8 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"> <h2>Circumcision and sexuality</h2> Perhaps no issue has been more bitterly or emotionally debated than the question of what difference circumcision makes to the experience of sex. Circumcision promoters insist that it makes no difference or even improves a man's sex life and that women prefer circumcised partners. Critics of circumcision point to a considerable body of evidence that circumcision makes a big difference, that there is no evidence that women in general prefer circumcised partners, and that - on the contrary - women may enjoy sex more with uncircumcised men. For much of the twentieth century enthusiasts for routine circumcision have echoed the sentiments of the Victorian sexual health expert (and chastity advocate) William Acton: Although it is possible that it [the foreskin] may increase the pleasure derived from the act of sexual congress, there is no evidence that Jews, and those who have undergone circumcision, do not enjoy as much pleasure in the copulatory act as the uncircumcised; – at any rate, the former do not complain.[1] The claims are clear: first, that circumcision makes no difference to a male’s experience of sex; second, that even if it did men do not complain about what they are missing. An obvious point to note is that Acton’s first assertion directly contradicts the medical knowledge of his own day; throughout history and up to the end of the nineteenth century it was generally held by authorities on medical and sexual matters that the foreskin made a significant contribution to the sexual pleasure of both men and their partners. Far from there being “no evidence”, there is so much that the problem becomes one of selection: from many possible sources we may cite the early eighteenth century surgeon John Marten as representing the orthodox position: This Nut is … cover’d with the preputium or Fore-skin, which is of a loose texture, for the better covering of the Nut, and furling itself up behind the Ring or Hoop, to uncover it; therefore serves as a Cap to the Nut, and to enlarge the pleasure that attends Enjoyment, for in the act of Coition it flips backwards and forwards, being tied together with a membranous String call’d the Fraenum or Bridle, and causes the greater pleasure thereby, both to the Man and the Woman … The cutting of this Preputium or Fore-skin, is done by the Jews, and call’d Circumcision; by having of which taken away, ‘tis said those People lose much of the pleasure in the act of Copulation.[2] Acton’s statement is even inconsistent with the medical wisdom of the Victorian period, since it was precisely the erotic significance of the foreskin that led the physicians of that “anti-sensual age” to urge its removal.[3] As the prominent surgeon Jonathan Hutchinson expressed it: The only function which the prepuce can be supposed to have is that of maintaining the penis in a condition susceptible of more acute sensation than would otherwise exist. It may be supposed to increase the pleasure of coition and the impulse to it. These are advantages, however, which in the present state of society can well be spared, and if in their loss some degree of increased sexual control should result, one should be thankful.[4] Acton himself acknowledged the contribution of the foreskin to sexual pleasure when he denounced it as “a source of serious mischief” and a constant threat to the strict continence he regarded as essential to both morals and health.[5] In the twentieth century the Puritanism of the Victorians gradually softened, and sexual pleasure came to be seen as a good thing, even a human right, rather than a menace to health and virtue.[6] Advocates of routine circumcision thus found it necessary to minimise the adverse effects of such surgery on sexuality and to focus strictly on its benefits for health. For this purpose they have relied heavily on a sloppy and irrelevant piece of research that Masters and Johnson claim to have carried out and published in their much-read book on human sexual response. References 1. Acton, W. The functions and disorders of the reproductive organs in childhood, youth, adult age and advanced life. 3rd edn. Philadelphia: Lindsay and Blakiston, 1865, p 22 2. Marten, J. Gonosologium novum: Or a new system of all the secret infirmities and diseases natural, accidental and venereal in men and women. London, 1709; Facsimile reprint, New York: Garland Publishing, 1985, p 12 3. Moscucci, O. Clitoridectomy, circumcision and the politics of sexual pleasure in mid-Victorian Britain. In: Miller AH and Adams JE ed. Sexualities in Victorian Britain. Bloomington: Indiana University Press, 1996 4. Hutchinson, J. The advantages of circumcision. Medical Review 1900;3:642 5. Darby, R. A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain. Chicago: University of Chicago Press, 2005. chap 6 6. Cook, H. The long sexual revolution: English women, sex and contraception 1800-1975. London: Oxford University Press, 2004 <h3>Three questions</h3> We cannot hope to settle the question here, but three points ought to be made. First, it defies common sense and logic to assume that cutting the part of the penis that contains the vast bulk of the pleasure-sensing nerves could not make a difference to sexual function and sensation. The loss of the mobile sheath of tissue must also make a huge difference. Secondly, although some men who choose circumcision as adults and say that it improved their sex life, you cannot assume that the effects of circumcision in adulthood are the same as the operation in infancy or childhood. If you cover a baby's eyes at birth he will never learn to see properly because he needs the stimulus of light on the optic nerve to activate the neuronal pathways in the brain that control vision. There is evidence (from studies by Immerman and Mackey - both advocates of circumcision, incidentally) that something similar may occur if the foreskin is removed in infancy. It may well be that circumcision did improve the sex lives of some men, but in most cases this would have been because they had severe phimosis that inhibited any movement of the foreskin. Most such problems these days can be fixed by application of steroid cream. Thirdly, why should men have to prove to the satisfaction of the circumcision promoters that the foreskin makes a significant difference to sexual experience before they are allowed to keep it? The foreskin is a natural part of normal human anatomy (indeed, of all mammals), and the default position should be that it is a useful, beneficial or at least non-injurious structure. If the foreskin was as malevolent as the circumcision promoters claim, you would think that evolution might have abolished it by now. <h3>New research into nerve structure of penis shows foreskin to be the sexually dynamic element</h3> Ken McGrath, Senior Lecturer in Pathology at the Faculty of Health, Auckland University of Technology and Member of the New Zealand Institute of Medical Laboratory Scientists discusses his research into the neural anatomy of the human penis and the physical damages caused by circumcision. McGrath is author of The Frenular Delta: A New Preputial Structure published in Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, Proceedings of the Sixth International Symposium on Genital Integrity: Safeguarding Fundamental Human Rights in the 21st Century, held December 7-9, 2000, in Sydney Australia. Abstract: Textbooks and papers referring to penile function state that the source of penile sensation is solely the glans and often justify the existence of the prepuce by stating it protects the 'sensitive' glans. These statements are contrary to the neuro-anatomical and physiological facts accumulated over more than a century. This study reviews the findings of Taylor, et al., that the prepuce is the primary sensory platform of the penis, and describes a new preputial structure. This interview was taped in Berkeley, California 2010 and from the <a href="http://www.circumcisionharm.org/">Global Survey of Circumcision Harm.</a> Removal of the male foreskin and the female clitoral hood (female foreskin) are anatomically equivalent. However, neurologically speaking, removal of the male foreskin is as destructive to male sexual sensory experience as removal of the clitoris is for females. This video discussion of penile and foreskin neurology explains why. Contrary to popular Western myth, many circumcised women do report the ability to feel sexual pleasure and to have orgasm, albeit in a compensatory manner that differs from intact women [suggested reading: Prisoners of Ritual by Hanny Lightfoot-Klein]. Similar compensatory behaviours for achieving orgasm are at work among circumcised men, who must rely on the remaining 50% or less of their penile nerve endings. Just as clitoridectomized girls grow up not knowing the levels of pleasure they could have experienced had they been left intact, so too are men circumcised in infancy unaware of the pleasure they could have experienced had they not had 50% of their penile skin removed. The above video also explains what's really behind the erroneous comment made by some circumcised men that they 'couldn't stand being any more sensitive'. <a href="https://www.youtube.com/watch?v=DD2yW7AaZFw" rel="noopener" target="_blank">Watch Ken McGrath's lecture on Youtube.</a> <h2>Scientific studies document harm of circumcision</h2> Two careful studies published in the world's leading jounral of urology, BJU International, demonstrate that circumcision damages the penis and cuts both sexual capacity and sexual satisfaction. <h3>Korea: Worse sex life after circumcision</h3> Two Korean researchers, DaiSik Kim and Myung-Geol Pang, studied 373 sexually active men, of whom 255 were circumcised and 118 were not. They found that circumcision reduced sexual pleasure in most cases and that a significant minority of men reported major injury to their penis, causing bleeding, scarring and chronic pain. Summarizing their results, the authors write: "There were no significant differences in sexual drive, erection, ejaculation, and ejaculation latency time between circumcised and uncircumcised men. Masturbatory pleasure decreased after circumcision in 48% of the respondents, while 8% reported increased pleasure. Masturbatory difficulty increased after circumcision in 63% of the respondents but was easier in 37%. About 6% answered that their sex lives improved, while 20% reported a worse sex life after circumcision." Conclusion: There was a decrease in masturbatory pleasure and sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings. DaiSik Kim and Myung-Geol Pang, <a href="http://www.cirp.org/library/sex_function/kim2006/">The effect of male circumcision on sexuality</a>. BJU Int 99(3):619-22 <h3>United States: Circumcision cuts sensitivity of penis</h3> Meanwhile, researchers in the United States have found that circumcision removes the most sensitive part of the penis. Researcher Dr Morris Sorrells and others enlisted 159 men from the San Francisco Bay area, 91 of them circumcised, and conducted touch-sensitivity tests, using an instrument that presses with calibrated hairs, on 17-19 different places on their penises. The men could not see where they were being touched. It was found that the most sensitive part of a circumcised penis was on the scar in the middle underneath. But several places on the foreskin were more sensitive than that while the glans of the uncircumcised penis was more sensitive than in the circumcised. The paper is summarised here: Objective: To map the fine-touch pressure thresholds of the adult penis in circumcised and uncircumcised men, and to compare the two populations. Subjects and methods: Adult male volunteers with no history of penile pathology or diabetes were evaluated with a Semmes-Weinstein monofilament touch-test to map the fine-touch pressure thresholds of the penis. Circumcised and uncircumcised men were compared using mixed models for repeated data, controlling for age, type of underwear worn, time since last ejaculation, ethnicity, country of birth, and level of education. Results: The glans of the uncircumcised men had significantly lower mean ( SEM ) pressure thresholds than that of the circumcised men, at 0.161 (0.078) g ( P = 0.040) when controlled for age, location of measurement, type of underwear worn, and ethnicity. There were significant differences in pressure thresholds by location on the penis ( P < 0.001). The most sensitive location on the circumcised penis was the circumcision scar on the ventral surface. Five locations on the uncircumcised penis that are routinely removed at circumcision had lower pressure thresholds than the ventral scar of the circumcised penis. Conclusions: The glans of the circumcised penis is less sensitive to fine touch than the glans of the uncircumcised penis. The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates the most sensitive parts of the penis. Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU International 2007;99:864-9 <a href="http://www.cirp.org/library/anatomy/sorrells_2007/">Full text of article from CIRP</a> <a href="http://www.circumstitions.com/Sexuality.html">Further discussion, with diagrams and illustrations at Circumstitions</a> See also a revealing article by Paul Festa in Nerve magazine, <a href="http://www.nerve.com/dispatches/festa/howinsensitive/index.asp?page=1">How insensitive: A new study confirms a long-time fear: Circumcised men are missing out</a> See also <a href="https://www.circinfo.org/quote.html">Historical quotes on circumcision, foreskin and sexual function on this site</a>. <h2>Male circumcision and female sexual pleasure</h2> There is good evidence that male circumcision affects female sexual pleasure - and for the worse, not the better. Circumcision promoters are putting a lot of effort into trying to persuade people that circumcised men make better lovers, or at least that women "prefer" circumcised men. It may be true that in societies where circumcision is widespread, some women say they prefer what they are accustomed to; but it is equally true that in societies that practise female circumcision, men prefer circumcised women because that is what they are accustomed to. It is also true that some women who experience uncircumcised sex for the first time never want to go back. In any case, the imagined sexual preferences of adults are not a valid reason for interfering with children's genitals. Kristen O'Hara (with Jeffrey O'Hara), Sex as Nature Intended It (Hudson USA, Turning Point Publications, 2001) See Kristen's website: <a href="http://www.sexasnatureintendedit.com/">www.SexAsNatureIntendedIt.com</a> O'Hara K, O'Hara J. <a href="http://www.cirp.org/library/anatomy/ohara/">The effect of male circumcision on the sexual enjoyment of the female partner</a>. BJU Int 1999;83 Suppl 1:79-84. Bensley GA, Boyle GJ. <a href="http://www.cirp.org/library/sex_function/bensley1/">Effects of male circumcision on female arousal and orgasm</a>. N Z Med J 2003;116(1181):595-6. <h2>Czech women more likely to experience good orgasms than women in the United States</h2> A study published in the Journal of Sexual Medicine has found that Czech women have more a satisfactory experience of sexual intercourse than women in the United States. The researchers conclude that this is because the key factor in whether a woman has an orgasm is the duration of intercourse, and that the average duration intercourse in Czechoslovakia was more than double that in the United States: 16.2 minutes among the Czechs, compared with only 7 minutes among the Americans. As the authors of the study comment, the results could reflect “a greater appreciation of intercourse and sensuality by Europeans than by Americans.” Since Czech men are generally not circumcised and American men are, they may also reflect the harmful effect of male circumcision on women’s sexual enjoyment.T hese results are in complete contradiction with the story usually told in the popular U.S. media, that circumcised men “can last longer” before climaxing. The study did not consider this factor, but since circumcision is all but known in Czechoslovakia we can be confident that vast majority of the partners of the Czech women were not circumcised. By contrast, given the high incidence of circumcision in the United States, we can also be confident that most of the partners in the U.S. studies were circumcised. The inevitable conclusion is that circumcised men climax sooner, probably because their reduced sensitivity reduces the pleasure they derive from intercourse so severely that the their pleasure is pretty much limited to the orgasm itself. For uncircumcised men, on the other hand, there is as much pleasure in getting there as there is in arriving – a happy situation that clearly benefits women as well. Source: Petr Weis and Stuart Brody, Women’s partnered orgasm consistency is associated with greater duration of penile-vaginal intercourse but not of foreplay, <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1743-6109.2008.01041.x/full">Journal of Sexual Medicine, Vol 6 (1), January 2009</a> <h2>Circumcision cuts sensitivity and damages sexual response</h2> A new study has found what thousands of circumcised men already know: that circumcision significantly reduces the sensitivity of the penis and has an adverse impact on male sexual functioning. The study, by researchers at the Department of Urology, Ghent University Hospital, Belgium, confirms earlier findings by <a href="http://www.cirp.org/library/sex_function/">Kim and Pang, Sorrells, Frisch and others</a> that the foreskin is the principal source of sensation in the penis, that it facilitates all kinds of sexual activity and enhances sexual pleasure. ABSTRACT What’s known on the subject? And what does the study add? The sensitivity of the foreskin and its importance in erogenous sensitivity is widely debated and controversial. This is part of the actual public debate on circumcision for non-medical reason. Today some studies on the effect of circumcision on sexual function are available. However they vary widely in outcome. The present study shows in a large cohort of men, based on self-assessment, that the foreskin has erogenous sensitivity. It is shown that the foreskin is more sensitive than the uncircumcised glans mucosa, which means that after circumcision genital sensitivity is lost. In the debate on clitoral surgery the proven loss of sensitivity has been the strongest argument to change medical practice. In the present study there is strong evidence on the erogenous sensitivity of the foreskin. This knowledge hopefully can help doctors and patients in their decision on circumcision for non-medical reason. Objectives To test the hypothesis that sensitivity of the foreskin is a substantial part of male penile sensitivity. To determine the effects of male circumcision on penile sensitivity in a large sample. Subjects and methods The study aimed at a sample size of ≈1000 men. Given the intimate nature of the questions and the intended large sample size, the authors decided to create an online survey. Respondents were recruited by means of leaflets and advertising. Results The analysis sample consisted of 1059 uncircumcised and 310 circumcised men. For the glans penis, circumcised men reported decreased sexual pleasure and lower orgasm intensity. They also stated more effort was required to achieve orgasm, and a higher percentage of them experienced unusual sensations (burning, prickling, itching, or tingling and numbness of the glans penis). For the penile shaft a higher percentage of circumcised men described discomfort and pain, numbness and unusual sensations. In comparison to men circumcised before puberty, men circumcised during adolescence or later indicated less sexual pleasure at the glans penis, and a higher percentage of them reported discomfort or pain and unusual sensations at the penile shaft. Conclusions This study confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning. Furthermore, this study shows that a higher percentage of circumcised men experience discomfort or pain and unusual sensations as compared with the uncircumcised population. Before circumcision without medical indication, adult men, and parents considering circumcision of their sons, should be informed of the importance of the foreskin in male sexuality. Source: Bronselaer GA, Schober JM, Meyer-Bahlburg HF, T'sjoen G, Vlietinck R, Hoebeke PB. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2012.11761.x/abstract">Male circumcision decreases penile sensitivity as measured in a large cohort</a>. BJU Int. 2013 Feb 4. doi: 10.1111/j.1464-410X.2012.11761.x. [Epub ahead of print] <h2>Foreskin has important sexual function: New research</h2> Research by scientists in Slovenia has confirmed <a href="http://www.cirp.org/library/sex_function/">previous research</a>, common knowledge and much personal testimony that the foreskin has an important sexual function. A paper by Simon Podnar, published in BJU International – the world’s leading urological journal – found that a reflex action known as the “penilo-cavernosus reflex” is rarely experienced by circumcised men. What this means in ordinary language is that circumcision, by excising the most important nerves of the penis, makes it less sensitive and less functional. The is result that men who retain their foreskins experience greater sexual excitability, better orgasm control and more pleasure. Writing in response to the article, Australia’s Greg Boyle welcomed the article for further developing the work of the late John Taylor and actually doing some objective, scientific investigation of the functions of the foreskin. This was a refreshing change from the ideologically-driven propaganda that pours out of the United States, more interested in exterminating foreskins than in understanding them. In fact, the foreskin is such a miracle of biological engineering that to destroy one without genuine need is an act of wanton vandalism. As Professor Podnar comments, “I see the prepuce as an ingenious device engineered to provide a strong sensory stimulation in a slippery environment”, the evolutionary purpose of which is to maximise the desire to reproduce. <h3>New research on the sexual function of the foreskin: The penilo-cavernosus reflex</h3> “It is known that foreskin, but not glans penis, contains a high density of fine-touch mechanoreceptors. Clinically the penilo-cavernosus reflex provides information on function of the sacral nerves. The study demonstrated that in the majority of circumcised men this reflex cannot be elicited clinically, but can be measured neurophysiologically.” Research by scientists in Slovenia has confirmed previous research by Dr John Taylor and others, common knowledge and much personal testimony that the foreskin plays an important role in male sexual response. A paper by Simon Podnar, published last year in BJU International – the world’s leading urological journal – found that a reflex action known as the “penilo-cavernosus reflex” is rarely experienced by circumcised men. What this means in ordinary language is that circumcision, by excising the most important nerves of the penis, makes it less sensitive and less functional; the result is that circumcised men experience less sexual excitability, less orgasm control and less pleasure. As Podnar writes, “The present study confirmed my previous observations that the penilocavernosus reflex is more difficult to elicit clinically in circumcised men. … The probable reason for this finding in circumcised men is the elimination of the most sensitive part of the penis (i.e. the foreskin), and to a lesser extent, desensitization of sensory receptors in the penile glans.” While the nerves of the foreskin are highly sensitive to light touch and gentle manipulation, those of the glans respond only to strong pressure, heat and pain. These findings have significance for treatment of male sexual dysfunction, including premature ejaculation, as well as urinary and bowel control. Source: Podnar S. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10364.x/abstract">Clinical elicitation of the penilo-cavernosus reflex in circumcised men</a> . BJU Int 2012; 109: 582–5. <h3>Commentary on Podnar’s research</h3> Writing in response to the article, Australia’s Greg Boyle welcomed the article for further developing the work of <a href="http://research.cirp.org/">the late John Taylor</a> and actually doing some objective, scientific investigation of the functions of the foreskin. It was refreshing to find a government sponsoring research aimed at improving our (highly inadequate) understanding of the anatomy and physiology of the foreskin, instead of merely cooking up yet more justifications for cutting it off. We will never understand the biology of the mature foreskin unless we can observe and study it in operation, as it were, and this will not be possible if it is routinely amputated in infancy. The full text of Greg Boyle’s letter and Simon Podnar’s reply follows: 1. Greg Boyle’s letter In a recent issue of the BJUI, Professor Podnar [1] reported his findings concerning the clinical elicitation of the penilo-cavernosus reflex in genitally intact men as compared with circumcised men. Previously, Taylor [2] had reported that, “Almost certainly, removal of the prepuce and its ridged band distorts penile reflexogenic functions but exactly how and to what extent still remains to be seen”. While Podnar’s study attempted to ascertain the magnitude of this reflexogenic disability, it is notable however that he used different stimulatory techniques in genitally intact vs circumcised men. As reported in his paper, Podnar tested the penilo-cavernosus reflex in intact men by squeezing the glans through the overlying foreskin, thereby stimulating the sensory receptors both within the foreskin itself as well as in the glans, whereas in circumcised men, the stimulus necessarily could only be applied to the glans (which is relatively devoid of fine-touch sensory receptors as compared with the inner foreskin with its dense innervation of Meisners’ corpuscles) [2–6]. This procedural discrepancy raises questions as to the validity of Podner”s clinical findings reported for circumcised and genitally intact men respectively. Circumcision and premature ejaculation In regard to PE, Podnar [1] repeated the common myth that “the glans is too sensitive”. To the contrary, PE with little or no sensation/feeling would suggest that the glans is not very sensitive at all. Many circumcised young men ejaculate prematurely but feel very little pleasurable sensation [7]. It would appear that PE may occur before there is much build-up of sexual excitement/tension, so that ejaculation is pretty much a “non-event”. Anecdotally, in the USA where most males have been subjected to routine neonatal circumcision, many young women have commented to their male partner, “Is that it?” Is it not more likely that it is precisely the lack of neurological control over the timing of ejaculation resulting from the severed neuronal circuitry after circumcision that is a major causal factor in PE? Indeed, Bollinger and Van Howe [8] pointed out that, “circumcised men are 2.56 times more likely to suffer from premature ejaculation, and, when the data were adjusted to include erectile dysfunction, that risk rose to 4.88 times”[9]. Moreover, “A recent multinational population survey using stopwatch assessment of the intravaginal ejaculation latency time (IELT) found that in Turkish men, the vast majority of whom are circumcised, had the shortest IELT [10,11]. This report is yet another small piece of the puzzle regarding the adverse effects of circumcision on sexual function [12,13], but cross-validation on much larger samples would seem important. There appears to be a paucity of research funds available to objectively investigate foreskin neurology, physiology, anatomy and sexual function, whereas formidable research resources appear to go to projects aimed at finding “justifications” for ablating the male foreskin. The whole area is still shrouded in myths and distorted by the fact that so much research is carried out in “foreskin-free zones” such as the USA. