12 10 240 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> OK, you may be thinking that even if very few uncircumcised boys experience a foreskin-related disability when young, but what about the other supposed health benefits of circumcision emphasised by the AAP and other advocates, such as reduced risk of sexually transmitted infections as an adult. We have sought to put that canard to rest as a piece of medical folklore on several occasions, but it persists. To show how wrong it is, here are comparative statistics for HIV, gonorrhoea and syphilis in (uncircumcised) Denmark compared with the (circumcised) United States: HIV-AIDS Denmark: 0.1-0.2% (2014, adults 15-49) http://www.unaids.org/en/regionscountries/countries/denmark United States: 0.4-0.9% (2012) http://www.unaids.org/en/regionscountries/countries/unitedstatesofamerica/ Gonorrhoea Denmark: 12.1 per 100,000 (2012) http://ecdc.europa.eu/en/publications/Publications/sexually-transmited-infections-HIV-AIDS-blood-borne-annual-epi-report-2014.pdf United States: 110.7 per 100,000 (2014) http://www.cdc.gov/std/stats14/std-trends-508.pdf Syphilis Denmark: 6.1 per 100,000 (2012) http://ecdc.europa.eu/en/publications/Publications/sexually-transmited-infections-HIV-AIDS-blood-borne-annual-epi-report-2014.pdf United States: 6.3 per 100,000 (2014) http://www.cdc.gov/std/stats14/std-trends-508.pdf So the (circumcised) United States has 4 times the level of HIV, and 10 times the level of gonorrhoea as (uncircumcised) Denmark. This suggests that the foreskin is protective against, and circumcision increases the risk of, urinary tract infections such as urethritis and gonorrhoea, at least in adulthood – which is what <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=25&Itemid=51" rel="noopener" target="_blank">Jonathan Hutchinson</a> found in 1855, and <a href="https://www.circinfo.org/newsindepth.html#nsu" rel="noopener" target="_blank">Ferris et al</a> in 2010. <h3>Male breast cancer more common than cancer of the penis</h3> Nor is prevention of cancer of the penis a valid reason for circumcision. Since the days of Jonathan Hutchinson, circumcision advocates have made much of the value of circumcision in preventing cancer of the penis (Morris et al, 2011). Whether or not it does so is less significant than the fact that penile cancer is a rare disease of older men – so rare that accurate statistics on incidence are difficult to find, and so rare that it is even less common than male breast cancer. The American Cancer Society (2016) estimates that 2600 cases of male breast cancer will be diagnosed in 2016 and that 440 men will die of it. The figures for cancer of the penis are 2030 cases and 340 deaths. If prophylactic removal of infant male breasts is not recommended as a breast cancer preventive, there is certainly no need for prophylactic removal of the foreskin as a penile cancer preventive. What are the key statistics about breast cancer in men? <a href="http://www.cancer.org/cancer/breastcancerinmen/detailedguide/breast-cancer-in-men-key-statistics" rel="noopener" target="_blank">The American Cancer Society estimates</a> for breast cancer in men in the United States for 2016 are: <ul> <li>About 2,600 new cases of invasive breast cancer will be diagnosed.</li> <li>About 440 men will die from breast cancer.</li> </ul> What are the key statistics about penile cancer? <a href="http://www.cancer.org/cancer/penilecancer/detailedguide/penile-cancer-key-statistics" rel="noopener" target="_blank">The American Cancer Society estimates</a> for penile cancer in the United States for 2016 are: <ul> <li>About 2,030 new cases of penile cancer will be diagnosed.</li> <li>About 340 men will die from penile cancer.</li> </ul> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision effect on STIs and cancer darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Circumcised men at equal risk of HPV infection</h2> A large-scale study at the University of Washington has found no difference in the incidence of HPV infection between circumcised and uncircumcised male college students. HPV (Human Papilloma Virus) is a large group of viruses that may cause genital warts, and are implicated in the genesis of genital cancers. HPV is very common among the sexually active population. but most people never show any symptoms. The risk factors for the development of cancer have been shown to be numerous different sexual partners and smoking. The new study confirmed previous research which showed that the location of the virus differed between circumcised and uncircumcised men: circumcised men tend to carry the virus on the shaft skin of the penis, while intact men are more likely to carry it on the glans. The study also also found that circumcised men have more sexual partners. In a previous study the researchers found found that for college females the circumcision status of their partner was NOT a risk factor for HPV infection in women. The authors comment that the African Random Clinical Trials, which seemed to show that uncircumcised men were more likely to carry the HPV virus, were seriously flawed because they took samples only from the glans (not from the shaft skin, where the virus is concentrated in the circumcised). ABSTRACT Background: The role of circumcision in male HPV acquisition is not clear. Methods: Male university students (aged 18–20 years) were recruited from 2003 to 2009 and followed up triannually. Shaft/scrotum, glans, and urine samples were tested for 37 human papillomavirus (HPV) genotypes. Cox proportional hazards methods were used to evaluate the association between circumcision and HPV acquisition. Logistic regression was used to assess whether the number of genital sites infected at incident HPV detection or site of incident detection varied by circumcision status. Results: In 477 men, rates of acquiring clinically relevant HPV types (high-risk types plus types 6 and 11) did not differ significantly by circumcision status (hazard ratio for uncircumcised relative to circumcised subjects: 0.9 [95% confidence interval{CI}: 0.7–1.2]). However, compared with circumcised men, uncircumcised men were 10.1 (95% CI: 2.9 –35.6) times more likely to have the same HPV type detected in all 3 genital specimens than in a single genital specimen and were 2.7 (95% CI: 1.6–4.5) times more likely to have an HPV-positive urine or glans specimen at first detection. Conclusion: We found no differences by circumcision status in overall HPV acquisition or in number of HPV types acquired. Findings held for all clinically relevant HPV types, as well as for the subgroups of high-risk types, high-risk -9 types, and HPV-16. This observation is consistent with findings from other longitudinal studies. Bottom line: Circumcision does not lower the risk of infection with Human Papilloma Virus. People who claim that uncircumcised men are more likely to develop or communicate genital cancers are ignoring the facts and spreading misleading information. Source: Kelley Van Buskirk et al, Circumcision and Acquisition of Human Papillomavirus Infection in Young Men, Sexually Transmitted Diseases 38 (12), December 2011. Journal homepage: http://journals.lww.com/stdjournal/pages/default.aspx Abstract available at journal - Published ahead of print: http://journals.lww.com/stdjournal/toc/publishahead <h2>Circumcision, human papilloma virus (HPV) and cervical cancer in women</h2> A review (2015) of the literature by a statistical and epidemiological experts shows there is no evidence that uncircumcised men are more likely to harbour HPV. Abstract: Genital infections with human papillomavirus (HPV) may be the most common sexually transmitted infections, but most infections with HPV are transient. While HPV infections may cause cervical cancer, only a handful of the hundred or so types of HPV are carcinogenic. Some have claimed, using a selective bibliography, that circumcision in males reduces the risk of HPV infections and the risk of cervical cancer in female sexual partners. The breadth and the quality of the epidemiological research regarding any association between male circumcision and HPV infections in general, and carcinogenic HPV in particular, will be considered. It will also be explored whether associations found in some studies can be attributed to other factors. Conclusion: The big lie To get to the truth, one needs to look beyond just the tip of the penis to get the full picture of the impact of circumcision on the risk for genital HPV infections. For all the hyperbole surrounding the propaganda of repeating the lie that circumcision reduces the risk of genital HPV infections in both men and women, the medical evidence simply does not support this claim. Anyone who makes these claims should be called out as a fraud. Source: Dr Robert Van Howe. <a href="https://www.academia.edu/13846777/Human_Papillomavirus_and_Circumcision_The_Story_Beyond_the_Tip" rel="noopener" target="_blank">Human Papillomavirus and Circumcision: The Story Beyond the Tip</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Cervical cancer, HPV and circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Prevention of cervical cancer in women is one of the oldest of the traditional medical motivations for circumcision of boys. The idea emerged in the early twentieth century, when circumcision was being widely hailed as the magic bullet against just about every disease and problem affecting the genital areas. The evidence was much the same as the evidence that circumcised men did not get syphilis: observations showed that Jewish women (whose husbands were of course circumcised) had a much lower incidence of cervical cancer than others. Circumcision promoters immediately hailed this observation as all the proof that was needed for the enforcement of widespread circumcision of male infants and boys. In relation to syphilis, sceptics pointed out that a much more likely explanation for the differing incidence of disease was simply that Jewish men and women were far less promiscuous than others and thus less likely to get infected. This argument was not then available in the case of cervical cancer, because it was not until very recently that it was recognised that this disease is also infectious, caused by a virus, and thus that it is nearly always caught through sexual contact. It is now appreciated that behaviour, not anatomy, is therefore the most important factor in susceptibility. This fact has not prevented today's circumcision promoters from demanding circumcision of male infants and boys so as to prevent cervical cancer in their future sexual partners. Since 2001, cervical cancer has been second only to AIDS as the fearsome bogey intended to drive parents to circumcise their baby boys. The idea was to target women, exploiting the fact that mothers were more protective of their children and thus less likely to favour circumcision than fathers. There was, however, always something distinctly creepy about the idea that a baby boy should be circumcised in order to reduce the risk of a disease in hypothetical adult women. The American legal scholar <a href="https://www.circinfo.org/waldeck.html">Sarah Waldeck has gone so far as to argue</a> that even if the claims about male foreskins causing cervical cancer in women were true, it would be ethically and legally impermissible to circumcise minors on this account because the person bearing the loss and risk was not the person reaping the benefit. The suggestion was also highly sexist: imagine the outrage if it was suggested that women should have part of their genitals excised in order to reduce the risk of disease in men! In truth, however, once it was realised that cervical cancer was spread by certain strains of a very common virus, the case against the foreskin collapsed. What is more, the development of a safe and effective vaccine, Gardasil, developed by the Australian scientist Ian Fraser, has made the whole controversy irrelevant. The aim of this page is to bring you accurate information on cervical cancer and the Gardasil vaccine from official websites, and then to look back at the use that circumcision promoters made of the cervical cancer scare in advocating their favourite fix. It may be of no more than academic interest now, but it provides chilling insights into their scientific method and ethical (un)awareness. <h2> <a id="facts" name="facts"></a>Facts on cervical cancer</h2> What is cervical cancer Cervical cancer is cancer of the cervix. The cervix is the lower part of the uterus, or womb, and is situated at the top of the vagina. Cervical cancer develops when abnormal cells in the lining of the cervix begin to multiply out of control and form pre-cancerous lesions. If undetected, these lesions can develop into tumours and spread into the surrounding tissue. Cause of cervical cancer Cervical cancer is caused by infection with certain types of a common virus, called human papillomavirus, or HPV. While other factors such as the oral contraceptive pill, smoking, a woman's immune system and the presence of other infections also seem to play a part, a woman has to have been infected with certain 'high-risk' HPV types before cervical cancer can develop. High risk types 16 & 18 are responsible for ~70% of all cervical cancers. Abnormal cervical cells are also caused by HPV infection, and these may be detected when a woman has a routine Pap smear. Human Papillomavirus (HPV) Human papillomavirus, or HPV, is a common virus that affects both females and males. There are more than 100 types of the virus. In fact, certain types of HPV cause common warts on the hands and feet. Most types of HPV are harmless, do not cause any symptoms, and go away on their own. About 40 types of HPV are known as genital HPV as they affect the genital area. More than 50% of people (males and females) will be infected with at least one type of genital HPV at some time. Genital HPV types may be "high-risk" types (such as HPV Types 16 and 18) that can cause cervical pre-cancer and cancer, or "low-risk" types (such as HPV Types 6 and 11) that can cause genital warts and usually benign (abnormal but non-cancerous) changes in the cervix. Both the "high-risk" and "low-risk" types of HPV can cause abnormal Pap smears. Anyone who has any kind of sexual activity involving genital contact could get genital HPV. That means it's possible to get the virus without having intercourse. And, because many people who have HPV may not show any signs or symptoms, they can transmit the virus without even knowing it. A person can be infected with more than one type of HPV. HPV is highly contagious. It is estimated that many people get their first type of HPV infection within their first few years of becoming sexually active. Genital HPV infection is not something to feel embarrassed or ashamed about. It is very common and most often goes away without any ill effects. It could almost be considered a normal part of being a healthy sexually active woman. <a href="http://www.cervicalcancer.com.au/">For full information about cervical cancer, see www.cervicalcancer.com.au</a> <h3>Facts from Australian Department of Health</h3> What is human papillomavirus (HPV) and how is it linked to cervical cancer? HPV is a sexually transmitted infection, mostly affecting women 20 to 24 years of age. Almost all abnormal Pap smear results are caused by HPV. In 98 per cent of cases, HPV clears by itself. In rare cases, if the virus persists and if left undetected, it can lead to cervical cancer. This usually takes about 10 years. What can be done to prevent cervical cancer? Early detection is the best protection from cervical cancer. Australia has one of the best national cervical screening programs in the world. Every year the Australian Government and the state and territory governments invest more than $90 million in the National Cervical Screening Program. This investment has cut deaths from cervical cancer by around 60 per cent since 1985 and has halved the number of cases of cervical cancer. Australia currently has the second-lowest incidence of cervical cancer and the lowest mortality rate from cervical cancer in the world. Are there vaccines available to protect people from HPV? There are many strains of HPV, only some of which can cause cancer. HPV strains 16 and 18 cause around 70 per cent of all cervical cancers. There is one vaccine (GARDASIL) which has been approved for use in Australia. This vaccine prevents infection from HPV strains 16 and 18 if individuals are vaccinated before they are infected with them. How does GARDASIL work? GARDASIL is administered as a series of three injections over a period of seven months. To ensure that some girls do not miss out, an immunisation program needs to run over a whole school year. All medicines and vaccines considered for funding by the Australian Government must first be approved by the Therapeutic Goods Administration (TGA) for use in Australia. This guarantees they are safe and clinically effective, but it does not assess their cost-effectiveness. The TGA approved GARDASIL on 16 June 2006 for females aged 9 to 26 years and males aged 9 to 15 years. <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/gardasil_hpv.htm">Commonwealth Department of Health Fact Sheet</a> <h3>Gardasil: A safe and effective vaccine</h3> The Therapeutic Goods Administration reports that Australia was one of the first countries to roll out a national cervical cancer immunisation campaign using Gardasil. To date more than 5.8 million doses of Gardasil have been distributed in Australia. The overall number of suspected adverse events reported following Gardasil administration is very low, and consistent with other new vaccines and adverse event rates reported in other countries. Worldwide, over 45 million doses have been distributed, with equally minimal side effects. <a href="http://www.tga.gov.au/alerts/medicines/gardasil.htm">For a full analysis of the safety of Gardasil, see TGA website.</a> <h2> <a id="hpvnews" name="hpvnews"></a>News reports on human papilloma virus and cancer</h2> <h3>Circumcision insignificant protection against cancer virus: Vaccination recommended</h3> An American study of of 4000 men in Brazil, Mexico and Florida (USA) has found that around half the population carries strains of the human papilloma virus (HPV) implicated in the generation of cervical and prostate cancer, but that the main risk factor for developing cancer is having a large number of sexual partners. Circumcision was found to have little protective effect against infection with the virus. Instead, the researchers recommend that vaccination with one of the new HPV vaccines that are already being given to women also be made available to men. The report follows Half of adult males carry HPV: Human papillomavirus lingers for months in men, study shows by Nathan Seppa Science News, Web edition, February 28th, 2011 The virus notorious for causing cervical cancer in women also turns up frequently in men and can hang on unnoticed for months or even years, researchers report online March 1 in Lancet. The study solidifies earlier research indicating that human papillomavirus is highly prevalent in men and strengthens the case for vaccinating men and boys against it, the report’s authors say. There are dozens of types of HPV, including more than 40 that can be transmitted sexually. Some can cause cancer. Two vaccines, Merck’s Gardasil and GlaxoSmithKline’s Cervarix protect against two types of cancer-causing HPV. Both vaccines are approved and recommended for girls and young women. Gardasil is also recommended for boys up to age 18 since its protection extends to two additional types of HPV that cause genital warts in males and females. It’s widely assumed that limiting the virus in men or women would diminish its spread in the whole population. But while HPV has been extensively studied in women, its prevalence is less well understood in men, says Joseph Monsonego of the Institute of the Cervix in Paris, writing in the same Lancet issue. For that reason, he says, the new study results “are of substantial interest.” Starting in 2005, epidemiologist Anna Giuliano of the H. Lee Moffitt Cancer Center & Research Institute in Tampa, Fla., and an international team of researchers recruited more than 4,000 men living in Brazil, Mexico and Florida into a study of HPV. The new study reports on the first 1,159 of these volunteers. Their average age was 32 and none had been vaccinated against HPV. Swabs of the penis and genital area of each man revealed that 50 percent were infected with at least one HPV type upon enrollment. The researchers repeated these exams every six months, and the men completed personal-history questionnaires. Over a median of 28 months, the group acquired 1,572 new HPV infections. The human immune system can clear HPV out of the body, and the men wiped out most of their new infections during the study period. But it took a median 7.5 months. Median clearance times didn’t vary substantially among the countries, but did vary between HPV types. Some cases lingered as long as 24 months in the men. HPV 16 is the type responsible for the most cervical cancers in women and is covered by both vaccines. It took a median of 12 months to clear. “It’s hanging around longer, and it’s completely asymptomatic,” Giuliano says. “You don’t even know you have it.” This silent infection means a person can transmit this HPV type for longer periods and “might help explain why HPV 16 is one of the most common types in both men and women,” she says. The data also reveal that men who reported having 10 or more sexual partners in their lifetimes had roughly twice as many HPV infections as did men who had had one partner. Giuliano says many insurance programs cover HPV vaccination in boys up to age 18. Male circumcision and the use of condoms have shown little protection against HPV infection, Monsonego says. “HPV vaccination in men will protect not only them but will also have implications for their sexual partners,” he says. <a href="http://www.sciencenews.org/view/generic/id/70435/title/Half_of_adult_males" rel="noopener" target="_blank">Science News, Web edition, February 28th, 2011</a> Additional source: A.R. Giuliano et al. Efficacy of quadrivalent HPV vaccination against HPV infection and disease in males. New England Journal of Medicine, Vol. 364, Feb. 3, 2011, p. 401. <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa0909537">Abstract here</a>. <h3> <a id="buskirk" name="buskirk"></a>Circumcised men at equal risk of HPV infection</h3> A large-scale study at the University of Washington has found no difference in the incidence of HPV infection between circumcised and uncircumcised male college students. HPV (Human Papilloma Virus) is a large group of viruses that may cause genital warts, and are implicated in the genesis of genital cancers. HPV is very common among the sexually active population. but most people never show any symptoms. The risk factors for the development of cancer have been shown to be numerous different sexual partners and smoking. The new study confirmed previous research which showed that the location of the virus differed between circumcised and uncircumcised men: circumcised men tend to carry the virus on the shaft skin of the penis, while intact men are more likely to carry it on the glans. The study also also found that circumcised men have more sexual partners. In a previous study the researchers found found that for college females the circumcision status of their partner was NOT a risk factor for HPV infection in women. The authors comment that the African Random Clinical Trials, which seemed to show that uncircumcised men were more likely to carry the HPV virus, were seriously flawed because they took samples only from the glans (not from the shaft skin, where the virus is concentrated in the circumcised). ABSTRACT Background: The role of circumcision in male HPV acquisition is not clear. Methods: Male university students (aged 18–20 years) were recruited from 2003 to 2009 and followed up