamp circumcision. Pediatrics 1996; 97: Neulander E, Walfisch S. Kaneti J. Amputation of distal penile glans during neonatal ritual circumcision -- a rare complication. Br J Urol 1996; 77: Sherman J, Borer JG, Horowitz M, Glassberg KI. Circumcision: successful glanular reconstruction and survival following amputation. J Urol 1996; 156: 842. Van Howe RS. Re: circumcision: successful glanular reconstruction and survival following traumatic amputation (Letter). J Urol. 1997;158:550. Coskunfirat OK, Sayiklkan S, Velidedeoglu H.. Glans and penile skin amputation as a complication of circumcision (letter). Ann Plast Surg 1999;43(4):457. Siegel-Itzkovich J. Baby's penis reattached after botched circumcision. BMJ 2000;321:529. Park JK, Min JK, Kim HJ. Reimplantation of an amputated penis in prepubertal boys. J Urol 2001;165:586-7.

References 4 Circumcision.ppt Ryan McAllister Pain Response
45. Taddio A, Koren G et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet, Vol. 349: Pages (March 1, 1997). Infection Gee, W. F., and Ansell, J. S.: Neonatal circumcision: A ten-year overview with comparison of the Gomco clamp and the Plastibell device. Pediatrics, 55:524, 1976. Fraser, I. A., Allen, M. J., Bagshaw, P. F., et al.: A randomized trial to assess childhood circumcision with the Plastibell device compared with a conventional dissection technique. Br. J. Surg., 68: , 1968. Meatitis Daley, M. C.: Circumcision. J.A.M.A., 214:2195, 1970. Lairdner, D. [sic, should be Gairdner]: The fate of the foreskin. A study of circumcision. Br. Med. J., 2:1433, 1949. Mackenzie, A. R.: Meatal ulceration following neonatal circumcision. Obstet Gynecol., 28:221, 1966. Patel, H.: The problem of routine circumcision. Can. Med. Assoc. J., 95:576, 1966. Necrosis Davidson, F.: Yeasts and circumcision in the male. Br. J. Ven. Dis., 53: , 1977. Money, J.: Ablatio penis: normal male infant reassigned as a girl. Arch Sex. Behav., 4: Sterenberg. N., Golan, J., and Ben-Hur, N.: Necrosis of the glans penis following neonatal circumcision. Plast. Reconstr. Surg., 68: , 1981. Major Morbidity Thorek, P., and Egel, P.: Reconstruction of the penis with split-thickness skin graft. Plast. Reconstruc. Surg., 4: 469, 1969. Woodside, J. R. Necrotizing fascitis after circumcision. Am. J. Dis. Child., 134:301, 1980. Annunziato, D. and Goldman, L. M.: Staphylococcal scalded skin syndrome. A complication of circumcision. Am. J. Dis. Child 132: ; 1978. Sussman, S. J., Schiller, R. P., and Shaskikumar, V. L.: Fournier's syndrome and review of the literature. Am. J. Dis. Child.