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2012.11250.x/full">Full text with references available from BJUI, 16 August 2012</a> 2. Simon Podnar’s reply There is a long lasting dispute about the physiological role of the prepuce in human. I see it as a tinny [sic] structure sitting at the evolutionary pinnacle, where our “selfish genes” fight their way into the next generation. Competition here is harsh, with no room for redundancy. I see the prepuce as an ingenious device engineered to provide a strong sensory stimulation in a slippery environment of a copiously lubricated vagina. Evolution achieved this by the tubular prepuce sliding during sexual activity over the conically shaped glans as far as the frenulum allows. Both, the prepuce and the frenulum, have rich mechanoreceptor innervation [1] sending a large sensory input to the brain. The goal of this mechanism is to achieve maximum procreative efficiency of the semen by optimising ejaculation in place and time. To achieve this, the brain also needs to be finely tuned with the genital sensory structures. Intuitively, removal of the penile most sensitive genital structure would lead not only to reduced sexual sensation [2], but also to more difficult achievement of ejaculation. This reasoning – named by Professor Boyle “common myth”– logically leads to a thought that circumcision might be a useful therapy for premature ejaculation (PE). In line with this, in my paper [3] I cited a report that found a reduction in PE in three of seven patients [4] circumcised due to different penile pathology (e.g., phimosis, balanitis, condyloma, etc.). However, I have to admit that these penile conditions made this empirical support unconvincing. Professor Boyle, by contrast, cites studies showing higher frequency of PE [5] and shorter intravaginal ejaculation latency time (IELT) [6] in circumcised men. Of these, higher frequency of PE in the circumcised seems more convincing, as no effect of circumcision status on IELT could be found in an international study after the exclusion of Turkey [6]. Islamic or Asian background was suggested to be a risk factor for PE irrespective of circumcision status [7]. Nevertheless, anything but lower frequency of PE and longer IELT in the circumcised sounds contra intuitive, and needs explanation. The answer, I believe, is neuroplasticity – changes in the thresholds and connectivity that occur within the CNS after circumcision. The method of the penilo-cavernosus reflex elicitation I used in my study [3] indeed activated only deep pressure and pain receptors [8] in the glans in the circumcised men. By contrast, in the intact men, the Meisners’ corpuscles [9] within the foreskin were also stimulated. However, I do not share the opinion of Professor Boyle that this reduces validity of my clinical findings. In both, the intact and circumcised men, I activated all the available sensory receptors at the tip of the penis, and I showed unequivocal differences in the elicitability of the penilo-cavernosus reflex in the two populations of men [3]. The finding is relevant both for using the reflex as a clinical test, and also for demonstration of possible functional differences. During sexual activity both the glans and the overlying foreskin are stimulated in intact men, as discussed above. However, I do agree that using this approach I could not differentiate absence of Meisners’ corpuscles in the foreskin or desensitisation of deep pressure and pain receptors in the glans as the reason for the reduced reflex elicitability found in the circumcised men. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2012.11250_2.x/full">Full text with references available from BJUI, 16 August 2012</a> <h2>Denmark study: Circumcision cuts sexual satisfaction in men and partners</h2> Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: A survey-based, cross-sectional study in Denmark, International Journal of Epidemiology 40 (5), October 2011, 1367-1381. ABSTRACT BACKGROUND: One-third of the world's men are circumcised, but little is known about possible sexual consequences of male circumcision. In Denmark (~5% circumcised), we examined associations of male circumcision with a range of sexual measures in both sexes. METHODS: Participants in a national health survey (n = 5552) provided information about their own (men) or their spouse's (women) circumcision status and details about their sex lives. Logistic regression-derived odds ratios (ORs) measured associations of circumcision status with sexual experiences and current difficulties with sexual desire, sexual needs fulfilment and sexual functio ning. RESULTS: Age at first intercourse, perceived importance of a good sex life and current sexual activity differed little between circumcised and uncircumcised men or between women with circumcised and uncircumcised spouses. However, circumcised men reported more partners and were more likely to report frequent orgasm difficulties after adjustment for potential confounding factors [11 vs 4%, OR(adj) = 3.26; 95% confidence interval (CI) 1.42-7.47], and women with circumcised spouses more often reported incomplete sexual needs fulfilment (38 vs 28%, OR(adj) = 2.09; 95% CI 1.05-4.16) and frequent sexual function difficulties overall (31 vs 22%, OR(adj) = 3.26; 95% CI 1.15-9.27), notably orgasm difficulties (19 vs 14%, OR(adj) = 2.66; 95% CI 1.07-6.66) and dyspareunia [painful intercourse] (12 vs 3%, OR(adj) = 8.45; 95% CI 3.01-23.74). Findings were stable in several robustness analyses, including one restricted to non-Jews and non-Moslems. CONCLUSIONS: Circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment. Thorough examination of these matters in areas where male circumcision is more common is warranted. <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=21672947" rel="noopener" target="_blank">Abstract of study available here</a> <a href="http://www.circumstitions.com/Sexuality.html#denmark" rel="noopener" target="_blank">Report of study with graphic illustrations</a> <a href="http://www.davidwilton.com/files/mc-and-sexual-function---denmark-2011.pdf" rel="noopener" target="_blank">Download study in full as pdf file</a> <h2>Researchers defend Danish study showing that male circumcision has adverse effect on sexual satisfaction</h2> In 2011 <a href="https://www.circinfo.org/controversy.html#frisch1">Circinfo.org reported a study</a> by Danish researchers which found that circumcision reduces sexual satisfaction not only in circumcised men, but also in their female partners. The study by Morten Frisch et al, published in the International Journal of Epidemiology in October 2011, examined the association of male circumcision with a range of sexual measures in both sexes. It found that circumcision was “associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment.” Not surprisingly, these conclusions did not please circumcision advocates such as Brian Morris, who has set himself the daunting task of proving not only that circumcision is a “biomedical imperative for the 21st century” for various "health" reasons, but also that that the amputation of the foreskin has no impact at all on sexual function (and may even improve the operation and appearance of of the penis). He fired off a lengthy critique in reply, denouncing Frisch’s motives as much as his methodology. In his response (International Journal of Epidemiology, February 2012), Frisch not only debunks these criticisms, but reveals that following publication Morris sent emails to his supporters, urging them to send letters of complaint about the article to the editors of the journal, and (what is worse) disclosing the fact (meant to be kept confidential) that he was one of the original peer reviewers and had recommended that the paper not be published at all. Compromising the confidentiality of the peer review process in this manner is a serious breach of publication ethics. In his dignified reply to this blatant lobbying, Frisch highlights the implausibility of Morris’s attempts to portray himself as a “neutral and unbiased authority” on the “medical benefits” of circumcision, while attacking anybody who dares to disagree with him as ideology-driven anti-circumcision activists. He points out that Morris obviously has his own agenda, revealed in an impressive record of anti-foreskin activism going back to the 1990s. Frisch defends the conclusions of his own study as supported by good evidence and casting grave doubt on optimistic (?) claims that circumcision has no impact on sexual function. <h3>Full text of Morten Frisch’s reply to Morris et al</h3> Morten Frisch, Author’s Response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Novel findings in our population-based survey, which had participation rates of 48% in men and 54% (not 40%, as wrongly mentioned by Morris et al.) in women, suggest, but by no means prove, the existence of non-trivial associations of male circumcision with frequent orgasm difficulties in men and with a range of frequent sexual difficulties in women, including orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment. Morris et al. should not be blamed for feeling unconvinced by our findings. However, as these critics repeatedly refer to Morris’ pro-circumcision manifesto [1] as their source of knowledge, their objectivity must be questioned. Morris et al. express concern over possible overfitting in our logistic regression models because we included a number of potentially confounding variables that differed between circumcised and uncircumcised men and between women with circumcised and uncircumcised spouses. However, as seen in Tables 3–6 of our paper, models with adjustment only for age provided odds ratios (ORs) similar to those obtained in the fully adjusted model, suggesting that this is mostly a theoretical concern. Next, Morris et al. suggest that we should have corrected for multiple testing even though such statistical manoeuvres are, at best, unnecessary and, at worst, deleterious to sound statistical inference in most epidemiological studies. [2] Morris et al. also claim that prevalence ratios would have been more appropriate measures of association than ORs. However, despite Morris et al.’s firm statement to the contrary, there is nothing inherently inappropriate about using ORs in cross-sectional studies, even in situations with common outcomes. In such situations, however, ORs should not be misinterpreted as prevalence ratios. We would have been wrong to claim that our OR of 3.26 implied that frequent sexual difficulties were 3.26 times more common in women with circumcised spouses than in women with uncircumcised spouses. Nowhere in our paper did we interpret ORs in such a flawed manner. In accordance with the cited reference [3] we simply noted that frequent sexual difficulties were more common in women with circumcised spouses and that the associated fully adjusted OR was 3.26. Next, Morris et al. argue that our finding of considerably higher rates of frequent orgasm difficulties in (partially) circumcised than uncircumcised Danish men (11 vs 4%, OR1/43.26) may not apply in countries where circumcision means complete amputation of the foreskin. This may well be the case. If partial amputation of the foreskin truly entails frequent orgasm difficulties in a noticeable proportion of men (as experienced by 11% of circumcised men in our study), comparable proportions may well be larger and associated ORs even higher in countries where circumcised men experience greater tissue loss due to more extensive circumcision procedures. Obviously, more data are needed from rigorous studies using carefully constructed questionnaires. The questionnaires used to assess potential sexual problems in the two cited randomized controlled trials in Kenya and Uganda were not presented in detail in the original publications. [4,5] Rather than blindly accepting such findings as any more trustworthy than other findings in the literature, it should be recalled that a strong study design, such as a randomized controlled trial, does not offset the need for high-quality questionnaires. Having obtained the questionnaires from the authors (RH Gray and RC Bailey, personal communication), I am not surprised that these studies provided little evidence of a link between circumcision and various sexual difficulties. [4,5] Several questions were too vague to capture possible differences between circumcised and not-yet circumcised participants (e.g. lack of a clear distinction between intercourse and masturbation-related sexual problems and no distinction between premature ejaculation and trouble or inability to reach orgasm). Thus, non-differential misclassification of sexual outcomes in these African trials probably favoured the null hypothesis of no difference, whether an association was truly present or not. Morris et al. should be commended for their creative attempt to dismiss the higher prevalence of frequent dyspareunia in women with circumcised (12%) than uncircumcised (4%) spouses (ORs between 4.17 and 9.00). They suggest that Danish women with circumcised spouses may be so psychologically troubled by the shape of their spouse’s penis that it might result in painful intercourse. A more plausible explanation would be that reduced penile sensitivity may raise the need among some circumcised men for more vigorous and, to some women, painful stimulation during intercourse in their pursuit of orgasm. Two of the authors, Morris and Waskett, both internationally recognized circumcision activists, [6,7] forget to declare their conflicts of interest. Even in situations that are out of context, Morris promotes himself as a neutral ‘authority on the extensive medical benefits of this simple surgical procedure’, [8] whereas at the same time he argues that neonatal male circumcision ‘should be made compulsory’ and that ‘any parents not wanting their child circumcised really need good talking to’. [9] In contrast, we conducted our survey without setting up any a priori hypotheses, because the limited and inconclusive literature on possible sexual consequences of circumcision would permit almost any imaginable a priori hypothesis. We had no intent to prove an already known ‘truth’ or disprove its contradiction. It is ironic that Morris et al. question the credibility of our findings, postulating that I have an ‘active involvement in opposition to male circumcision’. I have never expressed any objection, ethical, medical or other, against male circumcision as such. Unlike Morris, who believes that ‘circumcision is a biomedical imperative for the 21st century’, [1] I could not care less whether fully informed, healthy adults choose to get circumcised or not. Likewise, when foreskin pathology is present (which does not include the physiological tightness of the foreskin experienced transiently by most boys), and the problem cannot be treated conservatively, preputioplasty or partial circumcision may be a relevant solution, even in minors and others who are unable to consent to the operation. However, because ethical discussions about ritual circumcision are sometimes distorted by strong personal views, I openly declared that I have participated in national debates over ethical issues surrounding male and female circumcision. Like in critical letters to the editor following other recent studies that failed to support their agenda, [10–12] Morris et al. air a series of harsh criticisms against our study. As seen, however, the points raised are not well founded. It seems that the main purpose, as with prior letters, is to be able in future writings to refer to our study as an ‘outlier study’ or one that has been ‘debunked’, ‘rejected by credible researchers’ or ‘shown wrong in subsequent proper statistical analysis’. This in spite of the fact that our study was carried out using conventional epidemiological and statistical methods, underwent peer-review and was published in an international top-ranking epidemiology journal. I would like to thank the IJE editors for withstanding the pressure from one particularly discourteous and bullying reviewer who went to extremes to prevent our study from being published. After the paper’s online publication, I have received emails from colleagues around the world who felt our contribution was useful and potentially important. One colleague informed me that the angry reviewer was the first author of the above letter to the editor. In an email, Morris had called people on his mailing list to arms against our study, openly admitting that he was the reviewer and that he had tried to get the paper rejected. To inspire his followers, Morris had attached his two exceedingly long and aggressive reviews of our paper (12,858 words and 5291 words, respectively), calling for critical letters in abundance to the IJE editors. Breaking unwritten confidentiality and courtesy rules of the peer-review process, Morris distributed his slandering criticism of our study to people working for the same cause. Rather than resorting to such selective distribution among friends, Morris should make both reviews freely available on the internet by posting them in their entirety on his pro circumcision homepage (www.circinfo.net). Alternatively, interested readers should feel free to request them from me at the e-mail address above. Despite poorly founded criticisms and attempts at obstruction our findings suggest that male circumcision may be associated with hitherto unappreciated negative sexual consequences in a non-trivial proportion of men and women. Further carefully conducted studies are needed. <h3>References</h3> 1. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007;29:1147–58. 2. Perneger TV. What’s wrong with Bonferroni adjustments. Br Med J 1998;316:1236–38. 3. Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003;3:21. 4. Krieger JN, Mehta SD, Bailey RC et al. Adult male circumcision: effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med 2008;5:2610–22. 5. Kigozi G, Watya S, Polis CB et al. The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU Int 2008;101:65–70. 6. Circleaks. http://circleaks.org/index.php?title1/4Brian_Morr is (8 August 2011, date last accessed). 7. Circleaks. http://circleaks.org/index.php?title1/4Jake_H._ Waskett (8 August 2011, date last accessed). 8. Morris BJ. Renin, genes, and beyond: 40 years of molecular discoveries in the hypertension field. Hypertension 2011;57:538–48. 9. YouTube. http://www.youtube.com/v/7yDvL4hNny4 (8 August 2011, date last accessed). 10. Morris BJ, Wodak A. Circumcision survey misleading. Aust N Z J Public Health 2010;34:636–37. 11. Waskett JH, Morris BJ, Weiss HA. Errors in meta-analysis by Van Howe. Int J STD AIDS 2009;20:216–18. 12. Waskett JH, Morris BJ. Fine-touch pressure thresholds in the adult penis. BJU Int 2007;99:1551–52. SOURCE: Morten Frisch, Author’s Response to: Brian Morris et al, Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? International Journal of Epidemiology 41 (1), February 2012, 312-314. Morris’s letter in reply can be read in the same issue of the journal. The original article was Morten Frisch, Morten Lindholm and Morten Grønbæk, Male circumcision and sexual function in men and women: A survey-based, cross-sectional study in Denmark, International Journal of Epidemiology 40 (5), October 2011, 1367-1381. <h2> <a id="boyle" name="boyle"></a>Complications and harms of circumcision greater than thought</h2> In two recent papers, psychology professor Dr Greg Boyle considers the physical and mental harms of non-therapeutic circumcision. After reviewing the extensive literature in medical and scientific journals, he finds that not only are the risks and complications of the surgery greater than commonly believed, but also that the harms of foreskin loss itself (i.e. without complications) are far more extensive than most people think. These are very harms of circumcision that are completely ignored by circumcision advocates and bureaucratic policy makers (such as the US Centers for Disease Control), who talk narrowly about “risks vs benefits” and ignore the usefulness of the foreskin (contrary to what the <a href="http://www.cirp.org/library/cultural/maimonides/" rel="noopener" target="_blank">Jewish philosopher Maimonides</a> stated) and regard the removal of a healthy foreskin as no different from the removal of a diseased appendix. Professor Boyle particularly rejects recent claims by Morris and Krieger that circumcision “makes no difference” to sexual function as implausible and contradicted by the evidence, and notes that other experts have found serious flaws in their analysis. <h3>Short and long-term effects of infant and childhood circumcision</h3> ABSTRACT Non-therapeutic infant male circumcision is a permanent surgical alteration to the penis that may cause significant physical, sexual and psychological harm. Physical harms include unintended adverse effects of the surgery itself (e.g., complications such as bleeding, infection, excessive removal of foreskin leaving insufficient shaft skin to accommodate erections, etc.), as well as the inherent loss of healthy, functional tissue. Sexual harms that necessarily follow from circumcision include the loss of all sensation in the foreskin itself, and the loss of all sexual functions that involve the physical manipulation of the foreskin. Additional sexual harms that may follow circumcision include reduced sexual sensation in the remaining penile structures, difficulty with masturbation, increased chafing in both the circumcised man and his sexual partner, as well as reduced overall psychosexual/psychological tension relief and subjective satisfaction. Psychological harms include short-term trauma as well as the potential for long-term emotional disturbances, including sadness, frustration, distress, and anger—akin to post-traumatic stress disorder (PTSD). In this paper, the extent and severity of these various harms are considered and it is argued that they are more serious and more widespread than is commonly believed. Boyle, G. (2015) <a href="http://www.scirp.org/Journal/PaperInformation.aspx?PaperID=55727#.VTAz26Z5gmZ" rel="noopener" target="_blank">Circumcision of Infants and Children: Short-Term Trauma and Long-Term Psychosexual Harm</a>. Advances in Sexual Medicine, 5, 22-38. doi: 10.4236/asm.2015.52004. <h3>Fallacies of Morris, Krieger claims about circumcision and sexual satisfaction exposed</h3> A paper in a recent issue of Advances in Sexual Medicine shows that the literature survey in which Morris and Krieger claims to show that circumcision makes no difference to sexual experience is deeply flawed and inconsistent with the full range of the evidence. The abstract reads as follows: Morris and Krieger (2013) have argued that male circumcision does not impact adversely on sexual sensation, satisfaction, and/or function. In the present paper, it is argued that such a view is untenable. By selectively citing Morris’ own non-peer-reviewed letters and opinion pieces purporting to show flaws in studies reporting evidence of negative effects of circumcision, and by failing adequately to account for replies to these letters by the authors of the original research (and others), Morris and Krieger give an incomplete and misleading account of the available literature. Consequently, Morris and Krieger reach an implausible conclusion that is inconsistent with what is known about the anatomy and functions of the penile foreskin, and the likely effects of its surgical removal. Gregory J. Boyle, Does Male Circumcision Adversely Affect Sexual Sensation, Function, or Satisfaction? Critical Comment on Morris and Krieger (2013). <a href="http://www.scirp.org/Journal/PaperInformation.aspx?PaperID=55256#.VScSRqZ5gmY">Advances in Sexual Medicine, 31 March 2015</a>. <h2> <a id="bossio" name="bossio"></a>Where does the pleasure of penile stimulation come from?</h2> <h3>Thoughts on recent research by Bossio et al and their critics</h3> Research by Jen Bossio and colleagues on the nature of penile sensation in circumcised and normal males is to be welcomed. However uncertain or provisional some of their conclusions may be, their work represents a genuine attempt to shed light on an under-researched area of physiology and should stimulate further investigation. In the immediate term their research has provoked a strong <a href="http://www.huffingtonpost.com/brian-earp/does-circumcision-reduce-_b_9743242.html" rel="noopener" target="_blank">dissent from Brian Earp</a>, who argues that their principal conclusion – that circumcision makes little or no difference to penile sensitivity – is neither supported by their own evidence nor consistent with previous research on this question. A major cause of this disagreement may be that Bossio et al’s research methodology takes the foreskin and penis as separate structures whose properties can be analysed individually, while Earp regards them as elements of a single structure that produce the best results if they work together and which, therefore, should be analysed as a dynamic ensemble. There is sense in this view: when it comes to actual sexual activity, most uncircumcised men are not particularly interested in whether their foreskin, glans or penis shaft is more sensitive to light touch, heat or pain, but rather in the sensations arising from the movement of the foreskin over the glans, or from the friction between the inner foreskin (retracted and everted with erection) and whatever flesh or device is providing the pressure. As nineteenth century advocates of circumcision as a remedy for masturbation warned, it was the mutual stimulation of foreskin and glans that was the problem. The weakness of Bossio’s research methodology is that it examined the penis as a series of static and disconnected objects rather than as a system in motion. In other words, the problem with these touch tests (and it also affects the <a href="http://www.cirp.org/library/anatomy/sorrells_2007/" rel="noopener" target="_blank">Sorrels study</a>, which never got to the heart of the matter) is that they bear no relation to what actually happens during sex. In any sexual activity (wanking, oral, intercourse or whatever) the foreskin is under pressure and stimulated from both sides: from whatever is touching it on the outside, and by the pressure of the glans and shaft on the other side. Since foreskin and glans work together and mutually stimulate each other it is unrealistic to try to separate them and ask which makes the greater contribution to sexual sensation. They need to be studied together in actual situations where sex is taking place. So where should researchers go from here? One possibility is suggested by an informal experiment conducted by New Zealand pathologist Ken McGrath (University of Technology, Auckland) some years ago. He arranged for several adult volunteers (not circumcised) to masturbate to orgasm. In a subsequent session he deadened their foreskins with a local anaesthetic, got them to masturbate again, and to describe the sensations they experienced in comparison with normal conditions on the previous occasion. The results were striking. All subjects took far longer to reach orgasm and reported: <ul> <li>severe loss of sensation and pleasure;</li> <li>awareness of sensation from the glans (mostly from the frenular attachment and to a lesser extent the corona) of which they were normally unaware and which commenced quite late in the episode (i.e. just prior to orgasm);</li> <li>need for more pressure and vigour in stimulation;</li> <li>lack of rising pleasure during the period from the onset of tumescence to awareness of orgasmic approach (in contrast to their normal experience of steadily increasing sensation and pleasure);</li> <li>a sudden and unanticipated onset of orgasm (a lack of warning which surprised them);</li> <li>perception of deepness of sensory origin rather than a surface one as they normally experienced.