triannually. Shaft/scrotum, glans, and urine samples were tested for 37 human papillomavirus (HPV) genotypes. Cox proportional hazards methods were used to evaluate the association between circumcision and HPV acquisition. Logistic regression was used to assess whether the number of genital sites infected at incident HPV detection or site of incident detection varied by circumcision status. Results: In 477 men, rates of acquiring clinically relevant HPV types (high-risk types plus types 6 and 11) did not differ significantly by circumcision status (hazard ratio for uncircumcised relative to circumcised subjects: 0.9 [95% confidence interval{CI}: 0.7–1.2]). However, compared with circumcised men, uncircumcised men were 10.1 (95% CI: 2.9 –35.6) times more likely to have the same HPV type detected in all 3 genital specimens than in a single genital specimen and were 2.7 (95% CI: 1.6–4.5) times more likely to have an HPV-positive urine or glans specimen at first detection. Conclusion: We found no differences by circumcision status in overall HPV acquisition or in number of HPV types acquired. Findings held for all clinically relevant HPV types, as well as for the subgroups of high-risk types, high-risk -9 types, and HPV-16. This observation is consistent with findings from other longitudinal studies. Bottom line: Circumcision does not lower the risk of infection with Human Papilloma Virus. People who claim that uncircumcised men are more likely to develop or communicate genital cancers are ignoring the facts and spreading misleading information. Source: Kelley Van Buskirk et al, Circumcision and Acquisition of Human Papillomavirus Infection in Young Men, Sexually Transmitted Diseases 38 (12), December 2011. Journal homepage: http://journals.lww.com/stdjournal/pages/default.aspx Abstract available at journal - Published ahead of print: http://journals.lww.com/stdjournal/toc/publishahead <h3>Study finds no association between HPV risk and lack of circumcision</h3> A large-scale study has found no association between circumcision status and susceptibility to infections with human papilloma virus (HPV), a group of wart viruses responsible for genital herpes and implicated in the generation of cervical and other genital cancers. The study involved 3463 heterosexual men from 71 sites in 18 countries in Africa, Asia-Pacific, Europe, Latin America, and North America. Although there have been claims that circumcision may reduce the risk of infection with HPV, this study was unable to confirm such findings. ABSTRACT Background. We examined the baseline prevalence of penile, scrotal, and perineal/perianal human papillomavirus (HPV) in heterosexual men (HM). We also evaluated baseline characteristics of HM to assess factors associated with prevalent HPV detection. Methods. We tested serum samples from 3463 HM aged 16–24 years with 1–5 lifetime female sexual partners for antibodies to HPV 6, 11, 16, and 18. We collected baseline swab specimens for the detection of DNA of HPV 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59 from 3 areas: penile, scrotal, and perineal/perianal. Risk factors for prevalent HPV DNA detection were evaluated. Results. The prevalence of any tested HPV type was 18.7% at the penis, 13.1% at the scrotum, 7.9% at the perineal/perianal region, and 21.0% at any site. Having >3 lifetime female sexual partners had the greatest impact on HPV prevalence: odds ratio (OR) 3.2 (95% confidence interval (CI) 2.1–4.9) for HPV 6, 11, 16, and 18; and OR 4.5 (95% CI 3.3–6.1) for all HPV types tested. HPV DNA detection was highest in Africa. Neither condom usage nor circumcision was associated with HPV DNA prevalence. Conclusion. Genital-HPV DNA detection is common in young, sexually active HM. We found HPV to be most prevalent in African men and least prevalent in men from the Asia-Pacific region. Increased numbers of sexual partners was an important risk factor for HPV DNA prevalence. Source: Eftyhia Vardas et al. External Genital Human Papillomavirus Prevalence and Associated Factors Among Heterosexual Men on 5 Continents. Journal of Infectious Diseases 2011:203 (January 2011) 58-65. <h3> <a id="vaccine" name="vaccine"></a>Boys HPV vaccination program a success</h3> A program to vaccinate adolescent boys against human papilloma virus (HPV) has been hailed as a great success, with very few adverse side effects reported. Referring to an article in the 3 June issue of the Medical Journal of Australia, the director of the National HPV Vaccination Program Register, Dr Julia Brotherton, told MJA Insight that “The second round of the first year of human papillomavirus vaccinations for adolescent boys has been completed with no reports of serious adverse outcomes”. HPV is a large group of viruses, some of which can cause various types of cancer in both males and females (especially cervical cancer), as well as anal and genital warts. Some years ago Australian researchers developed an effective vaccine, and health authorities launched a program to vaccinate girls. As a result of this effort, the incidence of genital warts among young women has fallen by about 80%. The vaccine also provides protection for males, as well as ensuring that they will not be carriers of the virus and at risk of infecting female sexual partners; Australia is the first county in the world to endorse a program to vaccinate adolescent boys. Cate Swannell, <a href="https://www.mja.com.au/insight/2013/20/boys-hpv-vax-going-well">Boys’ HPV vax going well.</a> MJA Insight, 3 June 2013 Hazel J Clothier et al, <a href="https://www.mja.com.au/journal/2013/198/10/human-papillomavirus-vaccine-boys-background-rates-potential-adverse-events">Human papillomavirus vaccine in boys: background rates of potential adverse events</a>. Medical Journal of Australia 198 (10), 3 June 2013, 554-558. The HPV vaccine protects against the two main types of cancer-causing HPV (HPV16 and 18), as well as two types that cause genital warts. Clinicians have already seen a dramatic decrease in genital warts in young women since the vaccination program was introduced in mid-2007; the prevalence of genital warts plummeted from 9.6% in 2004, to less than 2% in 2010-11. It is likely that a similar decline in throat cancers will result from vaccination, especially as boys are included in the immunisation program in Australia. Dyani Lewis, <a href="https://theconversation.com/michael-douglas-oral-sex-and-cancer-the-facts-about-hpv-14897">Michael Douglas, oral sex and cancer – the facts about HPV</a>. The Conversation, 3 June 2013. This is an effective reply to circumcision advocates (such as those in the so-called Circumcision Foundation of Australia) who try to use fear of cervical and other cancers caused by HPV to promote forcible circumcision of baby boys. Unlike circumcision, vaccination is an effective, modern, scientific way to reduce the risk of infection with cancers and other serious diseases without harm or damage to the body. Vaccination is modern medicine; circumcision is nineteenth century quackery. <a href="https://www.circinfo.org/controversy.html#vacci">Circumcision and vaccination</a> <a href="https://www.circinfo.org/Circumcision_HIV_control_Australia.html">Circumcision is not a surgical vaccine</a> So much for the facts; now for the the mythology. <h2> <a id="scare" name="scare"></a>2002: The new cervical cancer scare</h2> The following essay was written in 2002, in response to the publication of Castellsague's article in the New England Journal of Medicine, and the subsequent media hoo-ha, the intellectual quality of which may be judged by the screaming headline in (where else?) the Sydney Morning Herald, which never misses an opportunity to defame the foreskin: "Men can double women's risk of cancer". It is not likely that Castellsague's research has done anything to reduce the incidence of cervical cancer, but you can be sure that it has succeeded in its other objective of accelerating the destruction of infant foreskins. That Castellsague's principal aim was the promotion of circumcision is indicated by his co-authorship of subsequent papers attacking the policy of the Royal Australasian College of Physicians and demanding routine circumcision throughout the western world as a "public health requirement". (See note below.) THE NEW CERVICAL CANCER SCARE In 2002 the latest scare about the possible "association" between the normal male genitals and an increased risk of cervical cancer seems to have had a lot of usually rational people running scared. This is an old claim, going back to the 1930s, when the causative agent was imagined to be smegma; now they have found a virus, but the scent of quackery (trying to scare people into needless, ineffective or nasty operations) is still strong. You can imagine the outcry if it were suggested that part of the external female genitalia should be amputated to protect men from disease, or even to protect women themselves. What is cervical cancer? Cervical cancer is caused by a virus, or group of viruses, known as Human Papilloma Virus (HPV). They are similar to the viruses which cause warts and herpes, though obviously far more dangerous. Like herpes, they can be spread by sexual contact, but only a few of those who harbour the virus actually develop cancer. Two of the major factors which cause the virus to become active seem to be smoking and poor nutrition. Although regular screening can greatly reduce the risk of cervical cancer in women - thanks to screening, the incidence of the disease in Australia has declined steadily for the past 20 years - the disease is a serious cause of death in Third World countries, where standards of hygiene are poor, malnutrition is common, and societies lack the resources for preventive programs. This last point has led some tunnel-visioned researchers to suggest that, since HPV can be transmitted sexually, the best way to control it is by altering the anatomy of the genitals - that is, by cutting parts of them off. These claims received massive publicity in 2002 following the publication of a polemical article in the New England Journal of Medicine by Xavier Castellsague and colleagues, and they have been eagerly parroted ever since by circumcision crusaders such as Brian Morris. The article was accompanied by fire-breathing editorials, the thrust of which was much the same as Cato's policy on Carthage back in the days of Republican Rome: Delenda est praeputium! (The foreskin must be destroyed!) Lessons of history Back in the 1860s the London doctor Isaac Baker Brown started performing clitoridectomies on women because the orthodox theory of nervous disease then in force held that epilepsy, hysteria and even insanity could be caused by "irritation" of the pudic nerve, brought on by masturbation, and cured by excision of the clitoris. (Amputation of the foreskin of boys had already been introduced with the same justification in mind.) Brown's technique was indignantly rejected by the British medical profession: even if the treatment worked, it was unethical and illegitimate to mutilate women's bodies in this way. One of his critics said: "this particular form of quackery is an operation which is in itself a mutilation. I will not call it an operation: it is a mutilation", which could not be sanctioned by a profession governed by the ethics of Hippocrates - "First, do no harm". (British Medical Journal, 6 April 1867). The frightening implication drawn from the cervical cancer study in the highly coloured editorial in the New England Journal of Medicine, and its even more extravagant press releases, is that that every male baby in the world should now be automatically circumcised. Such an extreme response should be rejected by the modern medical profession many reasons, but not least because such a mutilation of the male body is equally unethical. The NEJM (which has been waging a vendetta against the foreskin for decade) will apparently seize on almost anything in its efforts to keep routine male circumcision alive in the USA. At least a virus is a real cause, but if doctors are going to fight disease by amputating all the parts of the body where its infectious agents are thought to hide, there will not be much left for them to keep healthy. In the medical journals and among responsible health specialists, however, there has been no confirmation of Castellsague's opinions, and the focus of public health policy remains on prevention. On this page we reply to Castellsague's bizarre Victorian notions. NOTE: Brian Morris, Stefan Bailis, Xavier Castellsague, Thomas Wiswell, Daniel Halperin, "RACP's policy statement on male circumcision is ill-conceived", Australian and New Zealand Journal of Public Health, Vol. 30 (1), 2006. The article concluded by demanding that the RACP revise its policy so as to emphasise "the prophylactic health benefits" of circumcision and "the low rate of mostly minor complications associated with this simple procedure, which for maximum benefits and minimal risk should ideally be performed in the neonatal period". The editors of the journal were so edgy about such partisan advocacy that the article was followed by a commentary by an Australian public health specialist that more or less rebutted every one of the authors' many claims. Incidentally, quite apart from the fact that the alleged "advantages" of prophylactic circumcision are a matter of controversy and doubt, there is no evidence at all that it must be done in infancy for maximum benefits, and plenty of evidence that neonatal circumcision is significantly more risky and harmful than if done later. The real reason circumcision promoters want it done soon after birth is that babies can't object. <h2> <a id="claim" name="claim"></a>Claims for link between the foreskin and cervical cancer:</h2> <h3>Not new; not medically valid; not ethical</h3> Despite the enormous publicity received by the recent article by Dr Xavier Castellsague et al in the New England Journal of Medicine, and more especially by the alarmist editorial in the same issue by Drs Dimitri Trichopoulos and Hans-Olov Adami. It should be noted that, despite the impressions given by the NEJM editorial and press coverage, the original study was based on and was intended to apply only to the Third World, not to developed countries. There are many flaws in the NEJM study and subsequent suggestions that all boys should be compulsorily circumcised at birth to protect women from cervical cancer. These fall into the following categories: <ul> <li>statistical evidence from developed countries contradicts claims</li> <li>failures of logic</li> <li>ignorance of medical history</li> <li>lack of knowledge about previous claims about an association between normal male anatomy and risk of disease dubious ethics</li> <li>a misguided and false concept of the role of medicine</li> </ul> Evidence from the developed world contradicts claims The incidence of cervical cancer in Australia has been declining as the rate of male circumcision has declined. The effect of media reports based on the press release issued by the NEJM has been to give ammunition to advocates of routine circumcision in wealthy countries, enabling them to scare parents into having their newborn sons circumcised. This is despite the fact that cervical cancer rates in the developed world are low, and declining, and that male circumcision, if it has any impact at all, is a blunt and relatively ineffective means of intervention, with regrettably severe side effects. They suit doctors such as Australia's Dr Terry Russell who has boasted of getting "a lot of personal satisfaction" from performing up to 2,000 circumcisions a year, and has claimed that "there is no other single procedure that would give a person as much protection against as many diseases as does circumcision" (60 Minutes, 8 October, 2000). Other advocates of circumcision make equally bizarre claims. According to <a href="http://www.acsh.org/publications/priorities/0904/circyes.html">Dr Edgar Schoen</a>, perhaps the most aggressive champion of forcible and universal routine circumcision in the USA (though he is keen to see it everywhere else as well), "A one-week-old circumcised boy has a significant health advantage over his uncircumcised contemporary." If that were the case, one might expect males in the USA to enjoy better health than their counterparts in comparable developed countries, but this table, showing circumcision rate in comparison with life expectancy and rates of HIV infection and cervical cancer, does not appear to support that contention. <table class="table100pc"> <tbody> <tr> <th class="lightblue">Country</th> <th class="lightblue">Human development index</th> <th class="lightblue">Incidence of circumcision in adults (%)</th> <th class="lightblue">Male life expectancy</th> <th class="lightblue">Prevalence of HIV in adults (cases per 100,000)</th> <th class="lightblue">Cervical cancer incidence (cases per 100,000)</th> </tr> <tr> <td class="grey">USA</td> <td class="grey">6</td> <td class="grey">70</td> <td class="grey">73.9</td> <td class="grey">61</td> <td class="grey">8</td> </tr> <tr> <td>Australia</td> <td>2</td> <td>55</td> <td>76</td> <td>15</td> <td>7</td> </tr> <tr> <td class="grey">Canada</td> <td class="grey">3</td> <td class="grey">50</td> <td class="grey">75.9</td> <td class="grey">19</td> <td class="grey">8</td> </tr> <tr> <td>Britain</td> <td>14</td> <td>20</td> <td>75</td> <td>11</td> <td>9</td> </tr> <tr> <td class="grey">Sweden</td> <td class="grey">4</td> <td class="grey"><5</td> <td class="grey">77</td> <td class="grey">8</td> <td class="grey">9</td> </tr> <tr> <td>Norway</td> <td>1</td> <td><5</td> <td>75.4</td> <td>7</td> <td>13</td> </tr> <tr> <td class="grey">Finland</td> <td class="grey">10</td> <td class="grey"><5</td> <td class="grey">73.7</td> <td class="grey">5</td> <td class="grey">4</td> </tr> <tr> <td>Japan</td> <td>9</td> <td><5</td> <td>77.3</td> <td>2</td> <td>11</td> </tr> </tbody> </table> Sources: Human Development Index and Life Expectancy: United Nations Development Program, Human Development Report 2001 <a href="http://www.undp.org/hdr2001/">http://www.undp.org/hdr2001/</a> Circumcision Prevalence: Own estimates HIV Prevalence: UNAIDS <a href="http://www.unaids.org/epidemic_update/report/Table_E.htm">http://www.unaids.org/epidemic_update/report/Table_E.htm</a> Cervical Cancer: CANCERMondial <a href="http://www-dep.iarc.fr/">http://www-dep.iarc.fr/</a> Australia, Canada and Britain were selected because of their cultural similarities with the USA and because they have an intermediate level of circumcision prevalence. The Scandinavian countries and Japan were selected because they have very low rate of circumcision. There is nothing in the table to suggest that circumcision confers any health advantage at all, let alone a significant one, to males in the USA compared with males in the other countries. There is a strong correlation between circumcision prevalence and HIV prevalence, and a negative correlation between circumcision and life expectancy. Although the primary purpose of the table is to test Dr Schoen's claim, it also provides an opportunity to observe that any association between male circumcision and cervical cancer is also very weak. Virus lives in male and female genital tissue Human papillomavirus does not generate spontaneously. It did not originate in the foreskin of the man who is infected. He was most probably infected with it by one of his female partners. There is a continuous cycle of infection from male to female to male or, equivalently, from female to male to female. Headlines such as that in the Sydney Morning Herald, "Men can double women's risk of cancer" (in inch high letters across the top of page 3), with its none too subtle implication that men are to blame for the cycle, simply reflect a thoughtless culture of selective (and sexist) blame - a mood in which amputative surgery can be performed upon a male now, without his consent, on the pretext that it may reduce the probability of a hypothetical female partner a long time in the future developing a disease - a disease, moreover, that is largely preventable by other (non-injurious) means. Paradoxically, the double standard in current attitudes would make it a serious crime to perform any surgery upon females which was thought to benefit males. The startling fact is that cervical cancer has been declining in Australia, along with decline in the rate of male circumcision. In April 2002 the Cancer Council of New South Wales released its annual report on cancer in NSW, <a href="http://www.cancercouncil.com.au/cncrinfo/research/reports/stats/index.htm">Cancer Incidence and Mortality in NSW 2000</a>. The report showed that cervical cancer cases in NSW declined from an average of 363 new cases in the five years 1988-1992 to 267 in 2000. At the same time the Council issued a <a href="http://www.cancercouncil.com.au/cncrinfo/news/index2.htm">media release</a> in which it stated: "Cervical cancer to halve by 2010". The statement continued: "Numbers of new cervical cancer cases are expected to continue to decline from 267 to 195 in the period 2001 to 2010. Rates are also expected to almost halve from 7.4 to 4.7 per 100,000 in 2001 to 2010." By these calculations, if Dr Castellsague's figures for the relative risk of cervical cancer among women with circumcised partners compared with women with uncircumcised partners could be applied to NSW, and the risk to a female of developing cervical cancer was reduced by 25 per cent (in accordance with the overall Odds Ratio in his Table 4) if she had a circumcised male partner as opposed to an uncircumcised male partner (a premise which is not supported by the data and trends cited in the succeeding two paragraphs), more than one thousand circumcisions would be required to prevent one case of cervical cancer. Would it not be cheaper, more effective, more productive of happiness and more ethical to encourage those women who do not have regular pap smears to do so? The steep decline in the number of cervical cancer cases in the decade 1990 to 2000 took place at he same time as a significant decline in the percentage of sexually active men who had been circumcised. During the decade, Australia was in transition from a population with a predominantly circumcised male population to a predominantly uncircumcised one. Thus, across time there is actually an association between circumcision and cervical cancer. Among the three most populous states in Australia, accounting for almost 80 percent of the Australian population, Queensland had the highest rate of cervical cancer, NSW the second highest, and Victoria the lowest. Queensland also has the highest proportion of circumcised males, NSW the second highest, and Victoria the lowest. Thus, across space there is also an association between circumcision and cervical cancer. Failures of logic Even if it were true that women had a higher risk of picking up HPV from uncircumcised men, why should it follow that all boys should be circumcised? It could be argued with equal logic that uncut men faced a greater risk of picking up HPV from infected women and thus that the focus of prevention should be on purifying them. Dr Castellsague and his team are not blaming women for infecting men with HPV, but where else do they get it from? If the foreskin provides a nest for the virus, so does the clitoral hood and the folds of the labia in females; perhaps routine circumcision of women would reduce the incidence of HPV infection and penile cancer in men. Because western doctors regard amputation of any part of the female genitals as mutilation, however, they have no interest in exploring this intriguing therapeutic possibility, and they do not try to find associations between normal female anatomy and risk of disease. It is a different story in the Islamic cultures which practise various forms of female circumcision, where both doctors and religious leaders do indeed make similar claims about its benefits for women's health, including its effect in reducing the incidence of cancer, herpes and AIDS. Early detection: pap smears While it seems remiss of the study not to have mentioned the possibility of a vaccine affecting the utility of circumcision, yet another search, for "smear", turns up empty too. One might have expected some comparison of the relative effectiveness of pap smears and male circumcision in preventing cervical cancer. No doubt there are immense obstacles to providing all women in poor countries with regular tests, but the same indigent circumstances would guarantee high rates of injury, morbidity and mortality arising from circumcision carried out in such primitive conditions. Deaths and injuries resulting from male circumcision have always been swept under the carpet; in many of the latter cases the victim may not even be aware that a functional problem or deformity is the result of a circumcision injury. The Harvard School of Public Health is sponsoring another research program, led by Dr Sue Goldie and Jane Kim, on a cheap method of screening for and thus preventing cervical cancer in Third World countries. Their work suggests that Dr Trichopoulos (a professor at HSPH) may be not be regarded so highly by his colleagues there as the media has assumed. See: <a href="http://www.hsph.harvard.edu/press/releases/press572002.html">New Approach to Cervical Cancer Screening Could Save Lives, Billions in Health Care Costs</a> Inconsistencies with Dr Castellsague's previous studies Dr Castellsague's analysis showed inconsistencies with several of the detailed studies on which it was meant to be based. To take a striking example, in a study published in 1997 and cited in 2002, he found that Colombia has eight (8) times the incidence of cervical cancer as Spain. Given that the rate of male circumcision would be about the same in each country (i.e. very low), this alone would seem to exonerate the foreskin - or would do in a court of law where reasonable doubt was the rule. It shows that the real causes are not anatomy, but poverty, ignorance, lack of personal hygiene (whether from lack of running water or deficiency of knowledge or both) and promiscuity, particularly with prostitutes, without using condoms. The most important factor is simply poverty. Cervical cancer is a less serious problem in developed countries because they have the wealth and education to keep it at a low level through regular medical check-ups, and the medical resources to treat it effectively in the early stages. Such conditions do not apply in the developing world. The really important points are in the opening and last three paragraphs: <ol> <li>Incidence of cervical cancer in Spain is 6/100,000; in Colombia 48/100,000; yet the rate of male circumcision in the two countries is about the same.