Male circumcision (from Latin circumcisio, meaning "to cut around") is the surgical removal of some or all of the foreskin (prepuce) from the penis. It is estimated that one-third of males worldwide are circumcised. It is most prevalent in the Muslim world (where it is near-universal), parts of Southeast Asia, Africa and the United States; it is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia and Oceania. The origin of circumcision is not known with certainty; the oldest documentary evidence for it comes from ancient Egypt. Various theories have been proposed as to how it began, including as a religious sacrifice and as a rite of passage marking a boy's entrance into adulthood. It is considered religious law in Judaism and established tradition in Islam to circumcise sons.
In modern times, for infants, the procedure is often performed using devices such as the Plastibell, or the Gomco or Mogen-style clamps. The foreskin is opened and then separated from the glans after inspection. The circumcision device (if used) is placed, and then the foreskin is removed. Topical or locally-injected anesthesia may be used to reduce pain and physiologic stress. For adults, general anesthesia is an option, and the procedure is often performed without a specialized circumcision device. A review of literature worldwide found circumcisions performed by medical providers to have a median complication rate of 1.5% for newborns and 6% for older children; almost no severe adverse events were found for either group. Bleeding, infection, and removal of an improper amount of skin are the most common complications. Questions of whether circumcision carries lasting psychological effects, and what its effects are on sexual function, are both poorly determined, with various studies reporting mixed results.
Circumcision may be indicated for both therapeutic and prophylactic reasons. It is a treatment option for phimosis, posthitis and other such conditions. A Cochrane meta-analysis of studies done on sexually active men in Africa found that circumcision reduces the infection rate of HIV among heterosexual men by 38%–66% over a period of 24 months, and studies have concluded it is cost-effective in sub-Saharan Africa. The World Health Organization (WHO) recommends considering it as part of a comprehensive HIV program in areas with high endemic rates of HIV. Circumcision reduces the incidence of HSV-2 infections by 28%, and is associated with a reduced risk of both urinary tract infections (UTIs) and penile cancer. Studies of its protective effects against other sexually transmitted infections have been inconclusive.
Circumcision is controversial. Ethical questions have been raised over removing healthy, functioning genital tissue from a minor, and opponents of circumcision state that infant circumcision infringes upon individual autonomy and represents a human rights violation. Some medical associations take the position that the parents should determine what is in the best interest of the infant or child; others state parents are not entitled to demand medical procedures contrary to their child's best interests, or infringe on the right of the child to make an informed choice for himself when older. Summaries of the views of professional associations of physicians state that none recommend routine circumcision, and that none recommend prohibiting the practice. The legal status of circumcision sees a wide range of treatment from legislative bodies around the world.
Circumcision surgery with hemostats and scissors
If anesthesia is to be used, there are several options: local anesthetic cream (EMLA cream) can be applied to the end of the penis 60–90 minutes prior to the procedure; local anesthetic can be injected at the base of the penis to block the dorsal penile nerve; local anesthetic can be injected in a ring around the middle of the penis in what is called a subcutaneous ring block. It is also possible to use general anesthetics in the case of adult surgery, though not the standard practice.
For infant circumcision, devices such as the Gomco clamp, Plastibell, and Mogen clamp are commonly used, together with a restraining device. With all these devices, the same basic procedure is followed. First, the amount of foreskin to be removed is estimated. The foreskin is opened via the preputial orifice to reveal the glans underneath and ensure it is normal. The inner lining of the foreskin (preputial epithelium) is bluntly separated from its attachment to the glans. The device is placed (this sometimes requires a dorsal slit) and remains there until blood flow has stopped. Finally, the foreskin is amputated. Sometimes, the frenulum band may need to be cut from the corona near the urethra to ensure that the glans can be freely and completely exposed.
Adult circumcisions are often performed without clamps and require four to six weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal. In some African countries, male circumcision is often performed by non-medical personnel under unsterile conditions. After hospital circumcision, the foreskin may be used in biomedical research, consumer skin-care products, skin grafts, or β-interferon-based drugs.
Studies comparing healthcare cost to benefits of circumcision have reached varying conclusions. Some found a small net benefit of circumcision, some found a small net decrement, and one found that the benefits and risks balanced each other out and suggested that the decision could "most reasonably be made on nonmedical factors.".
According to the American Academy of Pediatrics' 1999 Circumcision Policy Statement, "There is considerable evidence that newborns who are circumcised without analgesia experience pain and physiologic stress." One of the supporting studies found a correlation between circumcision and intensity of pain response during vaccination months later. While acknowledging that there may be other factors than circumcision to account for different levels of pain response, they stated that they did not find evidence of such. They therefore recommended to use pain relief for circumcision. Other medical associations also cite evidence that circumcision without anesthetic is painful.
Stang, 1998, found 45% of physicians responding to a survey who circumcise used anaesthesia – most commonly a dorsal penile nerve block – for infant circumcisions. The obstetricians in the sample used anaesthesia less often (25%) than the family practitioners (56%) or pediatricians (71%). Howard et al. (1998) surveyed US medical doctor residency programs and directors, and found that 26% of the programs that taught the circumcision procedure "failed to provide instruction in anesthesia/analgesia for the procedure" and recommended that "residency training in neonatal circumcision should include instruction in pain relief techniques". A 2006 follow-up study revealed that the percentage of programs that taught circumcision and also taught administration of topical or local anesthetic had increased to 97%. However, the authors of the follow-up study also noted that only 84% of these programs used anesthetic "frequently or always" when the procedure was conducted.
Glass, 1999, stated that Jewish ritual circumcision is so quick that "most mohelim do not routinely use any anaesthesia as they feel there is probably no need in the neonate." Glass continued, "However, there is no Talmudic objection and should the parents wish for local anaesthetic cream to be applied there is no reason why this cannot be done." Glass also stated that for older children and adults, a penile block is used. In 2001 the Swedish government passed a law requiring all boys undergoing a bris to be given anaesthetic administered by a medical professional.
Comparisons of the dorsal penile nerve block and EMLA (lidocaine/prilocaine) topical cream methods of pain control have revealed that while both are safe, the dorsal nerve block controls pain more effectively than topical treatments. Neither method eliminates pain completely. The ring block may provide more effective pain control than either of these treatments. The use of sucrose pacifiers and comfortable, padded chairs may also help.
The effect of circumcision on sexual function is poorly determined, with studies reporting mixed effects. The American Academy of Pediatrics points to a survey (self-report) finding circumcised adult men had less sexual dysfunction and more varied sexual practices, but also noted anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males. A 2002 review stated that "the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings—many of which are lost to circumcision, with an inevitable reduction in sexual sensation experienced by circumcised males." The authors concluded, "intercourse is less satisfying for both partners when the man is circumcised". Hirji et al. (2005) state that "Reports of [. . .] psychological trauma are not borne out in studies but remain as an anecdotal cause for concern."
In January 2007, the American Academy of Family Physicians (AAFP) stated "The effect of circumcision on penile sensation or sexual satisfaction is unknown. Because the epithelium of a circumcised glans becomes cornified, and because some feel nerve over-stimulation leads to desensitization, many believe that the glans of a circumcised penis is less sensitive. [. . .] No valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction." A 2010 review reported that "despite conflicting results in some of the historical observational studies, most recent articles do not show evidence of adverse effects on sexual function." A review which analysed the data from eight clinical trials concluded that the "evidence suggests that adult circumcision does not affect sexual satisfaction and function."
The British Medical Association (BMA) states that "it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks." Milos and Macris (1992) argue that circumcision encodes the perinatal brain with violence and negatively affects infant-maternal bonding and trust. Goldman discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure. Furthermore, Schultheiss (1998) reports males attempting to undo the effects of circumcision through the practice of foreskin restoration. Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, citing a longitudinal study which did not find a difference "in relation to a number of developmental and behavioural indices." A literature review by Gerharz and Haarmann (2000) reached a similar conclusion. Boyle et al. (2002) state that circumcision may result in psychological harm, including post-traumatic stress disorder (PTSD), citing a study reporting high rates of PTSD among Filipino boys after either ritual or medical circumcision.
After reviewing the literature, the American Academy of Pediatrics (2012) found that acute complications "most commonly involve bleeding, infection, or an imperfect amount of tissue removed," and that "significant acute complications are rare," occurring in about 1 in 500 newborn procedures; severe to catastrophic complications were so rare that they were only reported as case reports. The AAP also found it difficult to report an overall complication rate due to scant data on complications, and inconsistencies in how a "complication" was classified across the literature reviewed.
In their review of the medical literature, the American Academy of Family Physicians (2007) found that the complications of infection, bleeding, and failure to remove enough foreskin occur in less than 1% of procedures, and make up the vast majority of all complications. They also found "more serious complications have also occurred," and that "evidence-based complications from circumcision include pain, bruising, and meatitis."
The American Urological Association (2007) stated that neonatal circumcision is "generally a safe procedure when performed by an experienced operator," and that although the possibility for serious complications exists, "when performed on healthy newborn infants as an elective procedure, the incidence of serious complications is extremely low."
The authors of a systematic review (2010) found a median complication rate of 1.5% among neonates, with a range of 0 to 16%. In older boys, rates varied from 2-14%, with a median of 6%. The median risk of serious complications was 0% in both cases.
The American Academy of Family Physicians (2007) states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision.