</li> </ul> All participants found the anaesthetized prepuce experience far less enjoyable, lacking the intense sensation they normally experienced, and rather unsatisfying in comparison. It could not be claimed that this small experiment to be in any way decisive. The sample size was absurdly small, the methodology was unapproved, and it might not have been possible fully to isolate the nerves of the foreskin in such as way as would correspond to the effects of circumcision. Nonetheless, the exercise is suggestive as a pilot study, and offers a different approach to the question – one that requires no expensive equipment or preparations, and carries no risk of harm to any of the participants. In a university research environment with the full range of medical specialists, including anaesthetists, it should be possible to overcome the methodological difficulties, and recruit sufficient volunteers to secure a robust result. <h1>Letters in urology journal criticise Bossio study</h1> A study by Bossio et al published in the Journal of Urology in June 2016 was widely misreported as showing that circumcision made no difference to the sensitivity of the penis. Even leaving aside the vagueness of this measure (do they mean sensitivity to pain or to pleasure? what about other measures of sexual functionality and satisfaction?) the reports seriously misrepresented the findings of the study, which actually showed that men with foreskins had a lower threshold of sensitivity and circumcised men a higher threshold – in other words, that men with foreskins were more sensitive to touch, and circumcised men less sensitive. As the authors admit in their reply to criticisms of their article published in a later issue of the journal, “the foreskin was observed to be most sensitive to fine touch pressure thresholds.” Of course, there are other issues to be taken into account, some of which are raised in the letters criticising the paper, but there is not the slightest basis for media and other reports that circumcision “makes no difference” to sexual experience. The following letters criticising the Bossio et al study on circumcision and penis sensitivity were published in the December 2016 issue of the Journal of Urology, with a reply by the original authors. 1. Professor Morten Frisch Bossio et al assessed penile sensitivity in circumcised and intact males using quantitative sensory measures, and concluded that infant circumcision likely entails only “minimal long-term implications for penile sensitivity.” However, this conclusion does not follow logically from their findings. Despite a small sample size (62 sexually non-dysfunctional males 18 to 37 years old, of whom 30 were neonatally circumcised and 32 were intact), the study confirmed findings from a prior <a href="http://www.cirp.org/library/anatomy/sorrells_2007/" rel="noopener" target="_blank">investigation by Sorrells et al</a>, which revealed significantly lower tactile thresholds (i.e. greater tactile sensitivity) in the foreskin compared to other examined penile sites (the glans and 2 shaft positions). Additionally the current study found significantly greater warmth sensitivity at the foreskin than at the glans (p = 0.02). Finally, the authors assessed thresholds for tactile pain and heat pain, and failed to find any significant evidence that the foreskin is more or less pain sensitive than other parts of the penis. These results suggest that 1) the foreskin is more sensitive to gentle touch than any other tested penile site, replicating prior research, 2) the foreskin may be more sensitive to subtle variations in temperature, at least compared to the glans, and 3) the foreskin appears to be no more or less sensitive to potentially uncomfortable tactile or temperature induced stimuli leading to sensations of penile pain. From these observations the logical conclusion would be that neonatal circumcision appears to be associated with reduced sensitivity in the adult penis. It is noteworthy that the findings of Bossio et al of greater foreskin sensitivity to tactile and temperature related stimuli emerged despite the fact that the examined outer cutaneous part of the foreskin may not even be the most sensitive part of this complex, double layered structure. Figure 2 in the article combines individual sensitivity threshold scores from the 30 circumcised and 32 intact males. To better understand the relevance and meaning of the study findings, I kindly urge the authors to repeat their analysis and provide a supplementary figure, in which they divide the results depicted in figure 2 into 2 separate panels (1 for intact and 1 for circumcised males), illustrating each of the 4 sensory threshold graphs as demonstrated for the combined group of 62 males in this figure. An additional simplified 4-graph panel for the 32 intact males may help readers to judge whether and to what extent the foreskin is more sensitive than other parts of the intact penis. Due to the apparent lack of statistically significant differences in sensitivity among the various non-foreskin penile sites, I suggest that Bossio et al recombine the original 5 tested anatomical sites, i.e. the foreskin, other penile sites (including the glans and the 2 penile shaft sites) and the forearm, to gain statistical power. I also would be interested to see the associated p values provided in a manner similar to that used in figure 2. Morten Frisch, Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark 2. Dr Alexandre Rotta In a study fraught with methodological problems Bossio et al conclude that “circumcision is not associated with changes in penile sensitivity” and believe they have provided “preliminary evidence to suggest that the foreskin is not the most sensitive part of the penis.” However, neither of these assertions is supported by their data. Although nowhere explicitly stated in the article, we assume that all penile sensitivity tests were performed in penises in the flaccid state. Such a testing condition can only provide an indirect hint as to what would occur during sexual arousal, which is the relevant situation to consider when studying penile sensitivity in this context. For unclear reasons the authors tested only a single site on the foreskin – a location on the dorsal unretracted external skin, somewhat proximal to the more sensitive tip of the penis - that previous research has already indicated may be less sensitive than other parts of the foreskin. Specifically if the authors wanted to determine the sensory thresholds of the foreskin of intact men compared to other penile sites, why would they not test its most sensitive point, or at least include a site representing the (widely considered to be) more sensitive transitional or internal surfaces of the foreskin that become exposed when the structure is pulled back? Due to differences in erection mechanics in the intact and circumcised penis, the tested sites on the penile shaft may not be comparable between the 2 groups during sexual activity. The penile shaft skin of circumcised males does not move back and forth a great deal during sex, so the penile shaft sites tested by Bossio et al in flaccid circumcised males may serve as a reasonable proxy for what those same subjects will experience while erect but not for their intact counterparts. During intercourse a considerable part of the penile shaft of intact males is covered intermittently by the everted mucosal portion of the foreskin, which rolls back and forth over the glans. During penetration the skin that covered the penile shaft in the flaccid state moves proximally closer to the pubis. Consequently the penile shaft skin measurements by Bossio et al are unlikely to represent analogous penile sites in sexually aroused intact and circumcised males. To provide a more meaningful comparison of penile shaft sensitivities in intact and circumcised males that might serve as a plausible proxy for what occurs in the erect state, penile shaft sensitivity tests in the flaccid state should have been carried out with the foreskin pulled back (as typically will be the case during sexual arousal) in intact males. Even with its underpowered sample and inadequate choice of cutaneous testing sites the conclusion of the authors that the foreskin is not the most sensitive part of the penis is certainly puzzling in light of figure 2, part A in the article, which shows the foreskin to be significantly more sensitive than any other tested site. The inference that surgical removal of this most sensitive penile segment would not decrease penile sensitivity seems logically and anatomically incoherent. Alexandre T. Rotta, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio 3. Professor Robert Van Howe et al This study examining penile sensitivity left us with several concerns. The report fails to adequately describe the main outcomes of the study, namely measurements broken down by circumcision status. Instead of average scores and standard deviations, the reader is provided with p values, statements about failing to find a statistically significant difference and a figure that collapses the data from the 2 groups into 1 group. Of interest is whether fine touch sensitivity was reduced in the glans in the flaccid penis of circumcised men, as has been reported in 3 previous studies. However, these results were not provided. Instead, the authors provide what could be characterized as pilot data, along with the number of participants needed for a more definitive study, while failing to report the results that are needed to design such a study. Several of the conclusions of Bossio et al do not follow from their findings. Although several of their tests were underpowered, and the maximum participant age was only 37 years (mean 24.2), the authors make sweeping generalizations regarding long-term implications of circumcision on penile sensitivity. Similarly they state that “this study challenges past research suggesting that the foreskin is the most sensitive part of the penis,” while at the same time reporting that the “foreskin of intact men was more sensitive to tactile stimulation.” Finally, the authors conclude that they “failed to consistently replicate the findings by Sorrells et al across stimuli” when they did, in fact, replicate our findings along the only dimension that was consistent - and hence even potentially replicable - between the 2 studies, namely assessment of fine touch thresholds. The authors struggle to explain some of their results but the histology may help. The glans is innervated mainly by free nerve endings, which primarily sense deep pressure and pain, so it is not surprising that the glans was more sensitive to pain. By contrast, the foreskin has a paucity of free nerve endings and is primarily innervated by fine touch neuroreceptors, so it was comparatively less sensitive to pain. On a positive note, it is heartening that the term “intact” has replaced “uncircumcised,” which is considered by many to be a pejorative term. Robert S. Van Howe, Department of Pediatrics, Central Michigan University College of Medicine; with Morris L. Sorrells, James L. Snyder, Mark D. Reiss and Marilyn F. Milos <h3>Reply by authors</h3> Based on a careful review of these letters, we believe that our conclusions have been misconstrued in different ways by the authors (and others, as apparent in media reports and on social media). We will attempt to clarify what our article indicates, what it does not indicate and how the responses to it highlight the need to improve the empirical rigor of research on the impact of circumcision on the sexual lives of men and their partners. Despite the widespread global practice of circumcision, as well as the public beliefs about the procedure, there is limited objective peer-reviewed research assessing the sexual correlates of circumcision. The purpose of our study was to use objective measures to assess penile sensitivity across circumcision status (intact, circumcised). We examined sensitivity on certain penile areas, as well as on the forearm, with a focus on the glans penis and the foreskin, using touch (punctate or fine touch pressure, pain) and heat (warmth detection, heat pain). The stimulus modalities we used are expected to activate penile nerve fibers more likely associated with sexual pleasure than measuring fine touch pressure thresholds alone. Statistical analyses revealed that the sensory thresholds of intact and circumcised men were remarkably similar - hence, the data were collapsed across the 2 groups. Although presented in graphic format in the full article, we have included a breakdown of descriptive statistics in this response, as requested by Frisch and Van Howe et al (see table). To reiterate the findings of the study, the foreskin was observed to be most sensitive to fine touch pressure thresholds. Indeed, this finding replicated the results reported by Sorrells et al. However, fine touch pressure, which was only 1 of 4 stimulus modalities assessed, activates nerve fibers that are likely less relevant for sexual pleasure than fibers activated by the other stimuli used in this study (stimuli that did not exhibit significant between group differences). Therefore, we maintain that we “failed to consistently replicate the findings by Sorrells et al across stimuli” (emphasis added). We also urge caution in the over-interpretation of this result (that the fine touch pressure threshold at the foreskin was significantly less than in other areas). This finding alone does not prove that circumcision reduces penile sensitivity, and it also does not prove that circumcision has no impact on the sexual lives of men. Insisting that this finding supports either the pro or anti-circumcision “camp” is not warranted, as it does not take into account the other study findings and ignores the limitations (e.g. small sample size). Instead, we consider the outcome of this study an indication of the need for further examination. In light of the misinterpretations of our findings we believe it necessary to further clarify what the results of this particular study do not indicate. The results of this series are not to be taken as the definitive answer concerning the circumcision debate. As we discuss in the article, the results do not address the role of the foreskin during sexual activity, nor was the study, as Rotta suggests, an exploration of the biomechanics of the foreskin during intercourse (an interesting question, indeed, but one that would be incredibly difficult to measured and one that we did not examine). This study was not an exploration of the direct impact of circumcision status on sexual function or on the experience of sexual pleasure. Furthermore, and importantly, we do not state whether the findings offer support to either side of the circumcision debate, but instead highlight the need for more empirically rigorous research. The strong reactions to this self-described preliminary study highlight the need for more research and serve as a “call to arms” for researchers interested in examining the sexual correlates of circumcision. This body of research is plagued by weak study design, such as the inclusion of non-random samples, equating outcomes of adult and neonatal circumcision without evidence to suggest that the 2 are comparable, failure to control for participant expectations of study outcomes and reliance on self-report to the exclusion of objective measures. These shortcomings represent a serious problem in this contentious field because they allow room for participant and author bias. One does not have to search far for these biases in the circumcision literature, such as frequent references to non-peer-reviewed articles and author involvement in anti or pro-circumcision advocacy groups. Are we, as scientists, not responsible for stepping back from questions about which we have a personal stake in the outcome? Research in this area should be conducted by those who are not personally invested in the circumcision debate. That was our initial goal. But following the severe reactions we have received, we wonder about who would want to continue (or even start) working on this topic without biased motivations. However, that is not what science is about. As comedian John Oliver stated in a recent commentary on the current state of science, “In science you don’t just get to cherry pick the parts that justify what you were going to do anyway.” We will continue to report what the data show, regardless of whether that reflects the popular vote, and hope that others in this field do the same. Journal of Urology, Vol. 196 (December 2016), 1821-26. References and the table referred to in the authors’ reply have been omitted. The original article, Examining Penile Sensitivity in Neonatally Circumcised and Intact Men Using Quantitative Sensory Testing by J.A. Bossio, C.F. Pukall and S.S. Steele, was published in Journal of Urology, Vol. 195 (June 2016) 1848-53. <h2>Impact of circumcision on body image and sexual function</h2> ABSTRACT Research exploring the impact of circumcision on the sexual lives of men has failed to consider men’s attitudes toward their circumcision status, which may, in part, help to explain inconsistent findings in the literature. … Men who were circumcised as adults or intact men reported higher satisfaction with their circumcision status than those who were circumcised neonatally or in childhood. Lower satisfaction with one’s circumcision status—but not men’s actual circumcision status—was associated with worse body image and sexual functioning. These findings identify the need to control for attitudes toward circumcision status in the study of sexual outcomes related to circumcision. Future research is required to estimate the number of men who are dissatisfied with their circumcision status, to explore the antecedents of distress in this subpopulation, and to understand the extent of negative sexual outcomes associated with these attitudes. Jennifer Bossio, Caroline Pukall. Attitude Toward One’s Circumcision Status Is More Important than Actual Circumcision Status for Men’s Body Image and Sexual Functioning. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28894958" rel="noopener" target="_blank">Archives of Sexual Behaviour, early view, 11 September 2017</a> What this study really found is that men are more likely to be happy with being circumcised if they have freely elected the operation for themselves. In other words, the key issue is not age, but consent. <h3> <a id="tim" name="tim"></a>Tim Hammond writes in response:</h3> The Archives of Sexual Behavior recently published findings by Canadian researchers Bossio and Pukall who identify a subpopulation of men subjected to nontherapeutic circumcision as children who experience distress over this genital modification. I personally consider this a validation of my two "circumcision harm" surveys that were published in <a href="http://www.noharmm.org/bju.htm" rel="noopener" target="_blank">1999 (BJU International)</a> and 2017 (<a href="https://www.academia.edu/34195618" rel="noopener" target="_blank">International Journal of Human Rights</a>, with co-author Adrienne Carmack). Although Bossio downplays that the distress might be related to any actual physical or sexual harm, she believes that a man's attitude toward his circumcision plays a larger role in the distress. Many years ago, circumcision advocate Edgar Schoen dismissed men's concerns by saying he thought the problem with these men lies more between their ears than between their legs. At the time, I took great offense to that comment, but I have come to believe that such comments presaged what is now being discussed relative to childhood MGM. To her credit Bossio consistently refers to the intact penis and to intact men, rather than uncircumcised, and discusses the "loss of the natural foreskin". She also called for more research into the "antecedents" of circumcision distress. I consider that the adverse physical, sexual, emotional and self-esteem consequences of NTC addressed in both of my surveys are among the "antecedents" to which refers. In her present article, Bossio did reference my 1999 survey, but not in relation to harm, rather with regard to the phenomenon of foreskin restoration. The 2017 Hammond/Carmack survey was just published in March of this year, so I'm sure it was not yet on Bossio's radar as she prepared her manuscript. Also to her credit Bossio suggests that this circumcision "distress" experienced by an as yet undetermined number of adult men should be addressed by medical associations when formulating any future policy statements regarding infant circumcision. I heartily agree. Tim Hammond is founder of the <a href="http://www.circumcisionharm.org/" rel="noopener" target="_blank">Circumcison Harm Survey</a>. References Earp, B. D., & Darby, R. <a href="http://pennjil.com/2017-penn-jil-online-symposium-circumcision-in-germany/" rel="noopener" target="_blank">Circumcision, sexual experience, and harm</a>. University of Pennsylvania Journal of International Law, 37(2) 2017, online symposium. Robert Darby & Laurence Cox. <a href="https://www.academia.edu/7104780/Objections_of_a_sentimental_character_The_subjective_dimension_of_foreskin_loss" rel="noopener" target="_blank">Objections of a sentimental character: The subjective dimensions of foreskin loss</a>. See also in-depth discussion on this site: <a href="https://www.darboninstitute.org/unquantifiable_subjectivity_circumcision_harms" rel="noopener" target="_blank">The unquantifiable subjectivities of circumcision harm</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 Circumcision cuts sexual satisfaction 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>Deaths and complications from circumcision in Australia as reported in selected Australian sources, 1919-2006</h2> <div class="indent"> <h3>1. Deaths</h3> <table class="table100pc"> <tbody> <tr> <th class="lightblue">Date</th> <th class="lightblue">Details</th> <th class="lightblue">Source</th> </tr> <tr> <td class="grey">1919</td> <td class="grey">Tuberculosis contracted during circumcision.</td> <td class="grey">Webster, MJA, 27 May 1939, 796-8</td> </tr> <tr> <td>1943</td> <td>Gangrene following circumcision.</td> <td>Barrett, MJA, 11 Dec 1943, 490</td> </tr> <tr> <td class="grey">1953</td> <td class="grey">Begg noted that figures for deaths from circumcision were not available, but reported Gairdner’s observation (1949) of 16 deaths annually in England and Wales for period 1942 to 1947 and commented: “There was every reason to believe that a proportionate mortality would prevail in Australia.”</td> <td class="grey">Begg, MJA,25 April 1953, 603-4</td> </tr> <tr> <td>1965</td> <td>“Dr R. Southby mentioned two neonatal deaths which had resulted from infection after circumcision in the last year, and other instances of surgical complications leading to litigation.”</td> <td>MJA, 28 August 1965, 393</td> </tr> <tr> <td class="grey">1966</td> <td class="grey">Two deaths from haemorrhage.</td> <td class="grey">Schlicht and Aberdeen, MJA, 27 August 1966, 436</td> </tr> <tr> <td>1967</td> <td>Report of one death in 1963 and one in 1964 as recorded by Commonwealth Statistician, who commented: “Figures of deaths from complications of circumcision for other reasons [other than ritual or preventive] are not available.”</td> <td>Wright, MJA, 27 May 1967, 1084</td> </tr> <tr> <td class="grey">1969</td> <td class="grey">Fredman noted that official statistics reported two deaths from 1959 to 1969, but added: “There is probably no adequate record of morbidity.”</td> <td class="grey">Fredman, MJA, 18 Jan 1969, 117-20</td> </tr> <tr> <td>1977</td> <td>Death from meningitis.</td> <td>Scurlock and Pemberton, MJA, 5 March 1977, 332-4</td> </tr> <tr> <td class="grey">1993</td> <td class="grey">Death from anaesthetic overdose, Brisbane. Reported by Queensland Law Reform Commission, Circumcision of Male Infants Research Paper, Brisbane 1993, p. 32</td> <td class="grey">Qld Law Reform Commission</td> </tr> </tbody> </table> <h3>2. Complications</h3> <table class="table100pc"> <tbody> <tr> <th class="lightblue">Date</th> <th class="lightblue">Details</th> <th class="lightblue">Source</th> </tr> <tr> <td class="grey">1920</td> <td class="grey">Tuberculosis following circumcision</td> <td class="grey">MJA, 24 June 1939, 942-3</td> </tr> <tr> <td>1965</td> <td>Two cases of infection, one with septicaemia and pneumonia, the other with Staphlycoccus</td> <td>Birrell, MJA, 28 August 1965, 393</td> </tr> <tr> <td class="grey">1966</td> <td class="grey">Infection leading to loss of a third of penis.</td> <td class="grey">See reference 6 below</td> </tr> <tr> <td>1970</td> <td>Leitch reported the incidence of complications at 15.5 per cent.</td> <td>Aust Paediatric Journal, 6, 1970, 59-65</td> </tr> <tr> <td class="grey">1972</td> <td class="grey">“Examining large numbers of children at school medical inspections over the last few years I am appalled at the phallic mutilations exhibited by many of these children, some of whom have even been subjected to a subsequent “tidying up” procedure after being badly mauled in infancy.”</td> <td class="grey">A. Clements, letter, MJA, 29 April 1972, 946</td> </tr> <tr> <td>1977</td> <td>Four cases of meningitis: one OK, one mildly retarded, one seriously retarded, one fatal.</td> <td>Scurlock and Pemberton, MJA, 5 March 1977, 332-4</td> </tr> <tr> <td class="grey">1982</td> <td class="grey">Meningitis: subsequent history unknown</td> <td class="grey">Procopius and Kewley, MJA, 9 January 1982, 15</td> </tr> <tr> <td>1997</td> <td>Two babies in Sydney suffer severe blood oxygen deprivation (hypoxaemia and methaemoglobinaemia) after administration of prilocaine as local anaesthetic during circumcision; authors of report note that both EMLA cream and prilocaine are not safe for use on very young babies.</td> <td>Prineas, Wilkins and Halliday, MJA, 2 June 1997, 615</td> </tr> <tr> <td class="grey">1997</td> <td class="grey">Shane Peterson in Perth successfully sues doctor who circumcised him as an infant for excessive tissue removal, leading to erectile difficulties and constant pain.</td> <td class="grey">See reference 7 below.</td> </tr> <tr> <td>1997</td> <td> Baby “nearly bleeds to death” after circumcision by Dr Aladdin Mattar, later deregistered. Details at <a href="http://www.nswmb.org.au/download.pl?param=143">www.nswmb.org.au/download.pl?param=143</a>. </td> <td> Daily Telegraph, 14 June and 17 Sept. 2000 </td> </tr> <tr> <td class="grey">2002</td> <td class="grey">RACP unable to give firm estimate of complications, but notes that reported incidence ranged from 2 to 10 per cent.</td> <td class="grey">RACP, Position statement on circumcision, September 2002</td> </tr> <tr> <td>2006</td> <td>Dr Suman Sood deregistered for ten years by NSW Medical Board for misconduct in relation to both abortion and circumcision, including an excessive incidence of circumcision complications. Details at <a href="http://www.nswmb.org.au/%20system/files/f10/f20/o585//SOOD.pdf">www.nswmb.org.au/ system/files/f10/f20/o585//SOOD.pdf</a> </td> <td>NSW Medical Board determination 774 of 2005, 6 October 2006.</td> </tr> <tr> <td class="grey">2010</td> <td class="grey">Melbourne Doctor Mohammed Mateen Ui Jabbar suspended for three months after incompetent circumcision of 2-year old boy using Plastibell device, resulting in severe injury to penis and and need for plastic surgery.