5 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"> <h1>Sore point</h1> <h3>Circumcision "a source of great anguish"</h3> Circumcision - beloved by the Victorians, crucial to two of the world's great religions, arguably a health boon - can be a cause of great anguish. Richard Johnson meets men finding ways to reverse a cut they wish they'd never had Guardian, Saturday October 29, 2005 Skin constantly renews itself. Foreskin is no different: stretch it, and it will grow. Which is why eight circumcised men are meeting in Watford town hall. They want new foreskins. "When people come to my house," says Laurie, "I don't go 'Hello there, I'm Laurie, I'm growing my foreskin', but I've often got research papers out on the table, so word gets out. I do find people are really very interested in what I'm doing." Laurie is sharing his experience of restoration, as the process of foreskin renewal is called, with fellow members of NORM-UK. In the US, where NORM was born (and where circumcision rates are somewhere around three-quarters of the male population, far higher than in Britain), it stands for National Organisation of Restoring Men. NORM-UK is about more than that, but Laurie is on a roll. And the others don't want to interrupt him - after all, in two and a half years, Laurie has achieved glans coverage when flaccid. In the world of restoration, that is major. NORM-UK meetings are small and intimate. Not usually as small and intimate as this one, but there's been a pile-up on the M1. There are a few handshakes, but otherwise little in the way of physical display - "People are always worried we're going to drop our trousers," says general manager David Smith. Laurie wouldn't be averse to the idea, to show off his stretching. Women stretch skin for reconstruction after a mastectomy. So why shouldn't men stretch a foreskin? Some men can't restore - they are too tightly circumcised and have no tissue left to grow, but others can and are availing themselves of products such as the TLC Tugger, Tug Ahoy and the Your-Skin cone. Some have found their own DIY solutions, using funnels and gaskets to stretch the foreskin, and sash-window weights to provide traction. The whole idea of restoration sounds funny, like the time that Laurie was having a go with sticky tape, the most primitive of the restoration methods. He pulled what skin he had left over his glans, and taped it down. "I only had the tape on for half an hour", says Laurie, "but it was hell. I was walking down the high street and suddenly had to dive into the nearest toilet to check my penis hadn't gone black, green or blue. Or dropped off altogether." It sounds funny, but it isn't. Not if it's happening to you. Smith remembers sitting through the scene in the film East Is East in which the father tries to catch the son and take him to be circumcised. "I remember the cinema was in hysterics," says Smith, "and they were laughing when he was wheeled into the operating theatre, but all I could hear was the boy's screams. My wife turned to me and said, 'I've got to go - I can't watch this.'" When the foreskin is removed, it leaves the glans exposed and that can be difficult - removing a protective layer and sometimes creating soreness. "I always had a problem with my penis giving me stimulation I didn't want," says Kevin, recalling how, as a boy, "I had to keep adjusting it through my pocket. I was near the climbing frame in the playground when, all of a sudden, everyone started chanting 'Kevin is dirty - he's always playing with himself'. I didn't like the feeling of being odd, of being deformed. Suicide would have been a good option." Kevin is now 56 with a fully restored foreskin. But he's left with the question, why was he circumcised in the first place? His mother read the Bible and went to Sunday school. "But I was conceived out of wedlock when she was 17. And my father was a divorcee. They wanted to get married in church, so I think I was circumcised as some kind of apology to Jesus. My father wasn't circumcised himself, so I really don't understand." And that is a feeling he shares with many members of NORM-UK. Meetings are on a first-name-only basis because members don't like to be identified. "Many men who come to meetings won't even speak to their families about the pain they're suffering - we are dealing with victims of abuse here," says Smith. NORM-UK currently has just short of 300 members. Less than one inquiry in 10 results in membership, but it isn't strictly about the numbers. "Men often want the information to restore," says Smith, "but they want to keep it to themselves. They are frightened about being found out. When they ring me up, they say, 'Please ensure that the information is in plain envelopes and don't put me on a mailing list.'" John D was like that. He felt abused because his circumcision was unnecessary - a course of antibiotics had already cleared up his urinary infection. "But my father agreed with the doctor, and told me I was going to have a minor operation," he says. "I remember the nurses giggling as I was taken off to theatre. They wore these big sickly grins, and said, 'We're taking you to be done up now. Hee hee hee.' I was eight, but suffice it to say that they knew what was happening to me and I did not ... I remember waking up," says John D, "after the general anaesthetic had worn off, and looking down. My beloved penis had been replaced with wrinkled skin, a collar of thorns - the black stitches - and an ugly great dome on top. I experienced shock at first, later deep anger and resentment. The stitches disappeared, but the mutilation didn't. My father said, 'I didn't think it would look like that.' It was misinformed consent." There are lots of horror stories about circumcision. Like the time in Baltimore in 1964 that it went so badly wrong that the doctors decided to change the child's sex. Or the time in London in 1991 when a 16-year-old was circumcised so badly that he bled all night and died. But these cases are extraordinary, and far from typical. Even for adults, circumcision is reckoned a safe and easy operation. Opponents of the procedure, however, don't see it like that. John E is blind. But it's not his blindness that keeps him from meetings. "It's the fact I feel I've been more devastated than everyone else," he says. "They've got their lives in order. And they've got sexual partners. I haven't. My life has been ruined by circumcision, although I hate that word. I prefer 'foreskin amputation'. It's not an operation - there's no medical benefit. It's a rite. A faith crime." In the Bible, circumcision was God's covenant with Abraham and the Jewish people. Of all of the commandments in Judaism, the brit milah (literally, covenant of circumcision) is probably the most universally observed. And although circumcision isn't actually mentioned in the Qur'an, it is mentioned in other Islamic texts. Most Muslims believe it's fundamental because Allah ordered Muhammad to follow the way of Abraham. Asked if NORM-UK has Jewish and Muslim members, Smith replies, "Yes we do, but it is difficult to estimate the number because if someone joins us we do not ask their religion, nor are we really interested." Religious circumcisions are frequently performed without anaesthetic, and are painful, even when performed on newborn babies. Adults can testify to the pain for themselves and can give their informed consent - but children can't. If, as opponents claim, circumcision is traumatic, and can result in lifelong damage - including psychological problems and a reduced sex drive - why are religious circumcisions still allowed? NORM-UK says, actually, they aren't allowed: the UN Convention on the Rights of the Child declares that violence to children cannot be justified on grounds of "religion, culture or tradition". Children are not the possessions of their parents to do with as they please - or submit to surgery unless absolutely necessary. We make an exception for circumcision because it's mentioned in Genesis. Dr Zuhair Zarifa, from Docklands in east London, is one of the few surgeons prepared to advertise the fact that he will circumcise males for religious or ethnic reasons. "Why not?" he says. "The operations are permitted by the General Medical Council. And they will happen whether I do them or not. It's much better for the operations to happen in my surgery under clinical conditions with anaesthetic, where I can provide all the necessary aftercare." Even nonpractising Jews tend to circumcise their sons. It was, after all, the first command given to Abraham and the defining physical mark of the Jewish people. Circumcision involves "Hatafat Dam Brit" - a drop of blood that seals a covenant. Which does, for some, suggest that removing the foreskin goes beyond what is required by God. But, according to Rabbi Dr Jeremy Rosen, that is to miss the point. "People are always trying to find rational reasons for Jewish laws," says Rosen. "They ask if our dietary laws improve hygiene. They ask if observing the Sabbath helps mental relaxation. And they ask if circumcision prevents STDs. But even if these rational reasons stood up to objective scrutiny, they wouldn't be a reason for keeping - or abandoning - our laws. One keeps to these rules out of religious commitment. I have no medical expertise," adds Rosen, who runs the London branch of the liberal Yakar Educational Foundation, "but I am convinced that circumcision is harmless, and not traumatic. But even if it is, we Jews have done pretty well on it over the years - and so indeed have Muslims." Circumcision on females was made illegal in the UK in 1985. The same protection is not extended to males precisely because it would involve taking on two of the world's great religions. Most forms of female circumcision are, certainly, more damaging than male circumcision, but the distinction in law between male and female circumcision just can't be justified objectively. It is a double standard. Circumcision was not practised in Britain until the 18th century and it really only gained popularity in the 19th century, after claims that it stopped the vile habit of masturbation. By stopping masturbation, Victorians thought circumcision would cure everything from epilepsy and hip trouble to asthma and alcoholism. In the first world war it was hailed as a defence against venereal disease, and by the second world war it had become an emblem of status; most of the middle and upper classes were eagerly circumcising their sons. Only in the late 1940s, with the introduction of the National Health Service, did numbers begin to fall - it is now estimated that around 20% of the current male population in the UK are circumcised. But whenever a new disease becomes a matter of social concern, circumcision is wheeled out as the cure. A recent paper in the British Medical Journal found a link between an intact foreskin and HIV infection - but a paper in the British Journal Of Urology found exactly the opposite. There is clear medical evidence that