9 10 240 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>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"> <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"> 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 recent study in Scotland concerns a group of 1000 children aged 0-16 years, consisting of 820 girls and 180 boys, who were referred to a centralized urinary tract infection unit in Western Scotland. UTIs are the only health problem for which there might conceivably be a tiny health benefit from early circumcision, but the study is of interest because it shows that UTIs are far more common in girls than in boys, and that circumcision is rarely necessary to correct cases of recurrent UTIs. The authors note that of the 180 boys referred for a first UTI, only 3 of them (1.7%) subsequently had to be circumcised due to recurrent UTIs. Since circumcision is rare in Scotland and “routine circumcision” practically unknown, it may be assumed that all (or nearly all) the boys were uncircumcised. This is suggested by the fact that the authors make no breakdown of the numbers by foreskin status. The authors also present age-specific male-female ratios showing that girls are far more subject to UTIs in all age groups, even among children under 6 month of age (where the M:F ratio is 1:2). This is in contrast to some other studies finding that in this age group boys outnumber girls. Given the nature and size of the study (unselected, consecutive material, except for the likely underrepresentation of children with prenatal urinary tract problems identified by ultrasound), the results provide solid evidence that UTIs in early infancy are not a particular male problem that requires particular “male solutions”. The protocol used here seems to catch the vast majority of children in need of intervention, and shows that circumcision has no preventive place in that protocol, except among those very few boys who experience recurrent UTIs. In other words, rather than advocating routine circumcision for the prevention of UTI in boys (which, in any case, occur in only 0.5%-1% of boys), circumcision should be reserved as an option in those very few boys (only 1.7% according to this study) who experience recurrent UTIS. This means that no more than about 0.01%-0.02% (2% of 0.5%-1.0%) of boys should ever need to be circumcised for this reason. Source: E. Broadis et al. ‘Targeted top down’ approach for the investigation of UTI: A 10-year follow-up study in a cohort of 1000 children. Journal of Pediatric Urology 2015 early view: http://dx.doi.org/10.1016/j.jpurol.2015.07.006 </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 Urinary tract infections: circumcision rarely needed darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>An American invention</h3> The first appearance of the claim that uncircumcised boys were more vulnerable to infections of the urinary tract was made by American doctors in 1982. This was the very time when the American medical profession became alarmed at the sharp decline in the number of parents wanting to get their boys circumcised. For all the fuss subsequently made abut UTIs, however, all the paper did was observe in passing that “95% of the [male] infants [with a UTI] were uncircumcised”. It failed to mention the vital fact that hardly any babies born at that hospital (Parkland in Dallas, Texas) were circumcised. The figure thus had no significance at all. Even if it did, it hardly mattered, for the paper continued: “All infants responded promptly to antimicrobial therapy.” That is to say, the infections cleared up quickly after treatment with antibiotics. Reference: Ginsburg G.M. and McCracken G.H. <a href="http://www.cirp.org/library/disease/UTI/ginsburg/">Urinary tract infections in young children</a>. Pediatrics 1982; 69: 409-12 Claims for the greater susceptibility of uncircumcised boys to UTIs, and thus for the desirability (if not the necessity) of circumcision, rely heavily on the research and publications of the American military doctor Thomas Wiswell. His studies have generally been taken as authoritative, even though they were not done on randomly selected “live” subjects, but retrospectively on boys born on army bases. Wiswell merely looked at the information on their charts and never examined the boys themselves or asked about their general management. All these clues are important. Having been born under military rule, it is pretty certain that all boys well enough to stand it would have been circumcised pronto in accordance with U.S. army policy. This suggests that premature or otherwise frail babies, considered too weak to tolerate the surgery, were over-represented among the intact. Many of these might well have been subjected to a catheter, and thus the vastly increased potential for infection that such interventions provide. Wiswell’s studies, like many of those that have followed, are fatally flawed beause they do no more than compare the incidence of UTIs in a group of circumcised boys with the incidence in a group of uncircumcised boys. They fail to take into account a number of vital factors, including: <ul> <li>anomalies in the urinary tract or bladder</li> <li>possible sources of the baby’s exposure to bacteria when taken away from his mother (e.g. from the hands or clothing of hospital staff)</li> <li>management of foreskin (whether left alone or intefered with)</li> <li>how quickly the boy started breast feeding </li> </ul> All these issues are highly relevant to the risk of UTIs and should have been factored into Wiswell’s conclusions. The policy in American military hospitals at the time when Wiswell collected his data was to apply the erroneous Edwardian advice that, if a baby was not circumcised, his foreskin should be retracted daily so at to allow the interior to be washed. This is very bad advice, as nothing could be better calculated to spread bacteria from the hands and clothing of medical and nursing staff and into the boy’s urethra, which would otherwise have been shielded by the tight, valve-like foreskin normal in infants. Discredited in Britain in 1949, this harmful routine was still commonly followed in the U.S.A. as late as the 1980s, and some deluded health “experts” still advise it today. This policy alone would probably account for many of the UTIs found in the uncircumcised sample. It may also be that excessive cleanliness favours the growth of harmful bacteria, since the liberal use of disinfectants common in hospitals kills the benign or neutral bacteria that would otherwise colonise skin surfaces and prevent harmful bacteria from gaining a foothold. <h2> <a id="Disprove" name="Disprove"></a>Recent studies disprove foreskin-UTIs link</h2> Since Wiswell’s inadequate and grossly flawed studies, research on far larger and more representative samples of boys and girls have disproved the claim of a causal link between the foreskin and a significantly heightened risk of UTI infection. <h3>Circumcision for the prevention of urinary tract infection in boys</h3> In an analysis of controlled trials and observational studies covering over 400,000 children, the authors concluded that although there was evidence that circumcision could reduce the incidence of urinary tract infections in boys, the protective effect was not sufficient to justify preventive or prophylactic circumcision with this object in mind. Extract from conclusion "The benefit of circumcision on UTI only outweighs the risk in boys who have had UTI previously and have a predisposition to repeated UTI. As this analysis has used a conservative circumcision complication rate of 2%, if the complication rate were in reality higher the risk–benefit analysis may not favour circumcision even in the higher risk populations. "In conclusion, the data we present do not support the routine circumcision of normal boys with standard risk in order to prevent UTI. However, our data suggest that circumcision of boys with higher than normal risk of UTI should be considered. As there is no direct evidence of the effect of circumcision on UTI in this group, confirmation through a randomised trial of circumcision in high risk patients would be beneficial. Using an OR of 0.2 (the upper limit of the 95% CI of the combined OR found in this study) and a power of 80%, the sample size required to study this hypothesis would be 140 (70 in each treatment arm), assuming a recurrence risk of 10%. "Until this additional information is available, the present data do not support the routine circumcision of boys to prevent UTI. However, circumcision should be considered in those with recurrent UTI or significantly increased risk of UTI." It should be noted that the equation used by the authors of the article was the very narrow calculus of estimated risk of surgery compared with estimated benefit. If they had factored in the loss of the foreskin and the affront to personal dignity and autonomy inherent in circumcision without consent, the balance would swing far more heavily towards the “don’t cut” end of the scale. It should also be noted that the author’s estimate of the risks of circumcision was, as they acknowledge, “conservative”: with estimates of the complication rate ranging from 2 to 10 per cent, they chose to base their calculations the lowest estimate (2%). Had they selected a mid-point, their conclusions would have been much stronger. As they write: “While circumcision is protective for UTI, the overall risk–benefit derived from circumcision in preventing UTI is not easily quantifiable, as the incidence of important sequelae of UTI (sepsis, permanent renal damage, hypertension, and chronic renal failure) are not known. The complication rate of circumcision is documented to be between 2% and 10%, and no data are available on the relative risks and benefits of circumcision. Thus we have used a conservative estimate of circumcision complications of 2% and assumed equal utility for benefits and harms in the following analysis.” It follows that a more comprehensive assessment of the risks of circumcision surgery would tilt the scales even further towards the position that prophylactic circumcision of normal boys should not be performed. D. Singh-Grewal, J. Macdessi, J. Craig Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies <a href="http://adc.bmj.com/content/90/8/853.full" rel="noopener" target="_blank">Archives of Diseases in Childhood 2005;90:853-858</a> (Registration needed for access) <h3>Antibiotic Prophylaxis and Recurrent Urinary Tract Infection in Children</h3> A study of Australian children found that long-term administration of low doses of antibiotics was effective in controlling UTIs in both male and female infants. The article made no mention of circumcision, except to state that only 4 per cent of the antibiotic (study) group and 5 per cent of the placebo (control) were circumcised. There was no difference in outcome observed between the circumcised and the uncircumcised boys. Conclusion: "Long-term, low-dose trimethoprim–sulfamethoxazole was associated with a decreased number of urinary tract infections in predisposed children. The treatment effect appeared to be consistent but modest across subgroups." Jonathan Craig, Gabrielle Williams et al Antibiotic Prophylaxis and Recurrent Urinary Tract Infection in Children New England Journal of Medicine, Vol. 361, October 2009, 1748-59 <h3>Risk factors for urinary tract infection in children</h3> The most recent Australian study aiming to identify the risk factors for UTIs in children found that parents grossly over-estimated the incidence of such infections, but that the foreskin was not a significant risk factor. The study suggested that a major contributing factor was leaving babies and toddlers in wet nappies. The simplest preventive strategy, therefore, was to let them run around without nappies or other clothing that allowed urine to accumulate against their body, or otherwise make sure that they were kept dry. Circumcision as a preventive strategy for UTIs was not considered. Abstract AIM: To identify risk factors for urinary tract infection (UTI) in children to inform the development of preventative strategies. METHOD: A validated questionnaire covering demographic factors, perinatal, developmental, bowel and urinary history was sent to a cross-sectional sample of parents of elementary school children randomly selected from the first 4 years of school. UTI was ascertained by parental report, verified by cross-referencing with microbiological reports for all positive cases and 50 randomly selected negative cases. RESULTS: Parents of 2856 children (mean age 7.3 years, range 4.8–12.8 years) responded. A total of 3.6% of children had a bacteriologically verified UTI, compared with 12.6% by parental report alone. Multivariate polychotomous logistic regression showed that a history of structural kidney abnormalities (odds ratio (OR) 15.7, 95% confidence interval 8.1–30.4), daytime incontinence (OR 2.6, 1.6–4.5), female gender (OR 2.4, 1.5–3.8), and encopresis (OR 1.9, 1.1–3.4) were independently associated with UTI. Daytime incontinence increased risk more in boys (8.3% vs. 1.2%) than girls (8.1% vs. 4.6%), and kidney problems increased risk in older compared with younger children (29% vs. 2% in _8 year olds, 0% vs. 4% in 4–6 year olds). CONCLUSIONS: Parents over-report UTI by about threefold. Effective treatment of daytime urinary incontinence and encopresis may prevent UTI in children, especially boys. Premala Sureshkumar, Mike Jones, Robert G Cumming, and Jonathan C Craig Risk factors for urinary tract infection in children: A population-based study of 2856 children Journal of Paediatrics and Child Health 45 (2009) 87–97 <h3> <a id="Increase" name="Increase"></a>Could circumcision increase incidence of UTIs?