</td> <td class="grey"><a href="https://www.circinfo.org/news.html#jabbar">See News Page</a></td> </tr> </tbody> </table> </div> <h2> <a id="adverse" name="adverse"></a>Adverse circumcision outcomes under-reported</h2> Unlike in underdeveloped countries, such as Turkey, Iran or Nigeria, where the incidence of serious adverse outcomes from circumcision runs as high as 20 per cent, [1] it is clear that deaths or serious complications from circumcision are not common in developed countries. Australia has an enviable record with respect to deaths from circumcision, none having been reported since 1993. There is, however, no room for complacency. As well as good medical practice, the absence of such reports is as much a consequence of the declining and now low incidence of infant circumcision and the difficulty of attributing deaths to circumcision when they are the result of later complications, such as infection, or of long term sequelae, such as depression and suicide. As shown on the above table, several authorities agree that there is no reliable record of mortality, and the Australian Institute of Health and Welfare has admitted that their statistics cannot identify deaths due indirectly to circumcision: “We have information on circumcision and there are external cause codes for complications of medical and surgical care. However, it is not possible to tell if the complication was a result of the circumcision. For example, the circumcision may have been undertaken in a previous admission, and the patient readmitted with a complication. If this was the case, we couldn’t tell that it was the same patient and we wouldn’t know for sure that the complication was due to the circumcision.” [2] It is a similar picture with respect to complications, the incidence of which is the subject of wide disagreement. In 1970 Leitch suggested a rate of 15.5 per cent, [3] while more recently the Royal Australasian College of Physicians cites estimates ranging from an implausible 0.06 per cent to an equally unlikely 55 per cent, depending on definition. It seems to regard a likely incidence as falling within the range of 2 to 10 per cent, and it warns that “serious complications, such as bleeding, septicaemia and meningitis may occasionally cause death”. [4] If the rate of complications is 15, 10 or even only 2 per cent, it is apparent that the small number of cases that get publicly reported represent only the tip of the iceberg; this under-reporting contributes to the illusion that circumcision is a safe and “harmless” operation. [5] Whatever the figure – and it seems unlikely that definitive statistics will ever emerge – it will readily be agreed that there must be a lower threshold of tolerance for adverse outcomes from unnecessary or cosmetic surgical procedures than from those which are genuinely required for a person’s health. This principle is all the more important when the person does not choose the surgery for himself. References: <ol> <li id="ref1">Ozdemir E. <a href="http://www.cirp.org/library/complications/ozdemir/">Significantly increased complications risk with mass circumcision</a>. British Journal of Urology 1997; 80: 136-139; Yegane RA, Kheirollahi AR, Salehi NA, et al. Late complications of circumcision in Iran. Padiatr Surg Int, 2006; 22: 442-445. A study of neonatal circumcision in Nigeria found a complication rate of 20.2 percent, with 3.1 per cent of the operations resulting in amputation of part of the glans – Okeke LI, Asinobi AA, Ikuerowo OS. Epidemiology of complications of circumcision in Ibadan, Nigeria. BMC Urology, 2006; 6: 21</li> <li id="ref2">Narelle Grayson, Hospitals and Mental Health Services Unit, AIHW, email message to Shane Peterson, 14 January 2004</li> <li id="ref3">I.O.W. Leitch, <a href="http://www.cirp.org/library/general/leitch1/">Circumcision: A continuing enigma</a>, Australian Paediatric Journal, Vol. 6, 1970, 60</li> <li id="ref4"><a href="http://www.racp.edu.au/page/health-policy-and-advocacy/paediatrics-and-child-health">RACP Policy statement on circumcision, 2009</a></li> <li id="ref5">Circumcision practitioners in Australia boast that the method they usually employ, the plastibell device, is painless, non-surgical and completely safe. All these claims are false and misleading. Because the foreskin is densely networked with nerves, cutting (or any rough handling) there is extremely painful; EMLA cream commonly used to dull the pain is not fully effective and is not recommended for use on the very young. Because the removal of the foreskin involves the amputation of tissue, it is certainly surgery. And there are over a dozen references in the medical literature to complications arising from use of the plastibell device. As recently as 2007 a baby boy in Canada died as a direct consequence of a plastibell circumcision. <a href="http://www.cirp.org/library/complications/EMLA/">Details of the dangers of EMLA cream</a> <a href="http://www.cirp.org/library/death/">Further information about deaths</a> <a href="http://www.cirp.org/library/complications">Further information about complications</a> </li> <li id="ref6">The victim sued the hospital and in 1987 was awarded $275,000 damages. Case reported in Australian Torts Reports 1987, Case 80-130, St Margaret’s Hospital for Women, Sydney, v. McKibbin; case discussed in Gregory J Boyle, J Steven Svoboda, Christopher P Price, J Neville Turner. <a href="http://www.cirp.org/library/legal/boyle1/">Circumcision of Healthy Boys: Criminal Assault?</a> 7 J Law Med 301, 2000; and Frank Bates. <a href="http://www.cirp.org/library/legal/bates1/">Males, medical mutilation and the law: Some recent developments</a>. 9 J Law Med 68, 2001</li> <li id="ref7">Shane Peterson, “Assaulted and mutilated: A personal account of circumcision trauma”, in George Denniston, Frederick Hodges and Marilyn Milos (eds), Understanding Circumcision: A Multi-disciplinary Approach to a Multi-dimensional Problem (London and New York: Kluwer Academic and Plenum Press, 2000).</li> </ol> <h2>Death of Ryleigh McWillis after Plastibell circumcision</h2> The following letter was sent by Circumcision Information Australia to the medical board in each state and territory in Australia, and to state health departments in South Australia, New South Wales and Queensland in March 2004. Risks associated with circumcision of male infants and children A recent Coroner's report from the province of British Columbia in Canada indicates that the risks inherent in the circumcision of male infants are greater than commonly appreciated. <a href="http://www.circumstitions.com/death-exsang.html">We enclose a copy of the Coroner's report</a> for your information. The report shows that the baby, Ryleigh Roman Bryan McWillis, aged one month, was circumcised in the Penticton Regional Hospital on 20 August 2002. He was released from the hospital into the care of his parents; suffered extensive bleeding from the wound; was returned to Penticton Hospital; and was subsequently transferred to the B.C. Children's Hospital, where he died less than 48 hours after the operation. The Coroner concluded that the death was due to "multiorgan hypoxic/ischemic injury due to hypovolemic shock as a result of massive hemorrhage from a circumcision site." Tragic though it is, there is nothing extraordinary in this outcome: bleeding and death are well-known complications of circumcision. [1-3] A similar case was reported by the Miami Herald in 1993, [4] a case occurred in Ireland in 2003, [5] and cases have also been recorded in Australia. (See below and Attachment 1.) Since the prepuce is highly vascularized, it is likely to haemorrhage when cut, and severing of the frenular artery is also possible during circumcision procedures. [6] Infants have a very small volume of blood in their bodies, and they can tolerate only about a 20 per cent blood loss before hypovolemia and hypovolemic shock set in, followed quickly by death. A 4000 gram male newborn has only 11.5 oz (340 ml) of total blood volume at birth, 85 ml per kilogram of weight. [7] Blood loss of only 2.3 oz (68 ml) - about a quarter of a cup - represents 20 per cent of total blood volume at birth, and is sufficient to cause hypovolemia. [8] The quantity of blood loss that might kill an infant - 85 ml - is easily concealed in today's highly absorbent diapers: Ryleigh's parents were quoted by the Canadian Broadcasting Corporation as stating that they had no way to know that their baby boy was bleeding to death. [9] Circumcision of infants, even in optimum conditions, thus carries an inherent danger of hypovolemic shock and death. The Coroner further shows that the doctor at Penticton Hospital performed the circumcision in the absence of any medical indication or need, but at the request of his parents. This practice - needless circumcision at parental request - is thus shown to be hazardous to children's lives. As Watters and Carroll have shown in their study of parental attitudes in rural New South Wales, parents rarely appreciate the risks associated with the excision of an infant's prepuce, and are ill-equipped to make decisions that should properly be made after expert paediatric advice or left to the boy himself. [10] It is a widely accepted principle that the primary duty of doctors is to consider the well-being of their patient above all else. [11] Medically unnecessary circumcisions at parental request are inconsistent with that paramount duty. Doctors must comply with ethical guidelines issued by the Australian Medical Association to "practise the science and art of medicine to the best of your ability." [12] Circumcision of male infants in the absence of any medical indication or need carries serious risks, offers no significant therapeutic benefit, and is inconsistent with those duties. Parents have a duty to protect their children and to act in their best interests. [13] Non-therapeutic circumcision of children infringes children's legal right to bodily integrity and their rights as human beings to life and security of person. [14] Election of medically unnecessary circumcision is inconsistent with parents' responsibilities to the child; indeed, it is debatable whether it is legally possible for them to give valid consent to the non-therapeutic circumcision of an incompetent minor. [15] We do not suggest that deaths or serious complications from circumcision are common in developed countries: Australia has an enviable record with respect to deaths from circumcision, none having been reported since 1993. There is, however, no room for complacency. As well as good medical practice, the absence of such reports is as much a consequence of the declining and now low incidence of infant circumcision (see Attachment 2) and the difficulty of attributing deaths to circumcision when they are the result of later complications, such as infection, or of long term sequelae, such as suicide. Several authorities agree that there is no reliable record of mortality (see Attachment 1), and the Australian Institute of Health and Welfare has admitted that their statistics cannot identify deaths due indirectly to circumcision: "We have information on circumcision and there are external cause codes for complications of medical and surgical care. However, it is not possible to tell if the complication was a result of the circumcision. For example, the circumcision may have been undertaken in a previous admission, and the patient readmitted with a complication. If this was the case, we couldn't tell that it was the same patient and we wouldn't know for sure that the complication was due to the circumcision." [16] It is a similar picture with respect to complications, the incidence of which is the subject of wide disagreement. In 1970 Leitch suggested a rate of 15.5 per cent, [17] while more recently the Royal Australasian College of Physicians cites estimates ranging from an implausible 0.06 per cent to an equally unlikely 55 per cent, depending on definition. It seems to regard a likely incidence as falling within the range of 2 to 10 per cent, and it warns that "serious complications, such as bleeding, septicaemia and meningitis may occasionally cause death". [18] If the rate of complications is 15, 10 or even only 2 per cent, it is apparent that the small number of cases that get publicly reported represent only the tip of the iceberg; this understatement contributes to the impression that circumcision is a safe operation. Whatever the figure - and it seems unlikely that definitive statistics will ever emerge - it will readily be agreed that there must be a lower threshold of tolerance for adverse outcomes from unnecessary or cosmetic surgical procedures than from those which are required for a person's health. This principle is all the more important when the person does not choose the surgery for himself. Although the incidence of circumcision in Australia is low by historic standards (around 12 per cent, compared with about 50 per cent in the early 1970s), there has been a gradual increase since 1993, and it is still disturbingly prevalent in New South Wales, South Australia and Queensland. If the frequency of the operation continues to increase, complications and adverse outcomes will become more common. It is clear that the surest way to avoid both complications and death from circumcision is by not performing the operation in the first place. Your attention is particularly drawn to the disturbingly high and increasing incidence of circumcision in New South Wales. Its frequency has risen by about 30 per cent over the past ten years and is now double that found in Victoria, the ACT, Tasmania, Western Australia and the Northern Territory. We suggest that the Canadian tragedy makes it timely to remind medical practitioners of the unavoidable risks of surgery and of their duty to protect infants and children from procedures that are not needed for, and which may well harm, their health and happiness. By ratifying the United Nations Convention on the Rights of the Child, Australia has pledged itself to protect children from "traditional procedures prejudicial to the health of children", [19] and it is hard to see how non-therapeutic male circumcision would not fall into that category. We seek your advice on how you propose to ensure that tragedies like the McWillis case do not occur in your state. We also ask you to advise us on whether you would be willing to adopt measures in order to: <ul> <li>alert health care providers to this incident;</li> <li>ensure that they follow the recommendations of the RACP's Policy statement on circumcision (2002) in warning parents who seek the operation of the real risks of the procedure;</li> <li>remind them that is their duty to act in the best interests of the child;</li> <li>point out that circumcision should be performed only when there is a compelling and immediate medical indication, and only after conservative treatments of foreskin problems have failed. (Medical ethics dictate conservative treatment prior to radical surgery involving amputation of tissue. [20])</li> </ul> We believe that such reminders would go far towards minimising the danger of exsanguination, hypovolemic shock and death as a consequence of non- therapeutic circumcision and greatly reduce the risk of adverse outcomes from therapeutically or otherwise justified circumcision. We urge that you take appropriate action and thereby continue to fulfil your board's obligation to protect the public, [21] especially its smallest and weakest members. Yours sincerely Shane Peterson Circumcision Information Australia 22 March 2004 References A pdf copy of the Coroner's report is available here. <a href="http://www.cirp.org/library/death/">http://www.cirp.org/library/death/</a> 1. Williams N, Kapila L. <a href="http://www.cirp.org/library/complications/williams-kapila/">Complications of circumcision</a>. Brit J Surg 1993; 80: 1231-6 2. Fetus and Newborn Committee, Canadian Paediatric Society (CPS). Neonatal circumcision revisited. Can Med Assoc J 1996; 154(6):769-80. <a href="http://www.cps.ca/english/statements/FN/fn96-01.htm">http://www.cps.ca/english/statements/FN/fn96-01.htm</a> 3. Beasley S, Darlow B, Craig J, et al. <a href="https://www.circinfo.org/previous_statements.html">Position statement on circumcision</a>. Sydney: Royal Australasian College of Physicians, 2002 <a href="http://www.racp.edu.au/hpu/paed/circumcision/"></a> 4. Baby bleeds to death after circumcision. Miami Herald, June 26, 1993. <a href="http://www.cirp.org/news/1993.06.21_death/">http://www.cirp.org/news/1993.06.21_death/</a> 5. Neans McSweeney. Baby dies after botched circumcision. Irish Examiner, Cork, Thursday, 21 August 2003 <a href="http://www.cirp.org/news/irishexaminer08-21-03b/">http://www.cirporg/news/irishexaminer08-21-03b/</a> 6. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44. <a href="http://www.cirp.org/library/anatomy/cold-taylor/">http://www.cirporg/library/anatomy/cold-taylor/</a> 7. Paediatric Handbook, editors J Smart, T Nolan, Sixth Edition, Blackwell Science Asia, Carlton South, Victoria, Australia, 2000, page 82. 8. Glancy GL. Shock in children warrants special considerations. Ski Patrol Magazine 1997, Summer 9. Canadian Broadcasting Corporation, Wednesday, 11 February 2004. Circumcision under attack. <a href="http://www.cirp.org/news/cbc02-11-04a/">http://www.cirp.org/news/cbc02-11-04a/</a> 10. Greg Watters and John Carroll, <a href="https://www.circinfo.org/watters.html">Just like dad: Maternal attitudes to neonatal circumcision in an Anglo-Celtic society</a>, paper given to Urological Society of Australasia, Scientific Meeting, Queenstown, NZ, 6 March 2003 <a href="http://www.circinfo.org/news.html"></a> 11. Australian Medical Association. <a href="https://www.circinfo.org/ethics.html">Code of Ethics</a> (1996). <a href="https://www.ama.com.au/web.nsf/doc/WEEN-5WW598"></a> 12. Ibid. 13. Beasley S, Darlow B, Craig J, et al. Position statement on circumcision. Sydney: Royal Australasian College of Physicians, 2002. <a href="http://www.racp.edu.au/hpu/paed/circumcision/"></a> 14. Articles 3 and 5. Universal Declaration of Human Rights, G.A. res. 217A (III), U.N. Doc A/810 at 71 (1948). <a href="http://www1.umn.edu/humanrts/instree/b1udhr.htm">http://www1.umn.edu/humanrts/instree/b1udhr.htm</a> 15. Gregory J Boyle, J Steven Svoboda, Christopher P Price, J Neville Turner. Circumcision of Healthy Boys: Criminal Assault? 7 J Law Med 301 (2000). <a href="http://www.cirp.org/library/legal/boyle1/">http://www.cirp.org/library/legal/boyle1/</a> 16. Narelle Grayson, Hospitals and Mental Health Services Unit, AIHW, email message to Shane Peterson, 14 January 2004 17. I.O.W. Leitch, "Circumcision: A continuing enigma", Australian Paediatric Journal, Vol. 6,1970, 60 <a href="http://www.cirp.org/library/general/leitch1/">http://www.cirp.org/library/general/leitch1/</a> 18. RACP Policy statement on circumcision, 2002<a href="http://www.racp.edu.au/hpu/paed/circumcision/"></a> 19. Article 24.3, U.N. Convention on the Rights of the Child (1989). UN General Assembly Document A/RES/44/25. <a href="http://www1.umn.edu/humanrts/instree/k2crc.htm">http://www1.umn.edu/humanrts/instree/k2crc.htm</a> 20. Committee on Medical Ethics. <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">The law & ethics of male circumcision - guidance for doctors</a>. London: British Medical Association, 2003. 21. New South Wales, Medical Practice Act 1992. Section 2A (1) <h2>Melbourne doctor suspended after plastibell circumcision goes wrong</h2> Melbourne, 12 November 2010: A Melbourne doctor has been suspended for inflicting severe injuries on a 2-year old boy during a “routine” circumcision operation. The boy was circumcised by Dr Mohammed Mateen Ui Jabbar, using the plastibell device on 29 January 2008, as a result of which he suffered gross swelling and severe scarring of his penis. The boy was unable to urinate after the operation and was taken to the Royal Children’s Hospital, where he required surgery to remove the plastibell device and six further operations on his penis, including plastic surgery. Dr Jabbar's disciplinary hearing at the Victorian Civil and Administrative Tribunal was held on 11-12 October, and the determination issued on 5 November. The case was reported in the Melbourne <a href="http://www.heraldsun.com.au/news/victoria/doctor-barred-but-still-at-work/story-e6frf7kx-1225952335067">Herald-Sun</a> on 11 November; the <a href="http://www.austlii.edu.au/au/cases/vic/VCAT/2010/1772.html">full determination can be read</a> at the Australasian Legal Information Institute (<a href="http://www.austlii.edu.au/au/cases/vic/VCAT/">Austlii</a>). This was the fourth time that Dr Jabbar had been reprimanded by the Victorian Medical Board, despite which he has been permitted to continue practising until his 3-month suspension takes effect on 22 November 2010. On previous occasions the doctor had been reprimanded for improperly touching a woman’s breasts and for prescribing testosterone for a male client without medical need. During an examination in 2006, the woman had asked for a routine skin inspection, but instead Dr Jabbar had squeezed her breasts and told her she needed cosmetic surgery because they were sagging but could be corrected with a breast lift or implants. On this occasion Dr Jabbar was reprimanded by the Medical Board and ordered to undergo counselling sessions. The fate of the boy is similar to a <a href="http://www.circumstitions.com/death.html#blocked">case in Canada</a>, where a baby boy died after circumcision with the plastibell device, which strangled his penis and blocked the urine passage. The <a href="http://www.circumstitions.com/methods.html#plastibell">plastibell device</a> is the most common method of circumcision used in Australia today. It consists of a kind of tourniquet that is tightened around the penis, thus strangling the foreskin, cutting of the blood supply and causing the tissue to die and fall off. It is similar to the rubber ring devices commonly used on farms to castrate calves and lambs. Some circumcision providers call this a bloodless or non-surgical method, but the truth is that any removal of tissue is surgery and will involve blood if the foreskin needs to be cut in order to apply the device. In another Canadian case a <a href="https://www.circinfo.org/canada_death.html">baby bled to death</a> after a routine circumcision using the plastibell. <a href="http://www.cirp.org/library/complications/" rel="noopener" target="_blank">Complications from plastibell circumcision</a> operations are quite common. <h3>Sex discrimination – against boys</h3> It is instructive to compare the mild censure given to Dr Jabbar with the criminal charges brought against Dr Graham Reeves, the “<a href="https://en.wikipedia.org/wiki/Butcher_of_Bega">butcher of Bega</a>”, for mutilating operations on women. At his trial in Sydney Dr Reeves attempted to defend his actions – involving the surgical removal of all or part of the external genitals of his female patients – by claiming that he was only doing it to save their lives. We might call this the circumcisers’ defence, since advocates of male circumcision likewise claim that they only circumcise boys in order to save them from future health problems or death from the terrible diseases they are sure to pick up if their foreskin is allowed to survive. It would appear that while doctors who harm women can end up on criminal charges, the most a doctor who harms boys can fear is a gentle slap on the wrist. One wonders how many other boys have suffered disfiguring injuries at the hands of Dr Jabbar. <h3>Disciplinary action against medical practitioners</h3> In 2010 State medical boards were replaced by a Commonwealth body, the <a href="http://www.ahpra.gov.au/Complaints-and-Outcomes/Decisions.aspx">Australian Health Practitioner Regulation Agency</a>. Details of charges of misconduct brought against medical practitioners can be searched on its website. <h2>Another reason not to circumcise: Australia faces big MRSA problem</h2> THE growing incidence of methicillin-resistant Staphylococcus aureus (MRSA) in the community has highlighted the need for Australian clinical practice guidelines to be developed for its treatment, experts say. Associate Professor Graeme Nimmo, State Director of Microbiology for Pathology Queensland and president of the Australian Society for Antimicrobials (ASA), said the steady increase in the prevalence of community MRSA was of national concern and all doctors and members of the community needed to be aware of it. He said it now accounted for 15-20% of all S. aureus infections in Australia and that rate was increasing. “The prevalence has been increasing steadily in the past decade,” he said. Professor Nimmo, who is also chair of the Australian Group for Antimicrobial Resistance, said MRSA appeared to be under control in hospitals, thanks to infection control initiatives. “Hospital strains [of MRSA] are not on the increase; in fact, they seem to be decreasing, but they are being replaced by the community ones,” he said. Professor Keryn Christiansen, a past president of both the ASA and the International Society for Infectious Diseases (ASID), said community MRSA was a major problem, particularly as it was infecting young, healthy people. It was extremely important for GPs to be aware of the big problem of community-acquired MRSA and to be able to recognise these infections, which were characterised by “a lot of pus”, she said. “I see people who come into hospital who require drainage and they have gone to their GP who has just put them on standard anti-Staph therapy that has no effect on MRSA,” Professor Christiansen, clinical microbiologist at PathWest Laboratory Medicine, Royal Perth Hospital, WA, said. The number one treatment was drainage of boils and abscesses, followed by broad-spectrum antibiotic therapy, culture and testing, and a change of antibiotics if MRSA was found on culture and sensitivity testing. Strains of particular concern that were becoming more common in Australia produced a toxin called Panton‒Valentine leukocidin (PVL), which caused more severe disease with a lot of pus formation and abscesses and required drainage and a longer hospital stay, Professor Christiansen said. “[PVL-positive MRSA] is sweeping across Australia and now accounts for around 20% of our community MRSA in WA and the vast majority of community MRSA on the east coast,” she said. “The other major worrying side of this is that the PVL-positive clones are infecting young, healthy people … in their teens, 20s and 30s.” Comment by A/Prof Michael Guinness Our experience exactly. I work in country NSW, where CA-MRSA has gone from nil in 2000 to 27% of all S.aureus isolated in 2009. Of shared concern is the greatly increased number of otherwise healthy young patients who are now being hospitalised for surgical management. … We have had four deaths so far ... how many more do they need before becoming proactive? Source: MJA Insight, Monday 17 January 2011 Comment: Doctors’ surgeries or specialist clinics where minor procedures such as circumcisions are performed are prime sites for the presence of MRSA, and pose a real risk of infection any time the skin is cut or punctures. This is yet another reason why unnecessary surgeries such as non-therapeutic circumcision should be avoided. <h2>Warning on risks of Plastibell circumcision device</h2> The authors of a study circumcision complications issue a particular warning against the Plastibell circumcision device, used on nearly 60% of the boys in their survey who required emergency treatment, pointing out that is not as safe as claimed by the circumcision providers and “specialist circumcision clinics” that commonly use it. They identify 4 recent studies detailing complications arising from the device and comment: “While it is reported to be a quick and simple method preferred by many providers, these studies have revealed method-dependent concerns. This includes concern about what is the appropriate length of time for the device to be retained, an increase in infection and increase in analgesia requirement post-operatively. We identified that 54 boys (58.7%) were circumcised by this method in the community. There was particular concern and poor understanding about the appropriate length of time the Plastibell ring should remain in situ, which could be addressed in improved information for parents.” Source: Grace Gold, Simon Young, Mike O’Brien, Franz E Babl. <a href="http://onlinelibrary.wiley.com/doi/10.1111/jpc.12960/abstract" rel="noopener" target="_blank">Complications following circumcision: Presentations to the emergency department</a>. Journal of Paediatrics and Child Health 51 (December 2015): 1158–1163. <h2>Melbourne 2015: High incidence of circumcision complications</h2> A study in Melbourne has found a disturbingly high incidence of circumcision complications requiring emergency treatment. Over a period of 29 months 167 boys were brought to the Royal Children’s Hospital casualty department suffering from circumcision-related injuries. The principal problems were: bleeding (53.9%), pain (38.3%), swelling (37.1%), redness (25.7%), decreased urine output (13.8%), fever (7.2%) and infection (6%). In addition, 29.9% were brought in because parents were shocked at the ugly post-circumcision appearance of the boy’s penis. About half the circumcisions (54%) had been performed for religious/cultural reasons, 30% for so-called medical reasons, and the remainder for reasons unknown. There was some difference in the incidence of complications between hospital-performed operations (40%) and those performed in the community, presumably by GPs and “specialist” clinic (60%), but not enough to justify the common assumption that hospital-performed operations are completely safe. The mean age of the boys was 3 years, but the boys circumcised by so-called community operators were much younger and had the highest incidence of complications. Since the total number of circumcision operations performed is unknown, it is impossible to work out the rate of complications, but 167 emergency presentations in a 2-year period seems disturbingly high, especially as Victoria’s overall incidence of circumcision is about half that of Australia as a whole (12% nationally). Such injuries represent a cruel burden of pain, suffering and disfigurement on baby boys, and absorb significant public health resources – a situation that is doubly unfortunate as the original surgery was completely unnecessary. While over half (54%) of the circumcisions were performed for cultural/religious reasons (mainly the preference of Muslim parents), 30% of the procedures were for “medical reasons”. Given the age of the boys this figure seems highly dubious and probably reflects mistaken diagnoses of phimosis (usually curable with medications if genuine) or even fraudulent attempts to ensure the Medicare rebate or free hospital treatment. Several other features of the study deserve comment. The age of the boys undergoing hospital circumcision (median age 4.23 years, mean 5.6 years) is markedly higher than those circumcised in the community (median age 3.9 MONTHS, mean 1.4 YEAR). The authors do not adequately discuss this when comparing their associated complication frequencies. While some people will misinterpret this study to claim that hospital doctors are better at circumcision operations than GPs and other community operators, you could just as well argue that infant circumcisions are more often associated with complications than circumcision at older ages. However, both claims may be true or false, and this study does not settle the matter. The study does not demonstrate markedly higher rates of complications following community-based compared hospital-based circumcisions. Since the study base is unknown, we cannot tell what proportions of all performed circumcisions (whether in hospitals or in the community) these 167 cases actually represent. Complications following hospital-based circumcisions are plausibly more likely to result in contacts to the hospital, because parents are routinely instructed by the operator/nurse to contact the emergency department in case of complications. On the other hand, we can only speculate as to what selected part of the total of community-based circumcisions will end up in the emergency department. Self-selection by parents and religious circumcisers of which boys with complications after community-based circumcisions should be referred to the emergency department may result in a skewed group of patients with relatively serious complications. This might partly explain the markedly higher hospital admission rate and greater proportion needing reoperation among community compared with hospital circumcisions. A puzzling feature of Table 1 is that 18 (30%) of the hospital-based circumcisions were of boys from Muslim families, but only 6 (10%) were circumcised for cultural/religious reasons. This means that 12 boys from Muslim families who ended up in the emergency department had been circumcised in the hospital for “medical reasons”. While some such boys may plausibly be referred for the same (often ill-advised or mistaken) “medical reasons” as boys from non-Muslim families, it seems odd that twice the number of hospital-circumcised Muslim boys end up in the ED when the circumcision was performed for medical reasons as compared with cultural/religious reasons (12 vs 6). Plastibell circumcision device criticized The authors of the study also warn that the Plastibell circumcision device, used on nearly 60% of the boys who required emergency treatment, is not as safe as claimed by the circumcision providers and clinics that commonly use it. They identify 4 studies detailing complications arising from the device and comment: “While it is reported to be a quick and simple method preferred by many providers, these studies have revealed method-dependent concerns. This includes concern about what is the appropriate length of time for the device to be retained, an increase in infection and increase in analgesia requirement post-operatively. We identified that 54 boys (58.7%) were circumcised by this method in the community. There was particular concern and poor understanding about the appropriate length of time the Plastibell ring should remain in situ, which could be addressed in improved information for parents.” Comment The whole situation described in this report is very sad. Despite the claim of “medical reason”, very few (if any) of the original circumcision procedures were medically necessary (and thus in the best interests of he child), and the result has been a cruel burden of suffering borne by innocent children and, on top of that, avoidable demands on the public health system. Circumcision advocates are keen to prove that the earlier circumcision is done the safer, but this study suggests the opposite: that it was the youngest boys who suffered the greatest number of complications. From an ethical point of view it hardly matters, as any non-therapeutic circumcision of a minor is in violation of basic bioethical and human rights principles. A more relevant comparison would be between child and adult circumcision, as adults can make their own choices and give informed consent. It is sometimes claimed that “better training” of operators would lead to a lower incidence of complications, but the real problem is the complexity, variability and tiny size of the juvenile penis: there can be little doubt that the only truly effective way to avoid complications <a href="https://www.academia.edu/16720502/To_avoid_circumcision_complications_avoid_circumcision" rel="noopener" target="_blank">not to circumcise in the first place</a>. The authors of the study could have made more effort in their conclusions: it is hard to see that counseling parents as to the appearance of the penis following circumcision does the boys any good. They would have benefited from not being circumcised in the first place. What is needed is regulation of the circumcision industry, as recommended by the Tasmania Law Reform Institute report, and counseling of parents that circumcision is not necessary and not recommended. Source: Grace Gold, Simon Young, Mike O’Brien, Franz E Babl. <a href="http://onlinelibrary.wiley.com/doi/10.1111/jpc.12960/abstract" rel="noopener" target="_blank">Complications following circumcision: Presentations to the emergency department</a>. Journal of Paediatrics and Child Health 51 (December 2015): 1158–1163. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision deaths and complications in Australia 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>Seven-day old baby died after circumcision</h2> DETECTIVES are investigating the death of a seven-day-old baby after he was circumcised. Stunned relatives at the Jewish ceremony saw the toddler experience breathing difficulties. He was taken to hospital but died eight days later. A post mortem found the infant died from cardiac arrest and oxygen starvation. Police are to interview family members and the senior rabbi who performed the operation at Golders Green Synagogue in North London. Concerns raised by doctors treating the baby have led to the probe being led by Scotland Yard’s child abuse investigators. Police and Home Office sources said the investigation was “highly unusual”. A Scotland Yard spokesman stated: “The death is being treated as unexplained at this early stage.” The baby died two weeks ago at University College Hospital, Central London. Circumcision of boys is an operation in which the foreskin is removed from the penis. With small babies, local anaesthetic is often sufficient and avoids the risks of a general anaesthetic. Some people believe the skin is redundant and gets in the way of hygiene. Others say it is a vital part of the male anatomy and should not be removed. Judaism considers circumcision to be an important ritual. The operation is usually performed by a mohel - a specialist in the procedure and its rituals. Many British mohels are doctors, rabbis or both. All have received appropriate medical and religious training. A spokesman for The United Synagogue, a membership of 35 orthodox synagogues in Greater London, said: “We are awaiting the results of the police enquiry and until then it would not be appropriate for us to comment further." The Mirror (London), 15 February 2007, Exclusive by Stephen Moyes <a href="https://tinyurl.com/2db9x5">http://tinyurl.com/2db9x5</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 Circumcision deaths and complications in the UK darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Canada: Circumcision questioned following plastibell death</h1> Opposition to circumcision in Canada is growing rapidly following the death of a baby in the province of British Columbia. The boy bled to death after being circumcised (using the plastibell device) in August 2002. The recently-released report of the BC coroner found that the baby, Ryleigh Roman Bryan McWillis, aged one month, was circumcised in the Penticton Regional Hospital on 20 August 2002. He was released from the hospital into the care of his parents; suffered extensive bleeding from the wound; was returned to Penticton Hospital; and was subsequently transferred to the B.C. Children's Hospital, where he died less than 48 hours after the operation. The Coroner concluded that the death was due to "multiorgan hypoxic/ischemic injury due to hypovolemic shock as a result of massive hemorrhage from a circumcision site." Tragic though it is, there is nothing extraordinary in this outcome: bleeding and death are well-known <a href="http://www.cirp.org/library/complications/">complications of circumcision</a>. A similar case was reported by the Miami Herald in 1993, a case occurred in Ireland in 2003, and cases have also been recorded in Australia. The Coroner further showed that the doctor at Penticton Hospital performed the circumcision in the absence of any medical indication or need, but at the request of his parents. This practice – needless circumcision at parental request – is thus shown to be hazardous to children's lives. As Dr Greg Watters and Stephen Carroll have shown in <a href="https://www.circinfo.org/watters.html">their study of parental attitudes </a>in rural New South Wales, parents rarely appreciate the risks associated with the excision of an infant's prepuce, and are ill-equipped to make decisions that should properly be made after <a href="http://www.circinfo.org/doctors.html">expert paediatric advice</a> or left to the boy himself. <h3>Circumcision under attack following baby boy's death</h3> CBC News British Columbia, 11 February 2004 PENTICTON, B.C. - The report on the death of an infant following a routine circumcision has triggered renewed calls to ban the procedure in B.C. Ryleigh Roman McWillis was a month old when he bled to death following the operation in Penticton in August, 2002. A coroner's report released this week makes no recommendations for change, which dismays his parents. Brent McWillis had hoped the coroner's report into the death of his son Ryleigh would help prevent a similar tragedy in future. "It was a very unfortunate and nightmarish thing that happened to us," he says. "The only thing I want to see is that it doesn't happen to anyone else's child." Ryleigh's parents say they'd like all hospitals to adopt better standards to care for infants following a circumcision. Meanwhile, other groups opposed to circumcision, are calling for an internal review by the B.C. College of Physicians and Surgeons. "This surgery is not necessary, and if the surgery is not therapeutic, the risk cannot be undertaken," says John Geisheker, the lawyer for the group, Doctors Against Circumcision. Dr. Eugene Outerbridge of the Canadian Pediatric Society says a study last year, showed male circumcision exposes children to risk, with no real medical benefit. But Outerbridge says an outright ban would violate the rights of religious minorities. <h3>Comment: "Wait until their sons can make the decision for themselves"</h3> CBC Radio (British Colombia), Friday, February 20, 2004 From Ottawa journalist Thom Barker, a clear and powerful statement calling for a ban on routine infant circumcision in Canada. A year and a half ago a baby in British Columbia bled to death after he was circumcised. Last week a coroner's report made no recommendation on the future of the practice. Thom Barker is a freelance writer in Ottawa. On Commentary he has a suggestion. Last week we were horrifically reminded that circumcising baby boys is not without the highest risk. It can and occasionally does lead to their deaths. But the articles I've seen on it recently didn't focus on how unnecessary it is; they discussed how circumcision should be done more safely. So with safety in mind here's my advice. Ban it! Stop mutilating infant boys for no good reason. For nearly 30 years now the Canadian Paediatric Society has officially stated that circumcision is medically unnecessary. Long term statistical evidence has proven that the risks of doing it outweigh the risks of not doing it, and medical ethicists almost universally decry it. So why do we continue to circumcise about one out of every five boys born in this country? Why do we continue to leave it up to the parents and doctors to decide? The first reason is familiarity. Circumcision has been and remains such a common practice - to make baby look like daddy - that we're reluctant to recognize it for what it really is: genital mutilation. To do so would be to condemn our parents, our friends, our siblings and possibly ourselves as guilty of criminal assault. More problematic is the religious justification. Childhood circumcision of boys is an integral aspect of the Jewish and Muslim traditions and cultures. But similar arguments based on tradition did not stop Canada in 1997 from banning female genital mutilation. It did not stop us because it was viewed as a human rights issue. In fact, as a society, we routinely override the rights of parents to protect children from perceived harm. So why doesn't this protection extend to infant boys? Male circumcision is hardly universal even among practising Jews and Muslims. In fact, there are significant numbers of both, including religious leaders, who advocate discontinuing the practice because it's contrary to more fundamental principles of their faiths, most importantly respect for human life. So even in the religious context it seems that parents have some freedom of choice. I was born Catholic. At about the same time that I might have had my foreskin removed, I was baptized instead. When I later renounced my Catholicism I resented having been baptized against my will. But fortunately I didn't have an irreversible physical deformity to forever remind me of it. Would it be so egregious to make parents wait until their sons can make the decision for themselves? There's no end to the legal protection adults have to damage themselves. For Commentary, I'm Thom Barker in Ottawa. <h2>Boy dies after Plastibell circumcision</h2> Mark Brennae, CanWest News Service, Published: Wednesday, June 13, 2007 <a href="http://www.canada.com/cityguides/ottawa/story.html?id=cb3b8281-4134-46ba-85d3-b076072bda75&k=25810">canada.com</a> OTTAWA — A one-week-old Ontario infant died from complications after undergoing a circumcision in a provincial hospital. Information about the case was published in the <a href="http://www.pulsus.com/journals/toc.jsp?sCurrPg=journal&jnlKy=5&isuKy=710">April 2007 edition of Paediatric Child Health</a>. The baby, whose name has been withheld by the parents, passed away after his kidneys [no, bladder] became enlarged to seven times their [its] normal size. The child was born at an unidentified Ontario hospital “sometime in the last three years,” said Dr. Jim Cairns, Ontario's deputy chief coroner. “The family wants to keep this anonymous.” No charges were ever laid and no legal action was ever taken in the case. According to the Paediatric Child Health article, the boy was “bottlefed and was reported to be doing well when he was circum[cis]ed.” Five hours later, the parents returned to their family doctor with the infant, who had become “irritable and had blue discolouration” below the belly button. Doctors noticed the discolouration and slight swelling of the penis, but sent the child home. Fourteen hours after the circumcision, according to Cairns, the child was brought to another hospital where doctors noted he was extremely irritable with marked swelling of the penis and bruising to the scrotum. The child was then transferred to a paediatric centre, where his bladder was diagnosed, Cairns said, to “seven or eight times its normal size.” The PlastiBell ring, which is used to hold back the foreskin after circumcision, was removed and drained and the child went into shock. “If the PlastiBell had been taken off five hours after he got there, he would be alive,” said Cairns [Perhaps. If the PlastiBell had never been used in the first he would certainly be alive.] The child's death was attributed to septic shock — “an overwhelming infection, leading to multi-organ failure,” Cairns said. “Death is rare after circumcision,” said Cairns. “But complications can happen.” The case was brought to Cairns' attention because the circumstances of every death of an Ontario child under five years of age must be reviewed by the provincial coroner's office. <h2>Another Canadian boy bleeds to death after circumcision</h2> Ontario newborn bleeds to death after family doctor persuades parents to get him circumcised. National Post, 25 October 2015 TORONTO — An Ontario doctor has been cautioned after a 22-day-old baby bled to death from a circumcision gone horribly wrong, underscoring the heated debate over a simple yet contentious procedure. Another physician involved in the case was urged by a medical governing body to be “mindful” of the operation’s dangers. But Ryan Heydari’s parents say the regulators who handled their complaints have shed little light on what led to Ryan’s death – or how to prevent similar tragedies in future. They say they did not even want the newborn circumcised — a view in line with longstanding recommendations from the Canadian Pediatric Society — but were persuaded to do so by a family physician. “We are so shocked that we will not have an answer to bring us some peace for our broken hearts, to prevent other cruel deaths like Ryan’s and to ensure that doctors take proper care of their patients,” mother Homa Ahmadi told the National Post. In fact, the case only became public because the couple appealed the original Ontario College of Physician and Surgeons rulings, which were rendered in secret. An appeal tribunal upheld this month a decision by the College to caution the doctor who saw Ryan in the emergency department hours after his circumcision, his diaper stained red with blood. The Health Professions Appeal and Review Board also confirmed the college’s separate advice to the pediatrician who conducted the procedure to be aware of its potential hazards, and document his efforts to get informed consent. The pediatric society said in a recent report that death from bleeding caused by circumcision is “extremely rare,” though it’s not completely unheard of. A five-week-old B.C. baby bled to death<a href="https://www.circinfo.org/account.html#ryleigh"> after being circumcised in 2003</a>. Ahmadi gave birth on Jan. 3, 2013 to a boy who loved attention, cried relatively little and seemed to actually smile. “He gave us the most amazing moments of our life,” says Ryan’s mother. She and husband John Heydari, who immigrated from Iran about 12 years ago, opposed having him circumcised, convinced that “mother nature created us the way she intended us to be.” But their family physician persuaded them it was a good idea for medical reasons, despite contrary advice from pediatric specialists. Once carried out on most Canadian boys and still common as a religious rite for Jews and Muslims, circumcision has generally fallen in popularity, rates hovering around 32 per cent. The pediatric society has long held that its risks – including pain to a small baby, bleeding and the chance of disfigurement of the penis – outweigh its benefits. But its report still recommended against routine circumcision of every newborn male, saying that it may make sense in certain cases. For those who have the procedure, “close follow-up in the early post-circumcision time period is critical,” the society warns. One urologist says he has encountered a few cases where circumcised babies had to undergo transfusions because of dangerous bleeding, and sees less-serious complications routinely. Dr. Jorge DeMaria of Hamilton’s McMaster University believes regulators should require doctors to prove they have undergone proper training before doing circumcisions. He also questions circumcising newborns for preventive-health reasons, in a country with low levels of HIV and wide availability of condoms. “In our setting, in North America, really it’s not necessary.” Ahmadi says she and her husband knew almost immediately after their son’s procedure that something was seriously wrong. The previously unfussy baby “was crying so much, so hard, and he wouldn’t stop,” she recalled in written answers to questions. “He was bleeding, and it only got worse over just hours … It was so obvious from the blood his tiny body had lost that he was in danger.” The pediatrician who did the circumcision told the College he conducts many of them, that Ryan’s was uneventful and there was no bleeding when he checked the dressing before the family left. The parents called about bleeding later that day, though, and he advised them to take Ryan to Toronto’s North York General Hospital, which they did. “We … waited for care that could have saved his life, but that level of care never came,” says Ahmadi. A sparse outline in the board’s decision says Ryan was eventually transferred to Sick Kids hospital, but died there seven days later. Pathologists said he succumbed to “hypovolemic shock” caused by bleeding from the circumcision, which emptied his body of 35 to 40 per cent of its blood. The doctor at North York General — whose name has been withheld according to College policy — was cautioned for failing to recognize the seriousness of the boy’s condition or treating “compensated shock” – the first stage of the condition. <h2>Too many circumcision complications in Canada hospitals</h2> In a <a href="https://pubmed.ncbi.nlm.nih.gov/24032062/" rel="noopener" target="_blank">study published in the August 2013 issue of the Canadian Urological Association Journal</a> urologists report a disturbingly high incidence of complications and other adverse outcomes from circumcisions performed on infants by surgeons in Ontario hospitals. The authors found that “most physicians performing neonatal circumcisions in our community have received informal and unstructured training. This lack of formal instruction may explain the complications and unsatisfactory results witnessed in our pediatric urology practice. Many practitioners are not aware of the contraindications to neonatal circumcision and most non-surgeons perform the procedure without being able to handle common post-surgical complications.” In other words, even under the most favourable conditions - qualified medical personnel, modern hospitals and the latest equipment, an advanced Western society - circumcision of infants still cannot be safely performed. Although they are not aware of it, the authors confirm the conclusion of <a href="https://assets.nationbuilder.com/darboninstitute/pages/1028/attachments/original/1753839786/Young_2013.pdf?1753839786" rel="noopener" target="_blank">Hugh Young's study of circumcision techniques</a>, that no fully satisfactory and entirely safe method has ever been devised and - given the complex and variable anatomy of the foreskin - none is ever likely to be. Unlike a finger, an arm, the gall bladder, or the appendix, the foreskin is not a discrete or self-contained member or organ that can easily be detached from the rest of the body. Since it is an extension of the penile skin system, there is no agreed point at which the “foreskin” ends and the rest of the penis skin begins, and thus no clearly-defined point at which the operator should start (or stop) cutting. As Young concludes, the structure of the foreskin does not lend it self to neat amputation, but is highly vulnerable to complications and messy cosmetic outcomes. Abstract A survey of circumcision methods and instruments is presented from an evolutionary perspective. Instruments for circumcising have evolved, but not in any coherent or consistent manner. Nor, after more than 4,000 years, has any consistent (“best”) method emerged for circumcising. This underlines fundamental problems with the operation. The instruments have been fetishized along with the operation. The article concludes: Unlike the hurricane lantern, they did not find the best method and stick with it; unlike the scissors, there was no great leap forward; unlike the car door handle, there was no smooth progression, from linear to annular to disposable, Instead, inventors have jumped back and forth, apparently having some nostalgia for the linear barzel, and perhaps some dislike of the necrosis of the Plastibell. It took the designers of the devices thousands of years to work out how to compress in a circle. They still have not accommodated the frenulum because the frenulum intractably complicates the cutting. And though it is common knowledge that the frenulum, the last remnant of Taylor’s ridged band, is the male G-spot, circumcisers have not yet formulated a consistent policy towards it and hence their devices do not treat it consistently. What this exposes is that no way of circumcising is without problems because the foreskin has not evolved in a way that lends itself to being removed. Sources: Hugh Young. Evolution of Circumcision Methods: Not “Just a Snip”, in G.C. Denniston et al (eds), Genital Cutting: Protecting Children from Medical, Cultural, and Religious Infringements. Dordrecht: Springer 2013. Jorge DeMaria, Alym Abdulla, Julia Pemberton, Ayman Raees, Luis H. Braga. Are physicians performing neonatal circumcisions well-trained? Canadian Urological Association Journal, Vol 7, August 2013 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision deaths in Canada darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>100+ circumcision deaths each year in United States</h1> Each year in the United States more than 100 newborn baby boys die as a result of circumcision and circumcision complications. This