circumcision reduces the incidence of cancer of the penis, and of the cervix for the women whose partners are circumcised, but even this is disputed by NORM-UK. It argues that the research is out of date and that a lack of cleanliness is more important to the transmission of disease than the lack of a foreskin. The organisation doesn't want to see circumcision banned altogether. It accepts there are a few medical conditions where it is necessary. The others can be treated by simple, nonsurgical means."We need to educate the medical profession," says Smith, "because they seem unaware of the alternatives to circumcision. They are certainly unaware of the problems that it is causing." John D is typical of NORM-UK members in that circumcision when he was a young boy changed his entire persona. "I became less sociable, and I started talking to myself. I was fearful of changing rooms. I had no close relationship with the opposite sex until I was 41, and I still haven't been able to reach orgasm through sexual intercourse. Over the years, I've had real problems with depression, and I'm sure I could trace it back to that day." These are not the issues foremost in doctors' minds. Take a look at the General Practice notebook, an online medical encyclopaedia used by GPs, and its listing for phimosis - a condition where the foreskin won't retract. Most infants are born with a foreskin that can't be retracted and the foreskin is often tight until after puberty. Phimosis disappears in almost all cases given time. A fully retractable foreskin occurs on its own in 99% of 18-year-olds. But the notebook recommends circumcision. The notebook makes no mention whatever of the noninvasive solutions to the problem - such as stretching, steroid cream or a simpler operation. Similarly, there are nonsurgical solutions to balanitis, a condition where the foreskin retracts too tightly, causing the glans to swell. "It sounds silly," says John D, "but balanitis can be cured by putting the penis in a bowl of sugar. The swelling goes down, and the foreskin returns to its resting position." Zarifa isn't sure about the bowl of sugar - but he insists that doctors always explore noninvasive options first. "The truth of the matter is that stretching can be quite painful," he says. "And it's quite an undertaking for a small child. For some boys, the pain of the stretching is as bad as the pain of the circumcision. And I would say that 40-50% of boys who use steroid cream end up having a circumcision in the end. But it's always the last option." The BMA supports conservative solutions where possible. But unnecessary circumcisions are still happening. And, as the Commons health committee noted, they are happening "because doctors don't understand the natural history of the foreskin". Circumcision for babies and for older people is dismissed as "the snip", but it can still result in serious bleeding, or an adverse reaction to the anaesthetic. "And you cannot cut off normal, healthy, sexually-functioning tissue without cutting off normal, healthy, sexual functioning," says Marilyn Milos, a nurse and director of the National Organisation of Circumcision Information Resource Centres in the US. "It's a sexual issue, and it's a human rights issue." The foreskin isn't a useless flap that evolution should have got rid of long, long ago - it's skin that is rich with blood vessels, highly innervated, and uniquely endowed with stretch receptors. These contribute greatly to the sexual response of the intact male. The stretching of the foreskin over the glans activates nerve endings, enhances sexual excitability, and contributes to the ejaculatory reflex. There's no escaping it - the foreskin is sexual tissue. Laurie can laugh now, but he missed his foreskin (it was removed when he was two). He was getting on for 60, and rapidly losing the feeling in his penis. "To be honest," he says, "sex was like pushing a rolling pin in. And I'm not referring to size when I say 'rolling pin' - you can get little rolling pins. I just could not feel a thing." His glans had been badly desensitised after years of rattling around - so much so that he could have an orgasm and not even feel it. That is when he approached NORM-UK. During heterosexual intercourse with a circumcised man, the penis removes natural lubrication as it moves in and out of the vagina. "So my poor wife was buying artificial lubricant by the gallon," says Laurie. During heterosexual intercourse with an uncircumcised man, the glans moves but the foreskin stays put. And so does the lubrication. The woman doesn't feel friction at all - what she does feel is a variation in pressure. Laurie is delighted. "And so is my wife," he says. "The skin grew in jumps. I did a lot of work for a long time and nothing happened, like with the sticky tape, but suddenly I woke up one morning and thought 'Where's that come from?' " The new foreskin didn't have the nerve endings it once did, but the glans recovered all its sensitivity. "For 40 years my wife and I had to use lubrication. Not any more. We're delighted." David Smith is NORM-UK's one paid employee. He started admitting he worked for the charity only after his parents died - he couldn't bear the questions. (The Charity Commission put the organisation on probation for 12 months to ensure that it was not a cover for pornography.) Smith's wages come out of a grant from Lloyds TSB. But, apart from him, the trustees are all volunteers. Running NORM-UK is a big job: liaising with Great Ormond Street to correct the circumcision "fact file" on the hospital website, setting up meetings with the Family Planning Clinic, and doing mail-outs to midwives, recommending the alternatives to circumcision. Meet the members of NORM-UK and you'll understand that it's more important to look at the complications of circumcision, and its physical and psychological side effects. In time, campaigners hope that routine circumcision will come to be seen as yet another deluded fad, along with bleeding, electro-convulsive therapy and the frontal lobotomy. --- In response to a letter agreeing that circumcision was immoral but questioning the comparison with female genital mutilation, the Guardian published the following letter from John Dalton. As a victim of male circumcision and a subject of Richard Johnson’s article (Sore Point, October 29), I have no wish to belittle the suffering of circumcised girls. I would, however, like to respond to Catherine Long’s objection to male circumcision being compared to female genital mutilation (Letters, November 5). Male and female circumcision both remove normal tissue from normal children without therapeutic need or personal consent. The time has come for children to be protected from non-therapeutic circumcision without prejudice in respect of race, religion or gender. John D Dalton Frizington, Cumbria <a href="http://www.guardian.co.uk/weekend/story/0,3605,1639243,00.html">Guardian Weekend Magazine, 12 November 2005</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 British men seek compensation for 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"> The Supreme Court of Canada has dismissed the appeal of a British Columbia man who tried to circumcise his four-year-old son on his kitchen floor with a carpet-cutting blade. The boy needed corrective surgery to repair the severe damage arising from the attack. In a 7-0 ruling, the justices left intact a Court of Appeal ruling that convicted the man of aggravated assault and assault with a weapon. The man was convicted at trial in October 2009 of criminal negligence causing bodily harm and acquitted on the two assault charges. The appeal court restored convictions on the assault counts and stayed the negligence charge, conditional on the conviction for aggravated assault. The man's appeal to the Supreme Court sought to have the assault charges thrown out again, but the justices dismissed the case. The original trial was told the man felt that his religious beliefs required that his son be circumcised. Doctors advised him to wait until the child was older and stronger before performing the procedure. The Crown dismissed the religious reasoning. “This is a case about child abuse,” the Crown argued. "This is not a case about the applicant’s religious freedom or circumcision generally." Source: Father who circumcised his son on the kitchen floor loses high court appeal, <a href="http://www.montrealgazette.com/news/Father+circumcised+kitchen+floor+loses+high+court+appeal/7561185/story.html">Montreal Gazette, 16 November 2012</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 Canada Supreme Court: circumcision "aggravated assault" and child abuse 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"> The Supreme Court of Canada has dismissed the appeal of a British Columbia man who tried to circumcise his four-year-old son on his kitchen floor with a carpet-cutting blade. The boy needed corrective surgery to repair the severe damage arising from the attack. In a 7-0 ruling, the justices left intact a Court of Appeal ruling that convicted the man of aggravated assault and assault with a weapon. The man was convicted at trial in October 2009 of criminal negligence causing bodily harm and acquitted on the two assault charges. The appeal court restored convictions on the assault counts and stayed the negligence charge, conditional on the conviction for aggravated assault. The man's appeal to the Supreme Court sought to have the assault charges thrown out again, but the justices dismissed the case. The original trial was told the man felt that his religious beliefs required that his son be circumcised. Doctors advised him to wait until the child was older and stronger before performing the procedure. The Crown dismissed the religious reasoning. “This is a case about child abuse,” the Crown argued. "This is not a case about the applicant’s religious freedom or circumcision generally." Source: Father who circumcised his son on the kitchen floor loses high court appeal, <a href="http://www.montrealgazette.com/news/Father+circumcised+kitchen+floor+loses+high+court+appeal/7561185/story.html">Montreal Gazette, 16 November 2012</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 Canada Supreme Court: circumcision "aggravated assault" and child abuse 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>Canadian doctors reject circumcision</h2> In a statement released on 9 September the Canadian Pediatric Society confirmed its long-standing opposition to routine circumcision of male infants and boys. The new policy states clearly that the recommendation of the CPS is against circumcision because the benefits are small and outweighed by the risks. This outcome has surprised some observers, who were expecting the CPS to follow the American Academy of Pediatrics to conclude, while not recommending circumcision, that the benefits exceeded the risks, and that circumcision was a matter of “parental preference”. In rejecting this assessment as scientifically unsound, the