</li> <li>Comparisons of HPV DNA prevalence in healthy men are difficult to interpret across studies.</li> <li>The correlation of HPV results of males with the results for their wives revealed little evidence of shared concordant infections (meaning they could not have infected each other).</li> <li>HPV DNA prevalences were significantly related to the sexual behaviour characteristics of the couple.</li> <li>Rates of HPV infection in the male population of Colombia are much higher than in Spain.</li> </ol> Dr Castellsague states: "In conclusion, the 5-fold difference in penile HPV DNA prevalences in the male populations of Colombia and Spain is consistent with the 8-fold difference in cervical cancer incidences between the two countries. Strong and statistically significant dose-response relationships were found between penile HPV DNA prevalence and all sexual behaviour-related variables of the couples in Spain but not in Colombia, where penile HPV prevalences were higher and of similar magnitude across all levels of the sexual behaviour variables. These data support the hypothesis that sexual promiscuity is the most important risk factor for penile HPV infections, which are in turn related to cervical carcinogenesis in their female sex partners." Did you catch that: "sexual promiscuity is the most important risk factor for penile HPV infections." On a more ironic note, Dr Castellsague reports proudly that "Informed consent was obtained from the women enrolled in the case-controlled studies ... and from their respective husbands" - a courtesy that Dr Trichopoulos and the NEJM do not propose to extend to the little boys they want to circumcise. Citation details: Journal of Infectious Diseases 1997 Aug;176(2):353-61, Citation #23 Prevalence of penile human papillomavirus DNA in husbands of women with and without cervical neoplasia: a study in Spain and Colombia. Castellsague X, Ghaffari A, Daniel RW, Bosch FX, Munoz N, Shah KV. Ignorance of medical history In a review of studies on a possible relationship between Trichloroethylene and kidney cancer for submission to the National Toxicology Program on which you and Dr Trichopoulos collaborated, you wrote: "It appears inconceivable to us that an investigator would ... rely on study principles and methodologies that were developed in the first half of the 20th century." How much more strongly does this observation apply to citations from cranky nineteenth century physicians like<a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=25&Itemid=51"> (Sir) Jonathan Hutchinson</a>, whom Castellsague quotes as having observed that circumcision provided a significant degree of protection against syphilis. Hutchinson's entire evidence for this remarkable and untenable claim consisted of the following data, based on a record of the incidence of venereal cases among Jewish and non-Jewish patients in his practice at the Metropolitan Free Hospital, London, during 1854: <table class="table50pc"> <tbody> <tr> <td width="100%"> </td> <th class="lightblue">Venereal cases</th> <th class="lightblue">Gonorrhoea</th> <th class="lightblue">Syphilis</th> </tr> <tr> <th class="grey">Non-Jews</th> <td>272</td> <td class="grey">107</td> <td>165</td> </tr> <tr> <th class="grey">Jews</th> <td>58</td> <td class="grey">47</td> <td>11</td> </tr> </tbody> </table> Hutchinson (1828-1913) used these figures to claim that Jews were less likely to contract syphilis because they were circumcised and later asserted that circumcision conferred virtual immunity to syphilis. The figures could equally well have been claimed to prove that Jews were more likely to contract gonorrhoea because they were circumcised. Such figures proved nothing at all, but they were the data upon which routine circumcision in the English-speaking countries was built. Hutchinson's deeper motivation in urging universal circumcision of male infants was that it would discourage masturbation and promote continence; he abhorred condoms as immoral and physically harmful; and he asserted to his dying day that leprosy was a form of tuberculosis, caused by eating bad fish. Dr Castellsague recited a list of diseases, beginning with Hutchinson's syphilis, the dread disease of his day, and ending with HIV, the dread disease of our time, yet omitted many of the other maladies for circumcision has been claimed as a preventive or cure in the intervening period, such as TB, polio, whooping cough, brass poisoning, epilepsy, and most of all, childhood masturbation. Dr Castellsague seems to take it as proven that circumcision does provide protection against various forms of venereal disease, especially syphilis, but that is simply not true. Innumerable studies have repeatedly failed to find firm evidence that uncircumcised men are more vulnerable to any forms of VD, and even so conservative an authority as the English Royal Commission on Venereal Diseases in 1916 found that syphilis was concentrated exactly where STDs, HPV and HIV are concentrated today: among poor and ignorant populations, living in dirty conditions and having frequent unprotected sex with multiple partners or prostitutes. Social distribution of syphilis <table class="table50pc"> <tbody> <tr> <th class="lightblue">Social class/occupation</th> <th class="lightblue">Death rate per million</th> <th class="lightblue">Death rate rank</th> </tr> <tr> <td>Upper and middle</td> <td>302</td> <td>3</td> </tr> <tr> <td class="grey">Intermediate</td> <td class="grey">280</td> <td class="grey">4</td> </tr> <tr> <td>Skilled labourer</td> <td>264</td> <td>5</td> </tr> <tr> <td class="grey">Intermediate</td> <td class="grey">304</td> <td class="grey">2</td> </tr> <tr> <td>Unskilled labour</td> <td>429</td> <td>1</td> </tr> <tr> <td class="grey">Textile workers</td> <td class="grey">186</td> <td class="grey">6</td> </tr> <tr> <td>Miners</td> <td>177</td> <td>7</td> </tr> <tr> <td class="grey">Agricultural labourers</td> <td class="grey">108</td> <td class="grey">8</td> </tr> </tbody> </table> Source: Royal Commission on Venereal Diseases, Final report of the commissioners, p. 19 (British Parliamentary Papers, 1916, Vol. 16) Circumcision at that time was most prevalent among the urban upper class, and rarest among rural (agricultural) workers and miners. Circumcision was also rare among unskilled labourers, but they were the group which lived in the worst urban squalor and practised the most sexual promiscuity. Even so ardent a champion of universal male circumcision as Australia's Professor Brian Morris is unable to do better than reach the equivocal conclusions that (1) "based on the bulk of evidence it would seem that at least some STDs could be more common in uncircumcised males under some circumstances"; but that (2) "there may be little difference in most STDs between those with and those without a foreskin".[1] If the evidence was there he of all people would be trumpeting it. As anybody acquainted with the history of syphilis knows perfectly well, circumcision played no role at all in the conquest of that disease, which was tamed in the early twentieth century by increasing use of condoms and the application of Metchnikoff's ointment and Salvarsan, and defeated in the 1940s by penicillin. 1. Brian Morris, In favour of circumcision (Sydney 1999), pp. 38 and 39. See the <a href="http://www.historyofcircumcision.net/index.php?option=content&task=view&id=64">scathing review by Basil Donovan</a> in Venereology, Vol. 12 (1999), pp. 68-9. Professor Donovan describes Morris as "a man on a mission to rid the world of the male foreskin" and some of his claims as "so dangerous" that the publishers ought to withdraw the book. Lack of knowledge about previous claims about an association between normal male anatomy and risk of disease Even more serious than Dr Castellsague's ignorance of the history of syphilis is his apparent unawareness of previous studies claiming an association between incidence of male circumcision and incidence of cervical cancer, and of their subsequent refutation. We have already been through all this. Apart from some quacks in the 1920s, the first serious study to implicate the foreskin as a cause of cervical cancer was by Sampson W. Handley in 1936 (Handley WS. The prevention of cancer. Lancet 1936 May 2;1(5879):987-91.) This had a very similar methodology to that of Dr Castellsague's study, taking mixed populations (Indians and native Fijians) in Fiji as its data. After that came Abraham Ravich who vehemently asserted the connection in Ravich A, Ravich RA. Prophylaxis of cancer of the prostate, penis, and cervix by circumcision. New York State Journal of Medicine, Vol 12, June 1951. Ravich believed that the foreskin caused not only cancer of the cervix and penis, but cancer of the prostate as well, as detailed in his crazy book, Preventing VD and cancer by circumcision (New York 1973). Widespread acceptance of the more limited theory came with an article by E.L. Wynder in 1954 (Wynder EL, Cornfield J, Schrott PD, Doraiswami KR. A study of environmental factors in carcinoma of the cervix. Am J Obstet Gynecol 1954;68:1016-52) which pushed America's already high rate of RNC to near universal levels, though it was not long before the study was called seriously into question. Wynder et al had based their assumptions about the circumcision status of the male partners of women with cervical cancer on a questionnaire filled in by the women. In 1958 two other researchers reported a large error in self-reporting of circumcision status among men: while 35 per cent reported themselves circumcised, examination by physicians showed that the true number was 44 per cent (Lilienfeldt AM, Graham S, Validity of determining circumcision status by questionnaire as related to epidemiological studies of cancer of the cervix. J Nat Cancer Inst. 1958;21:713-20). In 1960 Wynder revaluated and retracted his earlier study because he had realised that erroneous patient reporting had caused serious statistical errors. He found that 36 per cent of women did not know whether their husbands were circumcised or not, and that 24 per cent of his male patients were able to state correctly their own status (Wynder EL, Licklider SD. The question of circumcision. Cancer. 1960; 13:442-5). In another paper Wynder again conceded that his findings from 1954 were invalid: "The definitive determination of whether true association exists must await the conduct of an appropriate study within an ethnic group". This did not, however, prevent him from recommending the "more rapid spread of the practice of circumcision among newborn children" for other highly valid reasons. (Wynder, EL, Mantel N, Licklider SD. Statistical considerations on circumcision and cervical cancer. Am J Obstet Gynecol. 1960; 79:1026-30.) In 1971, in relation to cancer of the prostate, he felt obliged to differ from Dr Ravich and concede: "Circumcision: There was no significant difference between the non-Jewish cancer and control groups in this regard" (Wynder EL Mabuchi K, Whitmore WF. Epidemiology of cancer of the prostate. Cancer. 1971; 28:344-60). Although American doctors largely ignored Wynder's retractions and continued to cut as many boys as they could, researchers heeded his advice to carry out ethnic-specific studies, all of which found that there was no association between normal male anatomy and an increased risk of cervical cancer. A review of this literature is available at <a href="http://www.nocirc.org/statements/cervical_cancer_stmt2002.php">http://www.nocirc.org/statements/cervical_cancer_stmt2002.php</a> Such studies throw serious doubt on the validity and even the usefulness of those by Dr Castellsague and his team. Male and female genitals are much the same in both the industrial and the developing world, so that any differences in their susceptibility to disease must be found in the social, cultural and behavioural factors, which do differ considerably from one country to another. It is there that both the problem and the solution will be found to lie, not in tampering with normal human anatomy. Dubious ethics It has long been established that scientists are subject to ethical constraints. They are not certainly not allowed to perform unethical research. An example of ethics in action occurred recently when a study on the efficacy of various kinds of anaesthesia used for circumcision of newborn boys was aborted because when the researchers saw how much pain the non-anaesthetised control group was suffering, they decided it would be unethical to continue. (For details see <a href="http://www.cnn.com/HEALTH/9712/23/circumcision.anesthetic">http://www.cnn.com/HEALTH/9712/23/circumcision.anesthetic</a> ) Commendable though this was, it could hardly provide retrospective comfort to the 100 million or so American babies circumcised over the past hundred years with no form of pain control at all. Equally, scientists ought not to be able to make unethical proposals. At the very least, in the case of Castellsague's study, this would require the authors to address the question of whether the circumcision of baby boys showing no genital abnormalities is ethical. Since the alteration of the female genitals is regarded as unethical - and is illegal in many jurisdictions - and since the surgical removal of any other part of a normal male newborn is both unethical and illegal, it is not self-evident that the question can be answered in the affirmative. A recent study on the legitimacy of prophylactic medical interventions in children unable to give legal consent concluded that it was ethical only in the case of highly contagious diseases which could not be avoided by reasonable behavioural modification. (See F.M. Hodges, J.S. Svoboda, R.S. van Howe, "Prophylactic interventions in children: Balancing human rights with public health", Journal of Medical Ethics, Vol. 28, 2002, pp. 10-16). Yet a search for "ethics" and "ethical" in Dr Castellsague's study and the editorial turns up empty, except for the assurance that the study's protocols were approved by the local ethics committees. But what is at stake is not whether informed consent was obtained from the subjects of the study (for a harmless set of questions and non-injurious examination), but whether it is ethical to propose the removal of a normal, healthy body part from an individual without his agreement. Following publication of Dr Castellsague's Dr Trichopoulos was reported as saying: "I would recommend circumcision of all male babies", adding with apparent regret, "but I don't think that will ever happen" (Los Angeles Times, 15 April 2002), and further that "on the strength of the study, if he had a newborn son he would have him circumcised" (New York Times, 11 April 2002). Note the language: he would not seek circumcision for himself, even though he is (presumably) a sexually active adult; instead, he would circumcise a helpless baby who would probably not be sexually active with another person for at least sixteen years. We would like to see the calculations Dr Trichopoulos used to reach his conclusion that he would have a newborn son circumcised. How many newborn boys must be circumcised in order to prevent one case of cervical cancer? What is the total financial cost of circumcising so many boys? What is the cost of all the short-term complications and long-term sequelae? What is cost of the deprivation of bodily wholeness and physical pleasure? And what is the cost of the violation of the right of all those boys to a normal body and a compete set of external genitals? The principal putative beneficiary of the deed is an unknown person, most likely not yet born at the time of the deed. There is no guarantee that the deed will benefit anyone at all; in fact, it is highly unlikely that it will benefit anyone at all and thus probable that it will have been done in vain. If the son were to die before attaining the age of sexual activity, if the son were to be uninterested in women, or if, having reached heterosexual adulthood, displayed a low "sexual behaviour risk index", then the act of circumcising him as a newborn would have proved pointless. Dr Trichopoulos appears to be saying that he expects his son to have an intermediate or high "sexual behaviour risk index": that is the only circumstance in which Dr Castellsague's study found women with circumcised male partners less likely to develop cervical cancer. Evidently he also expects his son's female partners to neglect having regular pap smears: yet by this simple precaution the female partners could drastically reduce their likelihood of developing cervical cancer irrespective of whether he retains his foreskin or not. A false concept of the role of medicine Dr Castellsague seems to agree with Hamlet that "Diseases desperate grown, by desperate remedies are relieved" - that the seriousness of cervical cancer in Third World countries justifies desperate and heroic methods of treatment. But the severity of a problem does not necessarily demand severe or heroic methods at all: what it demands is effective methods. There is no evidence that the approaches used to control cervical cancer in the develop world will not work in the Third World; the suggestion that mass circumcision will be cheaper or easier to perform than educating women to have pap smears and men to practise safe sex is really an admission that people in Third World countries matter so little that they can be treated like animals. (See <a href="http://www.hsph.harvard.edu/press/releases/press572002.html">New Approach to Cervical Cancer Screening Could Save Lives, Billions in Health Care Costs</a>) It may at first look easier to force a baby to get circumcised than to persuade men to be less promiscuous or women to have regular check-ups, and to provide the necessary medical infrastructure for this, but it is not necessarily more effective as a disease control strategy, and it is certainly both immoral and likely to meet significant opposition. Medical research theorists must learn to accept the human body as nature made it, not devise tunnel-visioned strategies that require doctors to cut off the bits that annoy them. Medicine must learn to accept the human body as nature made it, imperfect though it may be, not try to turn it into the sort of streamlined machine it might have been if engineered by a committee of experts from the Harvard School of Public Health. Thanks to the workings of natural selection the foreskin is an integral part of the male genitals, and men have as much right to it as to their ear lobes, fingers, toes, kidneys, lungs and testicles. It may not be essential to survival, but nor are our limbs or the second unit of our duplicate organs; even non-essential items have their value and uses. You can imagine the outcry if it were suggested that part of the external female genitalia should be amputated to protect men from disease, or even to protect women themselves. Back in the 1860s the London doctor Isaac Baker Brown started performing clitoridectomies on women because the orthodox theory of nervous disease then in force held that epilepsy, hysteria and even insanity could be caused by "irritation" of the pudic nerve, brought on by masturbation, and cured by excision of the clitoris. (Amputation of the foreskin of boys had already been introduced with the same justification in mind.) Brown's technique was indignantly rejected by the British medical profession: even if the treatment worked, it was unethical and illegitimate to mutilate women's bodies in this way. One of his critics said: "this particular form of quackery is an operation which is in itself a mutilation. I will not call it an operation: it is a mutilation", which could not be sanctioned by a profession governed by the ethics of Hippocrates - "First, do no harm". (British Medical Journal, 6 April 1867). It is not the proper role of medicine pre-emptively to amputate parts of the body considered vulnerable to disease or implicated in disease transmission, but to protect all of it from harm; in the case of any part of the body except the foreskin, amputation is a last resort in cases of abnormality, injury or disease, not the starting point. Nobody has yet made the case that men are less entitled to a complete set of external genitals than women. <h2> <a id="rsvhpv" name="rsvhpv"></a>Circumcision, human papilloma virus (HPV) and cervical cancer in women</h2> A review (2015) of the literature by a statistical and epidemiological experts shows there is no evidence that uncircumcised men are more likely to harbour HPV. Abstract: Genital infections with human papillomavirus (HPV) may be the most common sexually transmitted infections, but most infections with HPV are transient. While HPV infections may cause cervical cancer, only a handful of the hundred or so types of HPV are carcinogenic. Some have claimed, using a selective bibliography, that circumcision in males reduces the risk of HPV infections and the risk of cervical cancer in female sexual partners. The breadth and the quality of the epidemiological research regarding any association between male circumcision and HPV infections in general, and carcinogenic HPV in particular, will be considered. It will also be explored whether associations found in some studies can be attributed to other factors. Conclusion: The big lie To get to the truth, one needs to