Sexually transmitted diseases
There is strong evidence that circumcision reduces the risk of HIV infection in heterosexual men in populations that are at high risk. Evidence among heterosexual men in sub-Saharan Africa shows a decreased risk of between 38 percent and 66 percent over two years and in this population studies rate it cost effective. There is little or no evidence that it protects against male-to-female HIV transmission, and whether it is of benefit in developed countries and among men who have sex with men is undetermined.
Human immunodeficiency virus
More than forty observational studies have been conducted to investigate the relationship between circumcision and HIV infection. Reviews of these studies have reached differing conclusions about whether circumcision could be used as a prevention method against HIV.
Experimental evidence was needed to establish a causal relationship between lack of circumcision and HIV, so three randomized controlled trials were commissioned as a means to reduce the effect of any confounding factors. Trials took place in South Africa, Kenya and Uganda. All three trials were stopped early by their monitoring boards on ethical grounds, because those in the circumcised group had a lower rate of HIV contraction than the control group. The results showed that circumcision reduced vaginal-to-penile transmission of HIV by 60%, 53%, and 51%, respectively. A meta-analysis of the African randomised controlled trials found that the risk in circumcised males was 0.44 times that in uncircumcised males, and that 72 circumcisions would need to be performed to prevent one HIV infection. The authors also stated that using circumcision as a means to reduce HIV infection would, on a national level, require consistently safe sexual practices to maintain the protective benefit.
As a result of these findings, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an efficacious intervention for HIV prevention but should be carried out by well trained medical professionals and under conditions of informed consent. Both the WHO and CDC indicate that circumcision may not reduce HIV transmission from men to women, and that data are lacking for the transmission rate of men who engage in anal sex with a female partner. The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should never replace known methods of HIV prevention. The Male Circumcision Clearinghouse website was formed by WHO, UNAIDS, FHI and AVAC to provide current evidence-based guidance, information and resources to support the delivery of safe male circumcision services in countries that choose to scale up male circumcision as one component of comprehensive HIV prevention services.
Circumcision has been judged to be a cost-effective method to reduce the spread of HIV in a population, though not necessarily more cost-effective than condoms. Some have challenged the validity of the African randomized controlled trials, prompting a number of researchers to question the effectiveness of circumcision as an HIV prevention strategy.
In addition to the studies which provided information about female-to-male transmission, some studies have addressed other transmission routes. A randomised controlled trial in Uganda found that male circumcision did not reduce male to female transmission of HIV. The authors could not rule out the possibility of higher risk of transmission from men who did not wait for the wound to fully heal before engaging in intercourse. A meta-analysis of data from fifteen observational studies of men who have sex with men found "insufficient evidence that male circumcision protects against HIV infection or other STIs."
Human papilloma virus
A 2007 meta-analysis of eight observational studies found no protective effect against human papillomavirus (HPV); critics reported that reanalysis of the same data showed a protective effect. A later analysis of 14 studies, by Bosch et al, found a protective effect. In 2011, a meta-analysis of 23 studies (including both randomised controlled trials and observational studies) found reduced risk of prevalent HPV and (though the evidence was less strong) some evidence of reduced risk of new HPV infections. In another analysis, in which 21 studies were included, there was a statistically significant reduction in prevalence of HPV, but no statistically significant association with new acquisitions was observed.
A 2009 meta-analysis of multiple studies found a significant association between genital warts and HPV and the presence of a foreskin, as well as HPV alone. While circumcision was associated with a lesser risk of genital warts alone, the association did not reach statistical significance. However, later analyses found no association between circumcision and penile warts.
Other sexually transmitted infections
Studies evaluating the effect of circumcision on the incidence of other sexually transmitted infections have reached conflicting conclusions. A 2006 meta-analysis of observational data from twenty-six studies found that circumcision was associated with lower rates of syphilis, chancroid and possibly genital herpes. More recently, a 2010 review of clinical trial data found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%. The researchers found mixed results for protection against Trichomonas vaginalis and Chlamydia trachomatis, and no evidence of protection against gonorrhea or syphilis. Among men who have sex with men, reviews have found insufficient evidence of an effect against sexually transmitted infections other than HIV, with the possible exception of syphilis.
Hygiene, infection, chronic and skin conditions
The American Academy of Pediatrics (1999) stated: "Circumcision has been suggested as an effective method of maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene." Circumcision is used therapeutically, as one of the treatment options for balanitis xerotica obliterans, phimosis, balanitis, posthitis and balanoposthitis.
An inflammation of the glans penis and foreskin is called balanoposthitis; that affecting the glans alone is called balanitis. Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. Although not as necessary as in the past, circumcision may be considered for recurrent or resistant cases. Most cases of these conditions occur in uncircumcised males, and affect 4 to 11% of uncircumcised boys. The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor. Yeasts, especially Candida albicans, are the most common penile infection, and are rarely identified in samples taken from circumcised males.
Phimosis is the inability to retract the foreskin over the glans penis; authors frequently distinguish between "physiologic" phimosis (or developmental non-retractility) and "pathological" phimosis. The latter is most commonly caused by balanitis xerotica obliterans, for which circumcision is the preferred treatment. The American Medical Association states that circumcision, properly performed, protects against the development of phimosis. Esposito et al. (2008) found topical steroid cream to be a good alternative to circumcision for phimosis, although circumcision is still required for patients where a phimotic ring persists even after steroid cream therapy has been tried.
Urinary tract infections
Circumcision is associated with a reduced risk of urinary tract infections (UTIs) however the magnitude of this benefit is likely to outweigh the risk only in those at high risk of UTIs.
Some UTI studies have been criticized for not taking into account a high rate of UTI's among premature infants, who are usually not circumcised because of their fragile health status. The AMA stated that "depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI," and noted one decision analysis model that concluded that circumcision was not justified as a preventative measure against UTI.
The American Academy of Pediatrics (1999) stated that studies suggest that neonatal circumcision confers some protection from penile cancer, but circumcision at a later age does not seem to confer the same level of protection. Further, because penile cancer is a rare disease, the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low.
Micali et al (2006) describe penile cancer as an "emerging problem", noting that "public health measures, such as prophylactic use of circumcision, have proven successful". The American Cancer Society (2012) stated, "Most experts agree that circumcision should not be recommended solely as a way to prevent penile cancer."
A 2011 meta-analysis concluded that childhood or adolescent circumcision substantially reduces the risk of invasive penile cancer. It was suggested that this may be due, in part, to reduced risk of phimosis, a predisposing factor for penile cancers. While the same study found "some evidence" of an association between adult circumcision and an increased risk of invasive penile cancer, the authors suggested this may have been due to adult circumcisions being used as a treatment for penile cancer or a condition that is itself a precursor to cancer, rather than a direct result of the procedure itself. With respect to the quality of the studies included in the meta-analysis, the overall risk of bias was evaluated as "high", leading to a possibility that the protective effect of circumcision was underestimated.
In 2012, Morris et al. reported that there is some evidence, albeit mixed, that circumcision may protect against prostate cancer; they called for more extensive research into the matter.
There are mixed interpretations regarding cervical cancer in female partners. Rivet (2002) summarising a meta-analysis by Bosch et al. in which seven studies were included, notes a "moderate but nonsignificant decrease in risk of cervical cancer", with a statistically significant reduction in partners of men at high-risk of HPV. In contrast, Van Howe (2009) stated that only one of sixteen studies found a statistically significant association remarking that "a positive association in 1 study out of 16 studies is what would be expected by chance alone."
Prevalence of circumcision by country
It is estimated that one-third of males worldwide are circumcised. and it is commonly practiced between infancy and the early twenties. The WHO has estimated that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), with almost 70% of these being Muslim. Circumcision is most prevalent in the Muslim world, parts of Southeast Asia, Africa, the United States, Israel, and South Korea. It is relatively rare in Europe, Latin America, parts of southern Africa, and most of Asia and Oceania. Prevalence is near-universal in the Middle East and Central Asia. The WHO states that "there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines". The WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe, and Klavs et al. report findings that "support the notion that the prevalence is low in Europe". In Latin America, prevalence is universally low. Estimates for individual countries include Spain, Colombia and Denmark less than 2%, Finland 0.006% and 7%, Brazil 7%, Taiwan 9%, Thailand 13% and Australia 58.7%.
The WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively. Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.
Circumcision in Ancient Egypt
The origin of male circumcision is not known with certainty. Various theories have been proposed as to how it began, including:
- As a religious sacrifice
- As a rite of passage marking a boy's entrance into adulthood
- As a form of sympathetic magic to ensure virility or fertility
- As a means of enhancing sexual pleasure
- As an aid to hygiene where regular bathing was impractical
- As a means of marking those of higher social status
- As a means of humiliating enemies and slaves by symbolic castration
- As a means of differentiating a circumcising group from their non-circumcising neighbors
- As a means of discouraging masturbation or other socially proscribed sexual behaviors
- As a means of removing "excess" pleasure
- As a means of increasing a man's attractiveness to women
- As a demonstration of one's ability to endure pain
- As a male counterpart to menstruation or the breaking of the hymen
- To copy the rare natural occurrence of a missing foreskin of an important leader
It has been suggested that the custom of circumcision gave advantages to tribes that practiced it and thus led to its spread. Darby describes these theories as "conflicting", and states that "the only point of agreement among proponents of the various theories is that promoting good health had nothing to do with it." Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practising circumcision, leading to its spread. Wilson suggests that circumcision "is likely to reduce insemination efficiency, reducing a man's capacity for extra-pair fertilizations by impairing sperm competition," and thus, "[m]en who display this signal of sexual obedience may gain social benefits if married men are selected to offer social trust and investment preferentially to peers who are less threatening to their paternity." It is possible that circumcision arose independently in different cultures for different reasons.