new CPS policy aligns itself with those of the Royal Australasian College of Physicians and child health experts in Britain and all European countries. Their position leaves the Americans more isolated than ever as the only medical organisation in the world to think that there is anything worthwhile in routine circumcision. <a href="https://www.academia.edu/12035421/Risks_benefits_complications_and_harms_Neglected_factors_in_the_debate_on_non-therapeutic_circumcision" rel="noopener" target="_blank">Scholars have criticised</a> the risk/benefit calculus as inadequate for the “circumcision decision”, as it fails to consider the value of the foreskin and the likely future wishes of the boy, or to give adequate weight to bioethical and human rights principles. It is nonetheless significant that the CPS could recommend against circumcision after a narrow calculation of the strictly medical issues considered pretty much on their own. Once you add the functions of the foreskin and bioethical issues to the equation, the case against circumcision becomes overwhelming. <a href="http://www.cps.ca/en/media/release-communique/canadian-paediatricians-revisit-newborn-male-circumcision-recommendations" rel="noopener" target="_blank">Media release by Canadian Pediatric Society</a> <a href="http://www.arclaw.org/resources/press-releases/arc-press-release-praising-canadian-pediatrics-position-statement-circumcis" rel="noopener" target="_blank">Media release by Attorneys for the Rights of the Child</a> <h2>Strengths and weaknesses in the 2015 Canadian Pediatric Society statement on newborn male circumcision</h2> <a href="http://blog.practicalethics.ox.ac.uk/author/brian-earp/" rel="noopener" target="_blank">Brian Earp, University of Oxford</a> The following critique by Brian Earp, research fellow at the University of Oxford is forthcoming in the Canadian Journal of Pediatrics and is available at his <a href="https://www.academia.edu/15746362/Strengths_and_weaknesses_in_the_2015_Canadian_Paediatric_Society_statement_on_newborn_male_circumcision" rel="noopener" target="_blank">Academia.edu page</a>. The latest statement from the Canadian Pediatric Society (CPS) on newborn male circumcision exhibits both strengths and weaknesses. Strengths include (1) acknowledgement that the foreskin is not redundant skin; that it “serves to cover the glans penis and has an abundance of sensory nerves” (p. 4); that it is adherent at birth and may take several years to become fully retractile; that this is normal and should not be pathologized as phimosis; that true phimosis can be treated non-surgically; (2) acknowledgement that the absolute risk for UTIs in boys is low; that it would take 100+ circumcisions to prevent 1 case; that UTIs may be over-diagnosed in genitally intact boys; that UTIs can be treated non-surgically; that “UTIs in children with normal kidneys do not result in long-term sequelae” (p. 2); (3) acknowledgement that the absolute risk of female-to-male heterosexual transmission of HIV in countries such as Canada and the USA is low; that findings from African trials concerning adult men may not translate to newborn boys in developed countries; that circumcision does not reduce male-to-female transmission of HIV; that safe sex practices must continue to be emphasized; (4) acknowledgement that penile cancer is rare in developed countries; that its association with intact male genitalia is primarily explained by the presence of phimosis; that HPV vaccines are expected to “dramatically decrease the incidence rate of cervical cancer” (p. 3), thereby obviating a role for circumcision; (5) acknowledgement that circumcision is painful; that this pain may have long-term adverse sequelae; that circumcision is a procedure with “lifelong consequences … performed on a [healthy] child who cannot give [his] consent” (p. 4); that the “authority of substitute decision makers is … usually limited [to] interventions deemed to be medically necessary” (p. 4); that newborn male circumcision does not satisfy this condition. Weaknesses include (1) failure to engage seriously with the literature on negative sexual effects of circumcision.[1][2][3] This includes a recent analytic review by Bossio et al.[4] as well as several published critiques of the studies by Kigozi et al. and Krieger et al.,[5][6] the latter of which did not use validated instruments. The CPS authors also conflate adult circumcision and infant circumcision in this section.[5] (2) failure to state that the cited cost-effectiveness estimate concerning lifetime risk of HIV acquisition did not demonstrate cost savings for circumcision in the majority population of white males; (3) failure to explain the inclusion of a brochure by an Australian pro-circumcision lobbying group with no official status[7] as one of three “Selected resources” (p. 5), rather than the official brochure of the Royal Australasian College of Physicians (RACP),[8] which advocates against neonatal circumcision; (4) failure to consider analogous interventions in girls.[9] The non-therapeutic removal of any amount tissue from the female genitalia prior to an age of consent, including procedures that are less invasive than male circumcision, is a crime in Canada, notwithstanding any health benefits that might or might not ensue.[10] References [1] Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol 2011;40(5):1367-1381. [2] Bronselaer GA, Schober JM, Meyer‐Bahlburg H F, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int 2013;111(5):820-827. [3] Dias J, Freitas R, Amorim R, et al. Adult circumcision and male sexual health: a retrospective analysis. Andrologia 2014;46(5):459-464. [4] Bossio JA, Pukall CF, Steele S. A review of the current state of the male circumcision literature. J Sex Med 2014;11(12):2847-2864. [5] Earp BD. Sex and circumcision. Am J Bioeth 2015; 15(2):43-45. [6] Frisch M. Author's response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol 2012;41(1):312-314. [7] Earp BD, Darby RJ. <a href="https://www.academia.edu/9872471/Does_science_support_infant_circumcision" rel="noopener" target="_blank">Does science support infant circumcision? A skeptical reply to Brian Morris</a>. Skeptic 2015;25(3)23-30. [8] Royal Australasian College of Physicians. <a href="https://members.racp.edu.au/page/paed-policy" rel="noopener" target="_blank">Policy statement and brochure for parents</a>. [9] Earp BD. <a href="https://www.academia.edu/10270196/Female_genital_mutilation_and_male_circumcision_Toward_an_autonomy-based_ethical_framework" rel="noopener" target="_blank">Female genital mutilation and male circumcision: Toward an autonomy-based ethical framework</a>. [10] Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr 2015;3(18):1-6. <h3>Canadian circumcision policy criticised by children’s health and human rights group</h3> “On right track, but could do better” VICTORIA, BRITISH COLUMBIA – (Sept. 9, 2015) – A just released policy on infant male circumcision by the Canadian Paediatric Society (CPS) was judged today by the Children’s Health & Human Rights Partnership (CHHRP) to be a step in the right direction, but was “nevertheless ‘predictably inadequate’ with respect to several specific issues." CHHRP Medical Director Dr. Christopher Guest, MD, FRCPC, said the new policy is consistent with international paediatric associations that affirm infant boys should not have their healthy foreskins routinely removed. Citing the position of the CPS that recognizes the unique sensory functions of the male foreskin, Dr. Guest asserted that, “A growing number of medical associations now recognize that an intact penis with a foreskin contributes to sexual pleasure for the male and his partner.” According to Guest, in 2010 the Royal Dutch Medical Association concluded, “the foreskin is a complex erotogenic structure that plays an important role in the mechanical function of the penis during sexual acts.” “Circumcision alters the structure of the penis, which inevitably alters function. Long term harm to men from infant circumcision has never been studied” Guest said. Despite this, Guest says men are reporting long-term adverse consequences at the Canadian-based online Global Survey of Circumcision Harm. Although the CPS failed to include it, Guest says scientific evidence has emerged that supports these men’s claims. In 2011, Dr. Morten Frisch published findings in the International Journal of Epidemiology showing that in Denmark, where circumcision is rare, ‘circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in their female partners, notably orgasm difficulties, dyspareunia [difficult or painful sexual intercourse] and a sense of incomplete needs fulfilment.’ Guest faulted the CPS for inclusion of “convenient untruths,” most notably a discussion of HIV being lower in circumcised men. He says such claims are based on methodologically weak African trials, which contradict global HIV trends, for example the United States, which has a high circumcision rate, yet a significantly higher rate of HIV infection than Sweden and Japan where circumcision is rare. “Even if the African trials were scientifically valid, they cannot be used to justify infant circumcision because infants are not sexually active persons,” he said. “Soap and water and safer sex practices, including condoms, can prevent disease.” According to Guest, the CPS failed to include crucial information from a 2012 report by the International NGO Council on Violence Against Children, which CHHRP sent to the CPS in 2014. The report stated that “non-consensual, non-therapeutic circumcision of boys, whatever the circumstances, constitutes a gross violation of their rights, including the right to physical integrity, to freedom of thought and religion and to protection from physical and mental violence.” “Medical associations in the Netherlands, Finland, Sweden, Norway, Denmark, Germany, and others confirm that there is no justification for circumcising infants in the absence of medical urgency,” Guest stated. “The CPS is out of step with those medical associations, who also urge an end to the practice due to ethical and human rights concerns.” Although the CPS concluded that routine infant circumcision is not recommended, and that the benefits of the surgery do not outweigh the risks (contrary to a 2012 claim by the American Academy of Pediatrics), Guest contends that the position statement is still insufficient due to its ambiguity in leaving the decision up to parents. “Parents are not physicians. They do not have the medical knowledge to decide if surgery is medically indicated for their child,” Guest asserted. He went on to say that, “Leaving a decision about medically unnecessary surgery up to parents is an ethical failure on the CPS’ part. Where else in medicine do physicians place this burden on parents, in order to obviate their own professional responsibility?” “Preservation of bodily integrity is a basic and universal human right that the CPS must articulate clearly in future statements,” Guest