look beyond just the tip of the penis to get the full picture of the impact of circumcision on the risk for genital HPV infections. For all the hyperbole surrounding the propaganda of repeating the lie that circumcision reduces the risk of genital HPV infections in both men and women, the medical evidence simply does not support this claim. Anyone who makes these claims should be called out as a fraud. Source: Dr Robert Van Howe. <a href="https://www.academia.edu/13846777/Human_Papillomavirus_and_Circumcision_The_Story_Beyond_the_Tip" rel="noopener" target="_blank">Human Papillomavirus and Circumcision: The Story Beyond the Tip</a> <h2> <a id="genes" name="genes"></a>Genetic mutation protects Jewish women</h2> For many years it was assumed that the low incidence of cervical cancer among Jewish women was related to the fact that most of their husbands were circumcised (though a few researchers tried to find an association withnot eating pork products). In 2003 new evidence came to light that the proverbially low incidence of cervical cancer among Jewish women has nothing to do with the condition of their husbands' penises, but is the effect of a genetic mutation. In an article published in the Israeli Medical Association Journal, Dr Joseph Menczer, of the Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, Wolfson Medical Center, Israel, found that there was little or no evidence of any "protective effect" from male circumcision, but that a genetic mutation common among Jewish women offered resistance to the virus which caused the cancer. Relevant paragraphs from Dr Menczer's article are as follows: "Although the dispute over the association of circumcision and cervical cancer in various populations is still ongoing [23,24], there seems to be no hard evidence that circumcision prevents its occurrence in Jewish women, and it is no longer considered to play a protective role. These findings support the possibility that the low prevalence of the homozygous arginine polymorphism may play a role in determining the low incidence of cervical cancer in Jewish women and may also explain the differences between the ethnic groups. If these observations are confirmed, then the low incidence of cervical cancer in Jewish women is genetically determined, and an explanation for the ethnic incidence pattern of cervical cancer in Jewish women has also finally been found." Conclusions "For many years it was predicted, on the basis of observations in selected cohorts or individual institutions, that the incidence of invasive cervical carcinoma in Israeli Jewish women will increase [37-39]. While ritual circumcision is still practiced widely, today only a minority of Jewish women observes the laws of Niddah. Sexual habits have also changed considerably, becoming far less stringent. In spite of these trends of the last four to five decades, the population-based incidence of cervical cancer in Israeli Jewish women has not increased and remains very low [22,40]. Braithwaite [6], who first noted the low incidence in Jewish women in 1901, suggested two explanations for this immunity. The first was the difference of race, and the second the difference in diet, namely "the absence of bacon and ham in the diet of Jews". He then added: "The latter is far more probable than the former, although there may be something in race". Now, a century after Braithwaite's original observation, it seems that there may indeed be something in "race"." Menczer J. <a href="http://www.cirp.org/library/disease/cancer/menczer1/">The Low Incidence of Cervical Cancer in Jewish Women:</a> Has the Puzzle Finally Been Solved? Israeli Medical Association Journal, Vol. 5, 2003, pp. 120-3 <h3>A concluding comment from Andrew Sullivan</h3> I may be a broken record on this but the news today that circumcision may have a small effect in restraining transmission of the HPV virus strikes me as likely to be misused. The argument against the circumcision of infants is not that it might not conceivably have some future health-benefits. The argument against infant male genital mutilation is that it is the permanent, irreversible disfigurement of a person's body without his consent. Unless such a move is necessary to protect a child's life or essential health, it seems to me that it is a grotesque violation of a person's right to control his own body. It matters not a jot why it is done. It simply should not be done - until the boy or man is able to give his informed consent. And to perform such an operation to protect the health of others is an even more unthinkable violation. It's treating an individual entirely as a means rather than as an end. I'm at a loss why a culture such as ours that goes to great lengths to protect the dignity and safety of children (and rightly so) should look so blithely on this barbaric relic. Yes, I know there are religious justifications for it. But even so, religions should not be given ethical carte blanche over the bodies of children. Would we condone a religious ceremony that, say, permanently mutilated a child's ear? Or tongue? Or scarred their body irreversibly? Of course not. So why do we barely object when people mutilate a child's sexual organ? <a href="http://www.andrewsullivan.com/">The Daily Dish, 12 April 2002</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Cancer of the cervix and circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Yet another wonderful benefit of circumcision?</h1> Do green jellybeans cause acne? <a href="http://xkcd.com/882/">As this cartoon neatly demonstrates</a>, the claim that they might is hardly less plausible than recent media headlines suggesting that the foreskin causes cancer of the prostate, and concluding (quite illogically) that circumcision of baby boys is, therefore, a desirable measure of public and individual health. There are three issues here: (1) whether “lack of circumcision” does significantly increase the risk of cancer of the prostate; (2) the hyperbolic newspaper reporting of one small study which claimed that perhaps it did, even if only a little bit; and (3) even if this claim were true, whether circumcision of infants was a logical and ethically acceptable response. <h2>Foreskin and risk of prostate cancer</h2> The claim that the presence of the foreskin increases the risk of prostate cancer, and therefore that all men ought to be circumcised, was first made in the 1940s by a cranky American doctor called Abraham Ravich, who believed that the disease was less common among his Jewish patients than in others. He managed to get a couple of articles published in American medical journals (always so hospitable to anti-foreskin propaganda), and in his old age compiled and self-published a whole book, Preventing VD and Cancer by Circumcision, in which he extolled the Mosaic code as the key to good health and a long life. A series of subsequent studies failed to find any association between lack of circumcision and increased risk of prostate cancer, however, and in its <a href="http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health">2010 policy statement on circumcision</a> the Royal Australasian College of Physicians noted tersely: “This association [between lack of circumcision and prostate cancer] has not been consistent, and more recent reviews have failed to confirm it.” This is a polite way of saying that the claim of a connection is bullshit. Just recently (March 2012) a paper in the American journal Cancer claimed that there was a slight difference in the incidence of cancer of the prostate between uncircumcised men and men who had been circumcised before their first sexual intercourse. The research was a retrospective case-control study of men who self-reported their circumcision status, sexual histories and some other information. There were 1754 men with prostate cancer and 1645 without prostate cancer in the study. Of the first group, 1207 (68.8%) were circumcised; of the second group, 1176 (71.5%) were circumcised – a difference of a mere 2.7%. This absolute difference was then translated by a series of statistical manipulations into a relative risk of 15%. <a href="http://skepticalscalpel.blogspot.com.au/2012/03/overhyped-research-on-prostate-cancer.html">As the Skeptical Scalpel points out</a>, however, the relative risk of developing prostate cancer was not significantly different in circumcised and uncircumcised men until the researchers looked at those who had been circumcised after their first episode of sexual intercourse. The number of men who had been circumcised after their first sexual encounter was only 68 (3.9%) of the men with prostate cancer and 41 (2.5%) of those without. Although the relative risk reduction was 15%, the confidence intervals were too wide (73% to 99%) to have much significance. Most importantly, this is only a relative risk reduction, not an absolute risk reduction, and it thus of no relevance to the question of whether men ought to get themselves circumcised, much less whether boys ought to be circumcised. A further weakness of the study is that it did not control for race or age – important issues, as African American men have double the rate of prostate cancer compared with whites and an overall circumcision incidence of only only 43%, and because the likelihood of prostate cancer rises sharply with increasing age. In addition, the study relied on self-report of circumcision status, which is wildly unreliable. It is, in short, a clinically unimportant finding based on self-report. The real questions are how such a poorly designed study got through peer-review and then published, and why it has been hyped so irresponsibly by the media. <a href="http://skepticalscalpel.blogspot.com.au/2012/03/overhyped-research-on-prostate-cancer.html" rel="noopener" target="_blank">See further discussion at Skeptical Scalpel</a> <a href="http://www.circumstitions.com/cancer-pros.html" rel="noopener" target="_blank">As Circumstitions points out</a>, if those members of the study population who were circumcised after their sexual debut had not been merged with those never circumcised, the figures would have no significance at all. The much vaunted 15% reduction in relative risk amounts to a 2.7% reduction in absolute risk. The age-adjusted risk of prostate cancer for Caucasians in the United States is 150 per 100,000 person-years, or 0.0015 per year. The lifetime risk is about 72 times this, 0.108 or 1 in 9.25. Circumcision reduced this risk in only 2.7% of those with prostate cancer in this study, with 71.5% of controls circumcised. If this is adjusted up to 100% circumcision the reduced risk would affect a mere 3.77% of those with prostate cancer. The overall Absolute Risk Reduction would then be 0.108x0.0377 or 0.0040716. This means that TWO HUNDRED AND FORTY-FIVE babies would need to be circumcised to prevent one (old) man from getting prostate cancer. This would be quite absurd for many reasons, not least because of the cost. <h2>The rabbi was wrong: Media hype misrepresents findings of prostate-circumcision study</h2> It is truly amazing how any study that appears to show the foreskin in a bad light gets worldwide publicity, when journal articles critical of circumcision and statements against the practice from responsible medical authorities are ignored. Of course the media seized on this study, with the usual wild headlines: “Circumcision Cuts Prostate Cancer Risk” (Scientific American); “Circumcision reduces prostate cancer risk” (UPI); “Circumcision Linked to Lower Risk for Prostate Cancer, Study Finds” (Yahoo News); and best of all, “Males of the Mideast Rejoice: Circumcision Reduces Prostate Cancer” (Asian News International) or, even more ridiculous, "The rabbi was right: Prostate cancer prevention from birth" (Bradenton Herald). It will be observed that all these news reports are from circumcising cultures, naturally pleased that science appears to be confirming their traditional wisdom. The last headline is particularly misleading, because it was not the rabbis who introduced circumcision to the Jewish religion, but the priests during the period of Temple Judaism, around 600 BC. What the rabbis introduced in the early Christian period was a new phase to the rite – metsitsah, in which the mohel (ritual circumciser) was required to suck the blood from the wounded penis after cutting off the foreskin. Needless to say, it would be hard to imagine anything more unhygienic, or more likely to spread disease, and there can be little doubt that devotion to metsitsah has been responsible for the deaths of countless Jewish babies over the centuries. The practice was largely abolished by Jewish reformers in the late nineteenth century, though it survives among some ultra-orthodox communities – notably in New York, where there have been <a href="http://www.circumstitions.com/news/news44.html#metzitzah12">several recent cases</a> of babies dying from herpes infection after being circumcised by orthodox mohels. What is even more bizarre about the scaremongering media coverage is that this latest study did not suggest even circumcision as a means of further lowering the risk (already quite small) of prostate cancer, but was most interested in a related question: the contribution of infection with human papilloma virus (HPV) to the risk of developing prostate cancer. There is a widely held belief that circumcised men are less likely to be infected with HPV, a view based largely on studies in Africa, but not confirmed by studies in the developed world; <a href="https://www.circinfo.org/news_2011.html#busk">the most recent study, by Van Buskirk et al</a> , found no difference. The whole sorry exercise seems to be just another chapter in the long history of the <a href="http://www.historyofcircumcision.net/">demonization of normal male anatomy</a>. <a href="http://xkcd.com/882/" rel="noopener" target="_blank">This cartoon</a> is a perfect representation of how the media reports circumcision studies <h2>Prostate cancer issue not relevant to debate about infant circumcision</h2> But even if the results of this study were valid, and circumcision did reduce the risk of a male developing prostate cancer by 15%, it would not be an argument for prophylactic circumcision of infants or boys. There are three main reasons for its irrelevance. (1) Although cancer of the prostate is one of the most common cancers affecting males, it still affects quite small numbers, and quite unpredictably; the risk factors appear to be age, race (or other genetic factors), smoking and exposure to HPV (through sexual intercourse with an infected partner.) The small numbers and risk reduction, as <a href="http://www.circumstitions.com/cancer-pros.html">Circumstitions points out</a>, are not sufficient to warrant general circumcision as a precaution against such a remote threat. (2) Cancers increase in frequency as people get older; an ageing population automatically means more cancers, irrespective of other factors, as the replication functions of bodily cells break down as we get older and wear out. It would be both illogical, unethical and highly cost-ineffective to circumcise over 200 babies now in order to prevent prostate cancer in one of them in 60 or 70 years time. Who knows what additional curative and preventive options we may have at our disposal by then? (3) Since HPV is acquired sexually, we can say that to some extent prostate cancer is a sexually transmitted infection. But since infants and children are not sexually active, they are at zero risk of STIs, protection against which does not become an issue until boys grow up and become sexually active. Even then, it is only those who engage in high risk behaviour who are at risk of infection. The only policy consistent with evidence-based medicine and medical ethics, therefore, is to leave boys’ foreskins alone until they are mature enough to understand the medical issues and possible effects of circumcision, advise them of the risks of unsafe sex and other high risk behaviour, alert them to the protective options, and allow them to make up their own minds about how they wish to manage them. The automatic assumption that circumcision means circumcision of (non-consenting) infants or young boys is based on the tacit understanding that very few adult males, or boys who have discovered the delights and pleasures of their foreskin, would volunteer to have it cut off. But if the average adult would refuse circumcision, it would clearly be a violation of bioethical principles to coerce a child, merely because he was too young to put up effective resistance. Men are perfectly entitled to prefer to run a slightly greater risk of prostate cancer in old age in return for more fun and a better sex life in youth; some would prefer the other option, but the essential point is that circumcision is the individual male’s right to choose. It is not a decision to be made by others, no matter how well-meaning: his penis, his decision. <a href="https://www.circinfo.org/Foreskin_owner_decide.html" rel="noopener" target="_blank">See further discussion on “Let the foreskin owner decide” page</a> <h2>Plenty of sex, better nutrition and more exercise mean a healthier prostate?</h2> Other studies suggest that more sex, better nutrition and adequate physical exercise will reduce risk of prostate cancer. <h3>1. Plenty of sex</h3> Douglas Fox, Masturbating may protect against prostate cancer, New Scientist, 16 July 2003 It will make you go blind. It will make your palms grow hairy. Such myths about masturbation are largely a thing of the past. But the latest research has even better news for young men: frequent self-pleasuring could protect against the most common kind of cancer. A team in Australia led by Graham Giles of The Cancer Council Victoria in Melbourne asked 1079 men with prostate cancer to fill in a questionnaire detailing their sexual habits, and compared their responses with those of 1259 healthy men of the same age. The team concludes that the more men ejaculate between the ages of 20 and 50, the less likely they are to develop prostate cancer. The protective effect is greatest while men are in their twenties: those who had ejaculated more than five times per week in their twenties, for instance, were one-third less likely to develop aggressive prostate cancer later in life. The results contradict those of previous studies, which have suggested that having had many sexual partners, or a high frequency of sexual activity, increases the risk of prostate cancer by up to 40 per cent. The key difference is that these earlier studies defined sexual activity as sexual intercourse, whereas the latest study focused on the number of ejaculations, whether or not intercourse was involved. The team speculates that infections caused by intercourse may increase the risk of prostate cancer. “Had we been able to remove ejaculations associated with sexual intercourse, there should have been an even stronger protective effect of other ejaculations,” they suggest. “Men have many ways of using their prostate which do not involve women or other men,” Giles adds. Macho exaggeration Giles accepts the possibility that the men who completed the questionnaires could have lied about their habits. But he doubts this skewed the results, since questions about masturbation are unlikely to evoke the same macho exaggeration as questions about, say, number of sexual partners. But why should ejaculating more often cut the risk of prostate cancer? The team speculates that ejaculation prevents carcinogens building up in the gland. The prostate, together with the seminal vesicles, secretes the bulk of the fluid in semen, which is rich in substances such as potassium, zinc, fructose and citric acid. Generating the fluid involves concentrating these components from the bloodstream up to 600-fold - and this could be where the trouble starts. Studies in dogs show that carcinogens such as 3-methylcholanthrene, found in cigarette smoke, are also concentrated in prostate fluid. “It’s a prostatic stagnation hypothesis,” says Giles. “The more you flush the ducts out, the less there is to hang around and damage the cells that line them.” Sexual repertoire His findings suggest an intriguing parallel between prostate cancer and breast cancer, as recent studies indicate that lactating reduces a woman’s risk of breast cancer, perhaps because this also flushes out carcinogens. Alternatively, ejaculation might induce prostate cells to mature fully, making them less susceptible to carcinogens. “All these mechanisms are totally speculative,” cautions breast cancer expert Loren Lipworth of the International Epidemiology Institute in Rockville, Maryland. But if the finding is confirmed, future health advice from doctors may no longer be restricted to diet and exercise. “Masturbation is part of people’s sexual repertoire,” says Anthony Smith, deputy director of the Australian Research Centre in Sex, Health and Society at La Trobe University in Melbourne. “If these findings hold up, then it’s perfectly reasonable that men should be encouraged to masturbate,” he says. Source: Douglas Fox, <a href="http://www.newscientist.com/article/dn3942-masturbating-may-protect-against-prostate-cancer.html">Masturbating may protect against prostate cancer</a>, New Scientist, 16 July 2003 ABSTRACT OF THE ORIGINAL ARTICLE G.G. Giles et al, <a href="http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410X.2003.04319.x">Sexual factors and prostate cancer</a>, BJU International 92 (3), August 2003, 211-216 OBJECTIVE To assess whether prostate cancer might be related to hormone levels and, by inference, to differences in sexual activity. PATIENTS, SUBJECTS AND METHODS In a case-control study of men with prostate cancer aged < 70 years at diagnosis and age-matched control subjects, information was collected on two aspects of sexual activity; the number of sexual partners and the frequency of total ejaculations during the third to fifth decades of life. RESULTS There was no association of prostate cancer with the number of sexual partners or with the maximum number of ejaculations in 24 h. There was a negative trend (P < 0.01) for the association between risk and number of ejaculations in the third decade, independent of those in the fourth or fifth. Men who averaged five or more ejaculations weekly in their 20s had an odds ratio (95% confidence interval) of 0.66 (0.49–0.87) compared with those who ejaculated less often. CONCLUSIONS The null association with the number of sexual partners argues against infection as a cause of prostate cancer in this population. Ejaculatory frequency, especially in early adult life, is negatively associated with the risk of prostate cancer, and thus the molecular biological consequences of suppressed or diminished ejaculation are worthy of further research. <h3>2. Better nutrition and more exercise reduce cancer risk</h3> Hot on the heels of the Cancer report comes a study in the Medical Journal of Australia which found that better nutrition and more exercise can significantly reduce the risk of many cancers, including prostate cancer. The abstract reads as follows: Objective: To estimate the number of cancers to be diagnosed in 2025 that could be prevented solely due to changes in diet and physical activity. Design and setting: We used an Australian population-based cancer database to estimate the total number of cancers to be diagnosed in 2025, by applying published age- and sex-specific population projections to current cancer incidence rates, and multiplying the projected numbers of cancers by estimates of population-attributable fractions. Main outcome measures: Projected number of preventable cancers that would be diagnosed in 2025. Results: Our projections suggest that there will be about 170 000 Australians diagnosed with cancer in 2025. This represents an increase of about 60% on the 2007 incidence. Almost 43 000 of these cancers (low estimate, 42 295; middle, 42 657; high, 43 990) could be prevented through improvements to diet and physical activity levels, including through their impact