</h3> Evidence from Israel suggests that circumcision in early infancy could cause UTIs. Is ritual circumcision a risk factor for neonatal urinary tract infections? Objective: Although circumcision is commonly believed to protect against urinary tract infection (UTI), it is not unusual in neonates in Israel, where almost all male infants are circumcised. The aim of the study was to evaluate the burden of neonatal UTI in Israel and its relationship to circumcision. Design: Medical records of neonates (?T2 months old) hospitalized with UTI were reviewed and demographic and clinical data were collected. The second part of the study consisting of a telephone survey to assess timing and details concerning the circumcision, included two groups: the study group consisting of parents of male infants, aged 8-30 days, hospitalized with UTI and a control group consisting of healthy neonates. Results: 162 neonates (108 males, 54 females) were hospitalized with UTI. Mean age at admission was significantly lower in males (27.5 vs 37.7 days, p=0.0002). The incidence of UTI in males peaked at 2-4 weeks of age i.e. the period immediately following circumcision. In females, the incidence tended to rise with age. Accordingly, male predominance disappeared at 7 weeks and the male-to-female ratio reversed. In the second part of the study, 111 males (?T1 month old) were included: 48 post-UTI and 63 as a control group. While evaluating the impact of circumcision technique, we found that UTI occurred in 6 of the 24 infants circumcised by a physician (25%), and in 42 of the 87 infants (48%) circumcised by a religious authority; the calculated odds ratio for contracting UTI was 2.8 (95% CI: 1-9.4). Conclusions: There was a higher preponderance of UTI among male neonates. Its incidence peaked during the early post-circumcision period, as opposed to the age-related rise in females. UTI seems to occur more frequently after traditional circumcision than after physician performed circumcision. We speculate that changes in the hemostasis technique or shortening the duration of the shaft wrapping might decrease the rate of infection after Jewish ritual circumcision. [Or in other words: Not circumcising would decrease the occurrence of Urinary Tract Infections.] Dario Prais, Rachel Shoov-Furman and Jacob Amir, Is ritual circumcision a risk factor for neonatal urinary tract infections? <a href="http://adc.bmj.com/cgi/content/abstract/adc.2008.144063v1?rss=1">Archives of Disease in Childhood, September, 2008</a> <h2> <a id="Breast" name="Breast"></a>Breast feeding: Best defence against UTIs</h2> <img alt="" class="image-left" height="152" src="https://www.circinfo.org/images/breastfeeding2.jpg" width="203"/>Another vital question is how soon the baby started breast-feeding, since mother’s milk is a valuable source of the antibodies that fight harmful bacteria. There are some interesting remarks about the value of breast milk as an anti-bacterial and anti-fungal agent in Sarah Hrdy‘s study, Mother Nature. Hrdy suggests that lactation evolved in mammals mainly because milk was not merely highly nutritious, but also a disinfectant: "A particular component of bodily secretions called lysozymes – enzymes present in human tears and blood that digest bacteria – was present in secretions accidentally applied to eggs. If this serendipitous secretion happened to protect eggs from fungi and bacteria during incubation, then leaking mothers would have higher hatching success than mothers that ran tighter ships. ... A protein specific to mother’s milk (alphalactalbumin) evolved from lysozymes. Newly hatched babies who lapped up this protein-rich antibiotic would have gotten a nutritional boost along with their immunological dose. If the anti-bacterial hypothesis is correct, colostrum, the thick, yellowish fluid present in the breasts before and for several days after birth, maybe the closest analogue to ancient mother's milk. Colostrum is packed with antibodies.” Lysozymes have also been found in the secretions of the foreskin: see articles by <a href="http://www.cirp.org/library/anatomy/parkash/">Parkash et al</a> and<a href="http://www.cirp.org/library/disease/STD/fleiss3/" rel="noopener" target="_blank"> Fleiss & Hodges</a>. Hrdy reports that some cultures (both ancient and modern) have enjoined mothers not to feed their babies colostrum, including British doctors from the 17th century, but that when they changed their minds (she does not say when) and advised mothers to breastfeed immediately, there was a rapid fall in the infant death rate in the first month of life. “Although parents in some cultures dispose of colostrum, in many others they incorporate it ... into customary childcare. An American nurse collecting a milk sample in a Swedish clinic was surprised when a new father requested a dab of the fluid. He immediately smeared it on the baby’s rump. “Why?” she asked. “Oh, to prevent diaper rash. A drop of milk can also be applied to a baby’s eyes to prevent infections.” [Trust the Swedes to know.] “Laboratory experiments corroborate such folk wisdom. Fresh mother’s milk in a test tube kills one of the main dysentery-causing amoebas, Entamoeba histolytica, along with another common diarrhoea-causing parasite, Giardia lamblia. A particular glycoprotein in mother’s milk (lactadherin) has been shown to protect against rotavirus, one of the major causes of infantile diarrhoea.” Sarah Blaffer Hrdy Mother Nature (Vintage pbk, 2000), pp. 135-7 <a href="http://www.nocirc.org/statements/breastfeeding.php" rel="noopener" target="_blank">More information on the importance of breast-feeding</a> <h3>Confirmed by other research</h3> These observations are confirmed by an article published in a leading Swedish medical journal in 2004. Marild S, Hanson S, Jodal U, Oden A, Svedberg K. Protective effect of breastfeeding against urinary tract infection. Acta Paediatr. 2004 Feb;93(2):154-6. AIM: To assess the possible protective effect of exclusive breastfeeding against first-time febrile urinary tract infection (UTI) in children. METHODS: Two children’s hospitals and local child health centres in the Goteborg area, Sweden, participated in a prospective case-control study. In total, 200 consecutive cases (89M, 111F), aged 0-6y, presenting with first-time febrile UTI were enrolled. The mean +/- SD age was 0.98 +/- 1.15 y. As control subjects, 336 children (147M, 189F) were recruited from the child health centre of the case, matched for age and gender and included consecutively for each case during the first days after diagnosis. The duration of exclusive breastfeeding was obtained from the case and controls by a standardized procedure. RESULTS: Ongoing exclusive breastfeeding gave a significantly lower risk of infection. A longer duration of breastfeeding gave a lower risk of infection after weaning, indicating a long-term mechanism. The protective role of breastfeeding was strongest directly after birth, then decreased until 7 months of age, after which age no effect was demonstrated. CONCLUSION: A protective role of breastfeeding against UTI was demonstrated. The study provides statistical support to the view that breast milk is a part of the natural defence against UTI. <a href="http://www.cirp.org/library/disease/UTI/hanson1/" rel="noopener" target="_blank">Read full text.</a> This article confirms <a href="http://www.cirp.org/library/disease/UTI/pisacane1992/">earlier work by Pisacane et al.</a> <h2> <a id="Conclusion" name="Conclusion"></a>Conclusion: Circumcision not warranted as UTI preventive</h2> The BOTTOM LINE, according to the British Journal of Urology: Routine circumcision is not warranted for UTI prevention Clinical question: How effective is circumcision in the reduction of risk of urinary tract infections? Routine circumcision does not provide enough reduction in risk of urinary tract infection (UTI) to justify the surgical complication risk. For boys at high risk of UTI, however, the reduction in risk may justify the procedure. (LOE = 2a–) REFERENCE: Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review or randomised trials and observational studies. Arch Dis Child 2005;90:853–8. SYNOPSIS : Reduction in risk of UTI is usually claimed as the major medical justification for routine circumcision. The meta-analysis was performed to quantify that risk reduction. They included twelve studies including more than 400,000 boys, including mostly cohort and case–control studies and one randomized controlled trial. Circumcision was associated with a significant reduction in episodes of UTI (odds ratio = 0.13; 95% CI, 0.08–0.20; P < .001). The randomized trial was consistent with the overall results, though it was too small to detect a statistically significance difference. An estimated 111 circumcisions must be performed to prevent one UTI in the general population. Since the expected surgical complication rate is at least 1%, the risk is unlikely to justify the benefit. In boys at higher risk (those with at least a 10% risk of UTI, for example), the surgery is medically justified. <a href="http://www.bjui.org/contentfullitem.aspx?id=306&LinkTypeID=1&SectionType=1" rel="noopener" target="_blank">Delivered as Daily POEM: 18/10/2005</a> (Registration needed for access) <h3>The bottom line</h3> Combining the rarity of UTIs with the small risk reduction attributable to circumcision, British doctors have calculated that it would take 195 circumcisions to prevent one UTI. REFERENCE: To T, Agha M, Dick PT, Feldman W. <a href="http://www.cirp.org/library/disease/UTI/to2/">Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection</a>. Lancet 1998;352(9143):1813-16 An earlier study found that "six hundred and twenty-five infant boys would need to be circumcised to prevent one UTI hospitalization in the first 5 years of life". REFERENCE: To T, Agha M, Dick PT. et al.<a href="http://www.cirp.org/library/disease/UTI/to/"> A cohort study on male neonatal circumcision and the subsequent risk of urinary tract infection</a>. Paediatr Child Health 1997;2 (supple A): 55A. The lessons of the information above can be summarized in these slogans The foreskin: As wonderful as mother’s milk. The foreskin and mother’s milk: Nature’s disinfectants or from the other angle: Circumcision: Another cruel blow for those who missed out on mother’s milk. Circumcision: The penalty if you don’t drink your milk. <h2> <a id="jpch" name="jpch"></a>Circumcision not recommended for urinary tract infection</h2> A study in the latest (April 2012) issue of the Australian Journal of Paediatrics and Child Health reviews the treatment and prevention options for urinary tract infections (UTI) in children. It finds that a UTI occurs in approximately 8% of girls and 2% of boys by 7 years of age, and outlines the best treatment options, depending on the nature of the infection and whether it recurs. The study does not recommend circumcision except in the few cases where recurrent episodes have failed to respond to medical (mainly antibiotic) treatment. The study notes that “approximately 20% of children who have had one UTI experience a symptomatic recurrence. Preventing UTI recurrence would avoid further episodes of illness, discomfort and family stress. The likelihood that preventing UTI would prevent clinically important kidney damage is unknown but likely to be very low, given the very low risk of clinically important kidney damage following UTI, and the modest benefit of prophylactic interventions. “The Royal Australasian College of Physicians’ policy position is that circumcision is not indicated as primary prevention. It could be estimated that between 110 and 140 circumcisions are required to prevent one UTI, while major complications occur in around 2%.** However, circumcision should be considered in boys with a high risk of recurrent febrile infection, that is boys with previous UTIs and/or high-grade VUR,*** where the number needed to treat is between 4 and 11, so that the benefits outweigh the risk of adverse effects.” Summary <ul> <li>Circumcision is not recommended after first UTI</li> <li>Consider circumcision in boys with recurrent UTI</li> </ul> Source: Gabrielle J Williams, Elisabeth H Hodson, David Isaacs and Jonathan C Craig, Diagnosis and management of urinary tract infection in children. <a href="http://onlinelibrary.wiley.com/doi/10.1111/jpc.2012.48.issue-4/issuetoc">Journal of Paediatrics and Child Health 48</a>, April 2012, 296-301 ** An improbably low figure. In the absence of a systematic and comprehensive study and agreed benchmarks, nobody knows the true incidence of complications. Quite apart from this issue, complications is only a small part of the story: what about the value of the foreskin, the harm of loosing it, the wishes of the individual and the moral harm of violating a person’s bodily integrity without his consent? *** VUR stands for vesicoureteric reflux, a rare condition in which urine flows backward into the kidney, sometimes causing damage. <a href="http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001494/">Further information from PubMed Health</a>. Note that their illustration shows penis with foreskin - i.e. not circumcised! Prevention of UTIs <a href="http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001534/" rel="noopener" target="_blank">United States National Library of Health</a> makes the following recommendations for preventing UITs in children. Circumcision does not rate a mention. <ul> <li>Avoid giving your child bubble baths</li> <li>Have your child wear loose-fitting underpants and clothing</li> <li>Increase your child's intake of fluids</li> <li>Keep your child's genital area clean to prevent bacteria from entering through the urethra</li> <li>Teach your child to go the bathroom several times every day</li> <li>Teach your child to wipe the anal-genital area from front to back to reduce the chance of spreading bacteria from the anus to the urethra</li> </ul> <h2>Further information</h2> <a href="http://www.cirp.org/library/disease/UTI/">Studies collected at CIRP</a> <a href="http://www.circumstitions.com/Utis.html">Analysis at Circumstitions</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 Urinary tract infections 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"> Circumcision in Australia: Further evidence on its effects on sexual health and wellbeing Jason A. Ferris, Juliet Richters, Marian K. Pitts, Julia M. Shelley, Judy M. Simpson, Richard Ryall, and Anthony M. A. Smith Australian and New Zealand Journal of Public Health, Vol. 34 (2), April 2010, 160-64 OBJECTIVE: To report on the prevalence and demographic variation in circumcision in Australia and examine sexual health outcomes in comparison with earlier research. METHODS: A representative household sample of 4,290 Australian men aged 16–64 years completed a computer-assisted telephone interview including questions on circumcision status, demographic variables, reported lifetime experience of selected sexually transmissible infections (STIs), experience of sexual difficulties in the previous 12 months, masturbation, and sexual practices at last heterosexual encounter. RESULTS: More than half the men (58%) were circumcised. Circumcision was less common (33%) among men under 30 and more common (66%) among those born in Australia. After adjustment for age and number of partners, circumcision was unrelated to STI history except for non-specific urethritis (higher among circumcised men, OR=2.11, p<0.001) and penile candidiasis (lower among circumcised men, OR=0.49, p<0.001). Circumcision was unrelated to any of the sexual difficulties we asked about (after adjusting for age) except that circumcised men were somewhat less likely to have worried during sex about whether their bodies looked unattractive (OR=0.77, p=0.04). No association between lack of circumcision and erection difficulties was detected. After correction for age, circumcised men were somewhat more likely to have masturbated alone in the previous 12 months (OR=1.20, p=0.02). CONCLUSIONS: Circumcision appears to have minimal protective effects on sexual health in Australia. <h3>Comment</h3> One of the most interesting findings of the study is that circumcision nearly doubles a male’s risk of non-specific urethritis (NSU). This result is consistent with Jonathan Hutchinson’s <a href="https://www.circinfo.org/cervical.html">notorious syphilis study</a> of 1854, which showed (though this point was never mentioned by circumcision enthusiasts) that circumcised men had a higher risk of gonorrhoea. Since NSU is a urinary tract infection, the finding must also cast serious doubt on the claim that circumcision significantly reduces the <a href="https://www.circinfo.org/utis.html">risk of UTIs</a> in male infants. A study published in the USA in 1987 also found that "lack of circumcision" did not increase the risk of gonoccocal urethritis, but that the foreskin had a protective effect against non-gonoccocal urethritis: Smith GL, Greenup R, Takafuji ET. <a href="http://www.cirp.org/library/disease/STD/smith/">Circumcision