said. “We Canadians, as well as our institutions and government, have an obligation to protect that right for all citizens, regardless of gender or age.” <a href="http://chhrp.org/" rel="noopener" target="_blank">The Children’s Health & Human Rights Partnership</a> was established in 2012 as a partnership of professionals in the fields of medicine, ethics, and law to further public education regarding non-therapeutic genital surgery on Canadian children. <a href="http://chhrp.org/index.php/news/canadian-childrens-rights-group-questions-new-circumcision-policy/" rel="noopener" target="_blank">The CHHRP statement is available here</a>. <h2>Revised circumcision policy issued by British Columbia, 2009</h2> Like Australia, Canada has a past history of widespread circumcision, but a dramatically falling incidence over the past couple of decades. Also as in Australia, it has been the medical profession itself, led by paediatric health authorities, that has taken the initiative to discourage the practice. In recent times Canadian medical authorities have been among the most outspoken opponents of routine (prophylactic) circumcision, and they have issued several <a href="http://www.cirp.org/library/statements/sask2002/">cautions against the practice</a>. Parallel with this attitude, State health authorities in the Canadian provinces (Manitoba partially excepted) do not pay for medically unnecessary circumcision operations, nor reimburse parents through the Canadian equivalent of Medicare unless the procedure is essential to correct a problem. Among the Canadian health authorities that have issued policies that recommend against circumcision is the College of Physicians and Surgeons of British Columbia, which released a revised policy in September 2009. The following points are highlights of the statement. “Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western counties. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention.” The new policy states clearly that “routine removal of normal tissue in a healthy infant is not recommended.” It also points out that: <ul> <li>proxy consent by parents is now being questioned. Many believe it should be limited to consent for diagnosis and treatment of medical conditions, and that it is not relevant for non-therapeutic procedures;</li> <li>an infant has rights that include security of person, life, freedom and bodily integrity.</li> </ul> The policy recommends that doctors should: <ul> <li>Advise parents that the current medical consensus is that routine infant male circumcision is not a recommended procedure; it is non-therapeutic and has no medical prophylactic basis; it is a cosmetic surgical procedure; current evidence indicates that previously-thought prophylactic public health benefits do not outweigh the potential risks.</li> <li>Provide objective medical information about the risk of complications and potential harm in infant male circumcision.</li> <li>Discuss the new ethical considerations of infant's rights and proxy consent in a non-therapeutic procedure.</li> </ul> The full text of the policy appears below. <h3>The College of Physicians and Surgeons of British Columbia</h3> <h2>Circumcision (Infant Male)</h2> Until recently, only public health and religious views were taken into consideration in the debate over infant male circumcision. However, our understanding of medical practice must change as research findings become available. The College is issuing this guide for physicians regarding routine infant male circumcision in light of evidence-based medicine and contemporary principles in ethics, law and human rights. Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention. From a religious standpoint, infant male circumcision is acknowledged to be an important ritual and an integral part of Jewish and Islamic religions. Male circumcision is also practiced in other parts of the world as a rite of puberty. A wider societal discussion on infant male circumcision is warranted based on a current understanding of bioethics that takes into account the non-therapeutic nature of the procedure as well as the high importance it plays in religious and traditional customs. This paper provides a discussion on current medical perspectives as well as relevant legal, human rights, and ethical considerations. Medical Perspectives Circumcision removes the prepuce that covers and protects the head or the glans of the penis. The prepuce is composed of an outer skin and an inner mucosa that is rich in specialized sensory nerve endings and erogenous tissue. Circumcision is painful, and puts the patient at risk for complications ranging from minor, as in mild local infections, to more serious such as injury to the penis, meatal stenosis, urinary retention, urinary tract infection and, rarely, even haemorrhage leading to death. The benefits of infant male circumcision that have been promoted over time include the prevention of urinary tract infections and sexually transmitted diseases, and the reduction in risk of penile and cervical cancer. Current consensus of medical opinion, including that of the Canadian and American Paediatric Societies and the American Urological Society, is that there is insufficient evidence that these benefits outweigh the potential risks. That is, routine infant male circumcision, i.e. routine removal of normal tissue in a healthy infant, is not recommended. Legal Considerations To date, the legality of infant male circumcision has not been tested in the Courts. It is thus assumed to be legal if it is performed competently, in the child’s best interest, and after valid consent has been obtained. At all times the physician must perform the procedure with competence and at all times, the parent and physician must act in the best interests of the child. Signed parental consent for any treatment is assumed to be valid if the parent understands the nature of the procedure and its associated risks and benefits. However, proxy consent by parents is now being questioned. Many believe it should be limited to consent for diagnosis and treatment of medical conditions, and that it is not relevant for non-therapeutic procedures. Human Rights Considerations The matter of infant male circumcision is particularly difficult in regards to human rights, as it involves consideration of the rights of the infant as well as the rights of the parents. Under the Canadian Charter of Rights and Freedoms and the United Nations Universal Declaration of Human Rights, an infant has rights that include security of person, life, freedom and bodily integrity. Routine infant male circumcision is an unnecessary and irreversible procedure. Therefore, many consider it to be “unwarranted mutilating surgery”. Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision. They claim that an infant’s rights should take priority over any parental rights to make such a decision. This procedure should be delayed to a later date when the child can make his own informed decision. Parental preference alone does not justify a non-therapeutic procedure. Others argue that this stance violates the parents’ right to religious or cultural expression, and that adherence to their religious and cultural practices would be in the best interests of the infant. Ethical Considerations Ethical considerations regarding infant male circumcision centre on the welfare (or “best interests”) of the infant and the potential benefit and harm associated with the procedure. Ethics points us to corrective vision, i.e. to question practices that have become routine, or which we take for granted. Therefore, each request for the procedure should be carefully evaluated, and an agreement to perform the procedure should take into consideration the ethical principles of beneficence (duty to benefit); non-maleficence (do no harm); veracity (accurate information); autonomy (consent); and justice (fairness). These principles are articulated in specific responsibility statements in the CMA Code of Ethics. Also included below are items relating to physicians rights and care of the patient. <h3>Canada Medical Association Code of Ethics</h3> Beneficence (duty to benefit) 1. Consider first the well-being of the patient. 14. Recommend only those diagnostic and therapeutic procedures that you consider to be beneficial to your patient and not others. For consideration Medical evidence is that the benefits of routine infant male circumcision do not outweigh the risks of complications from the procedure. Best interests also take into account the infant’s social circumstances. Non-maleficence (do no harm) 33. Refuse to participate in or support practices that violate basic human rights. For consideration Routine infant male circumcision does cause pain and permanent loss of healthy tissue. Veracity (adequate information) 13. Make every reasonable effort to communicate with your patients in such way that information exchanged is understood. For consideration Discussion should include the new understanding that there is a lack of evidence of a real medical benefit in routine infant male circumcision, that it is non-therapeutic, and that only in rare situations is there any clinical indication for the procedure. Specifics of potential risks and complications should also be explained. It is important to ensure a meaningful discussion between physician and parents, and that the information provided is understood. Autonomy (informed consent) 12. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability. For consideration Parents must be given accurate and impartial information to assist them in making an informed decision. The infant, the actual patient, is unable to give consent. Proxy consent by parents for a non-therapeutic procedure is debatable. Justice (fairness) 29. Recognize that community, society and the environment are important factors in the health of individual patients. For consideration Physicians should understand the basis for the request and consider the infant’s social and cultural circumstances and what might be in the infant’s best interest. Physicians’ Rights 8. Inform your patient when your personal morality would influence the recommendation or practice of any medical procedure that the patient needs or wants. For Consideration If your personal beliefs dictate against infant male circumcision, this should be made known to your patients, with an offer of referral to another physician competent in performing the procedure. Care of the Patient 3. Provide for appropriate care for your patient, including physical comfort and spiritual and psychosocial support. 4. Practice the art and science of medicine competently and without impairment. 