on obesity. It is likely that this is an underestimate of the true figure. The most preventable cancer types in 2025 were estimated to be bowel cancer and female breast cancer (10 049 and 7273 preventable cases, respectively). Conclusions: About 25% of cancers, or about 43 000 cancers in 2025, can potentially be prevented through improvements in diet and physical activity. It is imperative that governments, clinicians and researchers act now if we are to reduce the significant future human and financial burden of cancer. There is wide variation in the preventability of different kinds of cancer by diet and exercise, with cancer of the oesophagus at the top (72%) and cancer of the prostate at the bottom (16%). But a 16% absolute reduction in the number of prostate cancer cases is a far more impressive result than 15% relative risk reduction - and achieved by far more agreeable means. Peter D. Baade, Xingqiong Meng, Craig Sinclair and Philippa Youl, <a href="https://www.mja.com.au/journal/2012/196/5/estimating-future-burden-cancers-preventable-better-diet-and-physical-activity">Estimating the future burden of cancers preventable by better diet and physical activity in Australia</a>, Medical Journal of Australia 196, 19 March 2012 <h2>Further criticism of "lack of circumcision-prostate cancer" link</h2> <a href="https://www.youtube.com/watch?v=PZ602vTzs0c" rel="noopener" target="_blank">David Smith from Norm-UK criticises latest prostate cancer speculations</a> (Youtube video) </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Cancer of the prostate and the foreskin darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Cancer occurs when the mechanism controlling the replication of cells goes haywire and new cells proliferate beyond replacement level. The main causes of such malfunction are mutations to the DNA of the cell, usually caused by smoke, industrial chemicals or radioactive materials, and the effects of ageing, which increases the rate of copying errors as cells divide. The longer we live the more likely we are to get one form of cancer or another. Men are far more likely to get cancer of the prostate, lung, colon, bladder or exposed skin than of the penis, which is about the last place in the body where it is found. As the graphs below show, cancer of the cervix and vulva in females, as well as cancer in the male breast, is far more common than cancer of the penis - yet nobody proposes that we routinely excise female genital tissue or male breast tissue as a precaution against the risk of cancer in later life. <h2>A very rare disease: Lifetime risk of cancer of the penis</h2> The following is an excerpt from Professor Robert Van Howe’e lecture, “Math is Your Friend: A Consumer’s Primer to Understanding Epidemiology” One of the statistics that is bantered about is the lifetime risk of acquiring certain illnesses. This cannot be calculated from prevalence because illnesses can come and go, afflict different people for different lengths of time, result in early death, or present at different ages. We can however calculate lifetime risk from incidence estimates. Since incidence estimates are age-adjusted, the lifetime risk is approximately the yearly risk multiplied by the average lifespan, which is 72 years. So for penile cancer in the United States, the lifetime risk would be 0.0000058 X 72 or 0.0004176 (The precise formula gives an answer of 0.000417512). Lifetime risk is usually not expressed in this fashion because no one wants to count the number of zeroes following the decimal point, but as the inverse (1/x) of this number. In this case, the inverse is expressed as a one in 2395 lifetime risk. To put this in perspective the lifetime risk of breast cancer in women is one in eight. By comparison, penile cancer is a rare illness. Number Needed to Treat This can be taken a step further. The 2012 American Academy of Pediatrics Task Force report noted that you needed to circumcise 909 males for that one case of penile cancer. This estimate came from a discussion section of an article citing a 1980 opinion piece that assumed that it was impossible for circumcised men to get penile cancer.4 We now know that is nowhere near the truth. They also noted that a review article put this number at 322,000.5 The review article confused incidence with lifetime risk and failed to multiply it by 72 as discussed above. Neither number is correct. Interestingly, the Task Force had all the numbers at its disposal to make a rough estimate of the number needed to treat but failed to recognize this opportunity or act on it. Let's do the math they were unwilling to do. The lifetime risk, as we noted above, is 0.0004176. The Task Force report noted that the relative risk reduction for penile cancer by circumcision was between 1.5 and 2.3. If you take the lifetime risk of penile cancer and reduce it by a factor of 2.3 you get 0.0001815, which would be the expected lifetime risk for penile cancer in circumcised men. The absolute risk reduction would be the difference between the two rates: 0.0004176 minus 0.0001815 or 0.0002360. The number needed to treat is the inverse (1/x) of the absolute risk reduction or 4237. This means that 4237 infant males would need to be circumcised in order to prevent one case of penile cancer, which usually strikes on average at 80 years of age. If, however, the relative risk reduction is 1.5, the number needed to treat is 7184. Cost Effectiveness So how much does it cost to prevent one case of penile cancer using infant circumcision? If it takes 7184 circumcisions to prevent one case of penile cancer and each circumcision costs an average of $285 paid at the time of the procedure,6 the cost would be the product of these two numbers or $2,047,440. But the story does not end there. The money for the circumcision was spent at the time the male was circumcised, but penile cancer usually does not develop until about 80 years of age. So, for 80 years the opportunity of having that cash spent at the time of the procedure has been lost. These opportunity costs add up over 80 years. For example, if that money were put out at 3% interest for 80 years, the opportunity costs would be $21,786,584. If the money were to earn 5% interest for 80 years, the costs of preventing one case of penile cancer would be $101,474,076. This may explain why the American Academy of Pediatrics Task Force elected not to do the calculations. Source: Dr Robert Van Howe. <a href="https://www.academia.edu/13843697/Math_is_Your_Friend_A_Consumer_s_Primer_to_Understanding_Epidemiology" rel="noopener" target="_blank">Math is Your Friend: A Consumer’s Primer to Understanding Epidemiology</a> <h3>Cancer Council of Australia rejects circumcision</h3> The Cancer Council of Australia has come out strongly against recent (2012) claims that mass circumcision of boys is necessary as a preventive of cancer of the penis and prostate. In a statement released on 21 June, the Council warned that cancer of the penis was a rare disease in Australia, and that the evidence of circumcision having a protective effect was not sufficient to justify the operation. As to prostate cancer, the main risk factor was nothing more than getting old - a natural process that circumcision could do nothing to arrest. The statement concluded: “Taking into account these issues, the relatively lower burden of potentially preventable disease in Australia, and the complex cultural, ethical and legal issues surrounding the practice of circumcision, Cancer Council Australia does not recommend circumcision as a routine cancer-preventive procedure at this time.” Source: Cancer Council of Australia, <a href="http://www.cancer.org.au/news/news-articles/neonatal-male-circumcision-and-cancer.html" rel="noopener" target="_blank">Neonatal male circumcision and cancer</a> Further comment <a href="http://intactivistsofaustralasia.wordpress.com/">at Intactivists of Australia</a> <h2>Incidence and prevalence of cancer of the penis</h2> Cancer incidence in Australia by age cohort, showing that cancer is a disease of ageing and that male breast cancer is more common than cancer of the penis (cases per 100,000 per age-cohort) <img alt="" class="image-center" height="462" src="https://www.circinfo.org/images/Cancer1.png" style="float: left;" width="734"/> <img alt="" class="image-center" height="396" src="https://www.circinfo.org/images/Cancer2.png" width="663"/> According to the American cancer society (Cancer Facts and Figures 1996), the leading sites of cancer in males are: prostate 317,100 cases lung 98,900 colon and rectum 67,600 bladder 38,300 lymphoma 33,900; melanoma 21,100; oral 20,100; kidney 18,500; leukemia 15,300; stomach 14,000; pancreas 12,400; liver 10,800. Having listed prostate and testis separately, it listed “other and unspecified reproductive”. The projected number of cases of “other and unspecified reproductive, male” cancers for 1996 was 1,200. Even if we assume that these are all penile cancer cases – not all of which would be sited on or near the foreskin – that is a tiny fraction of all cancers. With a total of 649,100 cases of cancer in males, “other and unspecified reproductive” cancers in males amounted to 0.18% of malignancies. Having listed prostate and testis separately, it listed “other and unspecified reproductive”. The projected number of cases of “other and unspecified reproductive, male” cancers for 1996 was 1,200. Even if we assume that these are all penile cancer cases – not all of which would be sited on or near the foreskin – that is a tiny fraction of all cancers. With a total of 649,100 cases of cancer in males, “other and unspecified reproductive” cancers in males amounted to 0.18% of malignancies. The leading sites of cancers causing death are: lung 94,400 prostate 41,400 colon and rectum 27,400 pancreas 13,600 lymphoma 13,600 leukemia 11,600 oesophagus 8,500 liver 8,400 stomach 8,300 bladder 7,800 kidney 7,300 brain 7,200 Projected deaths from “other and unspecified reproductive” cancers in males were 220. That’s 0.093% of the total cancer deaths. Some of the rare cancers, apart from “other and unspecified reproductive, male” that men are more likely to get and perhaps die from, include: lip, tongue, mouth, pharynx, oesophagus, small intestine, larynx, bone, connective tissue, Hodgkin's disease, testis, and thyroid. Male breast cancer amounted to 1,400 cases, with 260 deaths. This means that American men are more likely to suffer from and die of breast cancer than penile cancer. Why does nobody suggest neonatal amputation of a male’s useless breasts to protect him against this malignancy? <h3> <a id="austfig" name="austfig"></a>Australian figures</h3> The figures are similar for Australia. The New South Wales Cancer Council reports that in 2005 four sites accounted for 63% of all new cancers in males. These were cancers of the prostate (31%), bowel (13%), melanoma (10%) and lung cancer (9%). The most common causes of male cancer deaths were lung (21%), prostate (14%) and bowel (13%). The word circumcision does not appear on the website of the NSW Cancer Council. <a href="http://www.nswcc.org.au/editorial.asp?pageid=9" rel="noopener" target="_blank">Go to NSW Cancer Council</a> Phimosis and cancer There is some evidence that severe phimosis accompanied by poor hygiene increases the risk of cancer of the penis. The correct answer here is not circumcision, but treatment to correct the phimosis and regular washing. Just why severe phimosis increases the risk of penile cancer is unclear, but it is possibly a consequence of the exposure of the skin to unwashed seminal secretions. Despite the persistence of such myths, the notion that sub-preputial moisture (“smegma”) is carcinogenic has been thoroughly debunked, but it is possible that chemicals in the seminal fluid could be carcinogenic over the long term. These have to be fairly lethal in order to protect the sperm from hostile antibodies in the female genital tract, which would otherwise kill such invaders before they could do their job. This might also explain why cancer of the prostate (where the seminal fluid tends to accumulate if not discharged regularly) is (relatively) so common. <h3>Could circumcision cause cancer?</h3> Some cases from Saudi Arabia, where nearly all boys are circumcised in accordance with Islamic custom, suggest that circumcision could increase the risk of cancer of the penis. Seyam RM, Bissada NK, Mokhtar AA, Mourad WA, Aslam M, Elkum N, Kattan SA, Hanash KA.* Outcome of penile cancer in circumcised men. J Urol. 2006 Feb;175(2):557-61 PURPOSE: We previously reported on a group of patients with post-circumcision carcinoma of the penis. We now study the long-term outcome of these patients. MATERIALS AND METHODS: We retrospectively reviewed the available charts of 22 patients presenting between October 1979 and May 2000. RESULTS: Of 22 patients 18 underwent ritual circumcision with extensive scar development. Median age at diagnosis was 62.4 years. The penile lesion was dorsal and proximally located in 15 patients. Median delay before diagnosis was 12 months. Clinically 14 patients had stage T1-T2 disease, with 13 having no lymph node involvement and none with distant metastasis, 8 patients had stage T3-T4 disease. A total of 15 patients were treated surgically with total penectomy (10) or conservative local excision (5), inguinal lymph node dissection (9) and subsequent penile reconstruction (3). Pathological staging in 15 patients revealed 10 patients with stage T1 and in 8 patients with lymph node dissection none had nodal metastasis. Histopathological classification was 20 squamous cell carcinoma, 1 sarcoma and 1 verrucous carcinoma. Six patients refused surgery and 1 was referred for palliation. Median followup was 14.5 months and median survival was 14.5 months. The 3-year survival was 42% for stage T1-T2 and 13% for T3-T4 (p = 0.0052). Median survival for the surgical group was 34 months whereas for nonsurgical group was 3 months (p = 0.0016). Recurrence-free survival in the surgical group was 50%. CONCLUSIONS: Penile carcinoma in circumcised men is a distinct disease commonly following nonclassic vigorous circumcision. Delayed diagnosis and deferring surgical treatment are associated with increased mortality. * Department of Urology, King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia. <a class="__cf_email__" data-cfemail="a5d7c8d6c0dcc4c8e5cdcad1c8c4ccc98bc6cac8" href="/cdn-cgi/l/email-protection">[email protected]</a> J Urol. 2006 Feb;175(2):557-61 <a href="http://www.cirp.org/library/disease/cancer/" rel="noopener" target="_blank">Read more about cancer of the penis at CIRP.</a> <a href="http://www.circumstitions.com/Cancer.html" rel="noopener" target="_blank">Read more about cancer of the penis at Circumstitions.</a> <a href="https://knol.google.com/k/george/the-foreskin-causes-cancer-myth/2y9nanfagw8nr/20?domain=knol.google.com&locale=en#view" rel="noopener" target="_blank">More information from Google Knowledge</a> <h2> <a id="risk" name="risk"></a>Risk factors for cancer of penis do not include foreskin</h2> The chapter on cancer of the penis in a new edition of an authoritative Oxford textbook on cancers points out that cancer of the penis is an extremely rare disease (in fact, less common than cancer of the male breast) and that the risk factors are preventable conditions, including pathological phimosis and infection with human papilloma virus. The foreskin is not a risk factor for cancer of the penis, and circumcision does not infallibly prevent it. The summary of the chapter follows: Penile cancers are rare primary malignancies located on the glans, foreskin, or shaft of the penis, excluding the urethra. The vast majority of penile cancers are epithelial tumors representing histological subtypes of squamous cell carcinoma (SCC). Most penile SCCs are believed to develop through preinvasive lesions known as penile intraepithelial neoplasia and penile carcinoma in situ. Penile cancers account for 0.1%–0.3% of all incident cancers (excluding non-melanoma skin cancers) in the United States and other developed countries and up to 1% of all cancers in some countries in sub-Saharan Africa. Annual incidence rates per 100,000 men (world standardized) are typically between 0.3 and 1.0 in developed countries, being 0.5 in the United States. During 2002– 2011, SEER data showed rather stable penile cancer rates with no statistically significant changes in incidence or mortality. Being rare in men younger than 40 years, penile cancers are typically diagnosed among men above age 60. The 5-year relative survival rate after penile cancer was 67% for all stages combined in US patients recorded in SEER registries during 2004–2010, with foreskin cancers having a more favorable prognosis than cancers at other penile sites. The two most important risk factors for penile cancer are pathological phimosis and infection with high-risk types of human papillomaviruses (HPV), which are both preventable conditions. Non-surgical strategies to reduce the frequency of pathological phimosis need consideration, particularly because rates of newborn circumcision are declining in the United States and elsewhere. Increased awareness among doctors and parents about the importance of non-interference with the physiological foreskin separation process in young boys, and the promotion of safe-sex practices, possibly combined with preadolescent gender-neutral HPV vaccination programs, will likely reduce the frequencies of pathological phimosis and sexually acquired HPV infections and, eventually, reduce the burden of penile cancer at the population level. Source: Frisch M. 2018. Penile Cancer. In: Thun M J, Linet M S, Cerhan J S, Schottenfeld D (Eds.), Cancer Epidemiology and Prevention (4th ed., pp. 1029-1038). Oxford University Press, New York. <a href="https://www.researchgate.net/publication/320958631_Penile_Cancer" rel="noopener" target="_blank">Full text available here</a> <h2> <a id="smegma" name="smegma"></a>Smegma is not carcinogenic</h2> Despite the importance of avoiding smegma so frequently stressed by enthusiasts for routine circumcision, there is no evidence at all that smegma is harmful. Why would it be? It's just a natural secretion like saliva, found in the genitals of both males and females. <a href="http://www.cirp.org/library/disease/cancer/vanhowe2006/">The carcinogenicity of smegma: Debunking a myth</a> RS Van Howe,* FM Hodges‡ *Department of Pediatrics, Michigan State University School of Human Medicine, Marquette, MI and ‡Berkeley, CA, USA, in Journal of the European Academy of Dermatology and Venereology, Vol. 20, 2006, pp. 1046-1054 Abstract Background: Smegma is widely believed to cause penile, cervical and prostate cancer. This nearly ubiquitous myth continues to permeate the medical literature despite a lack of valid supportive evidence. Methods: A historical perspective of medical ideas pertaining to smegma is provided, and the original studies in both animals and humans are reanalysed using the appropriate statistical methods. Results: Evidence supporting the role of smegma as a carcinogen is found wanting. Conclusions: Assertions that smegma is carcinogenic cannot be justified on scientific grounds. Extract from the conclusion The evidence does not support the theory that smegma is a cause of genital cancer. The smegma theory of disease was best stated by Boczko and Freed: "Smegma, a sterol, produced by Tyson’s glands in the epithelium of the retroglandular sulcus, has been implicated as the causative agent. It may be converted to a carcinogen by the action of the Mycobacterium smegmatis." [69] From the medical literature we have found that smegma is not a sterol, that there are no Tyson’s glands, that smegma is not converted to a carcinogen by M. smegmatis, and that M. smegmatis is not part of the normal genital flora. The myth is sustained only by its popularity among circumcision advocates. Some have extrapolated the smegma theory by hypothesizing that men with inadequate circumcisions may be at risk for cancer because smegma can accumulate under any foreskin remnants. [70] In similar fashion, Abraham Ravish expanded the smegma theory to indict smegma as the cause of prostate cancer by travelling upstream through the urethra to invade the prostate gland. [71] Davis-Daneshfar and Trueb speculated that chronic infection with M. smegmatis is the cause of plasma cell (Zoon’s) balanitis, [72] but Yoganathan et al. could not isolate the organism in any of their cases. [73] Some have shown an unwillingness to abandon the smegma theory. When it was postulated that sperm proteins caused cervical cancer, it was the smegma mixing with the sperm proteins that were to blame. [74] When diaphragm use was found to decrease cervical cancer, it was postulated that it provided a barrier to contact with smegma. [75] When it was clear that cervical cancer resulted from a viral infection, some still postulated that smegma was a necessary part for the viral exposure to be carcinogenic. [45] Those promoting the ‘cocoon’ theory prefer to think of smegma as a cofactor in the development of penile cancer. There are two reasons to dismiss this speculation. First, there is no scientific evidence to support the assertion. Second, it is analogous to declaring saliva a cofactor in the development of lip cancer in those who chew tobacco. Both saliva and smegma are bodily fluids that serve a function and, like any other bodily fluid, are present in organs than can develop a malignancy. The purpose of the scientific method is to distinguish between wishful thinking, strongly held pinion, and provable fact. The smegma theory of disease, which began as wishful thinking on the part of circumcision zealots such as Abraham Wolbarst and Abraham Ravich, has evolved into irrefutable dogma, but as modern physicians, we need to recognize that, until proved otherwise, smegma is harmless. References 69. Boczko S, Freed S. Penile carcinoma in circumcised males. N Y State J Med 1979; 79: 1903–1904. 70. Culp D. Penile cancer. J Iowa Med Soc 1973; 63: 201–202. 71. Ravich A, Ravich RA. Prophylaxis of cancer of the prostate, penis and cervix by circumcision. N Y J Med 1951; 51: 1519– 1520. 72. Davis-Daneshfar A, Trueb RM. Bowen’s disease of the glans penis (erythroplasia of Queyrat) in plasma cell balanitis. Cutis 2000; 65: 395–398. 73. Yoganathan S, Bohl TG, Mason G. Plasma cell balanitis and vulvitis (of Zoon). A study of 10 cases. J Reprod Med 1994; 39: 939–944. 74. Sandler B. Sperm basic proteins in cervical carcinogenesis. Lancet 1978; 2: 208–209. 75. Sandler B. Contraceptives and cervical carcinoma. Br Med J 1969; 1: 356–357. <a href="http://www.cirp.org/library/disease/cancer/vanhowe2006/">Full text available from CIRP.