as a risk factor for urethritis in racial groups</a>. Am J Public Health 1987;77:452-4. What is striking is how differently the media report these sorts of studies, depending on whether the foreskin has been found pathogenic, neutral or beneficial. There has been no coverage of this article in the Australian media, nor of the recent study by Adelaide researchers in Annals of Family Medicine, both of which conclude that circumcision is either useless for health or even harmful. But recall the numerous screaming headlines over the past decade every time some study or other showed that "lack of circumcision” was somehow associated with vastly increased risk of STDs, cancer, AIDS and tutti quanti. Actually, the reports rarely put it as cooly as that: usually they leave the impression, if they do not explicitly allege, that the mere presence of the foreskin is enough in itself to generate all these terrible diseases. Even a report on the Ferris/Richters study in <a href="http://www.6minutes.com.au/articles/z1/view.asp?id=515210">6Minutes does not escape</a> the anti-foreskin prejudice: its headline is “Circumcision benefits not seen in Australia”, but why not write "Circumcision can double risk of urethritis"? And don’t forget to <a href="http://www.6minutes.com.au/commentall.asp?artid=515210">check out the responses</a> to Prof. Morris’s comment. It's interesting to compare the Canadian media, where <a href="http://www.theglobeandmail.com/life/health/circumcision-health-benefit-virtually-nil-study-finds/article1427972/">newspapers reported the Adelaide study</a> at length, and regularly carry <a href="http://www.winnipegfreepress.com/life/health/its-well-past-time-to-end-male-circumcision-89252742.html">opinion pieces</a> critical of circumcision. In Australia, however, it seems to be impossible for anybody to utter a word against circumcision without being "balanced" - i.e. running through an exhaustive list of the "benefits" before muttering half-heartedly about a few remote risks or trivial disadvantages. Is everybody here too intimidated by Professor Voldemort and his “scientific” death eaters? If nothing else, they certainly seem to have mastered the Imperius and Confundus curses. </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 Urethritis: circumcision increases the risk darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Circumcised men at greater risk of some sexually transmitted infections</h2> Circumcision in Australia: Further evidence on its effects on sexual health and wellbeing Jason A. Ferris, Juliet Richters, Marian K. Pitts, Julia M. Shelley, Judy M. Simpson, Richard Ryall, and Anthony M. A. Smith Australian and New Zealand Journal of Public Health, Vol. 34 (2), April 2010, 160-64 OBJECTIVE: To report on the prevalence and demographic variation in circumcision in Australia and examine sexual health outcomes in comparison with earlier research. METHODS: A representative household sample of 4,290 Australian men aged 16–64 years completed a computer-assisted telephone interview including questions on circumcision status, demographic variables, reported lifetime experience of selected sexually transmissible infections (STIs), experience of sexual difficulties in the previous 12 months, masturbation, and sexual practices at last heterosexual encounter. RESULTS: More than half the men (58%) were circumcised. Circumcision was less common (33%) among men under 30 and more common (66%) among those born in Australia. After adjustment for age and number of partners, circumcision was unrelated to STI history except for non-specific urethritis (higher among circumcised men, OR=2.11, p<0.001) and penile candidiasis (lower among circumcised men, OR=0.49, p<0.001). Circumcision was unrelated to any of the sexual difficulties we asked about (after adjusting for age) except that circumcised men were somewhat less likely to have worried during sex about whether their bodies looked unattractive (OR=0.77, p=0.04). No association between lack of circumcision and erection difficulties was detected. After correction for age, circumcised men were somewhat more likely to have masturbated alone in the previous 12 months (OR=1.20, p=0.02). CONCLUSIONS: Circumcision appears to have minimal protective effects on sexual health in Australia. <h3>Comment</h3> One of the most interesting findings of the study is that circumcision nearly doubles a male’s risk of non-specific urethritis (NSU). This result is consistent with Jonathan Hutchinson’s <a href="https://www.circinfo.org/cervical.html">notorious syphilis study</a> of 1854, which showed (though this point was never mentioned by circumcision enthusiasts) that circumcised men had a higher risk of gonorrhoea. Since NSU is a urinary tract infection, the finding must also cast serious doubt on the claim that circumcision significantly reduces the <a href="https://www.circinfo.org/utis.html">risk of UTIs</a> in male infants. A study published in the USA in 1987 also found that "lack of circumcision" did not increase the risk of gonoccocal urethritis, but that the foreskin had a protective effect against non-gonoccocal urethritis: Smith GL, Greenup R, Takafuji ET. <a href="http://www.cirp.org/library/disease/STD/smith/">Circumcision as a risk factor for urethritis in racial groups</a>. Am J Public Health 1987;77:452-4. What is striking is how differently the media report these sorts of studies, depending on whether the foreskin has been found pathogenic, neutral or beneficial. There has been no coverage of this article in the Australian media, nor of the recent study by Adelaide researchers in Annals of Family Medicine, both of which conclude that circumcision is either useless for health or even harmful. But recall the numerous screaming headlines over the past decade every time some study or other showed that "lack of circumcision” was somehow associated with vastly increased risk of STDs, cancer, AIDS and tutti quanti. Actually, the reports rarely put it as cooly as that: usually they leave the impression, if they do not explicitly allege, that the mere presence of the foreskin is enough in itself to generate all these terrible diseases. Even a report on the Ferris/Richters study in <a href="http://www.6minutes.com.au/articles/z1/view.asp?id=515210">6Minutes does not escape</a> the anti-foreskin prejudice: its headline is “Circumcision benefits not seen in Australia”, but why not write "Circumcision can double risk of urethritis"? And don’t forget to <a href="http://www.6minutes.com.au/commentall.asp?artid=515210">check out the responses</a> to Prof. Morris’s comment. It's interesting to compare the Canadian media, where <a href="http://www.theglobeandmail.com/life/health/circumcision-health-benefit-virtually-nil-study-finds/article1427972/">newspapers reported the Adelaide study</a> at length, and regularly carry <a href="http://www.winnipegfreepress.com/life/health/its-well-past-time-to-end-male-circumcision-89252742.html">opinion pieces</a> critical of circumcision. In Australia, however, it seems to be impossible for anybody to utter a word against circumcision without being "balanced" - i.e. running through an exhaustive list of the "benefits" before muttering half-heartedly about a few remote risks or trivial disadvantages. Is everybody here too intimidated by Professor Voldemort and his “scientific” death eaters? If nothing else, they certainly seem to have mastered the Imperius and Confundus curses. FURTHER INFORMATION <a href="http://www.cirp.org/library/disease/STD/" rel="noopener" target="_blank">Read more about STIs on CIRP</a> <a href="http://www.circumstitions.com/STDs.html">Analysis at Circumstitions</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 Sexually transmissible infections: circumcised men at greater risk darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Prevention of sexually transmitted infections (STIs) has traditionally been one of the main selling points for circumcision of male infants and boys, both in the late nineteenth century and today - despite the facts that is adult men who get them and children don't. It seems that whenever a new disease involving the genitals appears, some people lose their heads and forget that diseases are not caused by normal anatomy, but by microorganisms abetted by human behaviour. <h3> <a id="vict" name="vict"></a>A Victorian mistake …</h3> Based almost entirely on the dubious evidence of a single publication by the English syphilis expert (and posthephobe)<a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=25&Itemid=51"> Jonathan Hutchinson</a> in the 1850s, Anglo-American doctors became convinced that circumcision would infallibly protect men from syphilis (the AIDS of that era). Beginning in the late nineteenth century, millions of baby boys in Britain, the USA and Australia were circumcised in the hope that it would overcome the health crisis then thought to be threatening the nation. As it turned out, circumcision had no impact on the incidence of syphilis at all, the prevalence of which was reduced by screening, early treatment, safe sex (especially condoms), and finally defeated when penicillin was introduced in the 1940s. The most important early measure in controlling syphilis was not medical at all but social: reducing the stigma attached to the disease so that people were no longer afraid to seek treatment. [1] It is thus hard to see why circumcision would be a rational step even for a sexually promiscuous adult. Nearly all STIs (with the obvious exception of AIDS) can be quickly cured with antibiotics, and the few that cannot (such as genital herpes) are mild in effect and can be kept under control by other drugs. Chlamydia, for example, can be cured with a single pill, and even a serious disease such as syphilis is still eliminated from the body by a course of penicillin. An adult may choose to get himself circumcised instead if he thinks that would be more effective, but he or she has no right to impose that choice on sexually-inactive children. <h3>… is repeated by twentieth century researchers ...</h3> In 2006 the United States journal Pediatrics published an article by David Fergusson et al purporting to show that circumcision reduced the risk of certain STIs (Chlamydia, genital warts, non-specific urethritis (NSU), gonorrhea and genital herpes, but not syphilis, genital ulcerative disease or HIV) by up to 50 per cent. The author’s modest suggestion that neonatal circumcision was thus a wise measure of public policy received massive publicity worldwide. Following a number of critical responses posted on the website of the on-line edition of Pediatrics, however, Fergusson was forced to moderate his claims, but the news services that picked up his breathless media release did not report the backdown, leaving readers with the false impression that a winning goal had been scored by the pro-circumcision team. David M. Fergusson, Joseph M. Boden and L. John Horwood. Circumcision Status and Risk of Sexually Transmitted Infection in Young Adult Males: An Analysis of a Longitudinal Birth Cohort. Pediatrics 2006;118;1971-1977. <a href="http://pediatrics.aappublications.org/cgi/eletters/118/5/1971">Critiques of the article and Fergusson’s response may be read here.</a> <h3>... and is corrected by Kiwis</h3> A year or so later another longitudinal study in New Zealand by Dickson et al found no such correlations. Although this was a much better study (because the sample size was much larger, the retention greater and the statistical analysis less shaky) it received almost no publicity. We shall try to make amends here. Objective: To determine the impact of early childhood circumcision on sexually transmitted infection (STI) acquisition to age 32 years.  Study design: The circumcision status of a cohort of children born in 1972 and 1973 in Dunedin, New Zealand was sought at age 3 years. Information about STIs was obtained at ages 21, 26, and 32 years. The incidence rates of STI acquisition were calculated, taking into account timing of first sex, and comparisons were made between the circumcised men and uncircumcised men. Adjustments were made for potential socioeconomic and sexual behavior confounding factors where appropriate.  Results: Of the 499 men studied, 201 (40.3%) had been circumcised by age 3 years. The circumcised and uncircumcised groups differed little in socioeconomic characteristics and sexual behavior. Overall, up to age 32 years, the incidence rates for all STIs were not statistically significantly different – 23.4 and 24.4 per 1000 person-years for the uncircumcised and circumcised men, respectively. This was not affected by adjusting for any of the socioeconomic or sexual behavior characteristics.  Conclusions: These findings are consistent with recent population-based cross-sectional studies in developed countries, which found that early childhood circumcision does not markedly reduce the risk of the common STIs in the general population in such countries. Reference: Dickson NP, Van Rood T, Herbison P, Paul C.<a href="http://www.cirp.org/library/disease/STD/dickson2008/"> Circumcision and risk of sexually transmitted infections in a birth cohor</a>t. J Pediatr 2008;152: 383-7. <h2> <a id="modern" name="modern"></a>Recent studies fail to find a link</h2> <h3>The other studies referred to are as follows.</h3> National Health and Lifestyle Survey, USA, 1992 (N=1511) “We find no significant differences between circumcised and uncircumcised men in their likelihood of contracting sexually transmitted diseases.” [2] British National Survey of Sexual Attitudes and Lifestyles, Britain, 2000 (N=4762) “We did not find any significant differences in the proportion of circumcised and uncircumcised British men reporting ever being diagnosed with any STI … We also found no significant associations between circumcision and being diagnosed with any one of the seven specific STIs.” [3] Australian Study of Health and Relationships, Australia, 2001-2002 (N=10,173) “No significant protective effect of circumcision is discernible for genital warts, chlamydia, genital herpes, gonorrhoea, non-specific urethritis or pubic lice.” [4] References 1. For details of the nineteenth century campaign to enforce mass circumcision as a preventive of syphilis, see Robert Darby,<a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=33&Itemid=56"> Where doctors differ: The debate on circumcision as a preventive of syphilis, 1855-1914</a>, Social History of Medicine, Vol. 16, 2003, 57-78; and his book, A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (University of Chicago Press, 2005) Chapter 12. 2. Laumann, EO, Masi CM, Zuckerman EW. <a href="http://www.cirp.org/library/general/laumann/">Circumcision in the United States</a>. Journal of the American Medical Association 1997;277(13): 1052-7. 3. Johnson AM, Mercer CH, Evans B. et al. Sexual behaviour in Britain: Partnerships, practices, and HIV risk behaviours. Lancet 2001;358(9296): 1835-42; and Dave SS, Johnson AM, Fenton KA, et al. Male circumcision in Britain: Findings from a national probability sample survey. Sex Trans Infect 2003;79: 499-500. 4. Richters J, Smith AMA, de Visser RO, et al.