is the alarming conclusion of a study, published in the <a href="http://www.berghahnjournals.com/view/journals/boyhood-studies/4/1/bhs040106.xml" rel="noopener" target="_blank">Journal of Boyhood Studies</a> which examined hospital discharge and mortality statistics in order to answer two questions: (1) How many baby boys dies as a result of circumcision in the neonatal period (within 28 days of birth)? (2) Why are so few of these deaths officially recorded as due to circumcision? The study, by researcher Dan Bollinger, concluded that approximately 117 neonatal deaths due directly or indirectly to circumcision occur annually in the United States, or one out of every 77 male neonatal deaths. This compares with 44 neonatal deaths from suffocation, 8 in automobile accidents and 115 from Sudden Infant Death Syndrome, all of which losses have aroused deep concern among child health authorities and stimulated special programs to reduce mortality. (Remember those red noses?) Why, the study asks, has the even greater number of deaths from circumcision not aroused the same response? Part of the answer lies in the fact that most circumcision-related deaths are not officially as recorded as due to circumcision at all, but to the immediate cause, most commonly stroke, bleeding, infection or reactions to anaesthesia. Medical statistics are thus at fault in that they do not give the true cause of death at all. Previous studies have given wildly varying estimates the death toll from circumcision. In 1949 paediatrician Douglas Gairdner found that sixteen British boys died each year, while more recent estimates range from a low of two boys per year to a high of as many as 230. Some textbooks and most circumcision promoters claim that there have never been any deaths from circumcision in a modern clinical context (whatever may happen in the insanitary conditions of the Third World). For his study Bollinger collected data from hospital records and government sources to attempt to provide a more accurate estimate of the magnitude of the problem. But another part of the answer lies in the unique place that circumcision occupies in American medical culture, as an entrenched cosmetic ritual that many parents feel they have to submit their baby boys to, and as a lucrative sideline that doctors are reluctant to abandon. American obstetricians can’t seem to rid themselves of the notion that circumcision of boys is somehow an integral part of childbirth. The study points out that “These boys died because physicians have been either complicit or duplicitous, and because parents ignorantly said ‘Yes,’ or lacked the courage to say ‘No.’” It further points out that because circumcision is a completely unnecessary operation, all these deaths are easily avoidable, and thus characterises the annual loss as neither a beneficial surgery nor a beneficent rite of passage, but as “an unrecognized sacrifice of innocents.” Because circumcision is unnecessary surgery (there being no pathology to treat in a normal male baby), the old calculus of surgical risk vs benefit is not nearly enough. “Risk assessment for an unnecessary surgery must be held to a higher standard than that for a life-saving surgery. We accept that a heart transplant carries with it a substantial risk of death, but without it there is a certainty of death. On the other hand, the risk from circumcision, which has no therapeutic value, needs to be zero for the infant’s sake, all the moreso because he is never consulted about whether he wishes to take his chances.” Bollinger argues that the scale of the problem remains unrecognised because of the inadequacies of the death-certificate system and unwillingness on the part of the doctors who performed the surgery or the hospitals where it took place to admit responsibility, or even to acknowledge that circumcision is a surgical operation which, like all surgery, carries real risks. Too often they have tried to blame incorrect care on the part of parents, or even the peculiarities of the boy himself. As well as analysing the figures, the study runs through some of the few prominent instances where circumcision was recognised as the true cause of death, including the Ryleigh McWillis case in Canada, and several United States deaths that somehow made it into the news. Some of these make chilling reading, as these excerpts from the article show: The first known reported circumcision-related deaths were in New York City, where circumcision was introduced. The first was Julius Katzenstein in 1856 and the second was one-week-old Myer Jacob Levy in 1858. Both boys were circumcised by a Dr. Abrahams, and the same coroner reviewed both deaths. The coroner found that Abrahams had performed the surgeries properly, and that the boys died from blood loss as a result of parental neglect. Neither boy had received a follow-up examination. Allen Ervin, born 1985, was in a coma for more than six years before he died. He had been on life support after his brain was damaged from oxygen deprivation during his circumcision. Demetrius Manker was born in 1993 and died soon thereafter from blood loss. The coroner’s examination found a large, gaping wound on the underside of the boy’s penis extending almost to the scrotum. The coroner listed cause of death as blood loss due to penile circumcision; however, there is no mention of further action being taken. A West Virginia child, whose name was withheld, was born in 1996 without incident and circumcised prior to hospital release. A few days later, the parents rushed him to the emergency room because he was having seizures and his penis had turned green in color. He died the next day from septicemia. Because the penis is highly vascularized, blood-loss is a risk even for boys circumcised past the neonatal period. In 2008, a 6-week-old Native American, Eric Keefe, died from massive blood loss. Hospital officials claimed that his circumcision was not to blame, but instead faulted the parents because they had administered over-the-counter pain medication that, they also claimed, thinned his blood. Death sometimes occurs following repair of a circumcision complication. Dustin Evans Jr., was circumcised soon after being born in 1998. The surgeon took so much shaft skin that the scar healed as a tight “collar” around his penis, preventing him from urinating. When he was later given an anesthetic in order to repair the damage, he immediately died of cardiopulmonary arrest. His father lamented, “You think, ‘What could go wrong with a circumcision?’ The next thing I know, he’s dead.” <h3>To stop killing boys, stop circumcising them</h3> The solution to the problem, Bollinger suggests, does not lie in improving surgical techniques or giving operator better training. “The problem is this: circumcision is a killer of baby boys. No one, except for some human-rights activists, is trying to save them. It is unlikely that improving circumcision techniques would eliminate these deaths. No matter how skilled the physician is, some deaths will always occur.” The only effective way to eliminate this death toll and save these boys is to admit that circumcision is unnecessary and potentially harmful surgery and stop performing it on neonates and minors. This would give all boys the chance to decide for themselves whether they wish to be circumcised, and (if they do) would allow them to choose it for themselves as adults, when the surgical risks are so much less severe. Source: Dan Bollinger, <a href="http://www.berghahnjournals.com/view/journals/boyhood-studies/4/1/bhs040106.xml" rel="noopener" target="_blank">Lost boys: An estimate of U.S. circumcision-related infant deaths</a>, THYMOS: Journal of Boyhood Studies, Vol. 4, No. 1, Spring 2010, 78-90. <h2>More circumcision death and injury in United States</h2> <h3>$429,000 awarded for circumcision disfigurement</h3> In August a Californian jury awarded $429,484 to an infant whose penis was disfigured for life by surgery. On Nov. 12, 2006, Evan Tank was circumcised by pediatrician Ralph Berberich, who accidentally cut the tip of Evan’s penis. Plaintiff’s counsel claimed that Berberich failed to remove adhesions tethering the foreskin to the glans, causing the glans to be pulled into the clamp along with the foreskin. Hence the glans was cut off along with the foreskin. Berberich countered that penis trauma is a recognized complication of the procedure and that Evan’s parents had accepted the risk The doctor argued that, rather than an error on his part, Evan probably had an unusual penile anatomy that caused his penis to be pulled into the clamp. Source: Recorder (San Francisco) August 12, 2009 Interesting that the operator tried to blame the infant’s anatomy rather than admitting negligence in his own technique. The fact is that all penises are different; if surgeons are going to muck around with them, they ought to examine each one carefully before they charge in. It's also interesting that the operator tried to defend himself by admitting that (additional) damage to the penis was so common as to be "a recognised complication of the procedure". A bit like Russian roulette. <h3>Parents sue over baby’s death after circumcision</h3> The parents of a 6-week-old boy who bled to death after a circumcision at Rosebud’s Indian Health Service Hospital last year are suing the government for wrongful death. According to documents filed Wednesday in federal court, Eric Keefe underwent a circumcision on June 13, 2008. His mother gave him Motrin and Tylenol for pain and he suffered massive blood loss at home that night, dying at the hospital the next morning. His parents, Forrest and Mary Keefe of Wood, say Dr. Douglas Lehmann failed to inform them of the type of pain medication they should have used. The Keefes are seeking $2 million for personal injury and wrongful death. Sturgis lawyer Mick Strain, who represents the plaintiffs, said he and the parents wouldn’t talk about the case until it is tried or settled. The file lists no attorney for the government. Source: Argus Leader [South Dakota], September 18, 2009 <h3>$2.3 million awarded for botched circumcision</h3> A Fulton County jury (Georgia, U.S.A.) has awarded $1.8 million in damages to a boy whose penis was severed in a botched circumcision. The state court jury gave another $500,000 to the boy’s mother in the decision rendered Friday. The case involves a child, identified only as D.P. Jr., who was born at South Fulton Medical Center in 2004. In a suit filed two years later, his mother contended that the doctor who circumcised him removed too much tissue and that his pediatrician failed to respond when a nurse complained of excessive bleeding. The tip of the penis was placed in a biohazard bag and might have been reattached if a urologist had attended to the boy within eight hours, one of the mother’s lawyers, David J. Llewellyn of Atlanta [and ARC] said. The jury found that both the pediatrician, Dr. Cheryl Kendall, and the physician who performed the circumcision, Dr. Haiba Sonyika, were negligent. South Fulton Medical Center was absolved of liability. The pediatrician’s lawyer, Roger Harris, said he disagreed that the jury’s decision indicated that Dr. Kendall was negligent because she didn’t go to the hospital. He hinted at an appeal. “We believe there was error committed during the course of the trial,” he said. Dr. Sonyika’s lawyer could not be reached for comment. Llewellyn said the money awarded by the jury is to cover the cost of medical treatments and psychiatric counseling for the boy and his family. The jury did not award punitive damages. The Atlanta Journal-Constitution is not naming the mother to avoid identifying the child. “This case does point out one of the dangers of circumcision that every parent must seriously consider when having the procedure done,” Llewellyn said. He contended that parents are not told of the risks of the procedure. Source: <a href="http://www.ajc.com/metro/content/metro/atlanta/stories/2009/03/30/botched_circumcision_suit.html">Atlanta Journal-Constitution</a>, Monday, March 30, 2009 <h3>Claim for circumcision damage in Chicago</h3> A Northwestern Memorial Hospital obstetrician is being sued for allegedly botching a circumcision of a 1-day-old baby and cutting off a portion of the infant's penis, <a href="http://www.wbbm780.com/pages/4206807.php?contentType=4&contentId=3833024">according to WBBM-AM 780</a>. The suit, filed Tuesday in Cook County Circuit Court by David Burden on behalf of his son Daniel Burden, claims that on Oct. 5, 2007, one day after Daniel was born, Dr. Marc Feldstein performed a circumcision on the boy. However, rather than removing only the foreskin, the doctor cut and removed a portion of the baby's penis, the suit said. After the procedure, baby Daniel was transferred to Children's Memorial Hospital to have emergency corrective surgery. Burden accuses Dr. Feldstein, Northwestern Women's Health Associates and Northwestern Memorial Hospital of medical negligence. The suit asks for more than $50,000. <a href="http://www.chicagobreakingnews.com/2009/04/lawsuit-claims-botched-circumcision.html" rel="noopener" target="_blank">Chicago Breaking News Centre, 15 April 2009</a> <h2>Utah (USA) study: Circumcision complications up to 5 times higher than expected</h2> INTRODUCTION AND OBJECTIVES: Circumcision remains a very common procedure in the United States. Published complication rates are lower than clinical practice suggests. We aimed to use a population-based claims database to define the regional 2 year complication rate in boys who underwent circumcision. We hypothesized that this rate would be between 1 and 5%. METHODS: The Utah All-Payer Claims Database (UAPCD) contains data from health insurance carriers, Medicaid, and third party administrators in Utah. The data consist of medical and pharmacy claims as well as insurance and health care provider data, and all residents in the State of Utah are included unless they opt out. The UAPCD was queried for all male patients aged 0-730 days undergoing circumcision (CPT 54150, 54160 and 54161) during the year 2013. Subjects were censored if they had less than 2 years of post-procedure data. Demographic, medical and procedure-specific data was abstracted. ICD-9 and -10 codes were used to identify infectious, bleeding, urethral, skin and wound healing-related complications. Encounters for circumcision revision (CPT 54161, 54163), or lysis of penile adhesions (CPT 54162) were noted. RESULTS: In 2013 there were 26,069 male births and 6298 circumcisions were captured. The mean age at circumcision was 9.8 days for those who had circumcision with a clamp (CPT 54150), 16.3 days for those who had a surgical circumcision other than clamp (CPT 54160) and 309.3 days for boys who had a formal circumcision after the neonatal period (CPT 54161). 725 (11.5%) complications were identified. The two most common complications were phimosis in 433 (6.9%) and other wound related complications such as acquired torsion, buried penis and edema in 168 (2.7%). Infectious/inflammatory (1.2%), urethral (0.5%), and bleeding (0.3%) complications were rare. 101 (1.6%) patients underwent surgical revision or lysis of penile adhesions. Complications did not differ significantly between patients who h the original circumcision in a hospital vs. an outpatient setting (p=0.33) or in an urban vs. rural location (p=0.22). When adjusted for healthcare setting and location, the difference in complications between patients less than 90 compared to those 90 to 730 days old was not significant. CONCLUSIONS: The incidence of post-circumcision complications at 2 years is much higher than expected at 11.5%, but does not appear to be influenced by age at circumcision, healthcare setting or a rural vs. urban location. A minority of subjects needed reoperation during the ensuing 2 years. Glen Lau, Jaewhan Kim, Anthony Schaeffer. Identification of circumcision complications using a regional claims database. <a href="http://spuonline.org/abstracts/2018/P21.cgi" rel="noopener" target="_blank">Spuonline reports</a>, February 2018. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision deaths in the USA 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"> OK, you may be thinking that even if very few uncircumcised boys experience a foreskin-related disability when young, but what about the other supposed health benefits of circumcision emphasised by the AAP and other advocates, such as reduced risk of sexually transmitted infections as an adult. We have sought to put that canard to rest as a piece of medical folklore on several occasions, but it persists. To show how wrong it is, here are comparative statistics for HIV, gonorrhoea and syphilis in (uncircumcised) Denmark compared with the (circumcised) United States: HIV-AIDS Denmark: 0.1-0.2% (2014, adults 15-49) http://www.unaids.org/en/regionscountries/countries/denmark United States: 0.4-0.9% (2012) http://www.unaids.org/en/regionscountries/countries/unitedstatesofamerica/ Gonorrhoea Denmark: 12.1 per 100,000 (2012) http://ecdc.europa.eu/en/publications/Publications/sexually-transmited-infections-HIV-AIDS-blood-borne-annual-epi-report-2014.pdf United States: 110.7 per 100,000 (2014) http://www.cdc.gov/std/stats14/std-trends-508.pdf Syphilis Denmark: 6.1 per 100,000 (2012) http://ecdc.europa.eu/en/publications/Publications/sexually-transmited-infections-HIV-AIDS-blood-borne-annual-epi-report-2014.pdf United States: 6.3 per 100,000 (2014) http://www.cdc.gov/std/stats14/std-trends-508.pdf So the (circumcised) United States has 4 times the level of HIV, and 10 times the level of gonorrhoea as (uncircumcised) Denmark. This suggests that the foreskin is protective against, and circumcision increases the risk of, urinary tract infections such as urethritis and gonorrhoea, at least in adulthood – which is what <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=25&Itemid=51" rel="noopener" target="_blank">Jonathan Hutchinson</a> found in 1855, and <a href="https://www.circinfo.org/newsindepth.html#nsu" rel="noopener" target="_blank">Ferris et al</a> in 2010. <h3>Male breast cancer more common than cancer of the penis</h3> Nor is prevention of cancer of the penis a valid reason for circumcision. Since the days of Jonathan Hutchinson, circumcision advocates have made much of the value of circumcision in preventing cancer of the penis (Morris et al, 2011). Whether or not it does so is less significant than the fact that penile cancer is a rare disease of older men – so rare that accurate statistics on incidence are difficult to find, and so rare that it is even less common than male breast cancer. The American Cancer Society (2016) estimates that 2600 cases of male breast cancer will be diagnosed in 2016 and that 440 men will die of it. The figures for cancer of the penis are 2030 cases and 340 deaths. If prophylactic removal of infant male breasts is not recommended as a breast cancer preventive, there is certainly no need for prophylactic removal of the foreskin as a penile cancer preventive. What are the key statistics about breast cancer in men? <a href="http://www.cancer.org/cancer/breastcancerinmen/detailedguide/breast-cancer-in-men-key-statistics" rel="noopener" target="_blank">The American Cancer Society estimates</a> for breast cancer in men in the United States for 2016 are: <ul> <li>About 2,600 new cases of invasive breast cancer will be diagnosed.</li> <li>About 440 men will die from breast cancer.</li> </ul> What are the key statistics about penile cancer? <a href="http://www.cancer.org/cancer/penilecancer/detailedguide/penile-cancer-key-statistics" rel="noopener" target="_blank">The American Cancer Society estimates</a> for penile cancer in the United States for 2016 are: <ul> <li>About 2,030 new cases of penile cancer will be diagnosed.</li> <li>About 340 men will die from penile cancer.</li> </ul> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision effect on STIs and cancer darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> The following article by Mihail Evans was published by the British Medical Journal, 19 February 2011 New legislation in France has led to more debate on whether wearing the veil amounts to the sexual repression of Muslim women. Islam’s treatment of women is a regular topic in the Western press, yet few jump to the defence of Muslim and other little boys subjected to childhood circumcision. Indeed, the circumcision of the grandson of President Sarkozy, ironically a proponent of the veil ban, made only the gossip pages in France. As a permanent surgical genital alteration, circumcision is arguably a much more serious matter. After all, a Muslim woman has, at least in theory, the option to throw away her veil. The circumcised man’s foreskin has been thrown away already. Few countries have banned male circumcision, but even symbolic alternatives to female genital mutilation are banned in almost all Western jurisdictions. While I was a student, a female academic at my institution published a piece supportive of male circumcision. This prompted a thought experiment: suppose we found a male academic supportive of the surgical modification of female genitals. Would his views be accepted? Why can a Jewish woman speak openly to defend male circumcision and a Somali man not defend female circumcision? Physiological research has undermined beliefs that the foreskin is “just a flap of skin” and shown it to be an integral part of the penis. With the foreskin considered an erogenous, multifunctional tissue, the established view of circumcision as a non-damaging excision is fatally undermined. It would be more appropriate to change our terminology, to speak of male genital mutilation rather than circumcision in the same way that we use female genital mutilation and not cliteradectomy. Finland is among the few places where male circumcision is illegal, although recent judicial decisions have backtracked on this law, making exceptions for some religious circumcisions. Bulgaria banned male circumcision in the 1980s, but more as part of a cultural war on its Muslim minority than out of any overtly humanitarian concern. My partner is Bulgarian, and it amazes me that under law in the United Kingdom I could legally take my son there and subject him to the sort of horrific circumcision recorded by a Bulgarian current affairs programme, yet my Somali neighbours would be prosecuted for attempting to appease traditional opinion by replacing female circumcision with a symbolic pinprick to the clitoral hood. The absurdity of the legal situation in the UK is exposed by the conviction of a man under child pornography legislation for possessing images of a traditional circumcision (BBC News, 21 Nov 2003, http://bbc.in/fzV3h0). Apparently images are illegal but the act is not. We rarely glimpse more than the very tip of the iceberg of the sexual and psychological damage caused by male circumcision. One symptom is the considerable number of men interested in foreskin restoration. That any man would be prepared to spend several hours a day for several years using taped, weighted, and tensioned devices to try to regrow a foreskin is testimony to the suffering caused in some cases. In browsing online forums such as www.restoringforeskin.org, you get a sense of the great missing continent of male conversations that are unspeakable in public: the Iranian brought up in the West who always feels something is missing when he sleeps with a woman, or the gay American man depressed that he does not have the penis he was born with, like his European lover. I am amazed at how male circumcision in developed countries is treated simply as a question of opinion. On online parenting sites, such as www.emmasdiary.co.uk and www.babymania.com, it is often treated as just another parental option, up there with bottle or breast. Most women in the UK do not circumcise their sons, but if a mother says she has had her son circumcised “to be like daddy” or for “tradition,” hardly an eyelid is batted. I was shocked by some comments from mothers, which seemed more callous than would be tolerated if gender roles were reversed. In one a mother wrote “LOL” (“laugh out loud”) after telling the forum that her circumcised 4 year old “wants his old penis back.” In another, a mother from South Africa says she has kept the dried foreskin “in case he wants it back later.” Elsewhere on the web, it is completely acceptable to express a preference for a “cleaner” circumcised penis on women’s sites such as www.cosmopolitan.co.uk. I cannot imagine that a man who advocated ways of making the vagina more “attractive” and “hygienic,” let alone by surgical means, would be given a moment’s hearing. Would it be acceptable for a man to say he wanted to scare girls by training as a female circumciser? Of course not, but the Times can print an interview in which the actress Isla Fisher jokes that she would like to train as a mohel to give boys a scare (“The comic world of Isla Fisher,” Times, 25 Jan 2009, http://bit.ly/hgjEdV). Legislation to outlaw male circumcision was put forward in Massachusetts, and although it was defeated campaigns continue in other states (see www.mgmbill.org). Dutch doctors also discussed a ban last year (BMJ 2010;340:c2987, doi:10.1136/bmj.c2987). But given the experience of Finland, which had to make religious exceptions after it initially banned all circumcisions, a better way to protect the genitals of young boys might simply be to use existing laws. The Tasmanian Law Reform Institute has suggested that male circumcision may breach existing child protection laws (http://bit.ly/eLfxId). And the media have hinted at the possibility of a test case in the UK (“Ritual circumcisions ‘illegal’,” Mirror, 17 Nov 2009, http://bit.ly/4GviWc). Finally, little boys in the West might be given the same rights as their sisters, but resistance is peculiarly high and comes from the most surprising quarters. Dr Evans is a former postdoctoral researcher in ethics and philosophy, University of the West of England; <a class="__cf_email__" data-cfemail="fa9793929b9396ba8893899f8f8ad4949f8e" href="/cdn-cgi/l/email-protection">[email protected]</a> Source: Brit Med J 2011;342:442 (19 February 2011) <h2>Comments from readers</h2> Manzoor Memon, Chigwell, UK As a medical student in a Muslim country, I never heard from peers or as a GP in East London any request for reversal of circumcision. The obsessive disorder with size and shapes of different parts of the body is a medical rather than ethical issue. The young boys with phimosis as a result of poor hygiene were referred for circumcision. Evans has ignored the scientific proof in BMJs (8th and 15th jan.2011) printed under short cuts or Guardian (21.6.2010) reporting 4 year study confirming male circumcision reduces HIV by 60%, hence 80% of Zimbabwean men aged between 15 and 29 are targeted in circumcision (painful stage) scheme aimed at reducing HIV infections. To outlaw circumcision in the USA (70% male circumcision) or stop vaccinations in third world is unscientific and young children should be covered by existing UN regulations on prevention of disease. Islam and Judaism recommend male circumcisions (Jesus peace be upon him was circumcised on the 8th day too). The female mutilation is cultural in some parts of Africa which predates Islam, Christianity and Judaism. Finally when woman goes in labour parity of sexes disappears. <h3>Ritualised child abuse</h3> Paquita C.B. de Zulueta, GP, Hon Senior clinical lecturer, Imperial College, London Evans courageously questions the ethical justification for male circumcision. As a GP I have often seen the raw lesions left by the surgery, the infections sometimes caused, the clear distress, and, on more than one occasion, a worrying mutilation of the penis whereby more than the foreskin had been removed. I find it odd that this practice is permitted in countries where there are no significant clinical benefits to the procedure. People cite the reduced risk of cervical cancer, but this has been addressed with the introduction of the HPV