</a> Why mice don't live in the foreskins of horses The article by Boczko and Freed relied heavily on an eccentric experiment from 1947 in which A. Plaut and A. C. Kohn-Speyer tried to induce cancer in mice by doses of smegma harvested from horses. Despite persistent applications, it appears that they were successful in producing cancerous lesions in only about 60 of 400 victims, and I say “appears” because the presentation of their results is so confusing that it is very difficult to work out just what the results were. They also reported that up to 500 days the smegma-treated mice actually fared better than those who missed out: a survival rate of 47% and 30% respectively. Had they stopped the experiment at that point they would have been forced to conclude that horse smegma boosted mouse health. The most one can say about this preposterous exercise is that it explains one of the great puzzles of zoology: why mice don't live inside equine prepuces. Plaut A, Kohn-Speyer AC. Carcinogenic action of smegma. Science 1947; 105: 391–392. <h2> <a id="circprost" name="circprost"></a>Circumcision may increase risk of prostate problems</h2> There is no evidence that the presence of the foreskin increases the risk of cancer of the prostate, but recent papers by Dr G.G. Giles et al show that circumcised men experience more prostate problems, and that prostate cancer is not related to STDs. Prevalence of urinary symptoms in urban Australian men aged 40-69. McCredie M; Staples M; Johnson W; English DR; Giles GG. Department of Preventive and Social Medicine, Dunedin Medical School, University of Otago, New Zealand. J Epidemiol Biostat 2001;6(2):211-8 BACKGROUND: This study was devised to determine the prevalence of urinary symptoms among men living in the Australian cities of Melbourne, Sydney or Perth, and to identify factors associated with the presence of moderate-to-severe urinary symptoms. METHODS: The study comprised a population-based sample of 1,216 men, aged 40-69 years, whose names were obtained through electoral rolls and who participated as controls in a case-control study of risk factors for prostate cancer. As part of a structured face-to-face interview, the men completed the International Prostate Symptom Score (IPSS). Men with moderate (IPSS = 8-19) or severe (IPSS > or = 20) urinary symptoms were compared with those with mild or no symptoms (IPSS < 8) using unconditional logistic regression. RESULTS: The age-specific prevalence of moderate-to-severe urinary symptoms (IPSS > or = 8) in men aged 40-49, 50-59, 60-69 years was 16%, 23% and 28%, respectively. Compared with men with no or mild urinary symptoms (IPSS < 8), men with moderate-to-severe symptoms were more likely to report not currently living as married [odds ratio (OR) = 1.5; 95% confidence interval (CI) 1.1-2.0] and being circumcised (OR = 1.5; 95% Cl 1.2-2.0). The increased likelihood associated with drinking an average of > 60g per day 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. <h4 class="style1">Comments</h4> There was no media coverage of this paper, but you can be sure that if the study had, on the contrary, shown that being circumcised was associated with reduced prevalence of urinary symptoms, there would have been newspaper headlines, and the circumfanatics would have been crowing about yet another reason to circumcise baby boys. <h4>How significant are these findings?</h4> Urinary symptoms are often an indication of benign prostatic hyperplasia (BPH). Enlargement of the prostate is a common male ailment, often requiring surgery such as transurethral resection of the prostate (TURP) to improve the sufferer's quality of life. In about 80% of cases, TURP results in infertility (because the semen goes into the bladder rather than being ejaculated) and in 5% to 8% of cases, TURP results in impotence. About 400,000 TURPs are performed annually in the US. If being circumcised increases a man's risk of BPH by 50% (as found in the study above), then if 60% of the at risk population in the US have been circumcised, almost 100,000 of the 400,000 TURPs (25 per cent) were the result of circumcision. Quite apart from the loss of function, think what a waste of surgical resources this represents. Statistics derived from: <a href="http://www.usrf.org/questionnaires/AUA_SymptomScore.html">http://www.usrf.org/questionnaires/AUA_SymptomScore.html</a> <a href="http://www.fonendo.com/noticias/9/2001/02/1.shtml">http://www.fonendo.com/noticias/9/2001/02/1.shtml</a> <a href="http://www.dva.gov.au/media/publicat/2001/prostate/index.htm">http://www.dva.gov.au/media/publicat/2001/prostate/index.htm</a> <h3>No link between STDs and prostate cancer</h3> In a separate study Giles et al found that prostate cancer was not associated with sexually transmitted diseases, but that it was associated with a low frequency of ejaculations. Sexual factors and prostate cancer. G.G. Giles, G. Severi, D.R. English, M.R.E. Mccredie, R. Borland, P. Boyle, J.L. Hopper. BJU International, Vol. 92, 2003, 211–216 OBJECTIVE: To assess whether prostate cancer might be related to hormone levels and, by inference, to differences in sexual activity. PATIENTS, SUBJECTS AND METHODS: In a case-control study of men with prostate cancer aged <70 years at diagnosis and age matched control subjects, information was collected on two aspects of sexual activity; the number of sexual partners and the frequency of total ejaculations during the third to fifth decades of life. RESULTS: There was no association of prostate cancer with the number of sexual partners or with the maximum number of ejaculations in 24 h. There was a negative trend ( P < 0.01) for the association between risk and number of ejaculations in the third decade, independent of those in the fourth or fifth. Men who averaged five or more ejaculations weekly in their 20s had an odds ratio (95% confidence interval) of 0.66 (0.49–0.87) compared with those who ejaculated less often. CONCLUSIONS: The null association with the number of sexual partners argues against infection as a cause of prostate cancer in this population. Ejaculatory frequency, especially in early adult life, is negatively associated with the risk of prostate cancer, and thus the molecular biological consequences of suppressed or diminished ejaculation are worthy of further research. In other words, the Victorians could not have been more wrong: the more ejaculations a man has, the lower his risk of prostate cancer, and the healthier he will be. <h3>No scientific evidence that circumcision reduces the incidence of cancer of the prostate</h3> In a brief commentary published in BJU International in 2007, Brian Morris and two friends claimed that the presence of the foreskin greatly increased the risk of cancer of the prostate, and therefore that mandatory circumcision at birth would save billions of dollars in health costs. In a letter published in reply, Robert Van Howe responds to these extravagant claims. SIR, The commentary by Morris et al. [1] builds a model for the impact of circumcision on prostate cancer based on three axioms for which there is little or no support. They begin with the notion that prostate cancer is caused by underlying inflammation or infection (possibly sexually transmitted diseases (STDs)), although a link to a specific pathogen remains elusive. This fairly new idea needs further study before basing treatment models on it, especially considering the lack of a correlation between the incidence of prostate cancer and cancer of the cervix, an increase in prostate cancer mortality among Roman Catholic priests, and being inconsistent with other studies [2]. Second, they postulate that uncircumcised men are at greater risk of STDs based on one study, while ignoring the eleven studies that show either no difference or that circumcised men have an overall greater risk of acquiring an STD. Finally, they postulate that uncircumcised men have a greater risk of prostate cancer based on four studies. Two of these studies are >40 years old and compare the risks of Jews to non-Jews. Prostate cancer incidence varies with race. In the USA, African Americans have nearly twice the risk of Whites, who have twice the risk of Asian Americans [3]. In a study that compared cases of prostate cancer to cases of BPH, circumcised non-Jews had three times the risk of prostate cancer than Jews (Odds ratio (OR) 3.23, 95% CI 1.56–6.69), indicating that Jews, as a racial category, were at lower risk [4]. The other two studies relied on patient report, an unreliable practice, to determine circumcision status.[5,6] The British study failed to consider ethnicity or race, so circumcision status might have been a marker of socioeconomic status [5]. The American study did consider race and found that uncircumcised Blacks had 2.6 times the risk of prostate cancer compared with Blacks circumcised as newborns, while the risk was 1.7 times higher for uncircumcised Whites compared with Whites circumcised as newborns [6]. Their third premise also ignores contrary evidence. In one study, when only non-Jews were considered, uncircumcised men trended towards lower risk of prostate cancer (OR 0.86, 95% CI 0.46–1.58) [7], while in another study no difference was found (OR 0.93, 95% CI 0.55–1.58) [8]. Similarly, no association has been found between PSA levels and circumcision status [9]. If circumcision reduced the risk of prostate cancer, it would be expected that the age-adjusted incidence of prostate cancer would decrease as the circumcision rate increased. In fact, the opposite has been documented [10]. Likewise, if Morris et al. [1] are correct, one would expect the incidence of prostate cancer in Europe to be 36–60% greater than the incidence in the White USA population. For the period 1983–1987, before PSA screening, the age-adjusted incidences of prostate cancer in Denmark, Finland, Iceland, Norway, and Sweden were 48.9, 61.8, 85.0, 71.8, and 81.6 per 100,000, respectively [11]. In 1986 the age-adjusted incidence among USA Whites was 86 per 100,000 [10]. Morris et al. failed to consider race. If Blacks constitute 11% of the USA population and are at twice the risk of prostate cancer, using the racially specific risks the number of cases of prostate cancer by circumcising everyone is 174,997 instead of 167,471. This decreases the estimated cost savings by US$ 125 million. Morris et al. conveniently chose to not estimate the lost opportunity costs of circumcising 562 704 infants. Using a cost of $195 per circumcision and the standard discount rate of 5% over 70 years, the lost opportunity costs are $3.3 billion, which overwhelms the $1.1 billion in estimated prostate cancer costs. The concept of using circumcision to reduce prostate cancer risk has no biological or epidemiological foundation. Even if one is willing to depart from reality and use the most extreme assumptions as put forth by Morris et al., circumcision of infants is not cost-effective. REFERENCES 1. Morris BJ, Waskett J, Bailis SA. Case number and the financial impact of circumcision in reducing prostate cancer. BJU Int 2007; 100: 5–6 2. Giles GG, Severi G, English DR et al. Sexual factors and prostate cancer. BJU Int 2003; 92: 211–6 3. Centers for Disease Control and Prevention. Comparing prostate cancer by race and ethnicity. Available at: http://www.cdc.gov/cancer/prostate/statistics/race.htm. Accessed September 2007. 4. Kaplan GW, O'Connor VJ The incidence of carcinoma of the prostate in Jews and gentiles. JAMA 1966; 196: 123–4. 5. Ewings P, Bowie C. A case-control study of cancer of the prostate in Somerset and east Devon. Br J Cancer 1996; 74: 661–6 6. Ross RK, Shimizu H, Paganini-Hill A, Honda G, Henderson BE. Case-control studies of prostate cancer in blacks and whites in southern California. J Natl Cancer Inst 1987; 78: 869–74 7. Wynder EL, Mabuchi K, Whitmore WF Jr. Epidemiology of cancer of the prostate. Cancer 1971; 28: 344–60 8. Rotkin ID. Studies in the epidemiology of prostatic cancer: expanded sampling. Cancer Treat Rep 1977; 61: 173–80 9. Oliver JC, Oliver RT, Ballard RC. Influence of circumcision and sexual behaviour on PSA levels in patients attending a sexually transmitted disease (STD) clinic. Prostate Cancer Prostatic Dis 2001; 4: 228–31 10. Stanford JL, Stephenson RA, Coyle LM et al. Prostate Cancer Trends 1973–1995, SEER Program, National Cancer Institute. NIH Pub. No. 99-4543. Bethesda, MD; 1999 11. Tretli S, Engeland A, Hadorsen T et al. Prostate cancer – look at Denmark? J Natl Cancer Inst 1996; 88: 128 Robert S. Van Howe, Case number and the financial impact of circumcision in reducing prostate cancer <a href="http://www3.interscience.wiley.com/cgi-bin/fulltext/118508122/HTMLSTART">BJU International, Vol. 100, Issue 5,1193-1194</a>; published online: 3 October 2007 The most laughable thing about Morris and friends’ eccentric conviction that "lack of circumcision" is a significant risk factor for cancer of the prostate is that the principal support he can muster for this notion is an old article in an obscure journal by an American crackpot called Abraham Ravich. His immortal classic, Preventing VD and Cancer by Circumcision (NY: Philosophical Library, 1973), sits on the curiosity shelves of second hand bookshops along with S.I. McMillen MD, None of these Diseases (Westwood NJ, 1963), in which "a physician testifies that health, happiness and even longer life can be yours if you follow the teaching of the Bible", and Robert B. Greenblatt MD, Search the Scriptures: A Physician Examines Medicine in the Bible (Philadelphia, 1963). Both books confine the Bible to the first few books of the Old Testament, and naturally praise circumcision with all the warmth of Peter Charles Remondino himself. It seems that McMillen's text went through many editions and has been widely distributed and read in the United States, which may help to explain certain peculiarities in the medical culture of that country. Further information <a href="https://www.circinfo.org/Foreskin_and_prostate_cancer.html">"Lack of circumcision" not a risk factor for cancer of prostate</a> <a href="http://www.prostate.org.au/articleLive/" rel="noopener" target="_blank">Prostate Cancer Foundation of Australia</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Cancer of the penis and prostate darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Balanitis xerotica obliterans (BXO) is a rare condition in which the foreskin becomes inflamed and hardened and covered with a dry whitish film. In adults the problem can result in progressive tightening of the foreskin, making retraction difficult and painful. The condition is poorly understood and the cause(s) unknown: it could be a viral, bacterial or fungal infection or (more probably) some sort of auto-immune response (where the body’s antibodies attacks its own tissue). The symptoms of BXO are similar to those of several other minor penis inflammations, so that its presence must be confirmed by appropriate specialist advice and finally established by laboratory analysis. Where BXO is confirmed, treatment options are limited: application of of steroid medications may help, but if they do not circumcision will be necessary. BXO is one of the very few conditions where therapeutic circumcision is warranted. The most recent comprehensive survey of the medical literature reached the conclusion that, although rare, BXO may be increasing in frequency; that diagnosis is difficult and often mistaken; and that the principal treatment is circumcision, possibly assisted by appropriate anti-inflammatory medications. The abstract of the paper reads as follows: OBJECTIVE Balanitis xerotica obliterans (BXO) is a chronic inflammatory disease that is considered as male genital variant lichen sclerosis. The incidence varies greatly in different series; diagnosis is mostly clinical but histopathological confirmation is mandatory. Various treatments are described, but there is no consensus that one is the best. MATERIALS AND METHODS A literature review was made of BXO and lichen sclerosis in boys under 18 years of age, between 1995 and 2013, analyzing demographic dates, treatments and outcomes. In addition to that, we reviewed BXO cases treated in our centers in the last 10 years. RESULTS After literature review, only 13 articles matched the inclusion criteria. Analyzing those selected, the global incidence of BXO is nearly 35% among circumcised children. Described symptoms are diverse and the low index of clinical suspicion is highlighted. The main treatment is circumcision, with use of topical and intralesional steroids and immunosuppressive agents. CONCLUSION BXO is a condition more common than we believe and we must be vigilant to find greater number of diagnoses to avoid future complications. The main treatment for BXO is circumcision, but as topical or intralesional treatments are now available with potentially good outcomes, they may be considered as coadjuvants. NOTE: The reference to 35% does not mean that 35% of children experience BXO, but that the condition was confirmed in 35% of the children referred with suspected BXO. The condition itself is quite rare. Soledad Celis et al. Balanitis xerotica obliterans in children and adolescents: A literature review and clinical series. Journal of Pediatric Urology 10 (1) February 2014, 34-39. <a href="http://www.jpurol.com/article/S1477-5131(13)00288-X/fulltext" rel="noopener" target="_blank">Full text available here.</a> <h3>Advice from paediatric surgeon</h3> A paediatric surgeon has sent a letter to Circumcision Information Australia, explaining that while he is strongly opposed to routine, non-therapeutic circumcision of boys, BXO is one of the few pathological conditions where circumcision is usually necessary. Throughout my training I have always been taught that BXO was the only absolute indication for circumcision. I am aware of some reports of steroid use and covered for a colleague in the UK once who used this as the first line of treatment. My experience was that this did not work, and that the disease usually progressed rapidly, making circumcision urgently necessary. I did a quick Google search, and also a search of the Journal of Pediatric Urology, with BXO and steroid as the search strategy. The only article I found that helped much was a review of the literature and case series from UK (St George's, London) Ireland (Dublin) and Chile by Celis et al [referenced above]. The main findings were that the incidence of BXO is increasing. Also that circumcision is the main treatment, with steroids and other treatments having a supporting role. Reading through the paper a couple of things caught my eye: 1. The correlation between clinical suspicion and histological diagnosis is not great — meaning that some clinically suspicious BXO turns out to be other scaring / inflammation. 2. Steroids, if they do work at all, only work with early inflammation affecting the prepuce and no scaring. I get the impression these patients had not had their diagnosis confirmed histologically 3. In a few patients who had trial of “tissue sparing surgery” (preputioplasty presumably) in a cohort from Chile there was a 100% relapse rate, needing to progress to circumcision. 4. Reinforcement of complications of inadequately treated BXO leading to progressive disease and significant morbidity needing complex surgical fixes as a result. My summation is therefore that there may be cases of early clinically suspicious BXO which may respond to steroids, but that this probably is not BXO anyway. For those patients with established scaring the only treatment that is reliably effective is a circumcision and that failure to do this exposes the patient to considerable risk of really significant complications of progressive scaring. The role of steroids, therefore, is as a way of excluding non-BXO in patients with inflammation that has not developed established scaring, to temporise and limit disease progression until a definitive circumcision is carried out by an appropriately trained surgeon under a general anaesthetic with adequate analgesia / penile block etc. I would also use post-operative steroids to further reduce the risk of meatal scarring when the inflammation has already spread onto the glans (which I have also seen), despite adequate circumcision. It would seem that whilst histologically it shares features of lichen sclerosis, the clinical behaviour of BXO is different to the disease seen in females. Sadly, at present, I do not think the strategy of primary treatment of established BXO with topical or intra-lesional drugs can be recommended. In the present state of medical knowledge the only sure cure for BXO is circumcision — though we may hope that medical treatments will eventually be developed. The surgeon adds that he is concerned by the number of Queensland boys who have been subjected to unnecessary Plastibel circumcision in infancy. I find it distressing how many boys are still subjected to the Plastibel circumcision. I see so many incidentally in my clinic (when looking at hernia, undescended testes etc) who have obviously had the Plastibel, with their shaft skin reaching only half way up the penis; and on occasions we get children referred with other complications — including buried penis, meatal stenosis and adherent preputial remnants. In Scotland the National Health Service policy was to provide cultural circumcisions (almost entirely for the Muslim population), performed by paediatric surgeons in hospital under general anaesthetic, on the basis that the state had to respect religious/cultural beliefs and that we had a duty of care to minimise the trauma and suffering experienced by the children who were going to get the operation anyway. I do not agree however with “prophylactic” or essentially cosmetic circumcisions, and I am signed up to the international opinion of paediatric surgeons that there is no place for “routine” neonatal circumcisions in the developed world [Referenced in circinfo.org website]. On the few patients that do have persisting symptoms associated with phimosis I will discuss the alternative of a preputioplasty [a surgical operation on the foreskin that loosens it with minimal loss of tissue]. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Balanitis Xerotica Obliterans (BXO) darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Hands Off My Foreskin! Dr. Martin Winckler on the Care of Baby Boys</h2> by Martin Winckler, M.D. © 2013 <a href="http://droitaucorps.blogspot.fr/2012/06/decalottage-chez-lenfant-conseils-aux.html" rel="noopener" target="_blank">Lire en Français ici</a>. Translated to English by Nicolas Maubert and Danelle Frisbie for DrMomma.org with Dr Winckler’s blessing. Dr. Martin Winckler is a general practitioner and author in France. Read more from him at his website, <a href="http://martinwinckler.com/">MartinWinckler.com.</a> Reposted at Circinfo.org by permission of <a href="http://www.drmomma.org/2013/02/hands-off-my-foreskin-dr-martin.html">Peaceful Parenting</a> (DrMomma.org), to which we extend our thanks. Many young mothers today are very worried because their mother, or their mother-in-law, or their doctor, told them they must “clean” the glans (head) of the penis of their baby boy, and that to do so, you must retract (i.e. roll back) the foreskin like a turtleneck. In reality, however, this should not be done. The practice of retraction only causes problems and has no benefits. What follows is an article interview printed in the L’Arbre à bébé Association's November 2005 issue. For this interview I answered some questions on the delicate topic of proper penile care and retraction that I am now sharing here with you. Question One: What is your position regarding foreskin retraction, as a physician and as a parent? Do you retract your own patients? Do you retract your own sons for 'cleaning?' Answer I have never retracted the foreskin of a boy. Not any one of my patients, nor any of my five sons. (I believe if I asked them what they think of foreskin retraction they would look at me like something was wrong with me to have such strange ideas!) Very early in my career, in the early 1980s, while reading the work of pediatrician Aldo Naouri, I had the notion that the practice of retraction was not only unnecessary, but aggressive for everyone -- starting with those most concerned (the boys), but also for their parents. The act itself is aggressive because once you touch a little boy’s penis, an erection is induced. Not all mothers [or fathers] are going to be comfortable with this, and we understand why. Boys will often smile or laugh that it tickles and very quickly we find that parents prefer to leave that area alone to care for itself. Question Two: What do you think of the arguments commonly used by proponents of retraction (that retraction will prevent adhesions, phimosis)? Answer Phimosis is the condition in which the orifice of the foreskin is too tight to allow the glans to leave when the boy is erect. So it can not interfere with boys until the age at which they are likely to have intercourse. However, most studies that have been done on the subject show that any amount of retraction, 'just a little' or a lot, has no medical function, neither for hygienic purposes, nor to prevent phimosis, which is an uncommon condition to begin with. It used to be said that retraction was necessary to fight against adhesions and to 'clean up' anything under the prepuce. However, preputial secretions are as normal as vulvar secretions in the little girls. There is nothing wrong with them whatsoever. Never have we suggested that we 'clean' the vulva of our daughters with a cotton swab, yet I have seen mothers try to pass a cotton swab under the foreskin of their son because a doctor told them to do so! Quite simply, the foreskin is self-cleaning. The orifice of the foreskin is tight at birth on purpose to prevent dirt (bacteria, viruses, etc.) from creeping into it. Retraction (a dilating force) is then entirely unnatural. And it hurts! Retraction causes tears and can cause paraphimosis (having the foreskin stuck in a retracted position behind a swollen glans) which itself is an emergency. This induced paraphimosis is actually much more common than true phimosis. A common scenario: A mom wanted to retract a boy (usually in the bath). The manipulation resulted in a retraction after erection. Suddenly, the foreskin 'turtlenecks' (squeezes) the glans, which then swells and turns purple. The child yells. And in a warm bath, it gets worse. [Vasocongestion takes place, leading to more blood flow, a throbbing erection, and tighter constriction.] In short, parents call the doctor and then one of two things happen. Either the doctor panics and sends the child and his parents to the emergency room, or the doctor understands what has just happened solves it very simply: <ol> <li>Do not pull the foreskin forward after retraction and paraphimosis (it does not work).