<a href="http://www.cirp.org/library/general/richters1/"> Circumcision in Australia: Prevalence and effects on sexual health</a>. Int J STD AIDS 2006;17: 547-54. <h3>STI and HIV risk not reduced by circumcision: New (2012) study</h3> A study of men attending a sexually transmitted diseases clinic has found that circumcised men reported significantly (but not greatly) more STDs in their lifetimes, were more likely to have been diagnosed with genital warts, and were more likely to have HIV. The 660 men in the sample were randomly sampled from an STD clinic waiting room. Almost a third of them were circumcised. Did you get that: despite what the circumcision promoters say, sexually transmitted infections and HIV were were more common in the circumcised men. The abstract of the article in the Journal of Sexual Medicine follows. Introduction. Circumcision among adult men has been widely promoted as a strategy to reduce human immunodeficiency virus (HIV) transmission risk. However, much of the available data derive from studies conducted in Africa, and there is as yet little research in the Caribbean region where sexual transmission is also a primary contributor to rapidly escalating HIV incidence. Aim. In an effort to fill the void of data from the Caribbean, the objective of this article is to compare history of sexually transmitted infections (STI) and HIV diagnosis in relation to circumcision status in a clinic-based sample of men in Puerto Rico. Methods. Data derive from an ongoing epidemiological study being conducted in a large STI/HIV prevention and treatment center in San Juan in which 660 men were randomly selected from the clinic's waiting room. Main Outcome Measures. We assessed the association between circumcision status and self-reported history of STI/HIV infection using logistic regressions to explore whether circumcision conferred protective benefit. Results. Almost a third (32.4%) of the men were circumcised (CM). Compared with uncircumcised (UC) men, CM have accumulated larger numbers of STI in their lifetime (CM = 73.4% vs. UC = 65.7%; P = 0.048), have higher rates of previous diagnosis of warts (CM = 18.8% vs. UC = 12.2%; P = 0.024), and were more likely to have HIV infection (CM = 43.0% vs. UC = 33.9%; P = 0.023). Results indicate that being CM predicted the likelihood of HIV infection (P value = 0.027). Conclusions. These analyses represent the first assessment of the association between circumcision and STI/HIV among men in the Caribbean. While preliminary, the data indicate that in and of itself, circumcision did not confer significant protective benefit against STI/HIV infection. Findings suggest the need to apply caution in the use of circumcision as an HIV prevention strategy, particularly in settings where more effective combinations of interventions have yet to be fully implemented. Source: Rodriguez-Diaz CE, Clatts MC, Jovet-Toledo GG, Vargas-Molina RL, Goldsamt LA, García H. More than Foreskin: Circumcision Status, History of HIV/STI, and Sexual Risk in a Clinic-Based Sample of Men in Puerto Rico. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1743-6109.2012.02871.x/abstract">Journal of Sexual Medicine, 15 August 2012</a> (Epub ahead of publication). <h2> <a id="vanhowe" name="vanhowe"></a>Circumcision and sexually transmitted infections: Circumcision does not reduce risk</h2> A large scale study of the relationship between circumcision and the risk of contracting a wide range of sexually transmitted diseases has found that circumcision makes very little difference, but that circumcised men are at greater risk of urethral infections such as gonorrhoea. Uncircumcised men are at greater risk for genital ulcers, but because urethral infections are far more common than ulcers, circumcised men are at greater risk of contracting an STD overall. For other infections, such as syphilis, herpes and human papilloma virus circumcision made no significant difference. The study by Robert Van Howe is what is called a meta-analysis: that is, it examines the methods and conclusions of previous published studies and surveys, and then systematically collates the results. In this case, Van howe identified nearly 100 studies and presented their findings in a series of tables, accompanied by commentary. It is one of the largest studies of the relationship between circumcision status and sexually transmitted disease ever published, with highly embarrassing conclusions for circumcision advocates, and particularly the American Academy of Pediatrics, which claimed in their recent policy statement that prevention of sexually transmitted diseases was a valid reason for circumcision of male infants. Compared with this analysis, the survey of the medical literature performed by the AAP’s “circumcision task force” is selective, unbalanced and skewed towards their bias in favour of circumcision. But as Van Howe comments, “the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.” ABSTRACT: The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhoea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type. Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection. In studies of general populations, there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature. Source: Robert S. Van Howe, Sexually Transmitted Infections and Male Circumcision: A Systematic Review and Meta-Analysis. ISRN Urology, April 2013 (Article ID 109846); http://dx.doi.org/10.1155/2013/109846. <a href="http://www.hindawi.com/isrn/urology/2013/109846/">The full article may be read at ISRN Urology on-line</a>. <h3>New study: Circumcision does not prevent sexually-transmitted infections</h3> A new study by urologists shows no link between circumcision and reduced risk of sexually-transmitted infections. Researchers performing a clinical study on over 800 African American men found that circumcision does not prevent STIs (sexually transmitted infections). The most important factor was the number of sexual partners. The researchers say their results throw doubt on commonly held beliefs about the connection between circumcision and STIs, which they say are largely based on extrapolations from studies performed on men in Africa. These African studies and their policy implications, which includes the recent American Academy of Pediatrics' <a href="https://www.circinfo.org/United_States_circumcision_policy.html">circumcision policy statement</a>, were widely criticized by child health experts and human rights organizations. The latest American study was performed by urologists from the University of Michigan, Ann Arbor, the University of Illinois, Chicago, and Mount Sinai Hospital in New York. The study was presented at the Annual Meeting of the American Society for Reproductive Medicine, held conjointly with the International Federation of Fertility Societies in Boston in October. Source: J.R. Gonzalez et al. <a href="http://www.fertstert.org/article/S0015-0282%2813%2902094-3/fulltext">A population-based study of circumcision and non-HIV sexually transmitted infections in a contemporary group of African American men: The flint men's health study</a>. Fertility and Sterility 100 (3) Supplement, September 2013 <a href="http://intactnews.org/node/330/1381528723/study-circumcision-does-not-prevent-sexually-transmitted-infections">Acknowledgements to IntactNews</a> <h2> <a id="isrn13" name="isrn13"></a>Circumcised men at greater risk of some sexually transmitted infections</h2> Circumcision in Australia: Further evidence on its effects on sexual health and wellbeing Jason A. Ferris, Juliet Richters, Marian K. Pitts, Julia M. Shelley, Judy M. Simpson, Richard Ryall, and Anthony M. A. Smith Australian and New Zealand Journal of Public Health, Vol. 34 (2), April 2010, 160-64 OBJECTIVE: To report on the prevalence and demographic variation in circumcision in Australia and examine sexual health outcomes in comparison with earlier research. METHODS: A representative household sample of 4,290 Australian men aged 16–64 years completed a computer-assisted telephone interview including questions on circumcision status, demographic variables, reported lifetime experience of selected sexually transmissible infections (STIs), experience of sexual difficulties in the previous 12 months, masturbation, and sexual practices at last heterosexual encounter. RESULTS: More than half the men (58%) were circumcised. Circumcision was less common (33%) among men under 30 and more common (66%) among those born in Australia. After adjustment for age and number of partners, circumcision was unrelated to STI history except for non-specific urethritis (higher among circumcised men, OR=2.11, p<0.001) and penile candidiasis (lower among circumcised men, OR=0.49, p<0.001). Circumcision was unrelated to any of the sexual difficulties we asked about (after adjusting for age) except that circumcised men were somewhat less likely to have worried during sex about whether their bodies looked unattractive (OR=0.77, p=0.04). No association between lack of circumcision and erection difficulties was detected. After correction for age, circumcised men were somewhat more likely to have masturbated alone in the previous 12 months (OR=1.20, p=0.02). CONCLUSIONS: Circumcision appears to have minimal protective effects on sexual health in Australia. <h3>Comment</h3> One of the most interesting findings of the study is that circumcision nearly doubles a male’s risk of non-specific urethritis (NSU). This result is consistent with Jonathan Hutchinson’s <a href="https://www.circinfo.org/cervical.html">notorious syphilis study</a> of 1854, which showed (though this point was never mentioned by circumcision enthusiasts) that circumcised men had a higher risk of gonorrhoea. Since NSU is a urinary tract infection, the finding must also cast serious doubt on the claim that circumcision significantly reduces the <a href="https://www.circinfo.org/utis.html">risk of UTIs</a> in male infants. A study published in the USA in 1987 also found that "lack of circumcision" did not increase the risk of gonoccocal urethritis, but that the foreskin had a protective effect against non-gonoccocal urethritis: Smith GL, Greenup R, Takafuji ET. <a href="http://www.cirp.org/library/disease/STD/smith/">Circumcision as a risk factor for urethritis in racial groups</a>. Am J Public Health 1987;77:452-4. What is striking is how differently the media report these sorts of studies, depending on whether the foreskin has been found pathogenic, neutral or beneficial. There has been no coverage of this article in the Australian media, nor of the recent study by Adelaide researchers in Annals of Family Medicine, both of which conclude that circumcision is either useless for health or even harmful. But recall the numerous screaming headlines over the past decade every time some study or other showed that "lack of circumcision” was somehow associated with vastly increased risk of STDs, cancer, AIDS and tutti quanti. Actually, the reports rarely put it as cooly as that: usually they leave the impression, if they do not explicitly allege, that the mere presence of the foreskin is enough in itself to generate all these terrible diseases. Even a report on the Ferris/Richters study in <a href="http://www.6minutes.com.au/articles/z1/view.asp?id=515210">6Minutes does not escape</a> the anti-foreskin prejudice: its headline is “Circumcision benefits not seen in Australia”, but why not write "Circumcision can double risk of urethritis"? And don’t forget to <a href="http://www.6minutes.com.au/commentall.asp?artid=515210">check out the responses</a> to Prof. Morris’s comment. It's interesting to compare the Canadian media, where <a href="http://www.theglobeandmail.com/life/health/circumcision-health-benefit-virtually-nil-study-finds/article1427972/">newspapers reported the Adelaide study</a> at length, and regularly carry <a href="http://www.winnipegfreepress.com/life/health/its-well-past-time-to-end-male-circumcision-89252742.html">opinion pieces</a> critical of circumcision. In Australia, however, it seems to be impossible for anybody to utter a word against circumcision without being "balanced" - i.e. running through an exhaustive list of the "benefits" before muttering half-heartedly about a few remote risks or trivial disadvantages. Is everybody here too intimidated by Professor Voldemort and his “scientific” death eaters? If nothing else, they certainly seem to have mastered the Imperius and Confundus curses. FURTHER INFORMATION <a href="http://www.cirp.org/library/disease/STD/" rel="noopener" target="_blank">Read more about STIs on CIRP</a> <a href="http://www.circumstitions.com/STDs.html">Analysis at Circumstitions</a> <h2> <a id="condoms" name="condoms"></a>Condoms best protection against STIs and HIV-AIDS</h2> <h3>New evidence that condoms highly effective against STDs and HIV</h3> Writing in the New England Journal of Medicine, 22 June 2006, Markus Steiner and Willard Cates confirm that condoms offer the best protection against the whole range of sexually transmitted infections. After a review of current medical opinion and the various alternatives, they conclude that consistent condom use offers significant protection against most STDS, including syphilis gonorrhoea, chlamydia, herpes and HIV in both women and men, and against HPV (human papilloma virus – the cause of cervical cancer) in women. They recommend that more effort be made to encourage sexually active people (and especially those with multiple partners) to use condoms consistently Markus Steiner and Willard Cates, “Condoms and sexually transmitted infections”, New England Journal of Medicine, Vol. 354, 22 June 2006, pp. 2642-43 There is nothing new or surprising in this. It has been well known since at least the 1850s that condoms were an effective barrier against infection by syphilis, and the radical English doctor George Drysdale urged their widespread adoption. Unfortunately, in the prudish atmospheres of the times, his suggestion was regarded as immoral and likely to encourage promiscuity, and most of the medical profession continued to preach against condom use and to recommend chastity instead. As a result, syphilis spread rapidly and reached such epidemic proportions that a Royal Commission had to be established to investigate ways of controlling it. Further information Robert Darby, A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain (University of Chicago Press, 2005) Peter Baldwin, Contagion and the state in Europe (Cambridge University Press, 1999) J. Miriam Benn, Predicaments of love (London: Pluto Press, 1992) A study of the remarkable sexual libertarian and condom pioneer, George Drysdale.Drysdale's amazing tract, Elements of Social Science: Physical, Sexual and Natural Religion, advocating free love, contraception to avoid unwanted pregnancy and condoms to avoid venereal disease, was first published in 1854. A complete text is available from <a href="https://books.google.com/">Google Books</a>. <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=88&Itemid=51">See also the essay on Drysdale at History of Circumcision.