vaccine, or they cite the higher incidence of rare diseases, such as penile cancer. HIV protection is not relevant in developed countries with low incidence. But even, if for the sake of argument, it were to provide significant protection to some diseases, do we conduct other elective procedures, such as appendicectomy, on children, in case they later on develop appendicitis (the risk of appendicitis in the USA is cited as being 0.25%)? The site of the wound is also relevant: an area that is particularly sensitive, exposed to urine and faeces, and in the context of an infant who cannot make sense of his distress and who cannot give consent. Evans is quite right to refer to the fact that many men seek to restore their foreskins by drastic means in order to enjoy more satisfying sexual lives or simply to restore their bodily integrity. Googling 'Restoring foreskin' yields 703,000 entries. The issue is sensitive because of the religious context, but arguably we need to consider the differences in hygiene and medicine as well as attitudes to children that existed at the time of the religious injunction as compared to the modern day, when we now have (finally!) the Convention of the Rights of the Child. The great religions promote compassion as a fundamental tenet - where is compassion in all of this? At least it should be done when the individual is autonomous and can make the choice authentically and freely, even if the surgery is more complicated. Some fathers justify it on the grounds of wanting their sons to be 'like them'. But do we insist that our children have to have the same anatomical defects that we have? And finally is the issue of cleanliness and purity not something to do with a disgust towards our 'animal' bodies rather than being based on sound scientific evidence? <h3>Primum non nocere</h3> Antony D. Lempert, GP, Wylcwm Street Surgery, Knighton, Powys Evans highlights well the disparity in the application of guiding principles to two distinct, though related scenarios. Some make the mistake of confusing this approach with weighted comparison of the relative harm of each. Non-therapeutic genital cutting of boys and girls causes different sets of serious problems; the principle of avoiding harm remains the same. Scales of harm are as unhelpful here as, for example, when considering the varied and overlapping harms of physical or emotional child abuse. In this context, calls not to mention non-therapeutic genital cutting of boys and girls in the same sentence display unhelpful gender discrimination. Failure to fully comprehend the basic premise that adults should not even touch, let alone cut, any child's genitalia for any purpose other than cleaning, dressing, medical examination or immediately necessary surgery, leaves boys and girls similarly unprotected. The GMC provides guiding principles for doctors treating those without the capacity to make their own decisions. (1) <ul> <li>Make the care of the patient your first concern</li> <li>Maximise a patient's ability to make decisions</li> <li>Consider whether lack of capacity is temporary or permanent</li> <li>Always take the least restrictive option</li> <li>Act in the best interests of the patient</li> </ul> It seems to be an act of faith not to compare the different application of these same principles in boys and girls. The evidence of harm for 'ritual circumcision' has been well-documented (2) & (3). No medical association in the world recommends non-therapeutic childhood genital surgery. To claim supposed therapeutic benefit for non-therapeutic surgery is an oxymoron and undermines scientific integrity. Without therapeutic benefit, cutting the body of a person unable to either consent or defend himself, is a criminal assault. All children deserve protection from such serious avoidable harm. (1) GMC Consent guidance: Making decisions when a patient lacks capacity 76a-c (2) Williams & Kapila British Journal of Surgery, Volume 80, 1231 -1236, October 1993. (3) Sorrells et al BJU International 99 (4): 864-869, April 2007) <h3>Male circumcision is not comparable to female genital mutilation</h3> Eleanor F Zimmermann, 4th Year Medical Student, Peninsula Medical School In response to Ms MacDonald and Mr Dalton, I would like to urge both to reconsider their views of comparing male circumcision to female genital mutilation (FGM). Male circumcision is although largely unconsented genital surgery that carries potential health risks, female genital mutilation (FGM) has such a long list of acute and long term complications that, as Dr Clarke clearly states, brings FGM to a completely different status where risks and ethical considerations are concerned. FGM is not confined to clitoridectomy - Type III (infibulation) involves excision of part or all of the external genitalia (the clitoris, labia minora and labia majora) with stitching of the labia minora or majora to narrow of the vaginal opening. (1) Young women who have undergone this type of FGM commonly suffer from a number of complications, including difficulty urinating, dysmennorhhea and also haematocolpos (accumulation of blood in the vagina). (1) When it comes to labour, these women have to be defibulated (surgical re-opening of the scar) in order for the baby to be delivered safely. (2) Obstetric management of these women is extremely complicated, and not without risks. (2) It has also been shown that women commonly avoid normal gynaecological screening such as smear tests and STI screening due to the difficulties associated with vaginal examinations. (3) In most cultures the legs of the victims are bound together after the procedure, and there are cases where some girls have broken their limbs due to being restrained during the procedure. (1) Children who have been brought back from 'holidays' having been mutilated don't feel able to communicate about their experiences, and often suffer from not only psychological complications but also recurrent urinary tract infections and dysmenorrhea, consequently often missing a number of days in education. The guardian has published a short documentary highlighting some of these problems: http://www.guardian.co.uk/uk/video/2010/jul/25/girls-facing-female-circumcision Although FGM is illegal in the UK, there have not yet been any prosecutions, (4) and mutilation is still being performed, both through parents taking their children abroad, and through 'cutters' being flown over to perform FGM on a mass scale in communities. (3) The reports online and on Youtube claiming that FGM is healthier and cleaner are outrageous. If we analyse the article sited in these videos, (5) the authors suppose the link between reduced HIV prevalence and FGM is based on confounders such as age at circumcision, type of circumcision and ethnicity. In fact women who have undergone FGM are less likely to engage in intercourse - either they can't, or they take no pleasure in it. This would be much like publishing an article looking at congenital impotence and HIV prevalence, concluding that impotent men have a significantly lower HIV prevalence, and claiming impotence is a protective factor for STI transmission. I have no doubt such a paper would get rejected by any publisher. In comparison, Brewer et al published results from a cross-sectional study showing an increased rate of HIV in those who had undergone either FGM or male circumcision.(7) When scientifically justifying the published studies claiming a reduced HIV transmission rate amongst circumcised males and speculating on the effect of FGM, HIV target cells, especially Langerhans cells that are present in the external genitalia may offer a link. Langerhans cells are present in the foreskin of males, and throughout the genitalia, but especially in the ectocervix of females. (8) As Ms MacDonald mentions of male circumcision: "In suggesting that forced male circumcision is justified where he may (possibly) reap some future reduction in cancer, HIV or even just smegma we open the door for these people to prove their case and demand a similar excision be promoted or pushed on women and girls." Similarly, the online resources that are pro-FGM are open to misunderstanding and abuse. Male circumcision is not comparable to female genital mutilation, although I agree that consideration should be given to banning male circumcision in childhood, and allowing for adults to make a fully informed decision as to whether they want the procedure or not. 1. RCOG. Female Genital Mutilation and Its Management. Green-top Guideline. No. 53. 2009 2. Rashid M, Rashid M. Obstetric management of women with female genital mutilation. The Obstetrician & Gynaecologist. 2007;9:95-101 3. FORWARD. Female Genital Mutilation: Information Pack. 2002 4. Carroll J. Metropolitan Police Authority. Female Genital Mutilation - MPS project Azure. Report 8. 2010 http://www.mpa.gov.uk/committees/cep/2010/101104/08/ 5. Stallings, R.Y., Karugendo, E.. "Female circumcision and HIV infection in Tanzania: for better or for worse? (3rd IAS conference on HIV pathogenesis and treatment)". International AIDS Society. http://www.ias- 2005.org/planner/Presentations/ppt/3138.ppt. 7. Brewer D, Potterat J, Roberts J, Brody S. Male and Female Circumcision Associated With Prevalent HIV Infection in Virgins and Adolescents in Kenya, Lesotho, and Tanzania. Ann Epidemiol.2007;17:217- 226. 8. Decatur M. Could Female Genital Cutting decrease the risk of HIV infection in a similar manner as male circumcision and if so, what implications does this have for Female Genital Cutting eradication efforts? http://www.ucl.ac.uk/network-for-student-activism/w/Could_Female_Genital_Cutting_decrease_the_risk_of_HIV_infection_in_a_similar_manner_as_male_circumcision_ and_if_so%2C_what_implications_does_this_have_for_Female_Genital_Cutting_eradication_efforts%3F <h3>Is it really unhelpful to compare male circumcision with female genital mutilation?</h3> Paul M Mason, Barrister-at-Law, Hobart, Tasmania Ann Savage's contribution neatly highlights the central conundrum of this male/female issue, namely the tension between cultural relativism and sex discrimination. One might have thought that the bonding and sense of passage into adulthood lay in the 3 months seclusion rather than the medically unnecessary surgery. But the European "solution" she describes opted for the latter over the former, and in pursuit of a modern European educational norm. Who interfered with overseas cultures in that case? And did those teenage boys give their own free and fully informed consent? As for girls; does not the goal of eradicating FGM/C (the culturally neutral UNICEF acronym) represent a colonialist interference with cultural needs? I have heard this argument put by a Kikuyu Kenyan PhD herself cut as a child. Intact girls, in Egypt for example where 97% are cut in some degree (UNICEF/WHO figures), suffer social isolation and embarrassment analogous to that of boys with foreskins differing from their own cultural norm. The ethical constant here is patient autonomy. No one should deny a mature intelligent adult - like Ann Savage for instance - the right to seek (and pay for) medically unnecessary cosmetic surgery on any part of her body. But no Doctor should perform it on her without her own consent at the behest of her parents. <h3>Re: Circumcision in boys and girls: Why the double standard?</h3> John P Warren, Retired Consultant Physician Mihail Evans's Personal View this week on genital cutting is most welcome. It is time for a debate among society at large, and particularly ethicists, lawyers, politicians, health professionals and child welfare agencies about the subject of non-therapeutic male circumcision of children. This procedure, carried out on healthy infants and boys too young to consent, defies all the normal standards of medical ethics, and exposes children to unnecessary pain and mutilation, as well as risk of complications. It can legally be performed by individuals without any medical qualification, who may be ignorant of surgical techniques and who cannot prescribe pain controlling medication. Dr Baombe's Rapid Response of 19 February mentions the distress of uncircumcised adolescent boys in countries where circumcision is common practice, but these boys have a remedy, that is to opt for circumcision. On the other hand boys and men who have been circumcised early in life and are distressed to discover their mutilation have no effective remedy, apart from non-surgical foreskin restoration, which takes years of applying tissue expansion techniques to the remaining penile skin. Even then, the result is not the same as a natural foreskin, as the lost specialised nerve endings do not regenerate. <h3>Forced circumcision cannot be medically justified</h3> Laura J MacDonald, Norm-UK Mihail Evans is right to highlight the double standards around our response to male and female circumcision (1). The responses which suggest that the spectre of HIV justifies male child circumcision are illogical. Real world data starkly contradicts the conclusions drawn from the controlled circumcision trials (2). But this is not the point. With women at double the risk of heterosexual aquisition of HIV(3) (and male circumcision offering them no reduction in risk) the real question is: why has no research been undertaken into the STD effects of a comparable female medical excision and/or keratinisation? Labial tissue for example is already known to be at greater risk of infections than foreskin - with myconium smegmatis ten times more prevalent in women!(4) This puts the 'hygiene' issue into perspective and shows the hypocrisy of those women who prefer their boys and men surgically 'cleansed'. Female circumcision advocates around the world from Dr Fuambai Ahmadu in Chicago, to Cleansexy on youtube; to Sheikh Yusuf Al Qaradawi in Egypt; to the Assalaam Foundation in Indonesia all claim health benefits follow their preferred form of female circumcision. In suggesting that forced male circumcision is justified where he may (possibly) reap some future reduction in cancer, HIV or even just smegma we open the door for these people to prove their case and demand a similar excision be promoted or pushed on women and girls. As such those who promote forced male circumcision undermine the rights of all of us. 1.BMJ 2011;342:d978 2. USAID Report February 2009 Levels and Spread of HIV Seroprevalence and associated factors: evidence from national household surveys 3. http://www.avert.org/women-hiv-aids.htm 4. Morrison AI. Non-specific urethritis investigated by Ziehl-Nielsen staining of the urethral discharge. Br J Vener Dis 1969; 45: 55-7 <h3>Non-therapeutic circumcision denies the child's right to autonomy</h3> John D Dalton, Trustee, NORM-UK In anticipation of the howl of protest that "female genital mutilation is in no way comparable to male circumcision", the two are to an extent directly comparable. Both remove normal tissue from the genitals of someone with no disease and who gives not personal consent. Female circumcision may in some cases be more damaging than male circumcision, but that is not he point. Rather the question is how it might later be perceived by the person whose body is altered. Non- therapeutic surgery is only ethically acceptable in the case of informed consenting adults. The question remains as to why every current GMC guidance document makes an explicit exception to non-therapeutic male circumcision. In the absence of such an exception the GMC guidance would clearly preclude non-therapeutic child circumcision. Perhaps the GMC would like to explain why there should be such an exception? <h3>Comment from CIA</h3> It seems strange that people can assert that male and female genital cutting cannot be compared when many experts have in fact compared them. What these deniers seems to mean is that male and female circumcision is not the same thing, a claim that nobody has ever made. But the fact that they are not the same does not mean that they do not have features in common, nor that they cannot be usefully compared. There has been a spate of articles over the past decade explaining both the similarities and differences between male and female genital cutting, and analysing the double standard to which Dr Evans refers, and we suggest that those who still have their head in the sands on this issue ought to do a bit more homework before they come out with their outdated assumptions. <a href="https://www.circinfo.org/ethics.html">Further information of ethics page</a> <a href="https://www.circinfo.org/female.html">Further information about female genital cutting</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 Circumcision in boys and girls: Why the double standard? 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>Royal Australasian College of Physicians disowns Brian Morris</h2> The following letter was sent to the Sydney Morning Herald by Professor David Forbes, Chair of the Paediatrics & Child Health Policy & Advocacy Committee, Royal Australasian College of Physicians. He is commenting on a disgraceful article about the RACP's recently released circumcision policy - an article that is not really a news item at all, but an editorial defending routine circumcision of innocent babies, criticising the RACP for rejecting the practice, and giving sympathetic coverage to the maverick views of the notorious circumcision fanatic, Professor Brian Morris. The article is quite in keeping with the SMH's decrepit pro-circumcision policy and expresses its complete failure to keep up with developments in science, medicine, medical ethics, human rights and law. Wake up, granny! The letter was posted at <a href="http://www.6minutes.com.au/articles/z1/view.asp?id=498029">6minutes - Interesting stuff for doctors today</a>. Please find copied below a letter sent to the SMH today in response to this article from the RACP. Dear Editor, Your Friday 11 article "Doctors circumspect on circumcision" warrants clarification on a number of issues. The key point of the recently released RACP statement on circumcision is that the RACP believes that at the present time there is not evidence to support routine circumcision of newborn and infant males. Your article sends a dangerous public health message that circumcision prevents HIV transmission. It is vital that everyone engage in safe sexual practices such as condom use, whether circumcised or not. Recent reports of circumcision offering some protection against HIV infection in Africa relate to circumcision of adult males, not of infants. Further the stated benefits of protection against urinary tract infection are marginal, and do not justify mass circumcision. Our changing understanding of the relationship between urinary tract infection and chronic renal disease further weakens the case for routine circumcision. There is evidence that circumcision does result in memory of painful experiences, and is not quite as simple and low risk as your report states. The Colleges' recent statement is not anti-circumcision, but clearly states that parents should be informed of risks and benefits, and then supported in their decision. When circumcision is undertaken it should be with appropriate anaesthesia, and by a skilled operator who can minimise the risks of side effects. The option of delaying the decision to circumcise is one way of dealing with the ethical and potential legal issues of undertaking an elective procedure on a minor. The procedure is not to be equated with vaccination, either in its delivery or in its effectiveness. It should be noted that Professor Morris, quoted in your report, is not a member of the RACP and is not and has not been engaged as a reviewer for the College. Yours faithfully, David Forbes, Chair, Paediatrics & Child Health Policy & Advocacy Committee Royal Australasian College of Physicians. 11 September 2009 <a href="http://www.6minutes.com.au/articles/z1/view.asp?id=498029">6minutes - Interesting stuff for doctors today</a> <a href="https://www.historyofcircumcision.com/templates/pages/medical_authorities_maintain_opposition_to_circumcision.html">RACP's new circumcision policy available here</a> <h3>The wit and wisdom of Brian Morris</h3> Professor Morris has been waging a one-man war against the foreskin since the mid-1990s, using his professorial position at Sydney University to give the impression that he speaks with the voice of medical authority. ("As a full professor at Australia's largest medical school I must insist ... etc etc etc".) On at least one earlier occasion in the past the university has felt obliged to caution Professor Morris for claiming to speak on behalf of the university, when he was only uttering his personal opinion. (Though the university has not gone so far as to require Morris to move his eccentric website from the Physiology Department's server.) Among Morris's charming eccentricities are the following gems: <ul style="font-weight: 400;"> <li>Louis XVI of France was forced to get circumcised in order to become capable of having sex with his wife.</li> <li>The former Pope died of a urinary tract infection caused by his foreskin.</li> <li>Boys should be circumcised to prevent their foreskins getting caught in the zipper of their jeans.</li> <li>Uncircumcised men need three showers a day to keep the stench of their foreskin down.</li> <li>Uncircumcised men always make a mess on the bathroom floor when taking a leak.</li> <li>Circumcision must be performed in infancy because if the choice was left up to the individual to make when he grew up he would make the wrong decision.</li> </ul> It is quite disgraceful that the SMH fawns on this maverick and cites his minority opinions against the considered judgement of Australian medical authorities. <h2>Sydney Morning Herald's twisted logic in attacking/defending circumcision</h2> Editorial: Arguments as old as the practice MORE than a billion men are circumcised and billions more have undergone the ritual over the centuries. The practice is both ancient and commonplace. Yet now we are supposed to accept the argument, promoted in some ethical circles, that circumcision is both dangerous and an infringement on the rights of the child. Any surgical procedure, however minor, is dangerous if performed crudely. The world is full of risks, with children the most vulnerable. What matters is proportionality. A report from the Tasmanian Law Reform Institute, released this week, suggests that, in the absence of specific laws relating to the practice of circumcision, it may be an abuse of the rights of the child. The report goes so far as to countenance that circumcision itself may, by its very nature, be an act of cruelty, law or no law. The matter has been given an airing after the Tasmanian Children's Commissioner, Paul Mason, sought guidance from the institute for the handling of cases where, for example, a dispute arises over whether a child should be circumcised. This is a nettlesome legal issue because cultural practice is divided and the law is largely silent. The cultural direction in Australia is moving away from circumcision. Western medical organisations no longer recommend routine neonatal circumcision. What used to be commonplace, involving more than 90 per cent of male infants born in Australia in the 1950s, has become a minority position. Only about one in seven newborn boys are circumcised. The majority of circumcisions involve religious customs, largely the rites of Muslims and Jews. The arguments for and against male circumcision are as old as the practice itself. In Australia, the procedure has a negligible rate of serious physical injury. Proponents argue the practice leads to lower rates of infection from sexually transmitted diseases, and has no adverse impact on sexual function. Opposition has largely come in the form of ethical arguments over the rights of the child being compromised by a procedure performed for no reason other than cultural practice, with the possibility of later psychological injury. The argument that circumcision involves psychological risks is finding growing support in medical studies. Common sense suggests that in a dispute between or within families over whether to circumcise, prudence favours leaving the child untouched. Common sense also suggests that where both parents want their child circumcised there are no compelling medical, legal or ethical grounds for not doing so. <a href="http://www.smh.com.au/news/opinion/editorial/tough-cop-on-site/2009/06/03/1243708503896.html?page=2" style="font-weight: 400;">Sydney Morning Herald, 4 June 2009</a> <h3>Comment</h3> The Sydney Morning Herald's editorial is quite in accord with its longstanding practice of giving prominent publicity to every half-baked slander against the foreskin that posthephobic toilers in America's bloated medical research industry cook up, and ignoring the vast body evidence to the effect that circumcision of minors is a harmful, cruel and unnecessary procedure that violates the rights of the child and is already technically illegal under existing laws of assault, mayhem and molestation - as the <a href="http://www.cirp.org/library/legal/QLRC/">Queensland Law Reform Commission found in 1993</a>. So long as ignorant editorial writers use their unaccountable power to champion bad habits it is unlikely that there will be any laws to restrict the practice of male genital mutilation, let alone the degree of protection from female genital mutilation afforded to women. The key facts that refute the editorial's concluding pontification are its earlier admissions that circumcision has always been a controversial and contested operation, and on a world scale a minority practice. These facts alone dictate that the only person entitled to make an irreversible decision about the shape of his penis is its owner. At least the SMH had the decency to publish Paul Mason's letter, pointing out the crazed illogic in the editorial's position. The way some circumcision promoters attempt to argue, you would think it was a large chunk of their brain that had been surgically removed in infancy. <a href="http://www.law.utas.edu.au/reform/">The paper by Tasmanian Law Reform Institute is here</a>. <h2>Stopping circumcision a matter of human rights</h2> Your editorial ("Arguments as old as the practice", June 4) misrepresents my input into the Tasmanian Law Reform Institute's issues paper on the validity of parental consent to unnecessary circumcision, and reveals a glaring non sequitur. You conclude that "there are no compelling medical, legal or ethical reasons for not" operating on a boy without his informed consent -- but only after observing that "the law is silent"; that circumcision "may be an act of cruelty"; that medical organisations no longer recommend routine circumcision; that "the possibility of ... psychological risks is finding growing support in medical studies"; and that "prudence favours leaving the child untouched". I did not refer the issue to the institute in connection with cases where a dispute arises whether to circumcise: the law is pretty clear that it will not proceed in those cases. I referred it in the context that babies are human beings and all human beings have the right to bodily integrity assured by the Universal Declaration of Human Rights (1948). I referred it in the context that the first principle of the Hippocratic Oath is "Do no harm" and that the irreversible, invasive and painful removal of any neurologically complex external organ of a powerless patient at the request of a third party is an ethical travesty. Your editorial seeks to seduce readers into denying babies and children their legal and human rights, while taxpayers are footing the bill through Medicare - circumcision is the only item that requires no medical indication for payment. One reason for its declining popularity in the West since the 1970s may be the influence of women, who see their babies as perfect and not for cutting: from this perspective unnecessary circumcision is a feminist issue. Paul Mason Commissioner for Children, Hobart <a href="http://www.smh.com.au/news/opinion/letters/stopping-circumcision-a-matter-of-human-rights/2009/06/05/1243708622222.html" style="font-weight: 400;">Letter: Sydney Morning Herald, 6 June 2009</a> <h2>Australian children healthier than ever: Boys with foreskins are happier</h2> The health of Australia's children continues to improve, according to the latest report on child health from the Australian Institute of Health and Welfare. During the period 1986-2006 there was a dramatic decline in infant and child deaths (which fell by half), improved survival in cases of cancer, and a reduction in the incidence of asthma. These are significant findings, given that the period 1986 to 2006 witnessed a huge decline in the incidence of circumcision, from about 40 per cent of boys in the early 1980s to about 10 per cent in 2006. It is thus good empirical proof that "lack of circumcision" does not increase child health problems. Even more significantly, it is a decisive refutation of "scientific" predictions by Terry Russell, Brian Morris and other diehard promoters of routine circumcision that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys and an ever-increasing death toll from urinary tract and bladder infections. No such problems are identified in this report, which does not even mention any health problems affecting the genito-urinary area. On the contrary, the halving of the death rate among infants and children suggests that leaving the foreskin in place has significantly improved child health outcomes and contributed to the decline in infant and child mortality. It is, after all, quite illogical to claim that a boy with great wound in his penis is somehow healthier than a boy who has not been injured there. As the British child health expert N.R.C. Roberton points out, "it is fundamentally illogical that mutilating someone might be beneficial." * Problems identified by the AIHW report include an increasing incidence or diabetes and obesity, more, tooth decay, too much television, not enough vegetables, and persistent poor health among indigenous Australians. It is hard to see how even a fanatic like Brian Morris could blame "lack of circumcision" for children not eating their vegetables. The Australian Institute of Health and Welfare is the Australian Government's premier health research foundation. <a href="http://www.aihw.gov.au/publications/index.cfm/title/10704">The full report and press release can be downloaded from the AIHW website. </a> Reference N.R.C. Roberton, "Care of the Normal Term Newborn Baby," in Textbook of Neonatology, eds. Janet M. Rennie, N.R.C. Roberton, 3rd edn. (Edinburgh: Churchill Livingston, 1999), 378-379. <h2>Circumcision criticised in Human Rights Consultation: Submission argues that boys need protection even more than girls</h2> The Commonwealth Government is holding a <a href="http://www.humanrightsconsultation.gov.au/">National Human Rights Consultation</a>, providing the individuals with an opportunity for you to express their views on human rights. The Consultation is run by an independent Committee, supported by a Secretariat within the Attorney-General's Department. The Consultation is a chance to hear people's ideas about human rights and talk about ways to protect and promote human rights in the future. The questions in which it is most interested are <ul> <li>Which human rights and responsibilities should be protected and promoted?