6. Recognize your limitations and the competence of others, and, when indicated, recommend that additional opinions and services be sought. For consideration As with any medical procedure, if for religious or cultural reasons you decide to perform an infant male circumcision, ensure that your skills are current. Expertise can be maintained only if a sufficient number of such circumcisions are performed. Recommendation Best medical practice includes the following standards of practice for doctors who are asked to circumcise male infants: <ul> <li>Keep up-to-date on the issues surrounding infant male circumcision, including the therapeutic medical indications and legal and ethical issues.</li> <li>Advise parents that the current medical consensus is that routine infant male circumcision is not a recommended procedure; it is non-therapeutic and has no medical prophylactic basis; it is a cosmetic surgical procedure; current evidence indicates that previously-thought prophylactic public health benefits do not outweigh the potential risks.</li> <li>Provide objective medical information about the risk of complications and potential harm in infant male circumcision.</li> <li>Discuss the new ethical considerations of infant’s rights and proxy consent in a non-therapeutic procedure.</li> <li>Listen to parents and consider the basis of their request, which may be based on religious or cultural practices.</li> </ul> [Conclusion] This paper is intended to help physicians use their professional judgement when a request is made for routine infant male circumcision. While parental preference is important, factors like the best available evidence regarding potential benefits and complications, alternatives to this intervention, the infant’s best interest, and current understanding of bioethics should be taken into consideration. You are not obliged to act upon a request to circumcise an infant, but you must discuss the medical evidence and the current thoughts in bioethics that dissuade you from performing this procedure. You must also inform the parents that they have the right to see another doctor. If you decide to perform the procedure for religious, cultural or other reasons: <ul> <li>Ensure that you have the necessary skills and experience, or ensure that the parents and child are referred to a physician who has these skills.</li> <li>Obtain valid consent from both parents and ensure that both parents sign a consent form.</li> <li>Provide the procedure under hygienic conditions with appropriate analgesia and aftercare.</li> </ul> RESOURCES CITED American Academy of Pediatrics. Task force on Circumcision. Circumcision Policy Statement. Pediatrics 1999; 103: 686-693 British Medical Association Committee on Medical Ethics: <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">The Law and Ethics of Male Circumcision: guidance for doctors</a>, March 2003 Canadian Medical Association. Code of Ethics. Can Med Assoc J 1996; 155: 1176A-B Canadian Paediatric Society. <a href="http://www.cps.ca/english/statements/FN/fn96-01.htm">Neonatal circumcision revisited</a>. Can Med Assoc J 1996: 154(6): 769-780 College of Physicians and Surgeons of BC. Code of Ethics. Policy Manual. College of Physicians and Surgeons of Manitoba. Neonatal Circumcision. Winnipeg: College of Physicians and Surgeons of Manitoba 1997 College of Physicians and Surgeons of Saskatchewan. Caution against Circumcision of Newborn Male Infants. Feb 2002 Christakis DA, Harvey E, Zerr DM et al. A Trade-off Analysis of Routine Newborn Circumcision. Pediatrics 2000. 105: 246-249 Goodman J. <a href="http://www.cirp.org/library/cultural/goodman1999/">Jewish Circumcision: an alternative perspective</a>. BJU International 1999. 83: Suppl. 1, 22-27 Paton M. The Ethics of Circumcising Male Babies. The Bioethics Bulletin (June 1992). Edmonton, University of Alberta. Richards D. <a href="http://www.cirp.org/library/legal/richards/">Male Circumcision: Medical or Ritual?</a> Journal of Law and Medicine 1996. 3:371-376 Somerville M. <a href="http://www.intact.ca/canary.htm">Altering Baby Boys’ Bodies: the ethics of male circumcision</a>. The Ethical Canary: Science, Society and Human Spirit. Toronto: Viking, 2000:202-219 Szasz T. <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=70&Itemid=0">Routine Neonatal Circumcision: Symbol of the Birth of the Therapeutic State</a>. Journal of Medicine and Philosophy 1996:21:137-14, 8 September 2009 </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 Canadian Pediatric Society: recommends against 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"> <h2>Canadian doctors reject circumcision</h2> In a statement released on 9 September the Canadian Pediatric Society confirmed its long-standing opposition to routine circumcision of male infants and boys. The new policy states clearly that the recommendation of the CPS is against circumcision because the benefits are small and outweighed by the risks. This outcome has surprised some observers, who were expecting the CPS to follow the American Academy of Pediatrics to conclude, while not recommending circumcision, that the benefits exceeded the risks, and that circumcision was a matter of “parental preference”. In rejecting this assessment as scientifically unsound, the new CPS policy aligns itself with those of the Royal Australasian College of Physicians and child health experts in Britain and all European countries. Their position leaves the Americans more isolated than ever as the only medical organisation in the world to think that there is anything worthwhile in routine circumcision. <a href="https://www.academia.edu/12035421/Risks_benefits_complications_and_harms_Neglected_factors_in_the_debate_on_non-therapeutic_circumcision" rel="noopener" target="_blank">Scholars have criticised</a> the risk/benefit calculus as inadequate for the “circumcision decision”, as it fails to consider the value of the foreskin and the likely future wishes of the boy, or to give adequate weight to bioethical and human rights principles. It is nonetheless significant that the CPS could recommend against circumcision after a narrow calculation of the strictly medical issues considered pretty much on their own. Once you add the functions of the foreskin and bioethical issues to the equation, the case against circumcision becomes overwhelming. <a href="http://www.cps.ca/en/media/release-communique/canadian-paediatricians-revisit-newborn-male-circumcision-recommendations" rel="noopener" target="_blank">Media release by Canadian Pediatric Society</a> <a href="http://www.arclaw.org/resources/press-releases/arc-press-release-praising-canadian-pediatrics-position-statement-circumcis" rel="noopener" target="_blank">Media release by Attorneys for the Rights of the Child</a> <h2>Strengths and weaknesses in the 2015 Canadian Pediatric Society statement on newborn male circumcision</h2> <a href="http://blog.practicalethics.ox.ac.uk/author/brian-earp/" rel="noopener" target="_blank">Brian Earp, University of Oxford</a> The following critique by Brian Earp, research fellow at the University of Oxford is forthcoming in the Canadian Journal of Pediatrics and is available at his <a href="https://www.academia.edu/15746362/Strengths_and_weaknesses_in_the_2015_Canadian_Paediatric_Society_statement_on_newborn_male_circumcision" rel="noopener" target="_blank">Academia.edu page</a>. The latest statement from the Canadian Pediatric Society (CPS) on newborn male circumcision exhibits both strengths and weaknesses. Strengths include (1) acknowledgement that the foreskin is not redundant skin; that it “serves to cover the glans penis and has an abundance of sensory nerves” (p. 4); that it is adherent at birth and may take several years to become fully retractile; that this is normal and should not be pathologized as phimosis; that true phimosis can be treated non-surgically; (2) acknowledgement that the absolute risk for UTIs in boys is low; that it would take 100+ circumcisions to prevent 1 case; that UTIs may be over-diagnosed in genitally intact boys; that UTIs can be treated non-surgically; that “UTIs in children with normal kidneys do not result in long-term sequelae” (p. 2); (3) acknowledgement that the absolute risk of female-to-male heterosexual transmission of HIV in countries such as Canada and the USA is low; that findings from African trials concerning adult men may not translate to newborn boys in developed countries; that circumcision does not reduce male-to-female transmission of HIV; that safe sex practices must continue to be emphasized; (4) acknowledgement that penile cancer is rare in developed countries; that its association with intact male genitalia is primarily explained by the presence of phimosis; that HPV vaccines are expected to “dramatically decrease the incidence rate of cervical cancer” (p. 3), thereby obviating a role for circumcision; (5) acknowledgement that circumcision is painful; that this pain may have long-term adverse sequelae; that circumcision is a procedure with “lifelong consequences … performed on a [healthy] child who cannot give [his] consent” (p. 4); that the “authority of substitute decision makers is … usually limited [to] interventions deemed to be medically necessary” (p. 4); that newborn male circumcision does not satisfy this condition. Weaknesses include (1) failure to engage seriously with the literature on negative sexual effects of circumcision.[1][2][3] This includes a recent analytic review by Bossio et al.[4] as well as several published critiques of the studies by Kigozi et al. and Krieger et al.,[5][6] the latter of which did not use validated instruments. The CPS authors also conflate adult circumcision and infant circumcision in this section.[5] (2) failure to state that the cited cost-effectiveness estimate concerning lifetime risk of HIV acquisition did not demonstrate cost savings for circumcision in the majority population of white males; (3) failure to explain the inclusion of a brochure by an Australian pro-circumcision lobbying group with no official status[7] as one of three “Selected resources” (p. 5), rather than the official brochure of the Royal Australasian College of Physicians (RACP),[8] which advocates against neonatal circumcision; (4) failure to consider analogous interventions in girls.[9] The non-therapeutic removal of any amount tissue from the female genitalia prior to an age of consent, including procedures that are less invasive than male circumcision, is a crime in Canada, notwithstanding any health benefits that might or might not ensue.