The oldest documentary evidence for circumcision comes from ancient Egypt and Greek historian Herodotus states that "the Egyptians and those who have learned it from them are the only people who practise circumcision". Circumcision was common, although not universal, among ancient Semitic peoples. In the aftermath of the conquests of Alexander the Great, however, Greek dislike of circumcision (they regarded a man as truly "naked" only if his prepuce was retracted) led to a decline in its incidence among many peoples that had previously practiced it.
Circumcision has ancient roots among several ethnic groups in sub-equatorial Africa, and is still performed on adolescent boys to symbolize their transition to warrior status or adulthood.
Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada, South Africa, New Zealand and to a lesser extent in the United Kingdom. There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The germ theory of disease elicited an image of the human body as a conveyance for many dangerous germs, making the public "germ phobic" and suspicious of dirt and bodily secretions. The penis became "dirty" by association with its function, and from this premise circumcision was seen as preventative medicine to be practised universally. In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation. Aggleton wrote that John Harvey Kellogg viewed male circumcision in this way, and further "advocated an unashamedly punitive approach." Circumcision was also said to protect against syphilis, phimosis, paraphimosis, balanitis, and "excessive venery" (which was believed to produce paralysis). Gollaher states that physicians advocating circumcision in the late nineteenth century expected public skepticism, and refined their arguments to overcome it.
Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 32% of newborn American boys were being circumcised in 1933. Laumann et al. reported that the prevalence of circumcision among US-born males was approximately 70%, 80%, 85%, and 77% for those born in 1945, 1955, 1965, and 1971 respectively. Xu et al. reported that the prevalence of circumcision among US-born males was 91% for males born in the 1970s and 84% for those born in the 1980s. Between 1981 and 1999, National Hospital Discharge Survey data from the National Center for Health Statistics demonstrated that the infant circumcision rate remained relatively stable within the 60% range, with a minimum of 60.7% in 1988 and a maximum of 67.8% in 1995. A 1987 study found that the most prominent reasons US parents choose circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns. However, a later study speculated that an increased recognition of the potential benefits of neonatal circumcision may have been responsible for the observed increase in the US rate between 1988 and 2000. A report by the Agency for Healthcare Research and Quality placed the 2005 national circumcision rate at 56%. Most recently, the Centers for Disease control used the Charge Data Master [CDM] from SDIHealth to estimate that 54.7% of American newborn males were circumcised in 2010 .
In 1949, the United Kingdom's newly formed National Health Service removed infant circumcision from its list of covered services, and circumcision has since been an out-of-pocket cost to parents. Among men (aged 15 years or older) who are neither Jews nor Muslims, the overall prevalence of circumcision in the UK is 6% according to the WHO's estimates. When "data from targeted oversampling of black Caribbean, black African, Indian, and Pakistani groups (the Natsal ethnic minority boost) were combined with the main [Natsal II] survey data", it was found that the prevalence of circumcision in the UK is age-graded, with 11.7% of those aged 16–19 years circumcised and 19.6% of those aged 40–44 years. There is a clear ethnic division: "With the exception of black Caribbeans, men from all ethnic minority backgrounds were significantly [(3.02 times)] more likely to report being circumcised compared to men who described their ethnicity as white". These particular findings "confirm that the prevalence of male circumcision among British men appears to be declining. This is despite an increase in the proportion of the British population describing their ethnicity as nonwhite"; indeed, the proportion of newborns circumcised in England and Wales has fallen to less than one percent.
The circumcision rate has declined sharply in Australia since the 1970s, leading to an age-graded fall in prevalence, with a 2000–1 survey finding 32% of those aged 16–19 years circumcised, 50% for 20–29 years and 64% for those aged 30–39 years.
In Canada, Ontario health services delisted circumcision in 1994.
The word "circumcision" comes from Latin circumcisio. "Circumcisio" comes from circum (meaning "around") and cædere (meaning "to cut").
Society and culture
A protest against infant circumcision.
Circumcision is controversial; Alanis and Lucidi (2004) even describe neonatal circumcision as "the world's oldest and most controversial operation."
Ethical questions have been raised over removing healthy, functioning genital tissue from a minor. Opponents of circumcision state that infant circumcision infringes upon individual autonomy and represents a human rights violation. Rennie et al. note that using circumcision as a way of preventing HIV in high prevalence, low-income countries in sub-Saharan Africa, is controversial, but argue that "it would be unethical to not seriously consider one of the most promising [. . .] new approaches to HIV-prevention in the 25-year history of the epidemic".
Views differ on whether limits should be placed on caregivers having a child circumcised.
Some medical associations take the position but the Royal Australasian College of Physicians (RACP) and the BMA observe that controversy exists on this issue. The BMA state that in general, "the parents should determine how best to promote their children's interests, and it is for society to decide what limits should be imposed on parental choices." They state that because the parents' interests and the child's interests sometimes differ, there are "limits on parents' rights to choose and parents are not entitled to demand medical procedures contrary to their child's best interests." They state that competent children may decide for themselves. UNAIDS states that "[m]ale circumcision is a voluntary surgical procedure and health care providers must ensure that men and young boys are given all the necessary information to enable them to make free and informed choices either for or against getting circumcised."
that the parents should determine what is in the best interest of the infant or child,
Some argue that the medical problems that have their risk reduced by circumcision are already rare, can be avoided, and, if they occur, can usually be treated in less invasive ways than circumcision. Somerville states that the removal of healthy genital tissue from a minor should not be subject to parental discretion and that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient. Denniston states that circumcision is harmful and asserts that in the absence of the individual's consent, non-therapeutic child circumcision violates several ethical principles that govern medicine.
Others believe neonatal circumcision is permissible, if parents should so choose. Viens argues that, in a cultural or religious context, circumcision is of significant enough importance that parental consent is sufficient and that there is "an absence of sufficient evidence or persuasive argumentation" to support changing the present policy.
Benatar and Benatar argue that circumcision can be beneficial to a male before he would be able to otherwise provide consent, that "it is far from obvious that circumcision reduces sexual pleasure," and that "it is far from clear that non-circumcision leaves open a future person's options in every regard."
Acknowledgment of pain
Williams (2003) argued that human attitudes toward the pain that animals (including humans) experience may not be based on speciesism, developing an analogy between attitudes toward the pain pigs endure while having their tails docked, and "our culture's indifference to the pain that male human infants experience while being circumcised."
In 2001, Sweden passed a law allowing only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anaesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the law, and in 2001, the World Jewish Congress stated that it was "the first legal restriction on Jewish religious practice in Europe since the Nazi era." In 2005, the Swedish National Board of Health and Welfare reviewed the law and recommended that it be maintained. In 2006, the U.S. State Department's report on Sweden stated that most Jewish mohels had been certified under the law and 3000 Muslim and 40–50 Jewish boys were circumcised eachyear. According to the Swedish National Board of Health and Welfare, the law "did not work" and most circumcisions are still made illegally.
In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised was illegal. However, no punishment was assigned by the court, and in 2008 the Finnish Supreme Court ruled that the mother's actions did not constitute a criminal offense and that circumcision of a child for religious reasons, when performed properly, is not a crime. In 2008, the Finnish government was reported to be considering a new law to legalize ritual circumcision if the practitioner is a doctor, "according to the parents' wishes, and with the child's consent", as reported. In December 2011, Helsinki District Court said that the Supreme Court's decision does not mean that circumcision is legal for any non-medical reasons. The court referred to the Convention on Human rights and Biomedicine of the Council of Europe, which was ratified in Finland in 2010.
As of 2007, all Australian states had stopped the practice of non-therapeutic male circumcision in public hospitals, but did not forbid the procedure from being performed in private hospitals.
In June 2012, a German district court in Cologne made what was widely seen to be a precedent-setting ruling that circumcision of infants and young boys for religious, non-therapeutic reasons amounts to "bodily harm" and is "criminal." Performing such a procedure had been up to that point in a legal gray area. Following widespread criticism largely from Muslim and Jewish groups, most fractions of the German parliament and Chancellor Merkel are calling for legislation to make religious circumcision of boys legal. In September, Reuters reported "Berlin's senate said doctors could legally circumcise infant boys for religious reasons in its region, given certain conditions."
Cultures and religions
Jewish ritual circumcision
Family circumcision set and trunk, ca. eighteenth century Wooden box covered in cow hide with silver implements: silver trays, clip, pointer, silver flask, spice vessel.
Illustrated account of the circumcision ceremony of Sultan Ahmed III
's three sons
In some cultures, males must be circumcised shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is commonly practised in the Jewish and Islamic faiths.