</a> Roger Davidson and Lesley Hall (eds) (2001), Sex, sin and suffering: Venereal disease and European society since 1870, (London: Routledge, 2001) Jane Tolerton, Ettie: A life of Ettie Rout (Penguin 1992) A biography of the courageous New Zealand woman who provided the diggers in World War I with safe sex advice and free condoms. <h3>Condoms 90 per cent effective against HIV infection</h3> Use of condoms, along with regular check-ups, could have contained the syphilis epidemic long before the discovery of penicillin in the 1940s provided a reliable cure. It may be a long time before we have a cure or vaccine for HIV-AIDS, and in the meantime condoms offer the best and most reliable protection for those who are determined to brave the perils of sexual promiscuity - as the following article suggests. Effectiveness of condoms in preventing HIV transmission Abstract The consistent use of latex condoms continues to be advocated for primary prevention of HIV infection despite limited quantitative evidence regarding the effectiveness of condoms in blocking the sexual transmission of HIV. Although recent meta-analyses of condom effectiveness suggest that condoms are 60 to 70% effective when used for HIV prophylaxis, these studies do not isolate consistent condom use, and therefore provide only a lower bound on the true effectiveness of correct and consistent condom use. A reexamination of HIV seroconversion studies suggests that condoms are 90 to 95% effective when used consistently, i.e. consistent condom users are 10 to 20 times less likely to become infected when exposed to the virus than are inconsistent or non-users. Similar results are obtained utilizing model-based estimation techniques, which indicate that condoms decrease the per-contact probability of male-to-female transmission of HIV by about 95%. Though imperfect, condoms provide substantial protection against HIV infection. Condom promotion therefore remains an important international priority in the fight against AIDS. Steven D. Pinkerton and Paul R. Abramson, “Effectiveness of condoms in preventing HIV transmission”, Social Science and Medicine, Vol. 44, No. 9, 1997, pp. 1303-1312 Further information Steven Pinkerton and Paul Abramson, “Condoms and the protection of AIDS”, American Scientist, Vol. 85, July-August 1997, pp. 364-73 Roger Short and Malcolm Potts, “Condoms for the prevention of HIV transmission: Cultural dimensions”, AIDS, Vol. 3 1989, Supplement 1, pp. S259-63 This paper urges urging mass distribution of condoms to high risk groups in the Third World, especially areas of Africa with rates of HIV infection. This was before Dr Short got the bright idea that foreskins might be an easier target than the AIDS virus and became a fanatical evangelist for universal routine circumcision. In fact, circumcision may discourage condom use, for two reasons. The first is that circumcised men have less feeling in their penis (because most of the nerves have been removed), and a condom blunts sensation even further. Secondly, Australian researchers have found that normal (uncircumcised) men actually find condoms easier and more comfortable to use: “Uncircumcised men were found … to be significantly less likely to report condoms slipping off than circumcised men. One possible reason might be that the increased bulk of the distal part of the penis provided by the presence of the foreskin helped to retain the condom.” Juliet Richters, John Gerofi and Basil Donovan, “Why do condoms break or slip off in use? An exploratory study”, International Journal of STD and AIDS, Vol. 6, 1995, pp. 11-18 A common reason why condoms slip off is because the wearer loses his erection. The most likely reason why this occurs is because he is not getting enough sensation through the latex, and this blunting of feeling will be more severe if he is circumcised and thus deprived of the thousands of nerve endings found in the foreskin. <h2>Sexual health of Australians: New study shows steady improvement</h2> The sexual health of Australians continues to improve. Despite alarmist headlines about rising chlamydia and HIV incidence, the Second Australian Study of Health and Relationships (ASHR2) found that most Australians aged 16 to 69 years were living sexually fulfilling lives with a very low incidence of sexually transmitted infections (STIs) and other problems. Newspaper coverage of the survey focused on the news that Australians were becoming more permissive towards sexual behaviour and engaging in a greater variety of sexual activities, but more significant is the finding that more Australians are practising safe sex regularly and that the incidence of STIs has decreased since the previous study in 2001-02. Among the most important findings: <ul> <li>significant declines in the proportion of respondents not using condoms or other contraception at first vaginal intercourse (down from 38% in ASHR1 to 29% in ASHR2 among men, and from 27% to 21% among women);</li> <li>significant increases from in the proportion of men and women using condoms during their most recent heterosexual experience (up from 25% to 29% among men, and from 18% to 23% among women);</li> <li>significant increases in knowledge about STIs and blood-borne viruses;</li> <li>a significant reduction in the proportion of men who had ever been diagnosed with an STI (down from 19% in ASHR1 to 15%in ASHR2), partially offset by an increase in the proportion of women who had ever been diagnosed with an STI (up from 17% to 20%).</li> </ul> The authors of the study conclude that “the sexual health of the Australian population has improved” since the turn of the century, and that more Australians are having sex in ways that reduce the risk of STIs and unintended pregnancies. They report, however, that there is always room for improvement and suggest that the next step should be a comprehensive national sexual health strategy. Further references Australian Department of Health. <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-national-strategies-2010" rel="noopener" target="_blank">National strategies for blood borne viruses and sexually transmissible infections</a>. Sydney Local Health District. <a href="http://www.slhd.nsw.gov.au/pdfs/sexualhealthstrategy.pdf">Sexual Health Strategy: Sexually Transmissible Infections</a> It is a matter of interest that none of these documents (not even the HIV-AIDS strategy), nor the ASHR2 papers, so much as mention the word “circumcision”. Yet the fact is that over the same decade in which the sexual health of Australians has improved, the proportion of uncircumcised men (i.e. men with foreskins!!) among the sexually active population has steadily increased. It is thus obvious that circumcision is irrelevant to favourable sexual heath outcomes. World Health Organisation definition of sexual health A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. Richard O. de Visser, Juliet Richters, Chris Rissel et al. <a href="http://www.publish.csiro.au/?nid=164" rel="noopener" target="_blank">Change and stasis in sexual health and relationships: Comparisons between the First and Second Australian Studies of Health and Relationships</a>. Sexual Health 11 (5), November 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 Sexually transmissible infections 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>Modern treatment of phimosis</h1> <h2>Non-surgical methods now the standard approach</h2> Much of the pressure for circumcision in the Victorian era and up until the 1960s was fear of phimosis - inability or difficulty in retracting the foreskin to expose the glans. In the nineteenth century this condition was wrongly believed to be the cause of a host of nervous and other diseases, leading many doctors to insist that unless the foreskin was fully mobile within a few weeks of birth, circumcision was essential. It was not until the 1940s that this error was corrected by <a href="http://www.cirp.org/library/general/gairdner/">Douglas Gairdner</a>, though it persists in parts of the United States to this day. Research since the 1940s has established that it is perfectly normal for the foreskin not to become retractable until a boy reaches puberty, and that there is no need for any intervention unless he is experiencing discomfort, since most cases resolve spontaneously as he matures. For cases of persistent phimosis, where there was discomfort, pain or other problems, it is true that there was probably no alternative to circumcision until the 1990s, when it was realised that the application of steroids caused the foreskin tissue to loosen and expand, thus permitting retraction. A host of articles in medical journals since the early 1990s has now established beyond any doubt that application of one or more of several different steroid creams to the foreskin is nearly always effective in resolving problem cases of phimosis. The notion that circumcision is the appropriate response to phimosis is now outdated and unscientific. The only situation where circumcision may still be necessary is in persistent cases of <a href="http://www.cirp.org/library/treatment/BXO/">Balanitis xerotica obliterans</a> (BXO or Lichen sclerosus - a very rare skin disease, possibly of fungal origin, but not yet fully understood) that do not respond to conservative treatment. (See further details below) Most of these articles <a href="http://www.cirp.org/library/treatment/phimosis/">are available on CIRP</a>, but an additional selection of articles is provided below. These show how assertions of the need for circumcision have decreased as understanding of normal penile development has improved. It is interesting to observe how allegations of the "need" for circumcision fade away as it is increasingly appreciated that, in most cases, the phimotic condition is normal and harmless, and that the foreskins of many healthy boys do not become fully retractable until puberty or even later. In the first paper below (early 1990s) doctors are still circumcising quite young boys whose foreskins have not become retractable if they do not respond quickly to the steroid treatment. But as more experience is gained (and as false Victorian/Edwardian understanding dissipates) the anxiety recedes. It comes to be appreciated that that it is quite normal for foreskins not to become retractable until puberty or after, and that in many cases they will do so naturally, even without treatment. What is particularly interesting about the results of many of the papers below is the number of boys in the control (non-treatment) group whose phimosis resolved quite naturally during the course of the study. The lesson here is to be patient and recall the old proverb: Fools rush in where angels fear to tread. It is doubtful whether any boy needs treatment unless he is still phimotic after puberty and experiencing discomfort, but is is certainly better to undergo a harmless course of steroid ointment than to suffer the risks and losses of amputating surgery. There is some evidence that extra testosterone can also held achieve foreskin mobility, suggesting that a low testosterone level may be connected with the phimotic condition in the first place. <h2>A selection of recent papers in medical journals</h2> <h3>The response of phimosis to local steroid application</h3> C. S. Kikiros, S. W. Beasley and A. A. Woodward ABSTRACT: The effectiveness of topical steroid application in relieving phimosis was studied in 63 boys treated with local application of steroid ointment to the foreskin. Betamethasone valerate 0.05% (42 patients), hydrocortisone 1% (18 patients), or hydrocortisone 2% (3 patients) was applied three times daily for 4 weeks. Thirty-seven of the patients treated with 0.05% betamethasone valerate ointment (half-strength Betnovate) showed an initial improvement and circumcision was performed on 5 non-responders. Six patients showed initial improvement but later redeveloped phimosis: they were given a further course of treatment, resulting in 2 satisfactory responses and 4 failures requiring circumcision. Two patients using 2% hydrocortisone and 16 using 1% hydrocortisone ointment showed improvement, but 2 of the latter group ultimately required circumcision. Overall, a permanent improvement was achieved in 51 of the 63 patients, with the ability to retract the foreskin after one or more treatments. The remaining 12 boys required circumcision. Local application of steroid ointment to the foreskin results in resolution of phimosis in the majority of cases, but if the foreskin has a circumferential white scar, it is slightly less likely to respond. Following cessation of steroids, phimosis redevelops in a proportion of patients. Pediatric Surgery International Vol 8, No 4, May 1993 <a href="https://www.circinfo.org/pdf/Phim-Kikiros.pdf" rel="noopener" target="_blank">Read full text as PDF (340 kb)</a> <h3>Treatment of childhood phimosis with a moderately potent topical steroid</h3> Wai-Tat Ng, Ning Fan et al BACKGROUND: Recently, topical steroid application has been shown by a small number of studies to be an effective alternative to circumcision for the treatment of phimosis. However, only potent or very potent corticosteroids have been more thoroughly studied in this treatment option. A prospective study was conducted to determine whether comparable results could be achieved using a weaker steroid cream. METHODS: Boys, 3–13 years of age, with non-retractable foreskin due to a tight ring at the tip were offered the regimen of twice-daily preputial retraction and topical application of 0.02% triamcinolone acetonide cream. The degree of preputial retractability was assessed at presentation and at 4 and 6 weeks of treatment. Success was defined as full retraction or free retraction up to agglutination of the foreskin to the glans. RESULTS: Eighty-three boys completed the treatment. Successful retraction was achieved in 48/83 (58%) patients after 4 weeks and 70/83 (84%) patients after 6 weeks of application. The overall response rate aggregated from six published series using 0.05% betamethasone was 87% at 4 weeks and 90% on completion of treatment. Thus, the results appear inferior when analysed at 4 weeks but compare favourably with those reported for a more potent steroid on completion of the full course of treatment. CONCLUSIONS: Even though the triamcinolone cream used in the present study is less potent than the more commonly used 0.05% betamethasone valerate cream, it could effect comparable improvements in foreskin retractability after 6 weeks of treatment. Australia and New Zealand Journal of Surgery Vol 71, 2001, 541-543 <a href="https://www.circinfo.org/pdf/Phim-Ng.pdf" rel="noopener" target="_blank">Read full text as PDF (52 kb)</a> <h3>Debe realizarse circuncisión en la infancia? [Should circumcision be performed in infancy?]