[10] References [1] Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol 2011;40(5):1367-1381. [2] Bronselaer GA, Schober JM, Meyer‐Bahlburg H F, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int 2013;111(5):820-827. [3] Dias J, Freitas R, Amorim R, et al. Adult circumcision and male sexual health: a retrospective analysis. Andrologia 2014;46(5):459-464. [4] Bossio JA, Pukall CF, Steele S. A review of the current state of the male circumcision literature. J Sex Med 2014;11(12):2847-2864. [5] Earp BD. Sex and circumcision. Am J Bioeth 2015; 15(2):43-45. [6] Frisch M. Author's response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol 2012;41(1):312-314. [7] Earp BD, Darby RJ. <a href="https://www.academia.edu/9872471/Does_science_support_infant_circumcision" rel="noopener" target="_blank">Does science support infant circumcision? A skeptical reply to Brian Morris</a>. Skeptic 2015;25(3)23-30. [8] Royal Australasian College of Physicians. <a href="https://members.racp.edu.au/page/paed-policy" rel="noopener" target="_blank">Policy statement and brochure for parents</a>. [9] Earp BD. <a href="https://www.academia.edu/10270196/Female_genital_mutilation_and_male_circumcision_Toward_an_autonomy-based_ethical_framework" rel="noopener" target="_blank">Female genital mutilation and male circumcision: Toward an autonomy-based ethical framework</a>. [10] Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr 2015;3(18):1-6. <h3>Canadian circumcision policy criticised by children’s health and human rights group</h3> “On right track, but could do better” VICTORIA, BRITISH COLUMBIA – (Sept. 9, 2015) – A just released policy on infant male circumcision by the Canadian Paediatric Society (CPS) was judged today by the Children’s Health & Human Rights Partnership (CHHRP) to be a step in the right direction, but was “nevertheless ‘predictably inadequate’ with respect to several specific issues." CHHRP Medical Director Dr. Christopher Guest, MD, FRCPC, said the new policy is consistent with international paediatric associations that affirm infant boys should not have their healthy foreskins routinely removed. Citing the position of the CPS that recognizes the unique sensory functions of the male foreskin, Dr. Guest asserted that, “A growing number of medical associations now recognize that an intact penis with a foreskin contributes to sexual pleasure for the male and his partner.” According to Guest, in 2010 the Royal Dutch Medical Association concluded, “the foreskin is a complex erotogenic structure that plays an important role in the mechanical function of the penis during sexual acts.” “Circumcision alters the structure of the penis, which inevitably alters function. Long term harm to men from infant circumcision has never been studied” Guest said. Despite this, Guest says men are reporting long-term adverse consequences at the Canadian-based online Global Survey of Circumcision Harm. Although the CPS failed to include it, Guest says scientific evidence has emerged that supports these men’s claims. In 2011, Dr. Morten Frisch published findings in the International Journal of Epidemiology showing that in Denmark, where circumcision is rare, ‘circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in their female partners, notably orgasm difficulties, dyspareunia [difficult or painful sexual intercourse] and a sense of incomplete needs fulfilment.’ Guest faulted the CPS for inclusion of “convenient untruths,” most notably a discussion of HIV being lower in circumcised men. He says such claims are based on methodologically weak African trials, which contradict global HIV trends, for example the United States, which has a high circumcision rate, yet a significantly higher rate of HIV infection than Sweden and Japan where circumcision is rare. “Even if the African trials were scientifically valid, they cannot be used to justify infant circumcision because infants are not sexually active persons,” he said. “Soap and water and safer sex practices, including condoms, can prevent disease.” According to Guest, the CPS failed to include crucial information from a 2012 report by the International NGO Council on Violence Against Children, which CHHRP sent to the CPS in 2014. The report stated that “non-consensual, non-therapeutic circumcision of boys, whatever the circumstances, constitutes a gross violation of their rights, including the right to physical integrity, to freedom of thought and religion and to protection from physical and mental violence.” “Medical associations in the Netherlands, Finland, Sweden, Norway, Denmark, Germany, and others confirm that there is no justification for circumcising infants in the absence of medical urgency,” Guest stated. “The CPS is out of step with those medical associations, who also urge an end to the practice due to ethical and human rights concerns.” Although the CPS concluded that routine infant circumcision is not recommended, and that the benefits of the surgery do not outweigh the risks (contrary to a 2012 claim by the American Academy of Pediatrics), Guest contends that the position statement is still insufficient due to its ambiguity in leaving the decision up to parents. “Parents are not physicians. They do not have the medical knowledge to decide if surgery is medically indicated for their child,” Guest asserted. He went on to say that, “Leaving a decision about medically unnecessary surgery up to parents is an ethical failure on the CPS’ part. Where else in medicine do physicians place this burden on parents, in order to obviate their own professional responsibility?” “Preservation of bodily integrity is a basic and universal human right that the CPS must articulate clearly in future statements,” Guest said. “We Canadians, as well as our institutions and government, have an obligation to protect that right for all citizens, regardless of gender or age.” <a href="http://chhrp.org/" rel="noopener" target="_blank">The Children’s Health & Human Rights Partnership</a> was established in 2012 as a partnership of professionals in the fields of medicine, ethics, and law to further public education regarding non-therapeutic genital surgery on Canadian children. <a href="http://chhrp.org/index.php/news/canadian-childrens-rights-group-questions-new-circumcision-policy/" rel="noopener" target="_blank">The CHHRP statement is available here</a>. <h2>Revised circumcision policy issued by British Columbia, 2009</h2> Like Australia, Canada has a past history of widespread circumcision, but a dramatically falling incidence over the past couple of decades. Also as in Australia, it has been the medical profession itself, led by paediatric health authorities, that has taken the initiative to discourage the practice. In recent times Canadian medical authorities have been among the most outspoken opponents of routine (prophylactic) circumcision, and they have issued several <a href="http://www.cirp.org/library/statements/sask2002/">cautions against the practice</a>. Parallel with this attitude, State health authorities in the Canadian provinces (Manitoba partially excepted) do not pay for medically unnecessary circumcision operations, nor reimburse parents through the Canadian equivalent of Medicare unless the procedure is essential to correct a problem. Among the Canadian health authorities that have issued policies that recommend against circumcision is the College of Physicians and Surgeons of British Columbia, which released a revised policy in September 2009. The following points are highlights of the statement. “Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western counties. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention.” The new policy states clearly that “routine removal of normal tissue in a healthy infant is not recommended.” It also points out that: <ul> <li>proxy consent by parents is now being questioned. Many believe it should be limited to consent for diagnosis and treatment of medical conditions, and that it is not relevant for non-therapeutic procedures;</li> <li>an infant has rights that include security of person, life, freedom and bodily integrity.</li> </ul> The policy recommends that doctors should: <ul> <li>Advise parents that the current medical consensus is that routine infant male circumcision is not a recommended procedure; it is non-therapeutic and has no medical prophylactic basis; it is a cosmetic surgical procedure; current evidence indicates that previously-thought prophylactic public health benefits do not outweigh the potential risks.</li> <li>Provide objective medical information about the risk of complications and potential harm in infant male circumcision.</li> <li>Discuss the new ethical considerations of infant's rights and proxy consent in a non-therapeutic procedure.</li> </ul> The full text of the policy appears below. <h3>The College of Physicians and Surgeons of British Columbia</h3> <h2>Circumcision (Infant Male)</h2> Until recently, only public health and religious views were taken into consideration in the debate over infant male circumcision. However, our understanding of medical practice must change as research findings become available. The College is issuing this guide for physicians regarding routine infant male circumcision in light of evidence-based medicine and contemporary principles in ethics, law and human rights. Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention. From a religious standpoint, infant male circumcision is acknowledged to be an important ritual and an integral part of Jewish and Islamic religions. Male circumcision is also practiced in other parts of the world as a rite of puberty. A wider societal discussion on infant male circumcision is warranted based on a current understanding of bioethics that takes into account the non-therapeutic nature of the procedure as well as the high importance it plays in religious and traditional customs. This paper provides a discussion on current medical perspectives as well as relevant legal, human rights, and ethical considerations. Medical Perspectives Circumcision removes the prepuce that covers and protects the head or the glans of the penis. The prepuce is composed of an outer skin and an inner mucosa that is rich in specialized sensory nerve endings and erogenous tissue. Circumcision is painful, and puts the patient at risk for complications ranging from minor, as in mild local infections, to more serious such as injury to the penis, meatal stenosis, urinary retention, urinary tract infection and, rarely, even haemorrhage leading to death. The benefits of infant male circumcision that have been promoted over time include the prevention of urinary tract infections and sexually transmitted diseases, and the reduction in risk of penile and cervical cancer. Current consensus of medical opinion, including that of the Canadian and American Paediatric Societies and the American Urological Society, is that there is insufficient evidence that these benefits outweigh the potential risks. That is, routine infant male circumcision, i.e. routine removal of normal tissue in a healthy infant, is not recommended. Legal Considerations To date, the legality of infant male circumcision has not been tested in the Courts. It is thus assumed to be legal if it is performed competently, in the child’s best interest, and after valid consent has been obtained. At all times the physician must perform the procedure with competence and at all times, the parent and physician must act in the best interests of the child. Signed parental consent for any treatment is assumed to be valid if the parent understands the nature of the procedure and its associated risks and benefits. However, proxy consent by parents is now being questioned. Many believe it should be limited to consent for diagnosis and treatment of medical conditions, and that it is not relevant for non-therapeutic procedures. Human Rights Considerations The matter of infant male circumcision is particularly difficult in regards to human rights, as it involves consideration of the rights of the infant as well as the rights of the parents. Under the Canadian Charter of Rights and Freedoms and the United Nations Universal Declaration of Human Rights, an infant has rights that include security of person, life, freedom and bodily integrity. Routine infant male circumcision is an unnecessary and irreversible procedure. Therefore, many consider it to be “unwarranted mutilating surgery”. Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision. They claim that an infant’s rights should take priority over any parental rights to make such a decision. This procedure should be delayed to a later date when the child can make his own informed decision. Parental preference alone does not justify a non-therapeutic procedure. Others argue that this stance violates the parents’ right to religious or cultural expression, and that adherence to their religious and cultural practices would be in the best interests of the infant. Ethical Considerations Ethical considerations regarding infant male circumcision centre on the welfare (or “best interests”) of the infant and the potential benefit and harm associated with the procedure. Ethics points us to corrective vision, i.e. to question practices that have become routine, or which we take for granted. Therefore, each request for the procedure should be carefully evaluated, and an agreement to perform the procedure should take into consideration the ethical principles of beneficence (duty to benefit); non-maleficence (do no harm); veracity (accurate information); autonomy (consent); and justice (fairness). These principles are articulated in specific responsibility statements in the CMA Code of Ethics. Also included below are items relating to physicians rights and care of the patient. <h3>Canada Medical Association Code of Ethics</h3> Beneficence (duty to benefit) 1. Consider first the well-being of the patient. 14. Recommend only those diagnostic and therapeutic procedures that you consider to be beneficial to your patient and not others. For consideration Medical evidence is that the benefits of routine infant male circumcision do not outweigh the risks of complications from the procedure. Best interests also take into account the infant’s social circumstances. Non-maleficence (do no harm) 33. Refuse to participate in or support practices that violate basic human rights. For consideration Routine infant male circumcision does cause pain and permanent loss of healthy tissue. Veracity (adequate information) 13. Make every reasonable effort to communicate with your patients in such way that information exchanged is understood. For consideration Discussion should include the new understanding that there is a lack of evidence of a real medical benefit in routine infant male circumcision, that it is non-therapeutic, and that only in rare situations is there any clinical indication for the procedure. Specifics of potential risks and complications should also be explained. It is important to ensure a meaningful discussion between physician and parents, and that the information provided is understood. Autonomy (informed consent) 12. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability. For consideration Parents must be given accurate and impartial information to assist them in making an informed decision. The infant, the actual patient, is unable to give consent. Proxy consent by parents for a non-therapeutic procedure is debatable. Justice (fairness) 29. Recognize that community, society and the environment are important factors in the health of individual patients. For consideration Physicians should understand the basis for the request and consider the infant’s social and cultural circumstances and what might be in the infant’s best interest. Physicians’ Rights 8. Inform your patient when your personal morality would influence the recommendation or practice of any medical procedure that the patient needs or wants. For Consideration If your personal beliefs dictate against infant male circumcision, this should be made known to your patients, with an offer of referral to another physician competent in performing the procedure. Care of the Patient 3. Provide for appropriate care for your patient, including physical comfort and spiritual and psychosocial support. 4. Practice the art and science of medicine competently and without impairment. 6. Recognize your limitations and the competence of others, and, when indicated, recommend that additional opinions and services be sought. For consideration As with any medical procedure, if for religious or cultural reasons you decide to perform an infant male circumcision, ensure that your skills are current. Expertise can be maintained only if a sufficient number of such circumcisions are performed. Recommendation Best medical practice includes the following standards of practice for doctors who are asked to circumcise male infants: <ul> <li>Keep up-to-date on the issues surrounding infant male circumcision, including the therapeutic medical indications and legal and ethical issues.</li> <li>Advise parents that the current medical consensus is that routine infant male circumcision is not a recommended procedure; it is non-therapeutic and has no medical prophylactic basis; it is a cosmetic surgical procedure; current evidence indicates that previously-thought prophylactic public health benefits do not outweigh the potential risks.</li> <li>Provide objective medical information about the risk of complications and potential harm in infant male circumcision.</li> <li>Discuss the new ethical considerations of infant’s rights and proxy consent in a non-therapeutic procedure.</li> <li>Listen to parents and consider the basis of their request, which may be based on religious or cultural practices.</li> </ul> [Conclusion] This paper is intended to help physicians use their professional judgement when a request is made for routine infant male circumcision. While parental preference is important, factors like the best available evidence regarding potential benefits and complications, alternatives to this intervention, the infant’s best interest, and current understanding of bioethics should be taken into consideration. You are not obliged to act upon a request to circumcise an infant, but you must discuss the medical evidence and the current thoughts in bioethics that dissuade you from performing this procedure. You must also inform the parents that they have the right to see another doctor. If you decide to perform the procedure for religious, cultural or other reasons: <ul> <li>Ensure that you have the necessary skills and experience, or ensure that the parents and child are referred to a physician who has these skills.</li> <li>Obtain valid consent from both parents and ensure that both parents sign a consent form.</li> <li>Provide the procedure under hygienic conditions with appropriate analgesia and aftercare.</li> </ul> RESOURCES CITED American Academy of Pediatrics. Task force on Circumcision. Circumcision Policy Statement. Pediatrics 1999; 103: 686-693 British Medical Association Committee on Medical Ethics: <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">The Law and Ethics of Male Circumcision: guidance for doctors</a>, March 2003 Canadian Medical Association. Code of Ethics. Can Med Assoc J 1996; 155: 1176A-B Canadian Paediatric Society. <a href="http://www.cps.ca/english/statements/FN/fn96-01.htm">Neonatal circumcision revisited</a>. Can Med Assoc J 1996: 154(6): 769-780 College of Physicians and Surgeons of BC. Code of Ethics. Policy Manual. College of Physicians and Surgeons of Manitoba. Neonatal Circumcision. Winnipeg: College of Physicians and Surgeons of Manitoba 1997 College of Physicians and Surgeons of Saskatchewan. Caution against Circumcision of Newborn Male Infants. Feb 2002 Christakis DA, Harvey E, Zerr DM et al. A Trade-off Analysis of Routine Newborn Circumcision. Pediatrics 2000. 105: 246-249 Goodman J. <a href="http://www.cirp.org/library/cultural/goodman1999/">Jewish Circumcision: an alternative perspective</a>. BJU International 1999. 83: Suppl. 1, 22-27 Paton M. The Ethics of Circumcising Male Babies. The Bioethics Bulletin (June 1992). Edmonton, University of Alberta. Richards D. <a href="http://www.cirp.org/library/legal/richards/">Male Circumcision: Medical or Ritual?</a> Journal of Law and Medicine 1996. 3:371-376 Somerville M. <a href="http://www.intact.ca/canary.htm">Altering Baby Boys’ Bodies: the ethics of male circumcision</a>. The Ethical Canary: Science, Society and Human Spirit. Toronto: Viking, 2000:202-219 Szasz T. <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=70&Itemid=0">Routine Neonatal Circumcision: Symbol of the Birth of the Therapeutic State</a>. Journal of Medicine and Philosophy 1996:21:137-14, 8 September 2009 </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 Canadian Pediatric Society: recommends against 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"> <h3>Canadian urologists reject routine circumcision</h3> In a major statement based on a comprehensive survey of the medical literature in January 2018, the Canadian Urological Association has concluded that routine prophylactic circumcision of male infants and boys is not justified as a preventive health measure. The statement is of particular interest because it reaches this conclusion on the basis of a very narrow calculation of medical benefits, costs and risks, pays little attention to the harms of circumcision (such as effect on male sexuality, moral harm of denying choice etc) and largely ignores bioethical and human rights issues. The statement emphasises that the results of clinical studies in underdeveloped regions with acute health and social problems cannot be mapped onto developed nations with quite different epidemiological and social environments, and point out that “The effect of MC has to be analyzed at the individual and societal level.” The statement is at pains to point out that the evidence as to the benefits and risks of circumcision is contradictory and inconclusive, and that much of it is of poor quality, especially studies claiming to show that circumcision has little impact on sexual sensation and function. The final conclusion is that while circumcision does offer some advantages, they are small, can be achieved by other, non-surgical means, and are outweighed by the risks and harms. This being the case, routine circumcision is not justified as a health measure and cannot be recommended. INTRODUCTION “Circumcision is the oldest planned operative procedure in the history of the human civilization but there continues to be a lack of consensus and strong opposing views on whether universal neonatal circumcision should be adopted as a public health measure. … A review of the literature