Jewish religious law states that circumcision is a mitzva aseh ("positive commandment" to perform an act) and is obligatory for Jewish-born males and for non-circumcised Jewish male converts. It is only postponed or abrogated in the case of threat to the life or health of the child. It is usually performed by a mohel on the eighth day of life in a ceremony called a brit milah (or Bris milah, colloquially simply bris), which means "Covenant of circumcision" in Hebrew. According to Jewish law, the foreskin should be buried after a brit milah. The rite is considered of such importance that in Orthodox communities, the body of an uncircumcised Jewish male will sometimes be circumcised before burial. Although 19th century Reform leaders described it as "barbaric", the practice of circumcision "remained a central rite" and the Union for Reform Judaism has, since 1984, trained and certified over 300 practicing mohels under its "Berit Mila Program".Humanistic Judaism argues that "circumcision is not required for Jewish identity."
The circumcision consists of three procedures, the first being the cutting of the foreskin. The second is the peeling back of the epithelium after the foreskin has been amputated. This procedure is called priah (Hebrew: פריעה), which means: 'uncovering'. According to Rabbinic interpretation of traditional Jewish sources, the 'priah' has been performed as part of the Jewish circumcision since the Israelites first inhabited the Land of Israel. According to Shaye J. D. Cohen, in Why Aren't Jewish Women Circumcised?: Gender and Covenant in Judaism, pg 25, the Torah only commands circumcision (milah.) David Gollaher has written that the rabbis added the procedure of periah to discourage men from trying to restore their foreskins: ‘Once established, periah was deemed essential to circumcision; if the mohel failed to cut away enough tissue, the operation was deemed insufficient to comply with God's covenant’ and ‘Depending on the strictness of individual rabbis, boys (or men thought to have been inadequately cut) were subjected to additional operations.’ In addition to milah (the actual circumcision) and priah, mentioned above, the Talmud mentions a third step, metzitzah, or squeezing some blood from the wound.
The Igbos of Nigeria also traditionally practice circumcision of infants on the 8th day. This tradition in particular has historically been cited as evidence of a link between the Igbos and the Jews.
In Islam, circumcision is mentioned in some hadith (it is referred as Khitan), but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended (Sunnah); others that it is obligatory. Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham. While endorsing circumcision for males, Islamic scholars note that it is not a requirement for converting to Islam.
The Roman Catholic Church formally condemned the ritual observance of circumcision and ordered against its practice in the Ecumenical Council of Basel-Florence in 1442. The Church presently maintains a neutral stance on circumcision as a medical practice.
Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches. Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership. Some Christian churches celebrate the Circumcision of Jesus. The vast majority of Christians do not practise circumcision as a religious requirement.
Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War. In West Africa infant circumcision may have had tribal significance as a rite of passage or otherwise in the past; today in some non-Muslim Nigerian societies it is medicalised and is simply a cultural norm. Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land, where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.
In the Pacific, circumcision or superincision is nearly universal among the Melanesians of Fiji and Vanuatu, while participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised. Circumcision or superincision is also commonly practiced in the Polynesian islands of Samoa, Tonga, Niue, and Tikopia, where the custom is recorded as a pre-Christian/colonial practice. In Samoa it is accompanied by a celebration.
Among some West African groups, such as the Dogon and Dowayo, circumcision is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males. Among the Urhobo of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te Oshare ("the boy is now man"), constitutes a rite of passage from one age set to another. For Nilotic peoples, such as the Kalenjin and Maasai, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set. In parts of Africa, the foreskin may be dipped in brandy and eaten by the patient, eaten by the circumciser, or fed to animals.
Positions of medical associations
As of 2010
, the Royal Australasian College of Physicians state: "After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. However it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons."
The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Neonatal circumcision revisited" in 1996 and "Circumcision: Information for Parents" in November 2004. The 1996 position statement says that "circumcision of newborns should not be routinely performed", and the 2004 information to parents says: 'Circumcision is a "non-therapeutic" procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social, or cultural reasons. [. . .] After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.'
The Finnish Medical Association opposes
circumcision of infants for non-medical reasons, arguing that circumcision does not bring about any medical benefits and it may risk the health of the infant as well as his right to physical integrity, because he is not able to make the decision himself. The association emphasizes that according to the Finnish constitution, the parents' freedom of religion and conscience does not produce the right to violate other people's (children's) right to physical integrity.
In Germany, in 2008, the German Association for Pediatric Surgery cautioned surgeons against allowing the ordering of the procedure for what could appear to be non-medical reasons.
The World Health Organization and UNAIDS currently
recommend circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV.
In the Netherlands, the Royal Dutch Medical Association (KNMG) stated in 2010 that non-therapeutic male circumcision "conflicts with the child's right to autonomy and physical integrity." They called on doctors to inform caregivers seeking the intervention of the (in their assessment) medical and psychological risks and lack of convincing medical benefits. They stated that there are as good reasons for legal prohibition of male circumcision as exist for female genital mutilation (FGM).
There is a spectrum of views within the BMA’s membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. Moreover, the Association states that “there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.” As a general rule, the BMA believe that “parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.” They also state that “both parents [...] must give consent for non-therapeutic circumcision”, and that parents and children should be provided with up-to-date written information about the risks involved.
The BMA state that parents should be informed about the lack of consensus within the medical profession with regard to the potential health benefits of non-therapeutic circumcision, adding that they consider the evidence for such benefits to be insufficient as the sole reason for carrying out a circumcision.
In a 2012 position statement, the American Academy of Pediatrics (AAP) stated that a systematic evaluation of the medical literature shows that the "preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure" and that the health benefits "are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns," but "are not great enough to recommend routine circumcision for all male newborns". The AAP takes the position that parents should make the final decision about circumcision, after appropriate information is gathered about the risks and benefits of the procedure. The 2012 statement shows a shift in the AAP's position from their 1999 statement in that the AAP says the health benefits of the procedure outweigh the risks, and supports having the procedure covered by insurance.
The AAP's 2012 position statement was also endorsed by the American College of Obstetricians and Gynecologists.
In 2011, the AMA released policy statements that parents should be given the opportunity to make an informed choice regarding circumcision for their infant sons, and opposing attempts to make circumcision illegal.
The American Academy of Family Physicians (2007) recognizes the controversy surrounding circumcision and recommends that physicians "discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son."
The American Urological Association (2007) stated that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks, stating that "while the results of studies in African nations may not necessarily be extrapolated to men in the United States at risk for HIV infection, the American Urological Association recommends that circumcision should be presented as an option for health benefits. Circumcision should not be offered as the only strategy for HIV risk reduction. Other methods of HIV risk reduction, including safe sexual practices, should be emphasized."
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The evidence indicates that neonatal circumcision prevents UTIs in the first year of life with an absolute risk reduction of about 1% and prevents the development of penile cancer with an absolute risk reduction of less than 0.2%. The evidence suggests that circumcision reduces the rate of acquiring an STD, but careful sexual practices and hygiene may be as effective. Circumcision appears to decrease the transmission of HIV in underdeveloped areas where the virus is highly prevalent. No study has systematically evaluated the utility of routine neonatal circumcision for preventing all medically-indicated circumcisions in later life. Evidence regarding the association between cervical cancer and a woman's partner being circumcised or uncircumcised, and evidence regarding the effect of circumcision on sexual functioning is inconclusive. If the decision is made to circumcise, anesthesia should be used.
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- ^ Van Howe, R.S. (January 1999). "Circumcision and HIV infection: review of the literature and meta-analysis". International Journal of STD's and AIDS 10: 8–16. doi:10.1258/0956462991913015. http://www.cirp.org/library/disease/HIV/vanhowe4/. Retrieved 2008-09-23. "Thirty-five articles and a number of abstracts have been published in the medical literature looking at the relationship between male circumcision and HIV infection. Study designs have included geographical analysis, studies of high-risk patients, partner studies and random population surveys. Most of the studies have been conducted in Africa. A meta-analysis was performed on the 29 published articles where data were available. When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis (odds ratio (OR) = 1.06, 95% confidence interval (CI) = 1.01–1.12). Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded."
- ^ O'Farrell N, Egger M (March 2000). "Circumcision in men and the prevention of HIV infection: a 'meta-analysis' revisited". International Journal of STD & AIDS 11 (3): 137–42. doi:10.1258/0956462001915480. PMID 10726934. http://ijsa.rsmjournals.com/cgi/pmidlookup?view=long&pmid=10726934. "The results from this re-analysis thus support the contention that male circumcision may offer protection against HIV infection, particularly in high-risk groups where genital ulcers and other STDs 'drive' the HIV epidemic. A systematic review is required to clarify this issue. Such a review should be based on an extensive search for relevant studies, published and unpublished, and should include a careful assessment of the design and methodological quality of studies. Much emphasis should be given to the exploration of possible sources of heterogeneity. In view of the continued high prevalence and incidence of HIV in many countries in sub-Saharan Africa, the question of whether circumcision could contribute to prevent infections is of great importance, and a sound systematic review of the available evidence should be performed without delay."
- ^ Weiss HA, Quigley MA, Hayes RJ (October 2000). "Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis". AIDS 14 (15): 2361–70. doi:10.1097/00002030-200010200-00018. PMID 11089625. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0269-9370&volume=14&issue=15&spage=2361. "Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised."