</li> <li>Are human rights sufficiently protected and promoted?</li> <li>How could Australia better protect and promote human rights?</li> </ul> The Committee has called for public submissions that address these questions and any other human rights about which people are concerned. <a href="http://www.humanrightsconsultation.gov.au/">For further details see the website.</a> A substantial submission from Dr Robert Darby has raised the question of circumcision and asked why boys are given no protection from unwanted alterations to their genitals when similar operations on girls or women are a serious criminal offence in most states. The submission argues that human rights include the right to bodily integrity and to protection from unwanted surgical interventions: In this submission it is argued that there is a glaring gap in the Australian human rights framework, namely, that boys are not given any protection against unwanted and unnecessary surgical interventions such as circumcision. It is suggested that boys are entitled to as much protection from circumcision (male genital mutilation) as girls from female genital mutilation (female circumcision). Since it is unlikely that any such protection will be provided by legislative measures, alternative means such as public education and the removal of financial incentives are proposed. <a href="http://www.humanrightsconsultation.gov.au/www/nhrcc/nhrcc.nsf/Page/Publicsubmissions_Submissions-Childrenandyoungpeoplesrights">Read the full submission here.</a> <a href="https://www.historyofcircumcision.com/templates/pages/human_rights_and_bodily_integrity.html">Submission text also available on this site.</a> <h2>Circumcision of male children "a hidden human rights violation"</h2> In the April 2007 issue of the Australian Journal of Human Rights, Ranipal Narulla argues that circumcision of male minors should be recognised as a violation of human rights. Synopsis Male circumcision is an accepted practice within Australian society, despite the fact that female circumcision is widely reviled in the Western developed world. This article will consider why society and the law treat circumcision of males and female differently. Analysis will focus upon the circumcision of male children in Australia, with reference to the United Kingdom and the United States of America. The similar social history of the practice within these jurisdictions is instructive when critically analysing the Australian context. The discussion will encompass the circumcision of all male children, as the issues of lack of consent and the imposition of a parent's religious and cultural norms upon the child are consistent for all minors, with specific focus on neonatal children where such extreme youth creates additional vulnerability. The absence of domestic law in Australia dealing with the circumcision of male children invites analysis of the protection afforded under international human rights instruments to which Australia is legally bound. This article deconstructs the medical myths that surround the circumcision of male children, and in so doing makes a strong argument for the need to recognise circumcision of male minors as a human rights violation. Ranipal Narulla, "Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation", Australian Journal of Human Rights, Vol. 12, April 2007, pp. 89-118 The Australian Journal of Human Rights is published by the <a href="http://www.ahrcentre.org/content/research_ajhr.htm" style="font-weight: 400;">Australian Human Rights Centre </a>at the University of New South Wales <a href="http://www.austlii.edu.au/au/journals/AJHR/" style="font-weight: 400;">On-line issues available from AustLii</a> <h4>Tasmanian Children's Commissioner wants circumcision banned</h4> <a href="http://www.childcomm.tas.gov.au/" style="font-weight: 400;">Tasmania's Children's Commissioner</a>, Paul Mason, wants the State Government to ban the non-medical circumcision of young boys. Female genital mutilation is illegal in Tasmania. Mr Mason said it's unfair that boys aren't given the same protection. "We're discriminating against the little baby boys themselves, because they're not safe whereas the little girls are," he said. He said circumcision is an abuse of human rights and should be outlawed until the person is old enough to decide for themselves. "It's a permanent procedure. They get no choice. It's painful -- even under anaesthetic." Mr Mason has prepared a report on the issue for the Council of Obstetric and Paediatric Mortality and Morbidity. The Council will forward a recommendation to the State Government. <a href="http://www.abc.net.au/news/stories/2007/08/13/2002944.htm?site=hobart" style="font-weight: 400;">ABC News, 13 August, 2007</a> <h4>Circumcision specialist censured and fined for improper conduct</h4> Dr Terry Russell, the ageing Queensland GP who has made a career and a fortune out of amputating the foreskins from baby boys, also seems keen to cut boys' tongues. In 2004 he was fined and censured by the Commonwealth Professional Services Review of Medicare services for falsely diagnosing "tongue tie" when the boys were brought to be circumcised, and cutting their tongue as well as their penis. The frenulum that tethers the tongue to the floor of the mouth is very similar to the frenulum that tethers the foreskin to the rest of the penis. Perhaps Dr Russell feels that any body part resembling the foreskin should be removed "just to be on the safe side". There was a time, back in the nineteenth century, when many doctors believed that surgery to correct so called "tongue tie" should be as routine as cutting off the foreskin. The Review reported that Dr Russell had been reprimanded, counselled and ordered to repay the $4,488.88 he had claimed from Medicare. The Committee noted that there was no clinical indication for cutting the tongue and thus that there was no basis for performing the procedure, nor for claiming the cost of the service under Medicare. Had the Committee looked into the cases of the boys brought in to be circumcised, it would have found that there was no clinical indication for circumcision either, and thus that there was no basis for that procedure to be charged to Medicare. Apparently, the government believes that it is OK to alter the appearance and function of the (highly visible) penis without the consent of the owner, but not to interfere with anybody's (usually concealed) tongue. The Medicare guidelines state clearly that Medicare does not cover "medical services which are not clinically necessary" or "surgery solely for cosmetic reasons". Why, then, does it continue to waste taxpayers' money on clinically unnecessary circumcision procedures? The full text of the report on Dr Russell follows. Director Dr John Holmes The Hon. Tony Abbott MHR Minister for Health and Ageing Parliament House Canberra ACT 2600 Dear Minister In accordance with subsection 63(1) of the Public Service Act 1999 and section 106ZQ of the Health Insurance Act 1973, I provide you with the 2003-2004 Annual Report of Professional Services Review for your presentation to Parliament. This report has been prepared in accordance with the Requirements for Annual Reports approved on behalf of the parliament by the joint Committee of Public Accounts and Audit under section 63 of the Public Service Act 1999. Yours sincerely John Holmes 5 October 2004 Dr Charles Terence Russell, General Practitioner, Qld Dr Russell practiced at Macgregor and Browns Plains in Queensland during the referral period of 1 January 1999 to 31 December 1999 inclusive. In relation to the rendering of MBS item 30278 (repair of tongue-tie) Dr Russell's conduct was found by the committee to be unacceptable to the general body of general practitioners. In the majority of services examined, the patients had seen Dr Russell for circumcision procedures. He subsequently performed repairs to tongue-ties. Given this pattern, the committee was concerned that while parents consulted with Dr Russell for circumcisions, he opportunistically diagnosed tongue-tie. The committee found there were no clinical indications for the services. The services were examined in accordance with an approved sampling methodology which resulted in a finding that 90 per cent of MBS item 30278 services rendered by Dr Russell during the referral period were inappropriate. The committee detailed its reasons in a final report to the Determining Authority. Dr Russell did not make a submission on the draft determination. The Authority issued a final determination directing that Dr Russell be reprimanded, counselled and repay $4 488.88. The determination came into effect on 13 February 2004. <a href="http://72.14.253.104/search?q=cache:qEsyOtL7VSwJ:www.psr.gov.au/docs/publications/PSRAR04.rtf+Russell+%2B+tongue-tie+%2B+Medicare&hl=en&ct=clnk&cd=3&gl=au" style="font-weight: 400;">Text available on-line here.</a> If the link does not work, <a href="https://www.google.com.au/search?source=ig&hl=en&rlz=&q=Russell+%2B+tongue-tie+%2B+Medicare&btnG=Google+Search&meta=cr%3DcountryAU%3E" style="font-weight: 400;">search for Russell +tongue tie +Medicare on Google</a>. <h4>Age op-ed writer calls circumcision male genital mutilation</h4> It's child abuse and it's time it was cut out Catherine Deveny <a href="http://www.theage.com.au/news/opinion/its-child-abuse-and-its-time-it-was-cut-out/2007/10/23/1192941062383.html" style="font-weight: 400;">The Age (Melbourne), October 24, 2007</a> People give plenty of reasons for circumcising their male children, writes Catherine Deveny. But most of them don't amount to anything. NO ONE seems to be able to explain to me why the circumcision of baby boys is not considered child abuse. Why in 2007 is it still acceptable for parents to have their babies' foreskins ripped off? How can it be legal, let alone ethical, for any human being to choose for another human being's body to be irreversibly mutilated? No medical reason, no rational thought and in many cases no aesthetic. Just because. I suggest that we should ban the use of the term "circumcision" and force people to use the term "genital mutilation". Because that's what it is. It's not "a personal choice", because that person is not making a choice. It's human rights abuse. The We Circumcised For Religious Reasons camp justify genital mutilation citing religion. They embrace the parts of religious texts that suit them and dismiss the ones that don't. And when I say "they", not all of them do. Many believers I know have all applied a little rational thought to the equation and just decided not to inflict unnecessary pain on their child or expose them to avoidable risk. They've decided to file that bit of the Holy Book under the other things that just don't fit; like selling your daughter into slavery or killing your neighbour if they work on the Sabbath. What kind of God would disapprove of you, stop loving you, or not give you eternal life if you don't mutilate your child's genitals? That doesn't sound like a nice kind of God. And what caring community would shun you, judge you or ostracise you for not inflicting genital mutilation on your child? Then we have the We Circumcised Our Boys So They Look The Same As Their Father camp. Sure, it's not fair for me to pick on people less fortunate in the brains department than the rest of us, but when they are subjecting innocent children to genital mutilation I'm going in swinging. I'm not going to bother asking the hard question "why do you need them to look like their father?", because you cannot reason with something that has not come from reason but from mindlessness. I ask the So They Look The Same As Their Father camp, why stop there? If you want them to look the same as their father, dye their hair, have them undergo cosmetic surgery and if the father has any tattoos or facial hair, sort that out too. Related to this camp is the We Circumcised Our Boys Because A Circumcised Penis Looks Nicer camp. We are talking the shallow end of the intelligence pool here. How would they feel if they had had their nipples, nose or ears cut off by their parents when they were a child because their parents thought "it looked nicer"? I must say that I do applaud these two camps on their frankness and honesty despite it revealing their stunning stupidity. After all, they could do what others do and make the decision for no rational reason and then rationalise it by joining the We Circumcised Our Boys For Health And Hygiene Despite Looking Closely At The Research camp. I have read the various studies suggesting that circumcision may reduce the spread of HIV and cervical cancer. I have also read the studies disproving the circumcision-reduces-infection myth. Here in Australia, all of these risks can be effectively and safely managed with condoms and cleanliness. That's right, a bit of frangers and face washers, rubbers and rubbing. Why would you expose a child to an unnecessary medical procedure and all the risks that come with it when you could teach them how to clean themselves and use a condom? Because you can, I suppose. By the same logic, removing all your children's teeth would prevent them getting fillings. Unless, of course, there is a sound medical reason to circumcise. And when I say sound, I mean sound as in last resort. I don't mean that you walk into a GP with a seven-year-old with a constricted foreskin that is not retracting and walk out with a referral to a surgeon to have your child's genitals mutilated, as a family I know could have. One of their sons had that very problem. They were offered a referral to a surgeon to have him circumcised. They didn't like the sound of that. Luckily they didn't have private health insurance, because that meant that they were given a referral to the Royal Children's Hospital, where they saw a general pediatric surgeon, or as their son referred to her, a Dick Doctor. Yes, she said, he could be circumcised, but she was having great success using an ointment available over the counter from the chemist. Three days later, the boy had a retracting foreskin. And two years later, he still does. The wonders of a health service on a budget as opposed to a private business. So if he wants to get himself circumcised as an adult, that's his choice. And he'll have that choice. Because when you circumcise someone, you can't uncircumcise them. <h4>Professor fails history:</h4> <h4>No evidence that Louis XVI was circumcised</h4> In the latest rewrite of his familiar list of "compelling" reasons as to why boys must not be allowed to keep their foreskins [1], Professor Brian Morris makes the extraordinary claim that Louis XVI, King of France 1754-93, was prevented from consummating his marriage to Marie Antoinette by his "tight foreskin", and was obliged to submit to circumcision so that he could perform his marital duties. This assertion is presented as one of the numerous reasons why circumcision is "a biomedical imperative" for the 21st century. The first point to make is that there is no evidence at all that Louis XVI was circumcised. Professor Morris seems to be awkwardly aware of the absence of evidence, for the only citation he provides for his claim is a reference to his own website. The story is one of the many anecdotes recorded as "compelling reasons" for circumcision by the notoriously unreliable circumcision evangelist <a href="https://www.historyofcircumcision.com/templates/pages/1902_dr_remondino_blasts_anti_circumcision_activists.html">Peter Charles Remondino</a>, who wrote in the 1890s that the King "was afflicted by a congenital phimosis which prevented the flow of semen from properly discharging itself". But even a fanatic such as Remondino was forced to concede that that there was no truth in the circumcision rumours, for even if it had been suggested, Louis refused to submit to the operation. Instead, according to Dr Remondino, he worked on dilating his foreskin manually, with such success that he soon fathered three children. [2] There has been much speculation as to why Louis and Marie took eight years to produce an heir. Explanations offered have included their strict religious educations, their traumatic childhoods, the extreme youth of the two spouses, and the condition of the King's foreskin. A reliable review of the case is provided by the Greek urologist G. Androutsos, who concludes that there is no evidence that Louis was circumcised, but suggests that he was probably late in reaching puberty and also that he might have had an associated persistent <a href="http://www.cirp.org/library/treatment/phimosis/">phimosis</a> or a short frenulum <a href="http://www.circumstitions.com/Frenbrev.html">(frenulum breve)</a> that made intercourse difficult. If so, it is possible that the problem was corrected by a very mild surgical intervention, involving no more than nicking the strands of tissue that tethered the foreskin, and not by amputating anything from the royal person. [3] This would have been similar to the operation for phimosis later recommended by the French sexual health authority Philippe Ricord, and practised in England by William Acton. [4] There is no firm evidence that Louis ever had any kind of surgery on his penis, but if he did have an operation, this is the most likely contender. Professor Morris's airy assertion that Louis was circumcised at the insistence of Marie-Antoinette's brother, Joseph II of Austria, is plainly false. References 1. Brian Morris, "Why circumcision is a biomedical imperative for the 21st century", BioEssays, November 2007 2. Peter Charles Remondino, History of Circumcision from the Earliest Times to the Present: Moral and Physical Reasons for its Performance, Philadelphia and London, F.A. Davis, 1891, pp. 201-2 3. Androutsos G., Le phimosis de Louis XVI (1754-1793) aurait-il ete a l'origine de ses difficultes sexuelles et de sa fecundite retardee?. Prog Urol. 2002; 12(1):132-7. <a href="https://www.historyofcircumcision.com/templates/pages/the_truth_about_louis_xvis_marital_difficulties.html">An English translation of this article is available on this site.</a> <ol> <li style="font-weight: 400;">William Acton,A Practical Treatise on the Diseases of the Urinary and Generative Organs (in Both Sexes), 2nd edition, London, Churchill, 1851, pp. 77-78</li> </ol> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision in the news in Australia 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"> On of the silliest arguments of the circumcision promoters is that circumcision is "just like vaccination". In this comparison they are treading in the footsteps of Dr Remondino and the enthusiasts of the 1890s, who claimed that universal circumcision would control syphilis (and many other diseases) in the same way as compulsory vaccination defeated smallpox. Unfortunately, only the second of these measures had scientific validity. A moment's thought will reveal the absurdity of the vaccination analogy: even blind Freddie could tell the difference between a boy who came back from the doctor after having had an injection and one who came back after having had his foreskin cut off. To mention a few obvious differences: <ul> <li> Vaccination confers immunity against specific diseases; even if the extravagant claims of its advocates were correct, circumcision could do no more than reduce risk (and not by much). Nobody will become immune to any disease by virtue of circumcision. </li> </ul> <ul> <li> Vaccination adds to the body's natural immune system; circumcision amputates a large and visually prominent part of the penis. </li> </ul> <ul> <li> Vaccination leaves at most a small spot or lump; circumcision disfigures and scars a man in his most sensitive region for life. </li> </ul> <ul> <li> Vaccination is an injection; circumcision is major surgery, accurately described as pre-emptive amputation. </li> </ul> <ul> <li> Vaccination does not diminish the functionality of any body part; circumcision has documented adverse effects on the function of the genitals. </li> </ul> <ul> <li> Vaccination is scientific medicine, with proven protective value; circumcision is a relic of Victorian quackery. </li> </ul> In <a href="https://www.circinfo.org/Circumcision_HIV_control_Australia.html">Not a surgical vaccine</a>, a paper published in the Australian and New Zealand Journal of Public Health in 2010, the authors criticised the analogy between circumcision and vaccination (so popular with anti-foreskin activists such as Professor Morris) as regrettable and misleading, and concluded that: “The colourful image of circumcision as ‘surgical vaccine’ is a contradiction in terms, on a par with ‘conjectural fact’; such rhetoric has no place in scientific debate.” Oddly enough, now that there is a vaccine for cervical cancer, circumcision promoters (who pride themselves on their scientific credentials) are going cold on vaccination and warn of terrible side effects and bad reactions. No doubt these do occur in a few cases, but they are nothing like the adverse effects of circumcision. Like the effectiveness of condoms against HIV and other STIs, effective vaccines destroy the argument for circumcision. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision is not comparable to vaccination 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 survey of recent medical literature on circumcision has concluded that many of the studies are of poor quality, are not sufficiently evidence-based, lack methodological rigour, and are often not applicable to developed countries. The paper, by J.A. Bossio and colleagues, concludes that more research is needed, particularly on the impact of circumcision on sexual experience and other harms and risks arising from the surgery. Parts of the abstract read as follows: Introduction. Male circumcision is one of the most commonly performed surgical procedures worldwide and a subject that has been the center of considerable debate. Recently, the American Academy of Pediatrics released a statement affirming that the medical benefits of neonatal circumcision outweigh the risks. At present, however, the majority of the literature on circumcision is based on research that is not necessarily applicable to North American populations, as it fails to take into account factors likely to influence the interpretability and applicability of the results. Results. This review highlights considerable gaps within the current literature on circumcision. The emphasis is on factors that should be addressed in order to influence research in becoming more applicable to North American populations. Such gaps include a need for rigorous, empirically based methodologies to address questions about circumcision and sexual functioning, penile sensitivity, the effect of circumcision on men’s sexual partners, and reasons for circumcision. Additional factors that should be addressed in future research include the effects of age at circumcision (with an emphasis on neonatal circumcision) and the need for objective research outcomes. Conclusion. Further research is needed to inform policy makers, health-care professionals, and stakeholders (parents and individuals invested in this debate) with regard to the decision to perform routine circumcision on male neonates in North America. CIA comment: For all it moderation of language, this paper, by three impartial observers, is a pretty devastating indictment of claims that the “benefits” of circumcision outweigh the risks. As the authors of the study point out, most of the research cited to back up this assertion was conducted in poverty-stricken Third World countries with poorly developed health services and high levels of sexually transmitted disease, especially HIV-AIDS. The results of this research is simply not applicable to developed countries such as north America, Canada and Australia. Just as serious is the study’s conclusion that much of the pro-circumcision literature is not based on sufficient evidence or conducted with sufficient methodological rigours to justify the sort of conclusions that the <a href="https://www.circinfo.org/United_States_circumcision_policy.html">American Academy of Pediatrics</a> came up with in 2012. As the authors of the survey point out, a great deal more research is needed before any firm conclusions about the balance of benefits, risks and harms can be reached. Source: Bossio JA, Pukall CF, and Steele S. <a href="http://onlinelibrary.wiley.com/doi/10.1111/jsm.12703/abstract" rel="noopener" target="_blank">A review of the current state of the male circumcision literature</a>. Journal of Sexual Medicine, Online first, 6 October 2014. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision literature full of gaps, lacks rigour and relevance ( darby