</h3> Julio César Morales Concepción, Emilio Cordiés Jackson et al OBJECTIVE: To evaluate prepuce development and retractibility in a group of boys. To point out the value of circumcision and preputial forced dilation during childhood. METHODS: Prepuce development and retractibility were evaluated in 400 boys ages between 0-16 year old. RESULTS: In boys under 1 year prepuce retractibility (assessed only in children who did not undergo forced dilation previously) was type I (non retractile) in 71.5% whereas type V (completely retractile) was only 5.5%. In adolescent boys type I prepuce was observed in 1 boy only, 1.6%, whereas type V was observed in 82.3%. Furthermore, it was observed that at the time of examination for the study 106 boys who had undergone forced dilation at an earlier age had balano-preputial adhesions again , which demonstrates that prepuce adheres again to glans penis in many boys after a forced dilation is performed. Only 11 boys were considered in need for circumcision, three of them for preputial orifice stenosis, which prevented normal urination, causing a preputial sac, one case due to a constrictive ring below the preputial edge that would have prevented ulterior retractibility, two cases with repetitive balano-posthitis, and five cases secondary to xerosal balanitis, accounting for 2.7% of all examined boys. CONCLUSIONS: Incomplete separation between prepuce and glans penis is normal and common among new-borns, progressing until adolescence to spontaneous separation, at which time it is complete in the majority of boys. Accordingly to the criteria we have sustained for years and present study's findings, circumcision has few indications during childhood, as well as forced preputial dilation. NOTE: This article makes the important point that premature or forcible separation of the foreskin from the glans before the boy is ready is likely to cause bleeding and subsequent adhesion as the torn surfaces fuse together as they heal. In other words, premature retraction may cause pathological phimosis. Arch. Esp. Urol., Vol. 55 No. 7, 2002, 807-811 <h3>[The use of corticosteroid cream to treat phimosis]</h3> van Basten JP, de Vijlder AM, Mensink HJ. Academisch Ziekenhuis, afd. Urologie, Postbus 30.001, 9700 RB Groningen, The Netherlands ABSTRACT: Many of the boys diagnosed with “phimosis”, who are referred for circumcision, do not have a dermatopathology and thus there is no indication for surgery. If an unretractable prepuce causes hygienic problems, and also in the case of dermatopathology, topical corticosteroid application may be an effective alternative to circumcision. In a literature search 13 studies were found on the effectiveness and the safety of topical steroid application for phimosis. Three of the studies were placebo controlled. A total of 1121 boys with an unretractable prepuce were treated with a topical corticosteroid, which was mostly applied twice daily. After a treatment duration of 4 to 8 weeks, about 75% of the patients achieved complete retractability of the prepuce. In the studies evaluated, local or systemic adverse effects were not noted. Different types of corticosteroids gave similar results. Topical corticosteroid application for the treatment of unretractable prepuce complaints seems to be effective and safe, and is therefore recommended before surgical intervention is considered. Ned Tijdschr Geneeskd. 2003 Aug 9;147(32):1544-7 (in Dutch) PMID: 12942843 [PubMed - indexed for MEDLINE] <h3>Phimosis: stretching methods with or without application of topical steroids?</h3> Zampieri N, Corroppolo M, Camoglio FS, Giacomello L, Ottolenghi A. Department of Surgical Sciences, Pediatric Surgical Unit, University of Verona, Verona, Italy ABSTRACT: Phimosis has been defined as unretractable foreskin without adherences or a circular band of tight prepuce preventing full retraction. We suggested a new treatment protocol combining betamethasone with stretching exercises to reduce the number of patients requiring surgery for phimosis. Between January 2003 and September 2004, 247 boys aged 4 to 14 years (mean 7.6) were included in this consecutive, prospective, open study. Patients were treated with 0.05% betamethasone cream applied to the distal aspect of the prepuce twice daily for the first 15 days, then once daily for 15 more days. Preputial gymnastics started 1 week after topical application of betamethasone. Ninety-six percent of patients receiving 1 or more cycles of betamethasone showed complete resolution of phimosis. There was a significant difference (P < .001) in response rate between the study and control groups. Only 10 boys in the study group had no response to steroid and stretching. Treatment with topical steroids, combined with stretching exercises, is a suitable alternative to surgical correction (preputial-plasty or circumcision). J Pediatr. 2005 Nov;147(5):705-6. PMID: 16291369 [PubMed - indexed for MEDLINE] <h3>Preputial retraction in children</h3> Abhinav Agarwal, Anup Mohta, Ritesh K Anand Department of Surgery, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India? OBJECTIVE: The aim of the study was to assess preputial retractability in children at various ages. MATERIALS AND METHODS: Nine hundred and sixty boys attending the hospital were included in the study. Children with hypospadias or history of preputial manipulation were excluded. Preputial anatomy was studied and subjects were classified into five groups as described by Kayaba et al. RESULTS: The prepuce could not be retracted at all so as to make even the external urethral meatus visible in 61.4% children aged 0-6 months while this decreased to only 0.9% in children aged 10-12 years. At the other end of the spectrum, while prepuce could not be fully retracted in any child below 6 months, it could be done in about 60% in the age group of 10-12 years. CONCLUSION: Preputial non-separation is the major cause of preputial nonretraction in the pediatric age group. Prepuce spontaneously separates from the glans as age increases and true phimosis is rare in children. Surgical intervention should be avoided for non-separation of prepuce. <a href="http://www.jiaps.com/text.asp?2005/10/2/89/16468" rel="noopener" target="_blank">J Indian Assoc Pediatr Surg 2005;10:89-91</a> (Full text) <h3>Topical hydrocortisone and physiotherapy for nonretractile physiologic phimosis in infants</h3> Jung Won Lee, Su Jin Cho, Eun Ae Park and Seung Joo Lee The following article suggests that steroid treatment to resolve phimosis can cure recurrent Urinary Tract Infections without the need for circumcision. ABSTRACT: The effect of hydrocortisone (HC), the steroid of lowest potency, and physiotherapy (PT) on non-retractile physiologic phimosis (PP) and the reduction of subsequent recurrent UTI was evaluated in male infants with UTI. Seventy-eight male infants with febrile UTI and nonretractile PP were prospectively randomized into HC (Plancol, n=39) and control (Vaseline, n=39) groups. Topical application of HC as a thin film around the preputial margin twice a day for four weeks with PT was instructed. The response rate in the HC group was 89.7% (35/39), which was significantly higher than the rate (20.5%; 8/39) in the control group (P<0.05). In the HC group, the response rate was much higher (96.1%) in the subgroup with PT than in the group without PT. Most of the response (88.5%) was observed within two weeks. During the following year, the recurrent rate of UTI was 7.1% (2/28) in the infants with retractile prepuces, which was significantly less than than the rate (29.6%; 8/27) in infants with nonretractile prepuces (P<0.05). In conclusion, topical HC and PT for 2–4 weeks proved to be a simple, safe and effective treatment for nonretractile PP in infants with UTI, and this procedure was beneficial in reducing recurrent UTI. Pediatric Nephrology <a href="http://www.springerlink.com/content/d21056m1818wp1w4/">Vol 21, No 8, August 2006, 1127-1130</a> <h3>Phimosis and topical steroids: new clinical findings</h3> Nicola Zampieri, Michele Corroppolo et al ABSTRACT: Phimosis has been defined as unretractable foreskin without adherences and/or a circular band of tight prepuce preventing full retraction. The aim of this study is to evaluate the efficacy (response rate) of topical steroids for the treatment of tight phimosis at different age stages. After using the same medication with different dosage schemes, a retrospective analysis was carried out to assess the efficacy of topical steroids in the treatment of tight phimosis. Patients were divided into three groups: group A (betamethasone scheme A), group B (betamethasone scheme B) and group C (control group). Remission of phimosis, with a complete exposure and without a narrowing behind the glans, was considered a complete response to treatment. The outcomes were then related to dosage scheme and patient’s age. The dosage for group A was more effective than the dosage for groups B and C (control group). Phimosis resolved in 90% (group A), 72% (group B) and 56% (group C) of cases. A successful treatment was closely related to the age of patients at the beginning of steroid application. The results showed that treatment with topical steroids, which in general gives good results, proved to be much more successful in patients aged between 4 and 8 years, suggesting the efficacy of an early beginning of the treatment. Pediatric Surgery International Vol 23, No 4, April 2007 <h3>Outcome and recurrence in treatment of phimosis using topical betamethasone in children in Hong Kong</h3> Wai-Hung Ku, Becky S-K Chiu and Kwai-Fun Huen AIM: To study the efficacy of treating phimosis with topical steroid, and its long-term outcome and side effects. We also looked into the effect of daily retraction and cleansing of prepuce on preventing recurrence of phimsosis. METHODS: This prospective study comprised 138 boys who were prescribed 0.05% betamethasone ointment (Diprocel) during 1 August 2001–31 July 2004. Five boys were excluded because of non-compliance. Of the remaining 133 boys, 108 were followed-up and assessed. Age ranged from 0.03 to 12.9 years (mean = 3.38, SD = 2.79). The number of treatment course received, short-term and long-term outcome, side effects and the effect of daily foreskin retraction were studied. RESULTS: The success rate of first treatment course was 81.5%, and 60.2% of boys remained free from phimosis upon latest assessment. The follow-up period ranged from 0.4 to 4.4 years (mean = 2.45, SD = 0.90). There were no side effects noted. We found a significant and linear relationship between daily foreskin retraction and sustained resolution of phimosis. CONCLUSION: Topical steroid is an effective and safe treatment for phimosis, especially when combined with a good hygiene practice of the foreskin with daily cleansing and retraction. A trial of topical steroid treatment should be offered upon considering circumcision. Journal of Paediatrics and Child Health Vol 43, Nos 1-2, January 2007 <a href="https://www.circinfo.org/pdf/Phim-WaiHung.pdf" rel="noopener" target="_blank">Read full text as PDF (148 kb)</a> <h3>Phimotic ring topical corticoid cream (0.1% mometasone furoate) treatment in children</h3> Flavio de Oliveira Pileggi, Yvonne A.M.V.A. Vicente BACKGROUND: Phimosis, owing to the presence of a preputial fibrotic ring, is surgically treated in 1% of children. During the last decade, however, topical steroid treatment has been proposed for phimosis. METHODS: We present a double-blind study comparing 0.1% mometasone furoate topical cream vs moisturizing cream (placebo) for the treatment of phimosis. Children aged from 2 to 13 years (n = 110) presenting with phimosis (Kikiro's classification grade 5) and scheduled for circumcision were included in this trial. The patients were evaluated after 8 weeks of topical treatment with moisturizing cream (n = 54) or steroid cream (n = 56). Non-responders from both groups received an additional 8 weeks of steroid cream treatment. RESULTS: In the steroid group, the ring disappeared and glans exposure was obtained in 49 (88%) of 56 patients vs 28 (52%) of 54 patients in the placebo group (P b.05). After a second treatment, in the steroid group, 5 of the 7 patients were finally cured vs 22 of the 26 in the placebo group (P b.05). Two children with persisting phimosis (Kikiro's retractability grade 5 and appearance grade 3) in the steroid group (4%) vs 4 children in the placebo group (7%) ended up receiving postectomy. CONCLUSION: The present investigation adds up and supports the effectiveness of phimosis topical corticoid treatment. Nevertheless, hygiene and preputial traction, when appropriately performed, seem to play an important role in the disappearance of the phimotic ring as well. New studies are necessary to confirm if this is true or not. Journal of Pediatric Surgery Vol 42, 2007, 1749-52 <a href="https://www.circinfo.org/pdf/Phim-Pileggi.pdf" rel="noopener" target="_blank">Read full text as PDF (200 kb)</a> <h3>Long-term efficiency of skin stretching and a topical corticoid cream application for unretractable foreskin and phimosis in pre-pubertal boys</h3> Ghysel C, Vander Eeckt K, Bogaert GA. Department of Urology-Pediatric Urology, University Hospital UZ Gasthuisberg, Leuven, Belgium. OBJECTIVES: To evaluate the long-term efficacy of topical application of a potent corticoid cream and skin stretching in the treatment of unretractable foreskin, pinpoint phimosis, balanopreputial adhesions and lichen sclerosus in prepubertal boys. METHODS: 462 prepubertal boys (mean age 4.7 years) with unretractable foreskin applied a topical potent corticoid cream together with skin stretching twice daily for 6 weeks. Follow-up interview of all patients was performed to evaluate long-term results (median 22 months). Short- and long-term results were compared and evaluated. RESULTS: 400/462 boys (86%) had a retractable prepuce after 6 weeks of treatment. 62/462 boys had no or only a partial response. After a median follow-up of 22 months, the treatment continued to be successful in 383/462 boys (83%). In 76/462 boys the foreskin was unretractable, of which 35 preferred surgical treatment. 12/462 boys presented with lichen sclerosus and the non-surgical treatment appeared efficient in 9/12 (67%). CONCLUSIONS: This study has shown that local application of a potent corticoid cream and skin stretching is a safe, simple and effective long-term treatment for all types of unretractable foreskin in prepubertal boys. The efficiency of the treatment was not related to the age of the patient or the type of unretractable foreskin. Urol Int. 2009;82(1):81-8. Epub 2009 Jan 20. PMID: 19172103 [PubMed - indexed for MEDLINE] <h3>Doctors often hazy about distinguishing normal phimosis from a pathological condition</h3> McGregor TB, Pike JG, Leonard MP, Phimosis: A diagnostic dilemma? Canadian Journal of Urology 2005 Apr; 12(2):2598-602 Abstract INTRODUCTION: Phimosis is defined as the inability to retract the foreskin. Differentiating between physiological phimosis and pathological phimosis is important, as the former is managed conservatively and the latter requires surgical intervention. Referrals of patients with physiological phimosis to urology clinics may create anxiety regarding the need for surgery amongst patients and parents, while unnecessarily expanding the waiting list for specialty assessment. OBJECTIVES: To determine the ability of referring physicians to differentiate physiological from pathological phimosis, and to see whether there is any difference in this ability between generalists versus specialists. MATERIALS AND METHODS: A retrospective chart review of 284 consecutive referrals for phimosis to the Children's Hospital of Eastern Ontario (CHEO) Urology Clinic during November 2000 - April 2003 was conducted. Referral sources included family physicians (FP), pediatricians (PD), emergency physicians (ER), and other subspecialists (SS). Data for this study were obtained from the original referral letters and cross-referenced with the impressions of the pediatric urologist following the initial patient encounter. The accuracy in diagnosing phimosis was evaluated among the various types of referring physicians. RESULTS: A total of 284 phimosis referrals were reviewed of patients ranging from 2 months to 16 years of age (mean = 6.6 years). The referral sources consisted of 222-GP, 33-PD, 23-ER, and 6-SS. The majority of referred cases were diagnosed by the attending pediatric urologist as physiological