- ^ a b Siegfried, N; M Muller, J Volmink, J Deeks, M Egger, N Low, H Weiss, S Walker, P Williamson (July 2003). Siegfried, Nandi. ed. "Male circumcision for prevention of heterosexual acquisition of HIV in men". Cochrane Database of Systematic Reviews (3): CD003362. doi:10.1002/14651858.CD003362. PMID 12917962. http://www.cirp.org/library/disease/HIV/cochrane2003/. Retrieved 2009-07-25. "We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted"
- ^ Mills E, Cooper C, Anema A, Guyatt G (July 2008). "Male circumcision for the prevention of heterosexually acquired HIV infection: a meta-analysis of randomized trials involving 11,050 men". HIV Medicine 9 (6): 332–5. doi:10.1111/j.1468-1293.2008.00596.x. PMID 18705758.
- ^ a b <Please add first missing authors to populate metadata.> (March 28, 2007) (PDF). New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. World Health Organization. http://www.who.int/hiv/mediacentre/MCrecommendations_en.pdf. Retrieved 2007-08-13.
- ^ "Male Circumcision and Risk for HIV Transmission and Other Health Conditions: Implications for the United States". Centers for Disease Control and Prevention. 7 February 2008. http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm. Retrieved 15 July 2011.
- ^ McNeil, Jr., Donald G. (March 3, 2009). "AIDS: New Web Site Seeks to Fight Myths About Circumcision and H.I.V.". New York Times: p. D6. https://www.nytimes.com/2009/03/03/health/03glob.html?_r=2&adxnnl=1&ref=scien. Retrieved February 1, 2012.
- ^ AVAC About male circumcision
- ^ Sansom, L.; Vimalanand S. Prabhu, Angela B. Hutchinson, Qian An, H. Irene Hall, Ram K. Shrestha, Arielle Lasry, and Allan W. Taylor (January 2009). Kissinger, Patricia. ed. "Cost-Effectiveness of Newborn Circumcision in Reducing Lifetime HIV Risk among U.S. Males". PLoS ONE 5 (1): e8723. doi:10.1371/journal.pone.0008723. PMC 2807456. PMID 20090910. //www.ncbi.nlm.nih.gov/pmc/articles/PMC2807456/. "Our results show that newborn circumcision is usually cost saving in the United States because of the low cost of the procedure, current lifetime risk of HIV among U.S. males and the high cost of treating HIV."
- ^ Mcallister RG, Travis JW, Bollinger D, Rutiser C, Sundar V (Fall 2008). "The cost to circumcise Africa". International Journal of Men's Health (Men's Studies Press) 7 (3): 307–316. doi:10.3149/jmh.0703.307. ISBN 1532-6306 (Print) 1933-0278 (Online). http://www.thefreelibrary.com/The+cost+to+circumcise+Africa.-a0189486243.
- ^ Mills, J.; N. Siegfried (October 2006). "Cautious optimism for new HIV/AIDS prevention strategies". Lancet 368 (9543): 1236. doi:10.1016/S0140-6736(06)69513-5. PMID 17027724. ""The inferences drawn from the only completed randomised controlled trial (RCT) of circumcision could be weak because the trial stopped early. In a systematic review of RCTs stopped early for benefit, such RCTs were found to overestimate treatment effects. When trials with events fewer than the median number (n=66) were compared with those with event numbers above the median, the odds ratio for a magnitude of effect greater than the median was 28 (95% CI 11–73). The circumcision trial recorded 69 events, and is therefore at risk of serious effect overestimation. We therefore advocate an impartial meta-analysis of individual patients' data from this and other trials underway before further feasibility studies are done."
- ^ Dowsett, G.W.; M. Couch (May 2007). "Male circumcision and HIV prevention: is there really enough of the right kind of evidence?" (PDF). Reproductive Health Matters 15 (29): 33–44. doi:10.1016/S0968-8080(07)29302-4. PMID 17512372. http://download.journals.elsevierhealth.com/pdfs/journals/0968-8080/PIIS0968808007293024.pdf.
- ^ Darby, R.; R. Van Howe (2011). "Not a surgical vaccine: there is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia". Australian and New Zealand Journal of Public Health 35 (5): 459–465. doi:10.1111/j.1753-6405.2011.00761.x. http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2011.00761.x/full.
- ^ Wawer, Maria et al. (18 July 2009). "Randomized Trial of Male Circumcision in HIV-infected Men: Effects on HIV Transmission to Female Partners, Rakai, Uganda". Lancet 374 (9685): 229–237. doi:10.1016/S0140-6736(09)60998-3. PMC 2905212. PMID 19616720. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60998-3/fulltext.
- ^ a b Millett GA, Flores SA, Marks G et al. (October 2008). "Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis". JAMA 300 (14): 1674–1684. doi:10.1001/jama.300.14.1674. PMID 18840841. http://jama.ama-assn.org/cgi/content/short/300/14/1674.
- ^ Van Howe, Robert S. (May 2007). "Human papillomavirus and circumcision: A meta-analysis". Journal of Infection 54 (5): 490–496. doi:10.1016/j.jinf.2006.08.005. PMID 16997378. http://www.cirp.org/library/disease/cancer/vanhowe2006b/. Retrieved 2008-09-18.
- ^ Castellsagué X, Albero G, Clèries R, Bosch FX (July 2007). "HPV and circumcision: a biased, inaccurate and misleading meta-analysis". J. Infect. 55 (1): 91–3; author reply 93–6. doi:10.1016/j.jinf.2007.02.009. PMID 17433445.
- ^ a b Bosch FX, Albero G, Castellsagué X (January 2009). [jfprhc.bmj.com/content/35/1/5.full.pdf "Male circumcision, human papillomavirus and cervical cancer: from evidence to intervention"]. J Fam Plann Reprod Health Care 35 (1): 5–7. doi:10.1783/147118909787072270. PMID 19126309. jfprhc.bmj.com/content/35/1/5.full.pdf.
- ^ a b Larke N, Thomas SL, Dos Santos Silva I, Weiss HA (November 2011). "Male circumcision and human papillomavirus infection in men: a systematic review and meta-analysis". J. Infect. Dis. 204 (9): 1375–90. doi:10.1093/infdis/jir523. PMID 21965090.
- ^ a b Albero G, Castellsagué X, Giuliano AR, Bosch FX (February 2012). "Male Circumcision and Genital Human Papillomavirus: A Systematic Review and Meta-Analysis". Sex Transm Dis 39 (2): 104–113. doi:10.1097/OLQ.0b013e3182387abd. PMID 22249298.
- ^ Weiss HA, Thomas SL, Munabi SK, Hayes RJ (April 2006). "Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta‐analysis". Sexually Transmitted Infections 82 (2): 101–9; discussion 110. doi:10.1136/sti.2005.017442. PMC 2653870. PMID 16581731. //www.ncbi.nlm.nih.gov/pmc/articles/PMC2653870/.
- ^ Leber, Mark J.; Anuritha Tirumani (June 8, 2006). "Balanitis". EMedicine. http://www.emedicine.com/derm/topic615.htm. Retrieved 2008-10-14.
- ^ Osipov, Vladimir O.; Scott M. Acker (November 14, 2006). "Balanoposthitis". Reactive and Inflammatory Dermatoses. EMedicine. http://www.emedicine.com/derm/topic615.htm. Retrieved 2006-11-20.
- ^ Edwards S (June 1996). "Balanitis and balanoposthitis: a review". Genitourin Med 72 (3): 155–9. PMC 1195642. PMID 8707315. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1195642/.
- ^ a b Aridogan IA, Izol V, Ilkit M (August 2011). "Superficial fungal infections of the male genitalia: a review". Crit. Rev. Microbiol. 37 (3): 237–44. doi:10.3109/1040841X.2011.572862. PMID 21668404.
- ^ a b Hayashi Y, Kojima Y, Mizuno K, Kohri K (2011). "Prepuce: phimosis, paraphimosis, and circumcision". ScientificWorldJournal 11: 289–301. doi:10.1100/tsw.2011.31. PMID 21298220.
- ^ Becker K (January 2011). "Lichen sclerosus in boys". Dtsch Arztebl Int 108 (4): 53–8. doi:10.3238/arztebl.2011.053. PMC 3036008. PMID 21307992. //www.ncbi.nlm.nih.gov/pmc/articles/PMC3036008/.
- ^ a b c "Report 10 of the Council on Scientific Affairs (I-99):Neonatal Circumcision". 1999 AMA Interim Meeting: Summaries and Recommendations of Council on Scientific Affairs Reports. American Medical Association. December 1999. pp. 17. Archived from the original on June 3, 2010. http://web.archive.org/web/20110513234553/http://www.ama-assn.org/ama/no-index/about-ama/13585.page. Retrieved January 31, 2012.
- ^ Esposito, Ciro; Antonella Centonze, Francesca Alicchio, Antonio Savanelli and Alessandro Settimi (2008). "Topical steroid application versus circumcision in pediatric patients with phimosis: a prospective randomized placebo controlled clinical trial". World Journal of Urology 26 (2): 187-190. doi:10.1007/s00345-007-0231-2. http://www.springerlink.com/content/14844u402164w261. Retrieved 2012 Sept 6.
- ^ Micali G, Nasca MR, Innocenzi D, Schwartz RA (March 2006). "Penile cancer". J. Am. Acad. Dermatol. 54 (3): 369–91; quiz 391–4. doi:10.1016/j.jaad.2005.05.007. PMID 16488287.
- ^ "Can Penile Cancer be Prevented?". http://www.cancer.org/Cancer/PenileCancer/DetailedGuide/penile-cancer-prevention.