on MC shows evidence of a vehement debate, often clouded by strong personal biases and lack of high quality evidence. Creation of a guideline specific to the need of Canadian infant males is therefore difficult given the level of evidence provided for each potential benefit, the lack of data directly applicable to the Canadian population, the inability to quantify the true complication rate of routine circumcisions accurately, uncertainty about the health benefits of a circumcision compared with other health interventions, the ethical issues and acceptability of a surgical procedure done by parental consent for future benefits, and the costs of training and implementation of any universal neonatal circumcision policy in Canada.” In its conclusion the statement emphasises that the results of clinical studies in underdeveloped regions with acute health and social problems cannot be mapped onto developed nations with quite different epidemiological and social environments, and point out that “The effect of MC has to be analyzed at the individual and societal level. For the individual Canadian neonate, there are definite advantages of a circumcision, but the exact estimates of the effect are unknown, the protection provided is not comprehensive, accrue over a life-time and can be achieved by other preventive health measures. … There are also clear risks associated with this surgical procedure and parents will continue to have to weigh the potential benefits and risks of neonatal circumcision. In an overall societal perspective, given our health care system and the socio-economic and educational status of our population, universal neonatal circumcision is not justified based on the evidence available." Source: Sumit Dave, Kourosh Afshar, Luis H. Braga, Peter Anderson. <a href="http://www.cuaj.ca/index.php/journal/article/view/5033/3371" rel="noopener" target="_blank">CUA guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants</a>. Canadian Urological Association Journal 2017 Dec. 1; Epub ahead of print. http://dx.doi.org/10.5489/cuaj.5033. Earlier policies and policies issued by the various provincial medical bodies and the Canadian Pediatric Society <a href="http://www.cirp.org/library/statements/">are available from CIRP</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 Canadian Urological Association: routine circumcision "not justified" 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"> <h3>Canadian urologists reject routine circumcision</h3> In a major statement based on a comprehensive survey of the medical literature in January 2018, the Canadian Urological Association has concluded that routine prophylactic circumcision of male infants and boys is not justified as a preventive health measure. The statement is of particular interest because it reaches this conclusion on the basis of a very narrow calculation of medical benefits, costs and risks, pays little attention to the harms of circumcision (such as effect on male sexuality, moral harm of denying choice etc) and largely ignores bioethical and human rights issues. The statement emphasises that the results of clinical studies in underdeveloped regions with acute health and social problems cannot be mapped onto developed nations with quite different epidemiological and social environments, and point out that “The effect of MC has to be analyzed at the individual and societal level.” The statement is at pains to point out that the evidence as to the benefits and risks of circumcision is contradictory and inconclusive, and that much of it is of poor quality, especially studies claiming to show that circumcision has little impact on sexual sensation and function. The final conclusion is that while circumcision does offer some advantages, they are small, can be achieved by other, non-surgical means, and are outweighed by the risks and harms. This being the case, routine circumcision is not justified as a health measure and cannot be recommended. INTRODUCTION “Circumcision is the oldest planned operative procedure in the history of the human civilization but there continues to be a lack of consensus and strong opposing views on whether universal neonatal circumcision should be adopted as a public health measure. … A review of the literature on MC shows evidence of a vehement debate, often clouded by strong personal biases and lack of high quality evidence. Creation of a guideline specific to the need of Canadian infant males is therefore difficult given the level of evidence provided for each potential benefit, the lack of data directly applicable to the Canadian population, the inability to quantify the true complication rate of routine circumcisions accurately, uncertainty about the health benefits of a circumcision compared with other health interventions, the ethical issues and acceptability of a surgical procedure done by parental consent for future benefits, and the costs of training and implementation of any universal neonatal circumcision policy in Canada.” In its conclusion the statement emphasises that the results of clinical studies in underdeveloped regions with acute health and social problems cannot be mapped onto developed nations with quite different epidemiological and social environments, and point out that “The effect of MC has to be analyzed at the individual and societal level. For the individual Canadian neonate, there are definite advantages of a circumcision, but the exact estimates of the effect are unknown, the protection provided is not comprehensive, accrue over a life-time and can be achieved by other preventive health measures. … There are also clear risks associated with this surgical procedure and parents will continue to have to weigh the potential benefits and risks of neonatal circumcision. In an overall societal perspective, given our health care system and the socio-economic and educational status of our population, universal neonatal circumcision is not justified based on the evidence available." Source: Sumit Dave, Kourosh Afshar, Luis H. Braga, Peter Anderson. <a href="http://www.cuaj.ca/index.php/journal/article/view/5033/3371" rel="noopener" target="_blank">CUA guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants</a>. Canadian Urological Association Journal 2017 Dec. 1; Epub ahead of print. http://dx.doi.org/10.5489/cuaj.5033. Earlier policies and policies issued by the various provincial medical bodies and the Canadian Pediatric Society <a href="http://www.cirp.org/library/statements/">are available from CIRP</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 Canadian Urological Association: routine circumcision "not justified" 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 Canberra doctor has been disciplined and subjected to practice conditions by the <a href="http://www.ahpra.gov.au/">Australian Health Practitioner Regulation Agency</a> – the Commonwealth authority that replaced the State medical boards a few years ago. The following conditions have been imposed on Dr Timothy Dermott O’Neill, a general practitioner in Dickson: 1. Will not undertake circumcision without the use of adequate analgesia in accordance with the Royal Australian College of Physicians (RACP) guidelines. 2. When performing a circumcision he will only use the appropriate equipment required in each specific case. 3. That he provides the Board every 12 months with a statement of the number of circumcisions he has performed and details of the anaesthetic procedure used in each of the circumcision procedures. This monthly notification is to continue until December 2013. In addition, O’Neill is required: 1. To see a Board appointed psychiatrist, at the Board’s expense, within three months of the publication of this decision. 2. To attend a mentor of his choice, for supervision, once a month for six months. For the mentor to prepare a written report at the end of this period, as to his progress, to the Board. APHRA has not provided the reasons for these conditions, but we may infer from the requirements that when O’Neill performed circumcisions he did not provide an appropriate, adequate or recommended anaesthetic; and that he used inappropriate instruments. The implication is that he was causing an unacceptable level of pain, injury and surgical complications in the unfortunate boys brought to his surgery. The requirement that he see a psychiatrist has disturbing implications, and one would like to know what factors led AHPRA to impose such a condition. When the AHPRA decision was reported in the <a href="http://www.canberratimes.com.au/act-news/unkindest-cut-restrictions-placed-on-doctors-20130216-2ekkn.html">Canberra Times</a> (17 Feb 2013), the name of the offending doctor was suppressed, and the journalist declined to give it to an inquiry from Circumcision Information Australia. Likewise, a request to AHPRA for his name was met with a refusal, and the useless advice that the presence of conditions or other disciplinary action on doctors could be checked on the AHPRA website – but to do this you need the name of the doctor. These obstructive attitudes suggest a greater interest in protecting the business interests of medical practitioners than the health and welfare of the public. Further questions leap to mind. Why is O’Neill performing circumcision operations at all, when Australian medical policy since 1971 has consistently stated that routine circumcision is certainly not necessary and probably undesirable? Is somebody who graduated as long ago as 1973, and who is now required to see a psychiatrist, really the sort of person who ought to be performing delicate surgical operations on small and highly sensitive body parts? We calculate that if O’Neill was 25 when he graduated he must now be 65, an age at which he (like most people) might be expected to be thinking of retirement. Finally, we note the presence of the usual sexist double standard. Why is somebody who damages the genitals of boys treated so much more leniently than somebody who damages the genitals of women, such as Graeme Reeves, widely denounced as a mutilator and recently gaoled in Sydney. (<a href="https://www.circinfo.org/Genital_mutilation_doctor_guilty.html">See report of Reeves’ trial on this site</a>.) No doubt the harm inflicted by O’Neill was less than that inflicted by Reeves, but the principle is not so different, and the judge in Reeves’ appeal case – increasing his gaol sentence – laid great stress on the lack of informed consent on the part of the patient. How many baby boys consent to have part of their penis cut off? Details of the registration of medical practitioners <a href="http://www.ahpra.gov.au/Registration/Registers-of-Practitioners.aspx">may be searched at the AHPRA website here</a>. You will need the name of the doctor and the state in which he/she practices. </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 Canberra circumcision doctor disciplined 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"> 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