phimosis across all referral sources, with the exception of subspecialists (FP = 75.2%, PD = 81.8%, ER = 56.5%, SS = 33.3%). Second to this was the diagnosis of pathological phimosis across all referral sources except SS (FP = 14.9%, PD = 12%, ER = 34.8%, SS = 50%). Overall, the circumcision rate for the 284 phimosis referrals reviewed was 14.4%. CONCLUSIONS: Our findings reveal that many physicians continue to face difficulties in distinguishing physiological phimosis from the pathological. As a result, many unnecessary referrals are made for phimosis . We suggest the implementation of improved educational measures regarding preputial pathophysiology in the medical curriculum. Such measures would serve two purposes: first, to reduce the number of unnecessary specialty referrals and secondly, to aid primary care physicians in recognizing the presence of physiological phimosis so that patients and families may be reassured of normalcy. <a href="https://www.circinfo.org/documents/Phim-Canada05.pdf">Download full text as PDF</a><a></a> <h3>Much confusion about phimosis, but uncircumcised penis requires no special care</h3> Thomas B. McGregor, John G. Pike, Michael P. Leonard, Pathologic and physiologic phimosis: Approach to the phimotic foreskin Canadian Family Physician 2007(March);53:445-448 Abstract OBJECTIVE: To review the differences between physiologic and pathologic phimosis, review proper foreskin care, and discuss when it is appropriate to seek consultation regarding a phimotic foreskin. SOURCES OF INFORMATION: This paper is based on selected findings from a MEDLINE search for literature on phimosis and circumcision referrals and on our experience at the Children’s Hospital of Eastern Ontario Urology Clinic. MeSH headings used in our MEDLINE search included “phimosis,” “referral and consultation,” and “circumcision.” Most of the available articles about phimosis and foreskin referrals were retrospective reviews and cohort studies (levels II and III evidence). MAIN MESSAGE: Phimosis is defined as the inability to retract the foreskin. Differentiating between physiologic and pathologic phimosis is important, as the former is managed conservatively and the latter requires surgical intervention. Great anxiety exists among patients and parents regarding non-retractile foreskins. Most phimosis referrals seen in pediatric urology clinics are normal physiologically phimotic foreskins. Referrals of patients with physiologic phimosis to urology clinics can create anxiety about the need for surgery among patients and parents, while unnecessarily expanding the waiting list for specialty assessment. Uncircumcised penises require no special care. With normal washing, using soap and water, and gentle retraction during urination and bathing, most foreskins will become retractile over time. CONCLUSION: Physiologic phimosis is often seen by family physicians. These patients and their parents require reassurance of normalcy and reinforcement of proper preputial hygiene. Consultation should be sought when evidence of pathologic phimosis is present, as this requires surgical management. <a href="https://www.circinfo.org/documents/Phim-Canada07.pdf">Download full text as PDF</a><a></a> <h3>Phimosis does not require circumcision</h3> Peter D Metcalf and Remon Elyas, Foreskin management: Survey of Canadian pediatric urologists Canadian Family Physician 2010;56:e290-5 (August 2010) Key points <ul> <li>Neonatal circumcision has decreased dramatically over the past decade, with pediatric urologists maintaining a conservative approach to foreskin management, despite consistent surgical referrals by family physicians.</li> <li>Pathologic and physiologic phimosis and asymptomatic ballooning while voiding are common reasons for referral; however, only in cases of pathologic phimosis, caused by balanitis xerotica obliterans, do all pediatric urologists advocate intervention, most with circumcision.</li> <li>Foreskin management typically involves reassuring the patient and parent, educating the patient on self-care, and topical steroids.</li> <li>Family physicians should be educated on the conservative management and care of the prepubertal foreskin and be able to distinguish between physiologic phimosis and balanitis xerotica obliterans in order to decrease patient and parent anxieties and manage most common foreskin conditions in practice.</li> </ul> <a href="https://www.circinfo.org/documents/Phim-Canada10.pdf">Download full text as PDF</a><a></a> <h3> <a id="shahid" name="shahid"></a>Phimosis: Circumcision outmoded treatment</h3> A thoroughly researched article in ISRN Urology by an Indian paediatrician confirms previous research showing that phimosis (inability to retract the foreskin) is normal in children and rarely requires intervention. He further points out that circumcision is an old fashioned and outmoded response to problem cases that has largely been superseded by medical rather than surgical treatments. Unlike papers by Americans and others from circumcising cultures, this survey does not start with the usual litany about circumcision being an ancient surgical procedure, performed by many savage and ignorant cultures blah, blah, blah, but at the proper place: with a discussion of the foreskin as a normal, functional part of male sexual anatomy, followed by a discussion of its development, anatomy and physiology. Only then does the author consider the occasional problems to which a non-retractile foreskin may give rise, and the appropriate responses (i.e. not involving wholesale destruction of the body part in question). The paper points out that there are two types of phimosis - physiological (normal) and pathological - and that only the last of these may warrant surgical intervention. The author is particularly concerned that there is still widespread confusion, among both parents and doctors, between these two types of phimosis, leading to many unnecessary and unwanted circumcision procedures. Better knowledge of foreskin physiology and modern treatment options is needed to minimise mistaken diagnoses of pathological phimosis, reduce the incidence of needless and often harmful surgery. ABSTRACT: Phimosis is nonretraction of prepuce. It is normally seen in younger children due to adhesions between prepuce and glans penis. It is termed pathologic when nonretractability is associated with local or urinary complaints attributed to the phimotic prepuce. Physicians still have the trouble to distinguish between these two types of phimosis. This ignorance leads to undue parental anxiety and wrong referrals to urologists. Circumcision was the mainstay of treatment for pathologic phimosis. With advent of newer effective and safe medical and conservative surgical techniques, circumcision is gradually getting outmoded. Parents and doctors should a be made aware of the noninvasive options [i.e. not involving cutting or removal of tissue] for pathologic phimosis for better outcomes with minimal or no side-effects. Also differentiating features between physiologic and pathologic phimosis should be part of medical curriculum to minimise erroneous referrals for surgery. Source: <a href="http://www.hindawi.com/isrn/urology/2012/707329/">Sukhbir Kaur Shahid, Phimosis in Children. ISRN Urology, 2012.</a> <h2>Balanitis Xerotica Obliterans</h2> Balanitis xerotica obliterans (BXO) is a rare condition in which the foreskin becomes inflamed and hardened and covered with a dry whitish film. In adults the problem can result in progressive tightening of the foreskin, making retraction difficult and painful. The condition is poorly understood and the cause(s) unknown: it could be a viral, bacterial or fungal infection or (more probably) some sort of auto-immune response (where the body’s antibodies attacks its own tissue). The symptoms of BXO are similar to those of several other minor penis inflammations, so that its presence must be confirmed by appropriate specialist advice and finally established by laboratory analysis. Where BXO is confirmed, treatment options are limited: application of of steroid medications may help, but if they do not circumcision will be necessary. BXO is one of the very few conditions where therapeutic circumcision is warranted. The most recent comprehensive survey of the medical literature reached the conclusion that, although rare, BXO may be increasing in frequency; that diagnosis is difficult and often mistaken; and that the principal treatment is circumcision, possibly assisted by appropriate anti-inflammatory medications. The abstract of the paper reads as follows: OBJECTIVE Balanitis xerotica obliterans (BXO) is a chronic inflammatory disease that is considered as male genital variant lichen sclerosis. The incidence varies greatly in different series; diagnosis is mostly clinical but histopathological confirmation is mandatory. Various treatments are described, but there is no consensus that one is the best. MATERIALS AND METHODS A literature review was made of BXO and lichen sclerosis in boys under 18 years of age, between 1995 and 2013, analyzing demographic dates, treatments and outcomes. In addition to that, we reviewed BXO cases treated in our centers in the last 10 years. RESULTS After literature review, only 13 articles matched the inclusion criteria. Analyzing those selected, the global incidence of BXO is nearly 35% among circumcised children. Described symptoms are diverse and the low index of clinical suspicion is highlighted. The main treatment is circumcision, with use of topical and intralesional steroids and immunosuppressive agents. CONCLUSION BXO is a condition more common than we believe and we must be vigilant to find greater number of diagnoses to avoid future complications. The main treatment for BXO is circumcision, but as topical or intralesional treatments are now available with potentially good outcomes, they may be considered as coadjuvants. NOTE: The reference to 35% does not mean that 35% of children experience BXO, but that the condition was confirmed in 35% of the children referred with suspected BXO. The condition itself is quite rare. Soledad Celis et al. Balanitis xerotica obliterans in children and adolescents: A literature review and clinical series. Journal of Pediatric Urology 10 (1) February 2014, 34-39. <a href="http://www.jpurol.com/article/S1477-5131(13)00288-X/fulltext" rel="noopener" target="_blank">Full text available here.</a> <h3>Advice from paediatric surgeon</h3> A paediatric surgeon has sent a letter to Circumcision Information Australia, explaining that while he is strongly opposed to routine, non-therapeutic circumcision of boys, BXO is one of the few pathological conditions where circumcision is usually necessary. Throughout my training I have always been taught that BXO was the only absolute indication for circumcision. I am aware of some reports of steroid use and covered for a colleague in the UK once who used this as the first line of treatment. My experience was that this did not work, and that the disease usually progressed rapidly, making circumcision urgently necessary. I did a quick Google search, and also a search of the Journal of Pediatric Urology, with BXO and steroid as the search strategy. The only article I found that helped much was a review of the literature and case series from UK (St George's, London) Ireland (Dublin) and Chile by Celis et al [referenced above]. The main findings were that the incidence of BXO is increasing. Also that circumcision is the main treatment, with steroids and other treatments having a supporting role. Reading through the paper a couple of things caught my eye: 1. The correlation between clinical suspicion and histological diagnosis is not great — meaning that some clinically suspicious BXO turns out to be other scaring / inflammation. 2. Steroids, if they do work at all, only work with early inflammation affecting the prepuce and no scaring. I get the impression these patients had not had their diagnosis confirmed histologically 3. In a few patients who had trial of “tissue sparing surgery” (preputioplasty presumably) in a cohort from Chile there was a 100% relapse rate, needing to progress to circumcision. 4. Reinforcement of complications of inadequately treated BXO leading to progressive disease and significant morbidity needing complex surgical fixes as a result. My summation is therefore that there may be cases of early clinically suspicious BXO which may respond to steroids, but that this probably is not BXO anyway. For those patients with established scaring the only treatment that is reliably effective is a circumcision and that failure to do this exposes the patient to considerable risk of really significant complications of progressive scaring. The role of steroids, therefore, is as a way of excluding non-BXO in patients with inflammation that has not developed established scaring, to temporise and limit disease progression until a definitive circumcision is carried out by an appropriately trained surgeon under a general anaesthetic with adequate analgesia / penile block etc. I would also use post-operative steroids to further reduce the risk of meatal scarring when the inflammation has already spread onto the glans (which I have also seen), despite adequate circumcision. It would seem that whilst histologically it shares features of lichen sclerosis, the clinical behaviour of BXO is different to the disease seen in females. Sadly, at present, I do not think the strategy of primary treatment of established BXO with topical or intra-lesional drugs can be recommended. In the present state of medical knowledge the only sure cure for BXO is circumcision — though we may hope that medical treatments will eventually be developed. The surgeon adds that he is concerned by the number of Queensland boys who have been subjected to unnecessary Plastibel circumcision in infancy. I find it distressing how many boys are still subjected to the Plastibel circumcision. I see so many incidentally in my clinic (when looking at hernia, undescended testes etc) who have obviously had the Plastibel, with their shaft skin reaching only half way up the penis; and on occasions we get children referred with other complications — including buried penis, meatal stenosis and adherent preputial remnants. In Scotland the National Health Service policy was to provide cultural circumcisions (almost entirely for the Muslim population), performed by paediatric surgeons in hospital under general anaesthetic, on the basis that the state had to respect religious/cultural beliefs and that we had a duty of care to minimise the trauma and suffering experienced by the children who were going to get the operation anyway. I do not agree however with “prophylactic” or essentially cosmetic circumcisions, and I am signed up to the international opinion of paediatric surgeons that there is no place for “routine” neonatal circumcisions in the developed world [Referenced in circinfo.org website]. On the few patients that do have persisting symptoms associated with phimosis I will discuss the alternative of a preputioplasty [a surgical operation on the foreskin that loosens it with minimal loss of tissue]. <a href="http://www.cirp.org/library/treatment/BXO/" rel="noopener" target="_blank">Further information about BXO from CIRP</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Phimosis: treatment 