- ^ a b Larke NL, Thomas SL, Dos Santos Silva I, Weiss HA (August 2011). "Male circumcision and penile cancer: a systematic review and meta-analysis". Cancer Causes Control 22 (8): 1097–110. doi:10.1007/s10552-011-9785-9. PMC 3139859. PMID 21695385. //www.ncbi.nlm.nih.gov/pmc/articles/PMC3139859/.
- ^ Morris BJ, et al. (2012). "Infant male circumcision: An evidence-based policy statement". Open Journal of Preventive Medicine 2 (1): 79–92. http://www.scirp.org/journal/PaperInformation.aspx?paperID=17415.
- ^ Rivet C (September 2003). "Circumcision and cervical cancer. Is there a link?". Can Fam Physician 49: 1096–7. PMC 2214289. PMID 14526861. //www.ncbi.nlm.nih.gov/pmc/articles/PMC2214289/.
- ^ Robert S Van Howe (January 2009). "Is neonatal circumcision clinically beneficial? Argument against". Nature Clinical Practice Urology 6 (2): 74–75. doi:10.1038/ncpuro1292.
- ^ Klavs I, Hamers FF (February 2008). "Male circumcision in Slovenia: results from a national probability sample survey". Sexually Transmitted Infections 84 (1): 49–50. doi:10.1136/sti.2007.027524. PMID 17881413.
- ^ a b Drain PK, Halperin DT, Hughes JP, Klausner JD, Bailey RC (2006). "Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries". BMC Infectious Diseases 6: 172. doi:10.1186/1471-2334-6-172. PMC 1764746. PMID 17137513. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1764746/.
- ^ a b c Castellsagué X, Bosch FX, Muñoz N et al. (April 2002). "Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners". The New England Journal of Medicine 346 (15): 1105–12. doi:10.1056/NEJMoa011688. PMID 11948269.
- ^ Frisch M, Friis S, Kjaer SK, Melbye M (December 1995). "Falling incidence of penis cancer in an uncircumcised population (Denmark 1943–90)". BMJ 311 (7018): 1471. doi:10.1136/bmj.311.7018.1471. PMC 2543732. PMID 8520335. http://bmj.com/cgi/pmidlookup?view=long&pmid=8520335.
- ^ Denniston, G (April 1996). "Circumcision and the Code of Ethics". Humane Health Care International 12 (2): 78–80. PMID 14986604.
- ^ Ko MC, Liu CK, Lee WK, Jeng HS, Chiang HS, Li CY (April 2007). "Age-specific prevalence rates of phimosis and circumcision in Taiwanese boys". Journal of the Formosan Medical Association = Taiwan Yi Zhi 106 (4): 302–7. doi:10.1016/S0929-6646(09)60256-4. PMID 17475607. "…the prevalence of circumcision slightly increased with age from 7.2% (95% CI, 5.3–10.8%) for boys aged 7 years to 8.7% (95% CI, 6.5–13.3%) for boys aged 13 years."
- ^ a b Richters, J et al. (2006). "Circumcision in Australia: prevalence and effects on sexual health". Int J STD AIDS 17 (8): 547–554. doi:10.1258/095646206778145730. PMID 16925903. http://www.cirp.org/library/general/richters1/. "Neonatal circumcision was routine in Australia until the 1970s … In the last generation, Australia has changed from a country where most newborn boys are circumcised to one where circumcision is the minority experience."
- ^ a b Ronald Immerman and Wade Mackey (1997). "A Biocultural Analysis of Circumcision". Social Biology 44 (3–4): 265–275. doi:10.1111/j.1467-9744.1976.tb00285.x. PMID 9446966. http://www.cirp.org/library/psych/immerman2/.
- ^ a b Robert Darby (2003). "Medical history and medical practice: persistent myths about the foreskin". Medical Journal of Australia 178 (4): 178–9. PMID 12580747. http://www.mja.com.au/public/issues/178_04_170203/dar10676_fm.html.
- ^ Wilson, Christopher G. (2008). "Male genital mutilation: an adaptation to sexual conflict". Evolution and Human Behavior 29 (3): 149–164. doi:10.1016/j.evolhumbehav.2007.11.008. http://www.anth.uconn.edu/degree_programs/ecolevo/mgmarticle.pdf=.
- ^ Tomb artwork from the Sixth Dynasty (2345–2181 BCE) shows men with circumcised penises, and one relief from this period shows the rite being performed on a standing adult male. The Egyptian hieroglyph for "penis" depicts either a circumcised or an erect organ. The examination of Egyptian mummies has found some with foreskins and others who were circumcised.
- ^ Herodotus, The Histories, 2.36, on Perseus
- ^ The book of Genesis records circumcision as God's covenant/command to Abraham. It was to be performed by the male child's eighth day after birth. Herodotus, writing in the fifth century BCE, lists the Colchians, Ethiopians, Phoenicians, and Syrians as a circumcising cultures.
- ^ The writer of the 1 Maccabees wrote that under the Seleucids, many Jewish men attempted to hide or reverse their circumcision so they could exercise in Greek gymnasia, where nudity was the norm. First Maccabees also relates that the Seleucids forbade the practice of brit milah (Jewish circumcision), and punished those who performed it–as well as the infants who underwent it–with death.
- ^ Marck, J (1997). "Aspects of male circumcision in sub-equatorial African culture history". Health Transit Review 7 (supplement): 337–360. PMID 10173099.
- ^ a b c d Gollaher, David (Fall 1994). "From ritual to science: the medical transformation of circumcision in America". Journal of Social History 28 (1): 5–36. doi:10.1353/jsh/28.1.5. http://www.cirp.org/library/history/gollaher/. Retrieved 2007-12-06.
- ^ Aggleton, P. (2007). "Roundtable: "Just a Snip"?: A Social History of Male Circumcision" (PDF). Reproductive Health Matters 15 (29): 15–21. doi:10.1016/S0968-8080(07)29303-6. PMID 17512370. http://www.hsph.harvard.edu/pihhr/files/RHM/RHM29-Aggleton.pdf. Retrieved 2008-12-17.
- ^ <Please add first missing authors to populate metadata.> (1855). "On the influence of circumcision in preventing syphilis". Medical Times and Gazette NS Vol II: 542–3.
- ^ a b Laumann, E.; C. Masi and F. Zuckerman (1997). "Circumcision in the United States. Prevalence, prophylactic effects, and sexual practice". JAMA 277 (13): 1052–1057. doi:10.1001/jama.277.13.1052. PMID 9091693. http://www.circs.org/library/laumann/index.html.
- ^ Xu F, Markowitz LE, Sternberg MR, Aral SO (July 2007). "Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999–2004". Sex Transm Dis 34 (7): 479–84. doi:10.1097/01.olq.0000253335.41841.04. PMID 17413536.
- ^ "Trends in circumcisions among newborns". National Hospital Discharge Survey. National Center for Health Statistics. January 11, 2007. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/circumcisions/circumcisions.htm. Retrieved 2008-08-19.
- ^ Brown, M.S.; C.A. Brown (August 1987). "Circumcision decision: prominence of social concerns". Pediatrics 80 (2): 215–219. PMID 3615091.
- ^ Nelson, C.P.; R. Dunn, J. Wan, J.T. Wei (March 2005). "The increasing incidence of newborn circumcision: data from the nationwide inpatient sample". Journal of Urology 173 (3): 978–981. doi:10.1097/01.ju.0000145758.80937.7d. PMID 15711354.
- ^ "U.S. circumcision rates vary by region" (PDF). Agency for Healthcare Research and Quality. January, 2008. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb45.pdf. Retrieved 2008-08-19.
- ^ Centers for Disease Control Morbidity and Mortality Weekly: Trends in In-Hospital Newborn Circumcision url=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6034a4.htm?s_cid=mm6034a4_w Accessed 19 Feb 2012
- ^ Dave SS, Fenton KA, Mercer CH, Erens B, Wellings K, Johnson AM (December 2003). "Male circumcision in Britain: findings from a national probability sample survey". Sexually Transmitted Infections 79 (6): 499–500. doi:10.1136/sti.79.6.499. PMC 1744763. PMID 14663134. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1744763/.
- ^ "In Australia and New Zealand, the circumcision rate has fallen considerably in recent years and it is estimated that currently only 10%–20% of male infants are routinely circumcised." (RACP: 2004)
- ^ Walton RE, Ostbye T, Campbell MK (1997). "Neonatal male circumcision after delisting in Ontario. Survey of new parents". Can Fam Physician 43: 1241–7. PMC 2255121. PMID 9241462. //www.ncbi.nlm.nih.gov/pmc/articles/PMC2255121/.
- ^ Van Howe, R. S.; Svoboda, J. S.; Dwyer, J. G.; Price, C. P. (January 1999). "Involuntary circumcision: the legal issues" (PDF). BJU International 83 (Supp1): 63–73. doi:10.1046/j.1464-410x.1999.0830s1063.x. PMID 10349416. http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410x.1999.0830s1063.x/pdf.
- ^ Tanne, Janice Hopkins (August 2005). "US group lobbies UN to outlaw male circumcision". British Medical Journal 331 (7514): 422. doi:10.1136/bmj.331.7514.422-b. PMC 1188135. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1188135/.