</li> <li>You must first empty the warm water bath. Then pour somewhat cooler water (but not iced/cold water) on the penis. The cooler water deflates the penile engorgement.</li> <li>Then gently squeeze the swollen glans (head) of the penis. As the penis deflates, the foreskin will start to roll back down over the glans by itself.</li> </ol> I saw dozens of situations like this one early in my career. It was always among boys whose mothers had a slight obsession of making sure their son was “clean”, or among those whose parents had conscientiously felt pressure to retract following the advice of a relative or highly invasive physician. So much so that their little boy was retracted three times each week - so often that these little boys begin to develop anxiety when their mothers approached them to change or “clean” them. The more mothers touched their boys’ penises in this fashion, the more young children became angry, the more it hurt, the more retraction became torment, until they developed paraphimosis. And then parents call for help. In short, it is a vicious cycle. Very quickly I started to pass along the message to young parents that they should not even touch the foreskin. Leave it alone. And with this advice, over the years, I began to see less and less paraphimosis among my patients. There were now more and more happy little boys who tugged on their own foreskin, laughing, without anxiety. And I saw more and more mothers delighted with the fact that they did not have to handle their son’s penis - in fact, they did not have to do anything for its care. I have not had any little boys need surgery on their penis during my career as a general practitioner, and I saw very few boys ever in need of surgery during medical school, because in my district, no doctor was a fan of retraction. Question Three: At what age should I be worried and consider surgery for a boy whose foreskin does not retract? Answer It’s simple: you should never worry because there is no reason to worry. Foreskin retraction is a cultural practice [in a few nations], and does not take place at all in other countries. Still, there are no more cases of phimosis or “problems” among those nations where foreskin retraction is unheard of. Retraction by someone other than a boy himself serves no purpose at any age. And yet, all parents of little boys can testify that fiddling and tugging on the foreskin are commonplace practices among infants and toddlers (up to eight to ten years old). This self-exploration causes no problems. Quite simply, the foreskin is not meant to be retracted by anyone other than the owner himself - it serves as a sheath to the glans in this way, a protector from outside invasion. As a child grows, the foreskin lengthens and softens over time. With puberty and masturbation, the foreskin opens on its own. It stretches along the penis little by little, allowing for erections to take place without cause for concern. By the time the hormones of puberty are in full swing, the vast majority of boys have already retracted their own foreskin and eased the preputial orifice open. Even if their prepuce was tightly closed in childhood, they do not have phimosis, and this is evident as young adults. So small is this concern that these boys do not even know the word 'phimosis!' In rare cases when there is a real issue, it is at puberty that this is discovered, not before. If a 'problem' arises before puberty, it is likely paraphimosis, because a boy is being retracted - see above. Throughout my career as a general practitioner [~30 years in 2013] I have only had to circumcise one single man, aged 22 years, who had developed untreatable phimosis that was the result of brutal retraction as an infant and child that left tight foreskin scarring on his penis. This started to bother him at puberty - not before. And, in fact, it was the way he was treated as a baby and child that caused the inflammation that resulted in his phimosis - not the other way around. He had to be circumcised as a result of improper care by those who did not know any better. When we repeatedly tear the foreskin at an age of development, it does lead to scarring, and this in turn tightens the foreskin over time, causing the problems we then blame on foreskin (rather than improper care). Question Four: What is your advice to a mother who does not know what a pediatrician will do to her baby during a check-up? What should she do if a physician suggests that she retract? How should she handle guilt-trips pushing improper care? Answer Retraction is a problem that exists merely because it is a matter of culture-based opinion and not a factual issue of prevention or health. Again, there is no evidence that retraction has even the slightest benefit, but its disadvantages are medically obvious. Doctors do not exist to dictate their personal opinions onto parents, and there should be no guilting of mothers who consciously decide they will not "mess with" the penises of their sons. In fact, I find these mothers to be the ones who are the most mentally stable and emotionally healthy. Would a mother okay the circumcision of her son just to please a physician who tells her it is "cleaner"? Of course not. The same goes for retraction. If a doctor talks about such things, tell him that you will leave your child to figure things out for himself, and if a problem arises down the road, you will deal with it at that point. Above all, do not let a physician who is suggesting retraction use your child for their demonstration. Just as there is zero justification in performing vaginal exams on infant and young girls, so also is there never justification to retract and examine the inside of a baby boy's or child's penis when there is nothing wrong. Doing so is not alright for girls, and it is not alright for boys. The only time a physician should be handling your child's genitals (gently!) is if the penis or vulva in question has a visible abnormality that requires examination. If this is not the case, then hands off! Source: Hands Off My Foreskin! Dr. Martin Winckler on the Care of Baby Boys by Martin Winckler, M.D. © 2013 <a href="http://www.drmomma.org/2013/02/hands-off-my-foreskin-dr-martin.html" rel="noopener" target="_blank">Originally posted at Peaceful Parenting, with comments from readers</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Advice on foreskin care from French doctor darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Cutting through circumcision and foreskin myths</h2> Further evidence that intelligent Americans are rejecting and abandoning circumcision is provided in a September issue of the on-line journal Psychology Today, which has published a series of articles tackling common myths about the foreskin and circumcision. In one of these articles Dr Darcia Narverez considers the perennial issues of hygiene, cleanliness and sexually transmitted diseases. <h3>Is circumcision cleaner and healthier?</h3> There's a lot of hype about how circumcision is better for a man's health. But is it really? Here is Part 2 of our series on myths about circumcision. Myth: You have to get the baby circumcised because it is really hard to keep a baby's penis clean. Reality check: In babies, the foreskin is completely fused to the head of the penis. You cannot and should not retract it to clean it, as this would cause the child pain, and is akin to trying to clean the inside of a baby girl's vagina. The infant foreskin is perfectly designed to protect the head of the penis and keep feces out. All you have to do is wipe the outside of the penis like a finger. It is harder to keep circumcised baby's penis clean because you have to carefully clean around the wound, make sure no feces got into the wound, and apply ointment. Myth: Little boys won't clean under their foreskins and will get infections. Reality check: The foreskin separates and retracts on its own sometime between age 3 and puberty. Before it retracts on its own, you wipe the outside off like a finger. After it retracts on its own, it will get clean during the boy's shower or bath. Once a boy discovers this cool, new feature of his penis, he will often retract the foreskin himself during his bath or shower, and you can encourage him to rinse it off. But he should not use soap as this upsets the natural balance and is very irritating. There is nothing special that the parents need to do. Most little boys have absolutely no problem playing with their penises in the shower or anywhere else! It was harder to teach my boys to wash their hair than it was to care for their penises. (Camille 2002) Myth: Uncircumcised penises get smelly smegma. Reality check: Actually, smegma is produced by the genitals of both women and men during the reproductive years. Smegma is made of sebum and skin cells and lubricates the foreskin and glans in men, and the clitoral hood and inner labia in women. It is rinsed off during normal bathing and does not cause cancer or any other health problems. Myth: "My uncle wasn't circumcised and he kept getting infections and had to be circumcised as an adult." Reality check: Medical advice may have promoted infection in uncircumcised males. A shocking number of doctors are uneducated about the normal development of the foreskin, and they (incorrectly) tell parents that they have to retract the baby's foreskin and wash inside it at every diaper change. Doing this tears the foreskin and the tissue (called synechia) that connects it to the head of the penis, leading to scarring and infection. Misinformation was especially prevalent during the 1950s and 60s, when most babies were circumcised and we didn't know as much about the care of the intact penis, which is why the story is always about someone's uncle. Doing this to a baby boy would be like trying to clean the inside of a baby girl's vagina with Q-tips at every diaper change. Rather than preventing problems, such practices would cause problems by introducing harmful bacteria. Remember that humans evolved from animals, so no body part that required special care would survive evolutionary pressures. The human genitals are wonderfully self-cleaning and require no special care. Myth: "My son was diagnosed with phimosis and so had to be circumcised." Reality check: Phimosis means that the foreskin will not retract. Since children's foreskins are naturally not retractable, it is impossible to diagnose phimosis in a child. Any such diagnoses in infants are based on misinformation, and are often made in order to secure insurance coverage of circumcision in states in which routine infant circumcision is no longer covered. Even some adult men have foreskins that do not retract, but as long as it doesn't interfere with sexual intercourse, it is no problem at all, as urination itself cleans the inside of the foreskin (note that urine is sterile when leaving the body.) Phimosis can also be treated conservatively with a steroid cream and gentle stretching done by the man himself, should he so desire it, or, at worst, a slit on the foreskin, rather than total circumcision. (Ashfield 2003) These treatment decisions can and should be made by the adult man. Myth: Uncircumcised boys get more urinary tract infections (UTIs.) Reality check: This claim is based on one study that looked at charts of babies born in one hospital (Wiswell 1985). The study had many problems, including that it didn't accurately count whether or not the babies were circumcised, whether they were premature and thus more susceptible to infection in general, whether they were breastfed (breastfeeding protects against UTIs), and if their foreskins had been forcibly retracted (which can introduce harmful bacteria and cause UTI) (Pisacane 1990). There have been many studies since which show either no decrease in UTIs with circumcision, or else an increase in UTI from circumcision. Thus circumcision is not recommended to prevent UTI (Thompson 1990). Girls have higher rates of UTI than boys, and yet when a girl gets a UTI, she is simply prescribed antibiotics. The same treatment works for boys. Myth: Circumcision prevents HIV/AIDS. Reality check: Three studies in Africa several years ago that claimed that circumcision prevented AIDS and that circumcision was as effective as a 60% effective vaccine (Auvert 2005, 2006). These studies had many flaws, including that they were stopped before all the results came in. There have also been several studies that show that circumcision does not prevent HIV (Connolly 2008). There are many issues at play in the spread of STDs which make it very hard to generalize results from one population to another. In Africa, where all the recent studies have been done, most HIV transmission is through male-female sex, but in the USA, it is mainly transmitted through blood exposure (like needle sharing) and male-male sex. [Circumcision has been shown to have no protective effect in these situations.] Male circumcision does not protect women from acquiring HIV, nor does it protect men who have sex with men (Wawer 2009, Jameson 2009). What's worse, because of the publicity surrounding the African studies, men in Africa are now starting to believe that if they are circumcised, they do not need to wear condoms, which will increase the spread of HIV (Westercamp 2010). Even in the study with the most favorable effects of circumcision, the protective effect was only 60% - men would still have to wear condoms to protect themselves and their partners from HIV. In the USA, during the AIDS epidemic of the 1980s and 90s, about 85% of adult men were circumcised (much higher rates of circumcision than in Africa), and yet HIV still spread. It is important to understand, too, that the men in the African studies were adults and they volunteered for circumcision. Babies undergoing circumcision were not given the choice to decide for themselves. Myth: Circumcision is worth it because it can save lives. Reality check: Consider breast cancer: There is a 12% chance that a woman will get breast cancer in her lifetime. Removal of the breast buds at birth would prevent this, and yet no one would advocate doing this to a baby. It is still considered somewhat shocking when an adult woman chooses to have a prophylactic mastectomy because she has the breast cancer gene, yet this was a personal choice done based upon a higher risk of cancer. The lifetime risk of acquiring HIV is less than 2% for men, and can be lowered to near 0% through condom-wearing (Hall 2008). How, then, can we advocate prophylactic circumcision for baby boys? Bottom line: Science and data do not support the practice of infant circumcision. Circumcision does not preclude the use of the condom. The adult male should have the right to make the decision for himself and not have his body permanently damaged as a baby. REFERENCES Ashfield, J., et al., <a href="http://www.cirp.org/library/treatment/phimosis/ashfield1/">Treatment of phimosis with topical steroids in 194 children</a>, JOURNAL OF UROLOGY, Volume 169, Number 3: Pages 1106-1108, March 2003. Auvert, B. et al., Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial, PLoS Med. 2005 Nov;2(11):e298. Epub 2005 Oct 25. Camille CJ, Kuo RL, Wiener JS. <a href="http://www.cirp.org/library/hygiene/camille1/">Caring for the uncircumcised penis: What parents (and you) need to know</a>. Contemp Pediatr 2002;11:61. Connolly, C. et al., <a href="http://www.cirp.org/library/disease/HIV/connolly2008/">Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002</a>, South African Medical Journal, October 2008, Vol. 98, No. 10. Hall, H. et al., Estimating the lifetime risk of a diagnosis of the HIV infection in 33 states, 2005-2005; J Acquir Immune Defic Syndr. 2008;49(3):294-297. Jameson, D. et al., The Association Between Lack of Circumcision and HIV, HSV-2, and Other Sexually Transmitted Infections Among Men Who Have Sex With Men, Sex Transm Dis. 2009 Nov 6. Pisacane A, et al. <a href="http://www.cirp.org/library/disease/UTI/pisacane/">Breastfeeding and urinary tract infection</a>. The Lancet, July 7, 1990:50. Thompson RS: <a href="http://www.cirp.org/library/disease/UTI/thompson/">Does circumcision prevent urinary tract infection? An opposing view</a>. J Fam Pract 1990; 31: 189-96. Wawer, M. et al., Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial, The Lancet, Volume 374, Issue 9685, Pages 229 - 237, 18 July 2009. Westercamp, W., et al., <a href="https://www.circinfo.org/AIDSnews.html#kenya">Male Circumcision in the General Population of Kisumu, Kenya: Beliefs about Protection, Risk Behaviors, HIV, and STIs</a>, PLoS ONE 5(12): e15552. doi:10.1371/journal.pone.0015552 Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985, 75: 901-903. Source: Darcia Narvaez, Ph.D, <a href="http://www.psychologytoday.com/blog/moral-landscapes/201109/more-circumcision-myths-you-may-believe-hygiene-and-stds">Circumcision myths you may believe: Hygiene and sexually transmitted diseases (STDs)</a>, Psychology Today, 13 September 2011. Darcia Narvaez is an Associate Professor of Psychology and Director of the Collaborative for Ethical Education at the University of Notre Dame, USA. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision myths you may believe darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> This leaflet is published by Circumcision Information Australia to complement the policy statement on circumcision issued by the Royal Australasian College of Physicians and to assist Australian and New Zealand parents care for their baby boys. <h2>1. RACP policy on circumcision</h2> The media are full of confusing information about the benefits, harms and risks of circumcision. After a thorough examination of the evidence, Australian and New Zealand doctors have concluded that there is no medical justification for circumcising normal male infants and boys in Australia and New Zealand. The circumcision policy statement issued by the Royal Australasian College of Physicians (RACP) in October 2010 states: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” This means that Australian and New Zealand doctors do not recommend circumcision of normal infants and boys unless there is a definite medical indication or need. The genitals of healthy babies do not need surgical modification or correction. The RACP does not recommend that boys be circumcised as a precaution against the risk of future problems or diseases to which they may be exposed later in life. Circumcision may be justified when there is a diagnosed disease or other problem that needs to be fixed, and it has not been resolved by non-surgical means after reasonable efforts. In these instances, medical treatment (with antibiotics or other medication) should always be tried first; surgery should be the last resort. <h2>2. Circumcision in Australia and New Zealand</h2> In Australia and New Zealand today circumcision of baby boys is rare, and the uncut penis is the normal thing among young people. But because both countries have a past history of widespread circumcision and many adult men are circumcised, parents are often anxious abut the subject. They may have heard stories from relatives that the uncircumcised penis is prone to problems or difficult to look after, or they may have been alarmed by media reports about epidemics in underdeveloped countries where circumcision is being deployed as a preventive health measure. There is no reason for these anxieties: the uncircumcised penis is very easy to look after, and health precautions that may be needed in underdeveloped countries are not relevant here. Although most parents will not circumcise their boys, some parents prefer to have their boys circumcised for social reasons, usually because they belong to particular ethnic/religious groups in which circumcision is a traditional practice. This guide aims to assist the majority of parents who will not have their boys circumcised, and also the minority of parents who choose circumcision for cultural/religious reasons. <h2>3. The normal (uncircumcised) boy</h2> <h3>(a) The penis</h3> The penis is covered by a double fold of sensitive, and in adults mobile, tissue, known as the foreskin or prepuce. The foreskin is an integral and functional part of the genitals of all humans, male and female (in whom it is also known as the clitoral hood). It has several known functions, including the protection of the head (glans) of the penis in infancy, accommodation of erections and the facilitation of sexual activity in adulthood. In baby boys the foreskin makes up a large proportion of the covering of the penis and usually ends in a tapering spout. Foreskin length is variable, but it is nearly always fused to the head of the penis (glans) in much the same way as the fingernail is connected to the nail-bed. As the boy grows, the two surfaces gradually separate and the foreskin is able to move freely back and forth over the glans. Like all organic processes, this can take time, and it is perfectly normal for a boy’s foreskin not to become retractable until puberty. The foreskin should never be forced back over the glans. Premature or forcible retraction is very painful for the boy, and may result in serious injury to the penis, including scarring that can permanently fuse the foreskin to the glans, narrow the foreskin opening (phimosis) or lead to paraphimosis (explained below). The first person to pull a boy’s foreskin back should nearly always be the boy himself. <h3>(b) Care of the penis</h3> Rule 1: Leave it alone! The infant penis requires no special care. For cleanliness, just wash the outside of your boy's penis with warm water and mild (baby) soap when you bathe him, or wipe it gently with a soft damp cloth or tissue. Do not make any attempt to clean inside his foreskin, and never try to pull it back. Soaps can irritate the sensitive skin at the tip and the inside of the foreskin: you should avoid getting soap on these sensitive areas, just as you prevent soap from getting in a baby’s eyes. Some boys produce a whitish, creamy material that builds up beneath the foreskin opening. This material, known as infant smegma, consists of skin cells shed by the inner foreskin and glans. Some parents become alarmed when they see smegma because they think it is pus and assume there is an infection that requires treatment. In fact, smegma is perfectly harmless and will work its way out of the foreskin opening, where it can be wiped away with a soft cloth or tissue. When a boy is old enough to wash himself, he can rinse his own penis when he takes a bath or