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>Concern at unnecessary circumcision</h1> <h3>Doctors worried by incorrect or fraudulent diagnosis of phimosis</h3> Even though routine neonatal circumcision is almost unknown in Britain and rare in Australia, New Zealand and Canada, too many boys between the ages of 4 and 10 are still circumcised because of "phimosis" - that is, because their foreskin cannot be fully drawn back. Many parents (and too many doctors) do not understand that it is quite common for the foreskin not to become fully retractable until the boy reaches puberty or even later, and that there is no need for any action unless he is suffering pain or discomfort. If he is and medical treatment is needed, the preferred treatment these days is application of steroid cream. A premature or (even worse) a fraudulent diagnosis of phimosis should not be used as an excuse to circumcise an otherwise healthy boy. <h3> <a id="mja" name="mja"></a>Medical Journal of Australia: Phimosis not a valid reason for circumcision</h3> Three important articles in Medical Journal of Australia (17 February 2003) argue that too many circumcisions are performed in Australia and that there is inadequate awareness of the value of the foreskin as a normal part of the male genitals. Dr Katrina Spilsbury and colleagues in Perth show that too many boys under six years old are being circumcised after a diagnosis of phimosis, but that most of these diagnoses must be mistaken or spurious because genuine (pathological) phimosis is very rare at that age. They suggest that parents and doctors need education on the normal development of the foreskin. This argument is confirmed by an editorial by Dr Paddy Dewan, a leading paediatric surgeon in Melbourne. In a historical article, "Medical history and medical practice", Dr Robert Darby dispels two persistent myths about the foreskin. He shows that circumcision as practised by tribal peoples did not arise as a health measure; and that it has been recognised since Greek antiquity that the foreskin plays an important role in the body's economy and makes a significant contribution to sexual function. The three articles are available from the <a href="http://www.mja.com.au/public/issues/178_04_170203/contents_170203.html">Medical Journal of Australia on-line</a> Comments in the media Young boys may be undergoing unnecessary circumcisions for a condition that can be effectively treated with creams, according to a study. The percentage of Australian boys being circumcised has fallen from 95 per cent in the 1930s to only 6.5 per cent 20 years ago. However, a West Australian report, published in the Medical Journal of Australia on Monday, reveals a high rate of circumcision for phimosis, a condition where the foreskin cannot be retracted, in boys under five. This is despite the condition - which can easily be confused with normal development of the penis - being rare among this age group. Dr Katrina Spilsbury, of the University of Western Australia's School of Population Health, reviewed the circumcision of boys in the state's hospitals between 1981-1999. Boys aged five and under had the highest rate of surgery for phimosis, representing about 300 circumcisions each year. More older boys were also being circumcised for phimosis, with a 70 per cent increase in the procedure among boys aged 10-14 during the period studied. "The past 19 years have seen a steady rise in the rate of medically indicated circumcision," Dr Spilsbury reports. "Most of the increase is the result of an increase in the rates of phimosis." Dr Spilsbury said if the current rate continued, about four per cent of boys would be circumcised for phimosis by the age of 15. This rate was seven times higher than the estimated occurrence of the condition, she said. "These findings imply a high rate of unnecessary surgery," writes Dr Paddy Dewan of the Royal Children's Hospital in Melbourne in an accompanying editorial. Dr Dewan suggests the high rates might be the result of "manipulation", either by parents who want to circumcise their child for cosmetic reasons or GPs who expect resistance from surgeons unless they give a medical reason for circumcision. Dr Spilsbury said phimosis could cause pain and urinary tract infections and was associated with sexual dysfunction and cancer in later life. However, there was evidence the use of steroid creams could reverse the situation in around four to six weeks, she said. The Age (Melbourne), Sunday 16 February 2003 DOCTORS have been advised to tell parents there is no medical reason to routinely circumcise boys. The policy statement developed by the paediatric and child health division of the Royal Australasian College of Physicians raises the prospect of future legal action if the surgery is performed. Parents who have their child circumcised and doctors who perform the surgery could face legal action when the child grows up. The stance follows a major review of existing information and reaffirms the position of the College of Paediatrics and the Australasian Association of Paediatric Surgeons. "Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure," the RACP says. "There is no medical indication for routine male circumcision." In Australia the circumcision rate has fallen in recent years to about 10 per cent of male infants. The rate of complications from neo-natal circumcision is between 1 and 5 per cent. The Advertiser (Adelaide) and Courier Mail (Brisbane), 19 May 2003 <h3> <a id="times" name="times"></a>Circumcision: Unnecessary, damaging and performed without consent</h3> The unkindest of cuts, by Simon Crompton Times on Line (London), 13 January 2003 THERE IS ONE OPERATION being carried out on thousands of British children by NHS doctors without any clinical need — and without the patient's consent. This procedure has an irreversible physical effect, yet there has been minimal public debate about the extent to which it is being performed. The procedure is non-religious circumcision, carried out on "therapeutic" grounds on 4 to 6 per cent of boys under 15. Increasingly, the expert consensus is that most non-religious circumcisions are carried out for reasons of family history, medical myth and professional laziness. Some campaigners claim that as many as five in six of these circumcisions are unnecessary and potentially traumatising. Circumcision has become the subject of bitter debate in the US, where 80 per cent of men are circumcised. Doctors Opposing Circumcision is one of a range of groups challenging the medical orthodoxy of circumcision at birth; their campaign has been buoyed by a statement from the American Medical Association that there is insufficient evidence of benefit to recommend routine neonatal circumcision. Here, the British Medical Association is reviewing its guidelines and is due to announce its findings in March; current guidance makes it clear that it is unethical to circumcise for therapeutic reasons where research shows that less invasive techniques are available. Norm-UK, an organisation which campaigns against circumcision, estimates that fewer than 1 per cent of boys require the operation, and that most of those performed on the NHS are unnecessary. Dr John Warren, a consultant physician and founder of Norm-UK, says that the main problem is that GPs and general surgeons are unaware of research indicating when circumcision is medically required. Specialist paediatric urological surgeons are better informed, but not all children are seen by these experts. Most non-religious circumcisions are performed on children whose parents are concerned about a tight foreskin that will not retract, a condition known as phimosis. "They think there is something wrong, even if it's causing the child no problems," says Warren, who works at the Princess Alexandra Hospital in Harlow, Essex. Yet research published as long ago as 1968 showed that 90 per cent of tight foreskins had resolved themselves by the age of four, and 99 per cent had developed normally by 17. "The message never filtered through, and a lot of people didn't accept it," says Warren. Family tradition also plays a part. Fathers and grandfathers who were circumcised may want their boys circumcised too (often on the basis that it is "cleaner"), and use the possibility of phimosis to get doctors to perform the procedure. Duncan Wilcox, consultant paediatric urologist at Great Ormond Street Hospital and Guy's Hospital in London, believes that this is the main reason why so many circumcisions are carried out unnecessarily. "As many as half of the parents who come to see me want their child to have a circumcision," he says. "But when I tell them that there is a risk, as with all operations, the majority are happy to wait and see if the foreskin retracts normally. Doctors are certainly pressurised, and there is always the occasional parent who will get through with pure persistence, or by saying that their child keeps getting infections." The issue would be less important if foreskin removal did not have physical and social implications which carry on into adulthood. Alex was circumcised at 25 during an operation to correct a bend in his penis. The surgeon decided — without Alex's consent — to remove the foreskin, an action that other surgeons have subsequently confirmed as unnecessary. "There was a huge reduction in erogenous tissue," says Alex, now 29, a systems analyst from Oxfordshire. "The feeling of pleasure has changed so much that I haven't been able to achieve orgasm since the operation. It had a disastrous effect on my relationship: my partner wondered whether it was her fault, and that contributed to the end of our relationship. Since then I've found it hard to get into a new relationship. "I am conscious of how I look, and girlfriends have given me quizzical looks. They are not used to seeing circumcised men. I haven't had the confidence to go into a public changing room since the operation." The foreskin contains a rich variety and concentration of specialised nerve receptors. In May 2002, a study in the British Journal of Urology reported that circumcision appears to result in decreased erectile function and penile sensitivity: 38 per cent of men circumcised as adults reported harm to sexual function. The practice of medical (as distinct from religious) circumcision began in Victorian times as a deterrent to masturbation, then thought to be the cause of insanity, epilepsy, hysteria, tuberculosis, short-sightedness and death. The practice became popular in the 1920s for reasons of hygiene and peaked in the 1940s. In 1949, researchers began to question whether a non-retracting foreskin was abnormal, and numbers have declined. Norm-UK has received hundreds of calls from men who feel ashamed or mutilated by the procedure. For young boys, the potential embarrassment of having a penis that looks different from those of their friends is obvious. Yet the psychological issues are complex: in a largely Jewish or Islamic community, this argument works as much in favour of circumcision as against it. Dr Lotte Newman, a former president of the Royal College of General Practitioners who chairs the circumcision working party of the Board of Deputies of British Jews, is troubled by developments in Sweden which may lead to a ban on child circumcision there. "The trend against circumcision affects those religions which practise it traditionally," she says. Such sensitivities may account for the neutral stance of mainstream medical organisations such as the General Medical Council, which states only that its soundings "demonstrated widely conflicting views in society, which neither doctors nor the GMC can resolve". But perhaps the issue ultimately comes down to one of consent. Adults need to know about the alternatives to have an accurate basis for decision-making. But Norm-UK's concern is that no one should consent to a circumcision on someone else's behalf, even if it is their own child. That means doing everything possible to treat conditions non-invasively until the patient can make an informed choice. "When I was a kid I had a circumcision and my brother didn't," says Warren. "It made me conscious of the issue as a medical student. Then I had to conduct the operation myself, and was horrified at what I was doing. I thought, one day I will stop this ridiculous practice." <a href="http://www.timesonline.co.uk/article/0,,589-540977,00.html">www.timesonline.co.uk/article/0,,589-540977,00.html</a> <h3> <a id="canada" name="canada"></a>Warnings from Canadian doctors</h3> Infant Male Circumcision The matter of routine infant male circumcision was a subject of discussion at a recent meeting of the College Council. The College has received repeated requests from special interest groups and individuals to "ban" this procedure. Their objections to routine infant male circumcision are based on a variety of factors including the lack of medical indications, the right of the newborn to make its own long term decisions, immediate risks, long term effects, ethical issues, and so on. The College's position on routine infant male circumcision is that it is a matter of patients' (or parental) choice, which may be based on traditional, religious, cultural or personal preference. The issue of perceived medical necessity is, in the opinion of most experts, no longer pertinent. Though some studies suggest slightly lower frequencies of urinary tract infection and decreases in HIV transmission in circumcised males, most physicians agree that the procedure should be regarded as a "cosmetic" procedure and in North America should be approached as such. Younger physicians (coming out of training programs) often do not have skill or experience in performing circumcisions and also may have little interest in acquiring such skills or being involved in the procedure. College Council did not identify any necessity to place restrictions on the availability of routine infant male circumcision, except to remind physicians that when performed routinely, this is a cosmetic surgical procedure which should only be considered after detailed discussion with the parents. This allows parental request and consent to be based on accurate and comprehensive information. Such discussions should include the fact that infant circumcision is not a medical necessity, that many experts including national pediatric associations do not recommend it, that there are risks such as bleeding and infection which can be significant in rare instances, and that currently the majority of male infants are not circumcised. Also, physicians should be aware that they are not required to accept the parents' request for routine circumcision if they are personally unable or unwilling to perform the procedure. Such requests should be referred to others in those situations. It is Council's opinion that the requests for this procedure will decrease through the natural evolution of public and medical opinion. As a uniquely North American cultural trend in the absence of medical indications, (except for requests based upon religious beliefs) routine infant circumcision will likely become an uncommon procedure. College of Physicians and Surgeons of British Columbia College Quarterly, Issue 38, Fall 2002 <a href="http://www.courtchallenge.com/letters/bccoll1.html%20">Further information</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 Doctors warn against misdiagnosis of phimosis darby