- ^ Rennie S, Muula AS, Westreich D (June 2007). "Male circumcision and HIV prevention: ethical, medical and public health tradeoffs in low‐income countries". Journal of Medical Ethics 33 (6): 357–61. doi:10.1136/jme.2006.019901. PMC 2598273. PMID 17526688. //www.ncbi.nlm.nih.gov/pmc/articles/PMC2598273/.
- ^ a b Paediatrics & Child Health Division, The Royal Australasian College of Physicians (September 2010) (PDF). Circumcision of Infant Males. http://www.racp.edu.au/index.cfm?objectid=65118B16-F145-8B74-236C86100E4E3E8E. Retrieved January 31, 2012.
- ^ "Information Package on Male Circumcision and HIV Prevention" (PDF). http://data.unaids.org/pub/InformationNote/2007/mc_briefing_pack1_en.pdf.
- ^ "Circumcision and the Code of Ethics, George C. Denniston, Humane Health Care Volume 12, Number 2". http://www.humanehealthcare.com/Article.asp?art_id=620.
- ^ Benatar, David; Benatar, Michael (2003). "How not to argue about circumcision" (PDF). American Journal of Bioethics 3 (2): W1–W9. doi:10.1162/152651603102387820. PMID 14635630. http://bioethics.net/journal/pdf/3_2_LT_w01_Benetar.pdf.
- ^ Williams, R. M. (2003-01). "On the Tail-Docking of Pigs, Human Circumcision, and their Implications for Prevailing Opinion Regarding Pain". Journal of Applied Philosophy 20 (1): 89–93. doi:10.1111/1468-5930.00237. http://www.blackwell-synergy.com/doi/abs/10.1111/1468-5930.00237. Retrieved 2008-06-24.
- ^ "Sweden restricts circumcisions". BBC Europe. October 1, 2001. http://news.bbc.co.uk/2/hi/europe/1572483.stm. Retrieved 2006-10-18. "Swedish Jews and Muslims object to the new law, saying it violates their religious rights."
- ^ Bureau of Democracy, Human Rights, and Labor (September 15, 2006). "Sweden". International Religious Freedom Report 2006. U.S. Department of State. http://www.state.gov/g/drl/rls/irf/2006/71410.htm. Retrieved 2007-07-04.
- ^ Omskärelse av pojkar. Rapport av ett regeringsuppdrag (S2005/7490/SK), Socialstyrelsen (Ruotsin sosiaalihallitus), 2007
- ^ "Court rules circumcision of four-year-old boy illegal". HELSINGIN SANOMAT, INTERNATIONAL EDITION. 2006-08-07. http://www.hs.fi/english/article/Court+rules+circumcision+of+four-year-old+boy+illegal/1135220958830. Retrieved 2007-09-17.
- ^ "Supreme Court: Properly performed religious based male circumcision no crime". Helsingin Sanomat. October 17, 2008. http://www.hs.fi/english/article/Supreme+Court+Properly+performed+religious+based+male+circumcision+no+crime/1135240316614. Retrieved 2008-10-17.
- ^ "Finland Considers Legalising Male Circumcision". Ylesiradio. 2008-07-31. http://www.yle.fi/news/left/id97605.html. Retrieved 2008-08-05.
- ^ a b Circumcision assault case brings fine – conviction but no punishment for parents, Helsingin Sanomat, HS.fi 2.1.2012
- ^ Pengelley, J (12 Nov 2007). "SA to ban most circumcisions in state hospitals". The Advertiser. http://www.news.com.au/national/sa-to-ban-most-circumcisions-in-state-hospitals/story-e6frfkvr-1111114853797. Retrieved 7 Apr 2012.
- ^ "Circumcision debate on Mornings". ABC Tasmania. August 15, 2007. http://www.abc.net.au/tasmania/stories/s2004776.htm. Retrieved January 31, 2012. "Victoria is following the lead of New South Wales, Western Australia and Tasmania, where non-medical circumcisions are not performed in public hospitals unless there is a medical reason to do so. However, male circumcision is not totally banned, as parents can elect to pay for the procedure in a private hospital."
- ^ Weinthal, Benjamin (July 19, 2012). "German court declares circumcisions a crime". Jerusalem Post. http://www.jpost.com/JewishWorld/JewishFeatures/Article.aspx?id=275326. Retrieved July 19, 2012.
- ^ "German MPs set to protect religious circumcision". BBC News Europe. July 19, 2012. http://www.bbc.co.uk/news/world-europe-18909640. Retrieved July 19, 2012.
- ^ Chambers, Madeline (July 19, 2012). "German MPs vow to protect circumcision after court ban". Reuters. http://www.reuters.com/article/2012/07/19/us-germany-circumcision-idUSBRE86I0L620120719. Retrieved July 19, 2012.
- ^ "Circumcision go-ahead". Sydney Morning Herald. July 19, 2012. http://www.smh.com.au/world/circumcision-goahead-20120719-22d5s.html. Retrieved July 19, 2012.
- ^ "Berlin reverses ban on religious circumcisions". MSNBC. Reuters. 9/5/2012. http://www.msnbc.msn.com/id/48914968/ns/world_news-europe/#.UEjj5FLfu5k. Retrieved September 06, 2012.
- ^ Shulchan Aruch, Yoreh Deah, 265:10
- ^ Lamm, Maurice (2000) . "6: Special Situations". The Jewish way in death and mourning. Middle Village, New York: Jonathan David Publishers, Inc. pp. 215–216. ISBN 0-8246-0423-7. LCCN 99-088942. "The custom is to circumcise male infants who have not undergone circumcision until then, usually during taharah."
- ^ adapted from Shamash (2007). "The Origins of Reform Judaism". Jewish Virtual Library. http://www.jewishvirtuallibrary.org/jsource/Judaism/The_Origins_of_Reform_Judaism.html. Retrieved 2007-11-03.
- ^ Berit Mila Program of Reform Judaism, Union for Reform Judaism website. Retrieved January 23, 2010.
- ^ Hilary Leila Kreiger (21 November 2002). "A cut above the rest". Jerusalem Post. http://jewishcircumcision.org/israel_news.htm.
- ^ http://books.google.co.uk/books?id=SF6fbjNe0yYC&printsec=frontcover&dq=when+did+metzitzah+start&source=bl&ots=J__eoABvZe&sig=YU0AuNHJ0nJHR1e1dniX1a7gTiE&hl=en&sa=X&ei=dKRDUIaYGeO80QXNhYGgAQ&redir_esc=y#v=onepage&q=milah&f=false
- ^ Talmud Bavli Tractate Yebamoth 71b: Rabbah b. Isaac stated in the name of Rab: The commandment of uncovering the corona at circumcision was not given to Abraham; for it is said, At that time the Lord said unto Joshua: 'Make thee knives of flint etc.' But is it not possible [that this applied to] those who were not previously circumcised; for it is written, For all the people that came out were circumcised, but all the people that were born etc.? — If so, why the expression. 'Again!' Consequently it must apply to the uncovering of the corona.
- ^ http://books.google.co.uk/books?id=PmL-LogqJ-YC&pg=PA283&lpg=PA283&dq=kohler+kaufmann+circumcision&source=bl&ots=ftmD5PeNFV&sig=H0OZSU4pIFeuUBd4AcXxbM4eA2E&hl=en#v=snippet&q=milah&f=false
- ^ Circumcision | title=A History Of The World’s Most Controversial Surgery | author= David Gollaher | publisher =Basic Books 2000 | pg =pg 17
- ^ Uzoma Onyemaechi. "Igbo Culture and Socialization". http://www.kwenu.com/igbo/igbowebpages/Igbo.dir/Culture/culture_and_socialization.html.
- ^ Al-Munajjid, Muhammed Salih. "Question #9412: Circumcision: how it is done and the rulings on it". Islam Q&A. http://www.islam-qa.com/index.php?ln=eng&ds=qa&lv=browse&QR=9412&dgn=4. Retrieved 2006-07-01.
- ^ Al-Munajjid, Muhammed Salih. "Question #7073: The health and religious benefits of circumcision". Islam Q&A. http://www.islam-qa.com/index.php?ln=eng&ds=qa&lv=browse&QR=7073&dgn=3. Retrieved 2006-07-01.
- ^ al-Sabbagh, Muhammad Lutfi (1996). Islamic ruling on male and female circumcision. Alexandria: World Health Organization. p. 16.
- ^ "Session 11—4 February 1442 (Bull of union with the Copts)". Eccumenical Council of Florence (1438–1445). Eternal Word Television Network. http://www.ewtn.com/library/councils/Florence.htm#5. Retrieved 2009-05-11. "Therefore it strictly orders all who glory in the name of Christian, not to practise circumcision either before or after baptism, since whether or not they place their hope in it, it cannot possibly be observed without loss of eternal salvation."
- ^ Slosar, J.P.; D. O'Brien (2003). "The Ethics of Neonatal Male Circumcision: A Catholic Perspective". American Journal of Bioethics 3 (2): 62–64. doi:10.1162/152651603766436306. PMID 12859824.
- ^ a b "The decision that Christians need not practice circumcision is recorded in Acts 15; there was never, however, a prohibition of circumcision, and it is practiced by Coptic Christians." "circumcision", The Columbia Encyclopedia, Sixth edition, 2001–5.