Major Morbidity Continued Kirkpatrick, B. V., and Eitzman, D. V.: Neonatal septicemia after circumcision. Clin. Pediatr., 13: , 1974. Procopis, P. G., and Kewley, G. D. Complication of circumcision. Med. J. Aust., 1:15, 1982. Death Cleary, T. G., and Kohl, S.: Overwhelming infection with group B beta-hemolytic streptococcus associated with circumcision. Pediatrics, 64: , 1979. Scurlock, J. M. and Pemberton, P. J.: Neonatal meningitis and circumcision. Med. J. Aust., 1: Innervation of the Foreskin Z. Halata and B. L. Munger, "The Neuroanatomical Basis for the Protopathic Sensibility of the Human Glans Penis," Brain Research 371 (1986): J. R. Taylor et al, "The Prepuce: Specialized Mucosa of the Penis and its Loss to Circumcision," British Journal of Urology 77 (1996): H. C. Bazett et al, "Depth, Distribution and Probable Identification in the Prepuce of Sensory End-Organs Concerned in Sensations of Temperature and Touch, Thermometric Conductivity," Archives of Neurology and Psychiatry 27 (1932): D. Ohmori, "Uber die Entwicklung der Innervation der Genitalapparate als Peripheren Aufnahmeapparat der Genitalen Reflexe," Zeitschrift fur Anotomie und Entwicklungsgeschichte 70 (1924): A. De Girolamo and A. Cecio, "Contributo alla Conoscenza dell'innervazione Sensitiva del Prepuzio Nell'uomo,' Bollettino della Societa Italiona de Biologia Sperimentale 44 (1968): A. S. Dogiel, "Die Nervenendigungen in der Haut der ausseren Genitalorgane des Menschen," Archiv fur Mikroskopische Anotomie 41 (1893): A. Bourlond and R. K. Winkelmann, "Linnervation du Prepuce chez le Nouveau-ne", Archives Belges de Dermatologie et de Syphiligraphie 21 (1965): R. K. Winkelmann, "The Erogenous Zones: Their Nerve Supply and its Significance," Proceedings of the Staff Meetings of the Mayo Clinic 34 (1959): R. K. Winkelmann, "The Cutaneous innervation of Human Newborn Prepuce," Journal of Investigative Dermatology 26 (1956): 53-67

References 6 Circumcision.ppt Ryan McAllister Decreased sensation
Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychological Reports 2001;88: Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5): Zwang G. Functional and erotic consequences of sexual mutilations. In: GC Denniston and MF Milos, eds. Sexual Mutilations: A Human Tragedy New York and London: Plenum Press, 1997 (ISBN ). Erectile problems Stinson JM. Impotence and adult circumcision. J Nat Med Assoc 1973;65:161. Sexual problems for female partner 77. O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1, Psychological Problems 78. Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychological Reports 2001;88: No difference in STD rate and wider set of sexual behaviors 79. Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13): Wider set of sexual behaviors and increased resistance to condom use 80. Michael RT, Wadsworth J, Feinleib J, et al. Private sexual behavior, public opinion, and public health policy related to sexually transmitted diseases: a US-British comparison. Am J Public Health 1998;88(5):

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81. Bollgren I, Winberg J. Letter. [Rebuttal of Edgar J. Schoen] Acta Paediatrica Scandinavia 1991; 80:575-7. 82. Amato D, Garduno-Espinosa J. Circumcision of the newborn male and the risk of urinary tract infection during the first year: A meta-analysis. Bol Med Infant Mex Volume 49, Number 10, October 1992, 83. Craig JC et al. Effect of circumcision on incidence of urinary tract infection in preschool boys. From the Department of Nephrology, Royal Alexandra Hospital for Children, Sydney, Australia. Cervical Cancer Elizabeth Stern; Peter M. Neely. "Cancer of the Cervix in Reference to Circumcision and Marital History," Journal of the American Medical Women's Association, vol. 17, no. 9 (September 1962): pp HIV AIDS S1 Chao A, Bulterys M, Musanganire F, et al. Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda-Johns Hopkins University AIDS Research Team. Int J Epidemiol 1994; 23: S2 Grosskurth H., Mosha F, Todd J, et al. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS 1995;9(8): S3 Van Howe RS. Circumcision and HIV-infection: meta-analysis and review of the medical literature. Int J STD AIDS 1999; 10: 8-16. S4 Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet 2001; 357: S5 Stallings R.Y.1, Karugendo E. FEMALE CIRCUMCISION AND HIV INFECTION IN TANZANIA: FOR BETTER OR FOR WORSE? IAS Conf HIV Pathog Treat 2005 Jul 24-27;3rd: Abstract No. TuOa0401. S6 Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial.. PLOS 2:e S7 Lot de Witte, Alexey Nabatov, Marjorie Pion, et al. Langerin is a natural barrier to HIV-1 transmission by Langerhans cells. Nature Medicine. 13:

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