Marked titles link to the actual articles, in the CIRP reference library

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

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

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

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

PMID: 12789187 [PubMed - indexed for MEDLINE]

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

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

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

PMID: 12771793 [PubMed - as supplied by publisher]

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

Well-known genital-cutting advocates Brian Morris and Jake Waskett (who claims to advocate only "parental choice"- negating the penis-owner's choice) have predictibly criticised the study, and Bollinger and Van Howe have replied. 

Abstract

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

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

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

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

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

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

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

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

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

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

PMID: 18318903 [PubMed - as supplied by publisher]

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

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

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

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

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

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

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

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

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

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

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

More

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

Developing World Bioethics, Wiley Online Library
September 9, 2020

Abstract

Campaigns to circumcise millions of boys and men to reduce HIV transmission are being conducted throughout eastern and southern Africa, recommended by the World Health Organization and implemented by the United States government and Western NGOs. In the United States, proposals to mass‐circumcise African and African American men are longstanding, and have historically relied on racist beliefs and stereotypes. The present campaigns were started in haste, without adequate contextual research, and the manner in which they have been carried out implies troubling assumptions about culture, health, and sexuality in Africa, as well as a failure to properly consider the economic determinants of HIV prevalence. This critical appraisal examines the history and politics of these circumcision campaigns while highlighting the relevance of race and colonialism. It argues that the “circumcision solution” to African HIV epidemics has more to do with cultural imperialism than with sound health policy, and concludes that African communities need a means of robust representation within the regime.

An excellent article, well worth reading.

penile cancer

immunology

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

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

Morten Frisch &Brian D. Earp, Circumcision of male infants and children as a public health measure in developed countries: A critical assessment of recent evidence

Global Public Health, May 19, 2016

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

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

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

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

PMID: 17823517 [PubMed - indexed for MEDLINE]

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

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

Hunter

nursing, general

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

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

Full text: 1 2 3 4 5

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PMID: 11434500 [PubMed - indexed for MEDLINE]

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

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

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

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

Summary

Introduction
Descriptions of the penile prepuce in anatomical and clinical texts either omit details or contain a small, yet potentially serious, error with regard to the manner of its attachment to the penis.

Objective
This study sought to cast light on a ubiquitous but poorly understood and under-appreciated structure, while correcting a long-standing mistake in the medical literature.

Study design
The foreskins of five male stillborn babies were dissected and carefully examined. Tissue from the apposing surfaces of the various regions of the inner and outer prepuce surfaces and the transition zone itself were collected, embedded in paraffin, sectioned, stained, examined and photographed under microscopy.

Results
Contradicting the prevailing descriptions in the literature that the inner prepuce is a single, uniform sheath, this study's observations and histological findings demonstrated that it actually splits into separate laminae that connect distally to the shaft at the base of the corona and proximally with the shaft fascia, respectively.

Discussion
The penile prepuce is a discrete and deceptively complex part of the male anatomy, yet key details of its interposing surfaces are inaccurately described or entirely omitted in the literature. Understanding the normal anatomy of the prepuce is critically relevant, particularly for urologists and others involved in the performance of circumcision. For example, avoiding potentially catastrophic avulsion of the inner preputial remnant beyond the coronal sulcus during circumcision and accurate assessment of tissue positioning prior to penile reconstruction in cases of hypospadias.

Conclusion
The findings of this study correct a misunderstanding in the anatomy of the prepuce.

Over the proximal border of the corona the inner prepuce spits into two laminae each of a separate orientation.

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

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

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

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

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

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

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

PMID: 19184514

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

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

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

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

Abstract

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

Design Prospective survey.

Setting Saskatoon, Sask.

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

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

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

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

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

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

Abstract

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

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

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

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

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

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

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

The complete paper (requires Adobe Acrobat Reader ).

PMID: 15890696 [PubMed - as supplied by publisher]

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

Abstract

OBJECTIVE: As a consequence of the discussion on whether the health benefits of newborn male circumcision outweigh the risks and the discrepancies in reported figures of complications, we evaluated the incidence and morbidity of foreskin surgery due to medical indications in boys from the Capital Region of Denmark in 2014.

METHODS: Medical records from all boys operated on the foreskin due to medical reasons in the Capital Region in 2014 were reviewed. Patients with hypospadias, ritual circumcision, and redo-surgery because of complications to nontherapeutic circumcision were excluded.

RESULTS: A total of 181 patients were included. The cumulative risk of undergoing [any] foreskin operation before 18 years of age was 1.7% [one in 59]. Forty patients had histologic verified balanitis xerotica obliterans (BXO) corresponding to a total risk of 0.37% [one in 270] of developing BXO. Mean age at surgery was 10.1 years (range 1–17). Phimosis was the most frequently reported indication (95.0%). The remaining 5.0% underwent surgery because of frenulum breve causing problems during erection. Before surgery, 27.1% had foreskin-related voiding problems and 17.1% had at least 1 episode of balanitis. Circumcision was initially performed in 44 cases. The remaining 137 patients had a foreskin-preserving operation performed. Nine boys had secondary circumcision after initially having foreskin-preserving operation. [A total of 53 "circumcisions" performed, making the risk of that 53/181 x 1.7% or one in 201]  Fifty patients initially had preputial histology performed. BXO was verified in 37 patients. Of the 9 patients with redo-surgery due to recurrent phimosis, a further 3 had histologically verified BXO.

CONCLUSIONS: Childhood foreskin-related problems in a region with no tradition of newborn male circumcision should not be neglected. [The real conclusion: Childhood foreskin-related problems are so rare, the likelihood of needing infant male genital cutting  ("circumcision") is negligible.]

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

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

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

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

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

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

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

In brief: newborn babies DO feel pain.

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

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

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

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

Abstract

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

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

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

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

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

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

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

and

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

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

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

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

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

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