- ^ Mattson CL, Bailey RC, Muga R, Poulussen R, Onyango T (February 2005). "Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya". AIDS Care 17 (2): 182–94. doi:10.1080/09540120512331325671. PMID 15763713.
- ^ "Greek Orthodox Archdiocese calendar of Holy Days". http://www.goarch.org/en/chapel/calendar.asp?Y=2007&M=1.
- ^ "Russian Orthodox Church, Patriarchate of Moscow". http://www.holytrinityorthodox.com/calendar/los/January/01-01.htm.
- ^ Ajuwon et al., "Indigenous surgical practices in rural southwestern Nigeria: Implications for disease," Health Educ. Res..1995; 10: 379–384 Health Educ. Res..1995; 10: 379–384 Retrieved 3 October 2006
- ^ Aaron David Samuel Corn (2001) (PDF). Ngukurr Crying: Male Youth in a Remote Indigenous Community. Working Paper Series No. 2. University of Wollongong. Archived from the original on 2006-08-28. http://web.archive.org/web/20060828084840/http://www.uow.edu.au/arts/sealcp/wkgpapers/wp2.pdf. Retrieved 2006-10-18.
- ^ "Migration and Trade". Green Turtle Dreaming. http://www.mfgsc.vic.edu.au/greenturtledreaming/EKmigrate.htm. Retrieved 2006-10-18. "In exchange for turtles and trepang the Makassans introduced tobacco, the practice of circumcision and knowledge to build sea-going canoes."
- ^ "RECENT GUEST SPEAKER". Australian AIDS Fund Incorporated. 2006. http://www.aids.net.au/aids-png-project-20060403.htm. Retrieved 2006-07-01.
- ^ "Weird & Wonderful". United Travel. http://www.getaway.co.nz/destination.asp?id=34. Retrieved 2006-07-01.
- ^ "Circumcision amongst the Dogon". The Non-European Components of European Patrimony (NECEP) Database. 2006. http://www.necep.net/articles.php?id_soc=12&id_article=84. Retrieved 2006-09-03.
- ^ Agberia, J. T. (2006). "Aesthetics and Rituals of the Opha Ceremony among the Urhobo People". Journal of Asian and African Studies 41 (3): 249. doi:10.1177/0021909606063880.
- ^ "Masai of Kenya". http://www.masaikenya.org/. Retrieved 2007-04-06. "Authority derives from the age-group and the age-set. Prior to circumcision a natural leader or olaiguenani is selected; he leads his age-group through a series of rituals until old age, sharing responsibility with a select few, of whom the ritual expert (oloiboni) is the ultimate authority. Masai youths are not circumcised until they are mature, and a new age-set is initiated together at regular intervals of twelve to fifteen years. The young warriors (ilmurran) remain initiates for some time, using blunt arrows to hunt small birds which are stuffed and tied to a frame to form a head-dress."
- ^ <Please add first missing authors to populate metadata.> (December 1949). "A Ritual Operation". British Medical Journal 2 (4642): 1458–1459. doi:10.1136/bmj.2.4642.1458. PMC 2051965. PMID 20787713. //www.ncbi.nlm.nih.gov/pmc/articles/PMC2051965/. "". . . in parts of West Africa, where the operation is performed at about 8 years of age, the prepuce is dipped in brandy and eaten by the patient; in other districts the operator is enjoined to consume the fruits of his handiwork, and yet a further practice, in Madagascar, is to wrap the operation specifically in a banana leaf and feed it to a calf.""
- ^ Fetus and Newborn Committee (March 1996). "Neonatal circumcision revisited". Canadian Medical Association Journal 154 (6): 769–780. PMC 1487803. PMID 8634956. http://www.cps.ca/english/statements/FN/fn96-01.htm. Retrieved 2006-07-02. "We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors."
- ^ "Circumcision: Information for parents". Caring for kids. Canadian Paediatric Society. November 2004. http://www.caringforkids.cps.ca/handouts/circumcision. Retrieved 2012-01-21. "Circumcision is a "non-therapeutic" procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social, or cultural reasons. To help make the decision about circumcision, parents should have information about risks and benefits. It is helpful to speak with your baby's doctor. After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions."
- ^ LAKIEHDOTUS POIKIEN YMPÄRILEIKKAUKSESTA VASTOIN LÄÄKÄRIN ETIIKKAA, Finnish Medical Association, 7.6.2004
- ^ Grauzone Vorhaut (31. october 2008)
- ^ Rabin, Roni (August 27, 2012). "Benefits of Circumcision Are Said to Outweigh Risks". NY Times. http://www.nytimes.com/2012/08/27/science/benefits-of-circumcision-outweigh-risks-pediatric-group-says.html. Retrieved August 31, 2012.
- ^ Brown, Eryn (August 26, 2012). "Pediatricians' group shifts in favor of circumcision". LA Times. http://www.nytimes.com/2012/08/27/science/benefits-of-circumcision-outweigh-risks-pediatric-group-says.html. Retrieved August 31, 2012.
- ^ AP (August 27, 2012). "Circumcision benefits outweigh risks and insurers should pay; pediatricians revise stance". Washington Post. http://www.washingtonpost.com/national/health-science/circumcision-benefits-outweigh-risks-and-insurers-should-pay-pediatricians-revise-stance/2012/08/26/49663aae-efb7-11e1-b74c-84ed55e0300b_story.html. Retrieved August 31, 2012.
- ^ Moyer, Christine (2011 Oct. 18). "Male circumcision ban defeated; health benefits lauded". American Medical News. American Medical Association. http://www.ama-assn.org/amednews/2011/10/17/prsd1018.htm. Retrieved August 29, 2012.
- ^ "AMA Adopts New Policies During Final Day of Semi-Annual Meeting". American Medical Association. 2011 Nov. 15. http://www.ama-assn.org/ama/pub/news/news/2011-11-15-ama-adopts-new-policies.page.. Retrieved August 29, 2012.
- Billy Ray Boyd. Circumcision Exposed: Rethinking a Medical and Cultural Tradition. Freedom, CA: The Crossing Press, 1998. (ISBN 978-0-89594-939-4)
- Anne Briggs. Circumcision: What Every Parent Should Know. Charlottesville, VA: Birth & Parenting Publications, 1985. (ISBN 978-0-9615484-0-7)
- Robert Darby. A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain. Chicago: University of Chicago Press, 2005. (ISBN 978-0-226-13645-5)
- Aaron J. Fink, M.D. Circumcision: A Parent's Decision for Life. Kavanah Publishing Company, Inc., 1988. (ISBN 978-0-9621347-0-8)
- Paul M. Fleiss, M.D. and Frederick Hodges, D. Phil. What Your Doctor May Not Tell You About Circumcision. New York: Warner Books, 2002. (ISBN 978-0-446-67880-3)
- Leonard B. Glick. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. New York: Oxford University Press, 2005. (ISBN 978-0-19-517674-2)
- Ronald Goldman, Ph.D. Circumcision: The Hidden Trauma. Boston: Vanguard, 1996. (ISBN 978-0-9644895-3-0)
- Paysach J. Krohn, Rabbi. Bris Milah. Circumcision—The Covenant Of Abraham/A Compendium of Laws, Rituals, And Customs From Birth To Bris, Anthologized From Talmudic, And Traditional Sources. New York: Mesorah Publications, 1985, 2005.
- Brian J. Morris, Ph.D., D.Sc. In Favour of Circumcision. Sydney: UNSW Press, 1999. (ISBN 978-0-86840-537-7)
- Peter Charles Remondino. History of Circumcision from the Earliest Times to the Present. Philadelphia and London; F. A. Davis; 1891.
- Holm Putzke, Ph.D. Die strafrechtliche Relevanz der Beschneidung von Knaben. Zugleich ein Beitrag über die Grenzen der Einwilligung in Fällen der Personensorge, in: H. Putzke u.a. (Hrsg.), Strafrecht zwischen System und Telos, Festschrift für Rolf Dietrich Herzberg zum siebzigsten Geburtstag am 14. Februar 2008, Mohr Siebeck: Tübingen 2008, p. 669–709 (ISBN 978-3161495700)
- Holm Putzke, Ph.D., Maximilian Stehr, Ph.D., and Hans-Georg Dietz, Ph.D. Liability to penalty for circumcision in boys. Medico-legal aspects of a controversial medical intervention, in: Monatsschrift Kinderheilkunde 8/2008, p. 783–788
- Rosemary Romberg. Circumcision: The Painful Dilemma. South Hadley, MA Bergan & Garvey, 1985. (ISBN 978-0-89789-073-1)
- Edgar J Schoen, M.D. Ed Schoen, MD on Circumcision. Berkeley, CA: RDR Books, 2005. (ISBN 978-1-57143-123-3)
- Edward Wallerstein. Circumcision: An American Health Fallacy. New York: Springer, 1980 (ISBN 978-0-8261-3240-6)
- Gerald N. Weiss M.D. and Andrea W Harter. Circumcision: Frankly Speaking. Wiser Publications, 1998. (ISBN 978-0-9667219-0-4)
- Yosef David Weisberg, Rabbi. Otzar Habris. Encyclopedia of the laws and customs of Bris Milah and Pidyon Haben. Jerusalem: Hamoer, 2002.
- George C. Denniston; Frederick M. Hodges; Marilyn Fayre Milos (2009). Circumcision and Human Rights. Springer. ISBN 978-1-4020-9166-7.
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