shower. Most boys learn how to pull their own foreskins back, but some may need to be shown how to do it. If, on the other hand, his foreskin is not yet retractable, he may need to be warned against forcing it. <h3>(c) Phimosis</h3> Phimosis derives from the ancient Greek word for muzzled, and refers to a condition in which the foreskin cannot be retracted (pulled back) to expose the glans. Nearly all babies and young boys have a foreskin that will not retract, and this is perfectly normal. There is no definite age at which the foreskin is meant to become retractable. Most boys will be able to retract their foreskins by age 8, but it is a highly variable process, and quite a few wait until puberty, and some take even longer. Young boys naturally tug at their foreskin and play with their penis, and this helps the foreskin to separate from the glans and become mobile at the individual’s own pace. No matter how long the process of foreskin separation takes, there is no need for any concern or anxiety unless the boy is experiencing pain or discomfort. Too many boys are needlessly circumcised between the ages of 3 and 7 because of a mistaken diagnosis of phimosis. In most cases they would have been perfectly all right if they had been left alone and allowed to develop naturally. If a boy is experiencing regular pain or discomfort from a tight or short foreskin (for example, when he does a wee or gets an erection), or if his urine stream is very feeble, medical advice should be sought. In such cases the preferred treatment is application of steroid ointment (usually betamethasone valerate) as prescribed by a paediatrician or other medical specialist. Severe phimosis that does not respond to topical medication may require surgery. Apart from circumcision, there are several surgical operations that may resolve the problem without loss of tissue. <h3>(d) Harm of premature retraction</h3> The most common cause of penis problems in infancy are attempts to stretch, dilate or forcibly retract the foreskin before it is ready. This is likely to cause tears in the foreskin tissue that may lead to infection; adhesion of the foreskin to the glans; and induced phimosis, when scar tissue resulting from tears and abrasion causes the tissue at the opening of the foreskin to harden and shrink. The most certain way to avoid foreskin problems in infancy and childhood is to leave the foreskin alone. <h3>(e) Minor problems</h3> Like all body parts, the foreskin is liable to a variety of minor problems, most of which resolve themselves without the need for any treatment. None of these problems require circumcision. Red or inflamed tip This can have many causes, including exposure to soiled nappies, soap, chlorinated water, antibiotics, or concentrated urine resulting from not drinking sufficient fluids. It rarely indicates an infection. The treatment depends on isolating the cause, but measures such as rinsing or soaking without soap, letting him lie or run around naked, tossing a handful of salt into his bath or ensuring that he drinks more water may assist and will do no harm. In most cases the problem will resolve spontaneously, but if it does not you should seek medical advice. Lumps under the foreskin These are caused by an accumulation of smegma and will disappear spontaneously or be extruded through the foreskin opening, at which point the material can be wiped away. As mentioned above, smegma is quite harmless, and its presence indicates that normal separation of foreskin and glans is taking place. Spraying Quite a few boys go through a phase when their urine tends to spray out when they urinate. In most cases it does not last long and resolves itself, but some boys take delight in their capacity to spray a great distance and sometimes engage in contests with their mates. If the spraying persists or if it is accompanied by urinary accidents or abdominal pain, it may indicate a bladder or urinary tract problem, and expert medical advice should be sought. Ballooning Some boys find that their foreskin balloons out when they urinate. This is another passing phase that will resolve itself as the foreskin opening widens. Since the ballooning tends to stretch the foreskin, it helps to achieve separation and retractability. As with spraying, some (mainly older) boys amuse themselves by deliberately holding their foreskins shut so as to force their urine stream to reach further. As with spraying contests, such typically boyish behaviour comes under the general heading of good manners and discipline; it is not a medical issue. Paraphimosis This is a potentially serious condition in which the foreskin has been pulled back behind the glans, becomes trapped there and cannot be brought forward to cover it again. In most cases the problem can be resolved by gently compressing the glans by squeezing it and allowing the foreskin to fall forward, but in rare cases (where the condition has persisted long enough for the foreskin to become so swollen that it threatens to strangle the penis), urgent medical attention is needed. In the meantime ice may help. Paraphimosis in infants and young boys is often caused by forcible premature retraction of the foreskin, and can easily be prevented by observing the golden rule of foreskin care: leave it alone! Occasionally it is caused by the boy himself, such as when retracts his foreskin while his penis is flaccid, but then gets an erection and finds he can’t return it to the normal position. In these cases it is usually only a matter of waiting for the erection to subside. Again, ice may hasten the process. Zipper injury If the foreskin gets caught in a zipper it is very painful and the boy may be screaming. Urgent medical attention must be sought, but in the meantime application of topical anaesthetic cream or spray will dull the pain. It may also be possible to free the foreskin by cutting the zipper at the base and carefully separating the teeth. The vital thing is not to tug at the foreskin, as this will only increase the pain and enlarge the injury. Ways to minimise the risk are not to give boys trousers with zippers until they are old enough to dress themselves; always ensure that he wears underpants; and take care when dressing him. Circumcised boys can also get their penis caught in a zipper, and in these cases the same general rules should be followed. <h3>(e) Conditions where circumcision may be indicated as a therapeutic treatment</h3> There are several conditions which may require circumcision, but only after non-surgical treatments of the problem have been given a fair trial, and after expert medical advice. The conditions are Balanitis xerotica obliterans (BXO) BXO or lichen sclerosis is recognizable by a whitish ring of hardened and often cracked tissue, with redness around it, that develops at the tip of the foreskin. As this condition progresses, the ring constricts the foreskin opening and prevents retraction. The origins of the condition are obscure, and it is quite uncommon – rarely seen before the age of 5 years, and affecting no more than about 1 per cent of boys by age 15. Presence of the condition must be confirmed by specialist advice. Conservative treatment, usually with steroid ointment or injections, should be attempted before surgery is considered. Minor surgery such as preputioplasty, which makes a small incision in the foreskin without loss of tissue, may be tried before circumcision is decided on. Severe recurrent attacks of balanoposthitis (infections of glans and foreskin) Balanoposthitis (from the Greek, balanos, meaning acorn, and posthe, foreskin) refers to inflammations of both the glans and foreskin. The condition may also feature dramatic swelling and reddening of the penis and foreskin, along with discharge, bleeding from the foreskin, difficulty urinating, and occasionally inability to urinate. The problem is quite rare, affecting no more than 4 per cent of boys between 2 and 5 years. The origins of the problem are unclear, but may be the result of infection or allergy. Although balanoposthitis may be recurrent, the episodes tend to become less frequent as the boy gets older, and usually disappear naturally. Diagnosis requires specialist advice, and initial treatment should consist of bathing, topical or oral antibiotics, and steroids. Where these fail and the episodes continue to be both frequent and severe, circumcision may be considered. Recurrent urinary tract infections (UTIs) Most urinary tract infections clear up after treatment with oral antibiotics, but circumcision should be considered in the case of recurrent UTIs, with feverish symptoms, that have not responded to antibiotics, and where the urinary tract is abnormal. Again, specialist diagnosis and advice are required. The most effective preventive of UTIs is breast milk. Severe traumatic injuries Circumcision may also be necessary in the case of severe traumatic injuries, as well as gangrene, frostbite and cancer, where the tissue cannot be salvaged. Such cases are very rare. NOTE: The decision to circumcise should not be taken lightly: the operation makes a permanent physical alteration to the body, and cannot be reversed. Since not all general practitioners are fully up to date with modern treatment options, specialist advice should always be sought in these cases, before such surgery is decided on. <h2>4. The circumcised boy</h2> Like all surgery, circumcision involves the cutting of tissue, nerves and blood vessels; and like all surgery it cannot be done without the risk of pain and complications, the most common of which are bleeding, scarring and various infections. Where anaesthetics are employed there may also be an adverse reaction to the anaesthetic used, and also to pain control drugs given after the operation. The severity of the risks and the requirements for after-care differ according to the age at which the circumcision is performed. <h3>(a) Risks of circumcision</h3> At birth, a baby’s foreskin and glans are usually fused to each other, in much the same way as the eyelids of a newborn kitten are sealed. Before circumcision can be performed, the foreskin must be forcibly separated from the glans, usually with a metal probe. The entire glans of the baby’s penis and the site of the incision then become raw wounds, liable to infection and bleeding, and extremely painful to touch. The open wound may also form an adhesion to the circumcision scar on the shaft of the penis. You should watch your baby very carefully for the first few days following circumcision to make sure that the wounds are healing. Immediate complications The following immediate complications of circumcision are most dangerous in the neonatal period (first month) and early infancy, but they are possible at any age. Bleeding Babies contain very little blood, and cannot afford to lose much. If the boy’s penis continues or starts to bleed following circumcision, you should seek urgent medical attention. Do not administer aspirin as pain relief in this situation, as this interferes with blood-clotting. Boys have died following circumcision because the nappies in which they were dressed absorbed the blood from the wound and parents did not notice they were bleeding until it was too late. Infection Infections can be communicated by the instruments used in the procedure, or from subsequent exposure of the raw surfaces to bacteria from medical personnel, dressings, nappies or the parents’ clothes or hands. Increasing redness, inflammation, swelling, oozing, or fever are all signs of infection. Infections spread rapidly in newborns, and serious diseases, such as meningitis, can quickly lead to death. If you see any sign of infection, medical attention must be sought immediately. Retention of urine Circumcision sometimes leads to blocking of the urethra (urine passage). If your baby goes longer than eight hours without doing a wee after being circumcised, the doctor should be notified immediately. Urethral fistula If your baby’s urinary opening (meatus) is not at the tip of his glans, or if urine comes out of any other opening in his penis, the doctor should be notified immediately. Dislodged Plastibell circumcision device If your baby has been circumcised with the Plastibell device, the plastic ring with a string tied around its rim on your baby’s penis should drop off within five to eight days. If it does not drop off within this period, or if it slips down from his glans and onto the shaft of his penis, or if you notice any swelling, the doctor should be notified immediately. Complications from anaesthetics The penile dorsal nerve block anaesthetic requires injections at the base of the penis. Needles puncturing tissue in this area are likely to cause bruising and may damage the dorsal nerve. Accidental puncture of the dorsal artery or vein can lead to internal bleeding and gangrene. If your baby has extensive bruising or swelling around the injection sites, the doctor should be notified. Topical anesthetics such as EMLA cream are not fully effective against circumcision pain, and carry the risk of depleting the baby’s blood oxygen. Such creams are not approved for use on babies under one month. If your baby turns bluish or grayish after the application of such creams, or if he becomes lethargic, medical attention must be sought urgently. Pain Whether or not an anaesthetic is used, your baby is likely to be in pain following the procedure. Some doctors prescribe post-operative pain medication, but it is not always effective and is never 100 per cent effective. You can comfort your baby by holding him, nursing him frequently, sleeping with him, and being especially careful when changing his nappy. Older babies and children can safely be given pain relief, such as paracetamol or codeine, but be cautious about giving aspirin if there is any sign of bleeding. Behavioural changes Feeding Some babies feed readily soon after they are circumcised, but many do not. Circumcision often interferes with breastfeeding, and there is no known method of re-establishing contact except by persistence. Sleep patterns Many parents worry because their baby sleeps an unusually long time after being circumcised. The procedure is a stressful and exhausting experience for a baby, and sleep will help him to recover. <h3>(b) Caring for the circumcision wound</h3> Dressing changes If your baby was circumcised with a Plastibell device, the plastic ring should be in place with no dressing on his penis. If your baby was circumcised with other devices, such as a Gomco or other forms of clamp, his penis may be bandaged with a gauze dressing to prevent the wound on his remaining foreskin and the open wound on his glans from sticking to each other or to a nappy. Some doctors recommend gently replacing this dressing when it is soiled; others recommend removing it after an hour or two. Some doctors recommend application of Vaseline to the wound with every nappy change for three weeks following the surgery so as to prevent the wound from sticking to the nappy. The yellowish crust on your baby’s glans forms part of the healing process and will fall off as the glans heals. Bathing Following circumcision the penis will be extremely sensitive to pain and care must be taken not to allow any abrasive materials to touch it. After he has done a poo, the circumcision area should be gently rinsed with warm running water. It is best to wait until the wound has healed (seven to ten days) before touching it or using a wash cloth or “baby-wipes.” Preventing adhesions Adhesions and skin bridges may form when the raw surfaces of the glans and remaining penile skin fuse together as they heal. This can be prevented by pulling the penile shaft skin behind the line of the incision gently away from the glans once a day and applying petroleum jelly for the first three weeks. Gentle retraction should be done regularly until your baby is a year old to ensure that the deeper layers of the wound heal without fusing to adjacent tissue. <h3>(c) Later complications</h3> Meatitis In the absence of the foreskin, the urinary opening (meatus) may become inflamed and ulcerated. As ulcers heal, scar tissue forms, constricts the meatus and causes a condition known as meatal stenosis. Meatal stenosis Constriction of the meatus impedes and sometimes blocks the flow of urine. Urine retained in the bladder may allow the growth of bacteria, which can lead to infections. If you notice anything irregular about your baby’s urine flow, the doctor should be notified. Surgery may then be required to enlarge the urinary opening. Preputial stenosis As it heals, the circumcision scar sometimes forms as a tight, constricted, inelastic ring, trapping the glans behind it. This condition may require corrective surgery. Buried penis Following circumcision, the penis may become entrapped by scar tissue and retract into the pubic fat. This condition may correct itself naturally but sometimes requires surgery. Boys whose buried penis is noticed before circumcision should not be circumcised. Excessive skin removal A common complication of circumcision is excessive removal of tissue, but it rarely becomes apparent until the penis reaches its full adult size at puberty. One important function of the foreskin is to provide the slack skin necessary to accommodate the enlargement of the adult penis when erect, meaning that a tight circumcision will make erections painful, and that a very severe operation may inhibit them. Both foreskin length and penis size vary immensely from one male to another, but before puberty it is impossible to know either of these details. There is not much that can be done in cases where there has been excessive skin removal, but a boy may be able to achieve some relief by utilising the stretching techniques developed for foreskin restoration. Scarring The size, colour and shape of circumcision scars vary from male to male, and some are more noticeable than others. Many circumcised males feel self-conscious about the scar on their penis, and some scars may be painful. Desensitization The foreskin is erogenous tissue – now understood to be the most sensitive part of the penis – and its loss tends to desensitizes the penis and affect sexual function. Circumcision also causes the surface of the glans to dry out, thicken, and become dull instead of glossy, and lighter in colour. Resentment and anger Increasing numbers of men are angry and resentful at having been circumcised in infancy or childhood without their agreement, and in some individuals the resentment leads to serious psychological and behavioural problems, and even suicide in rare cases. Parents should bear this risk in mind when considering whether to have their child circumcised. Circumcision Information Australia www.circinfo.org February 2011 <h2>References</h2> <a href="http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health" rel="noopener" target="_blank">Full RACP policy statement on circumcision</a> <a href="http://baps.org.uk/page14/page14.html" rel="noopener" target="_blank">British Association of Paediatric Urologists, Management of Foreskin Conditions</a> <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp" rel="noopener" target="_blank">British Medical Association, The Law and Ethics of Male Circumcision</a> American Academy of Pediatrics, <a href="http://www.cirp.org/library/normal/aap/">Care of the Uncircumcised Penis: Guidelines for Parents</a> Simpson ET, Barraclough P. <a href="http://www.cirp.org/library/hygiene/simpson1/">The management of the paediatric foreskin</a>. Aust Fam Physician 1998;27(5):381-3 Thomas B. McGregor, John G. Pike, Michael P. Leonard. <a href="https://www.circinfo.org/Treatment_of_phimosis.html">Pathologic and physiologic phimosis: Approach to the phimotic foreskin</a>. Canadian Family Physician 2007(March);53:445-448 Dewan PA. <a href="http://www.mja.com.au/public/issues/178_04_170203/dew10610_fm.html">Treating phimosis</a>. Med J Aust 2003 178 (4): 148-150 Camille CJ, Kuo RL, Wiener JS. <a href="http://www.cirp.org/library/hygiene/camille1/">Caring for the uncircumcised penis: What parents (and you) need to know</a>. Contemp Pediatr 2002;11:61 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision and penis care: guide for parents darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> A study by Dr Greg Watters and Stephen Carroll, of Deakin University, Victoria, has found that the reasons given by mothers for wanting to have their baby boys circumcised are based on outdated and mistaken information or bad advice from family members. A summary of the paper appears below. Introduction The routine, non-ritual circumcision of neo-natal males remains a controversial subject in Australia, New Zealand and other Anglo-Celtic settler societies. Circumcision was almost universal amongst Anglo-Celtic Australians until the 1960s. However, many surgeons and medical societies, including our own, now discourage this practice as unnecessary and potentially dangerous. Despite numerous efforts at the education of parents in the function and care of the foreskin, there remains a strong demand for circumcision amongst mothers of newborn males. This paper attempts to analyse the reasons for this demand. Methods The mothers of all boys born in Port Macquarie Base Hospital between June 1999 and June 2002 were retrospectively surveyed with a mailed questionnaire. A small group of those surveyed also took part in face-to-face interviews. The mothers' were asked if their sons were circumcised or if they had seriously considered circumcision prior to birth. The questionnaires also identified the demographics of theparticipants including their religion, level of education and ethnic origin. The mothers' attitudes towards routine circumcision and their perceptions of the advantages and disadvantages of the procedure were explored. Factors that influenced mothers in their decision-making, including information provided by medical practitioners, were identified. Results One hundred and twenty four of the 1027 mothers were sent questionnaires had changed address and could not be contacted. Of those who were contacted, 435 (48%) replied. To reduce the role of cultural and religious factors, 60 replies from mothers who did not identify themselves as Anglo-Celtic were discarded and 375 questionnaires were then analysed. Of the mothers who replied, 41% had had their sons circumcised and a further 36% had given it serious consideration. Mothers who chose circumcision were younger and more likely to have circumcised partners and fathers. They were more likely to profess a religious faith and be less well educated than mothers who did not consider circumcision. The perceived advantages of circumcision included pseudo-medical reasons (prevention of HIV, infections and cancers) and social reasons ("to look like dad", be cleaner, prevent masturbation etc). Mothers who chose circumcision claimed to be unaware of the potential risks of the procedure. They also strongly believed that it was a maternal right to have their son circumcised. Conclusions The medico-legal and ethical implications of these results are discussed. It is also argued that non-ritual, neo-natal circumcision is predominantly a cultural rather than a medical phenomena. As a result, education on the function and care of the foreskin will be unsuccessful if it is based solely on a medical model. The paper was given at a conference of urological surgeons in March2003. Just like dad: Maternal attitudes to neo-natal circumcision in an Anglo-Celtic settler society By Greg Watters, Port Macquarie Hospital, NSW and Deakin University, Vic, and Stephen Carroll, Deakin University Urological Society of Australasia 2003 Annual Scientific Meeting Queenstown, New Zealand 2 - 6 March 2003 Watters and Carroll are also authors of a useful book on the penis: Your Penis: A User's Guide <a href="https://www.amazon.com/exec/obidos/tg/detail/-/9838081507">http://www.amazon.com/exec/obidos/tg/detail/-/9838081507</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Why some mothers want to circumcise darby