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Circumcision

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  • This presentation may be freely distributed so long as it remains unmodified. Find the most recent version at www.notjustskin.org For more information contact info@notjustskin.org
  • While the U.S. is the only country in the world where infant genital cutting of any kind is routinely practiced, male genital cutting remains 7.5 times as frequent world-wide as female genital cutting. In general, where female genital mutilation is prevalent, male circumcision is also, though the reverse is not the case. Intact Male Populations: Virtually all: Chinese, Japanese, North Koreans, Vietnamese, Laotians, Cambodians, Burmese, Thais, Hindu, Sikh, Parsee and Christian Indians, Scandinavians, Zulus, Shona, certain other African nations, most Melanesian and some Western Polynesian (Rennell, Bellona) peoples, most Europeans, men of the former Soviet Union, Central and South Americans, New Zealand Maori, younger men of Britain and the Commonwealth. Genitally Cut Male Populations: About 500,000,000 Muslims, more than 100,000,000 U.S. Americans, about 25,000,000 Filipinos, some tens of millions of older men of Britain and the Commonwealth, some tens of millions of African tribesmen, about 14,000,000 South Koreans, 7,000,000 Jews, some hundreds of thousands of Central and Eastern Polynesians (Samoa, Tahiti, Tonga, Niue, Tokelau) and Melanesians (from Fiji, Vanuatu, parts of Solomon Islands and small parts of PNG), and some scores of thousands of aboriginal Australians. Female Genital Cutting is practiced predominantly in 28 countries in Africa. 1,3 Eighteen African countries have prevalence rates of 50% or higher, but these estimates vary from country to country and within various ethnic groups. 1,3 FGC also occurs in some Middle Eastern countries-Egypt, the Republic of Yemen, Oman, Saudi Arabia and Israel-and is found in some Muslim groups in Indonesia, Malaysia, Pakistan and India. 4 Some immigrants practice various forms of FGC in other parts of the world, including Australia, Canada, New Zealand, the United States and in European nations. 1,4 Toubia, N. (1999). Caring for Women with Circumcision. RAINBO: NY, NY. WHO. (Downloaded 8/9/01). Female Genital Information: Information Pack http://www.who.int/frh-whd/FGM/infopack/English/fgm_infopack.htm Rahman, A. & Toubia, N. (2000). Female Genital Mutilation: A Guide to Laws and Policies Worldwide. Zed Books Ltd: London, UK. Department of State. (March, 2001). Report on Female Genital Mutilation as Required by Conference Report (H. Rept. 106-997) to Public Law 106-429.
  • Many case studies of Female circumcision have been recorded by Hanny-Lightfoot Klein, who wrote Prisoners of Ritual: An Odyssey into Female Genital Circumcision in Africa after several years spent studying the practice and the people in Africa, with particular emphasis on the Sudan. Some of her publications are available at http://www.fgmnetwork.org/Lightfoot-klein/. The World Health Organization statement comes from its Fact Sheet No 241 June 2000 FEMALE GENITAL MUTILATION http://www.who.int/inf-fs/en/fact241.html What is Female Genital Mutilation?  Female genital mutilation (FGM), often referred to as ‘female circumcision’, comprises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons. There are different types of female genital mutilation known to be practiced today. They include: Type I - excision of the prepuce, with or without excision of part or all of the clitoris; Type II - excision of the clitoris with partial or total excision of the labia minora; Type III - excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation); Type IV - pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and any other procedure that falls under the definition given above. The most common type of female genital mutilation is excision of the clitoris and the labia minora, accounting for up to 80% of all cases; the most extreme form is infibulation, which constitutes about 15% of all procedures.   Health Consequences of FGM   The immediate and long-term health consequences of female genital mutilation vary according to the type and severity of the procedure performed.   Immediate complications include severe pain, shock, hemorrhage, urine retention, ulceration of the genital region and injury to adjacent tissue. Hemorrhage and infection can cause death.   More recently, concern has arisen about possible transmission of the human immunodeficiency virus (HIV) due to the use of one instrument in multiple operations, but this has not been the subject of detailed research.   Long-term consequences include cysts and abscesses, keloid scar formation, damage to the urethra resulting in urinary incontinence, dyspareunia (painful sexual intercourse) and sexual dysfunction and difficulties with childbirth.   Psychosexual and psychological health: Genital mutilation may leave a lasting mark on the life and mind of the woman who has undergone it. In the longer term, women may suffer feelings of incompleteness, anxiety and depression.   Who Performs FGM, at What Age and for What Reasons?   In cultures where it is an accepted norm, female genital mutilation is practiced by followers of all religious beliefs as well as animists and non believers. FGM is usually performed by a traditional practitioner with crude instruments and without anaesthetic. Among the more affluent in society it may be performed in a health care facility by qualified health personnel. WHO is opposed to medicalization of all the types of female genital mutilation.   The age at which female genital mutilation is performed varies from area to area. It is performed on infants a few days old, female children and adolescents and, occasionally, on mature women. The reasons given by families for having FGM performed include: psychosexual reasons: reduction or elimination of the sensitive tissue of the outer genitalia, particularly the clitoris, in order to attenuate sexual desire in the female, maintain chastity and virginity before marriage and fidelity during marriage, and increase male sexual pleasure; sociological reasons: identification with the cultural heritage, initiation of girls into womanhood, social integration and the maintenance of social cohesion; hygiene and aesthetic reasons: the external female genitalia are considered dirty and unsightly and are to be removed to promote hygiene and provide aesthetic appeal; myths: enhancement of fertility and promotion of child survival; religious reasons: Some Muslim communities, however, practice FGM in the belief that it is demanded by the Islamic faith. The practice, however, predates Islam.   Prevalence and Distribution of FGM Most of the girls and women who have undergone genital mutilation live in 28 African countries, although some live in Asia and the Middle East. They are also increasingly found in Europe, Australia, Canada and the USA, primarily among immigrants from these countries. Today, the number of girls and women who have been undergone female genital mutilation is estimated at between 100 and 140 million. It is estimated that each year, a further 2 million girls are at risk of undergoing FGM.   Current WHO activities related to FGM :  Advocacy and Policy Development A joint WHO/UNICEF/UNFPA policy statement on FGM and a Regional Plan to Accelerate the Elimination of FGM were published to promote policy development and action at the global, regional, and national level. Several countries where FGM is a traditional practice are now developing national plans of action based on the FGM prevention strategy proposed by WHO. Research and Development A major objective of WHO’s work on FGM is to generate knowledge, test interventions to promote the elimination of FGM. Research protocols on FGM have been developed with a network of collaborating research institutions as well as biomedical and social science researchers with linkages to appropriate communities. WHO has reviewed programming approaches for the prevention of FGM in countries and has organized training for community workers to strengthen their effectiveness in promoting prevention of FGM at the grassroots level.  Development of training materials and training for health care providers WHO has developed training materials for integrating the prevention of FGM into nursing, midwifery and medical curricula as well as for in-service training of health workers. Evidence based training workshops, to raise the awareness of health workers and to solicit their active involvement as advocates against FGM, have also been developed for nurses and midwives in the African and Eastern Mediterranean region. For further information, journalists can contact : WHO Press Spokesperson and Coordinator, Spokesperson's Office , WHO HQ, Geneva, Switzerland / Tel +41 22 791 4458/2599 / Fax +41 22 791 4858 / e-Mail: [email_address]
  • Female circumcision has also been practiced in the U.S. The pictures displayed here are taken from an article in General Practitioner titled “ Female Circumcision: Indications and a New Technique”. The amount and locations of tissue removed are clearly visible. A host of additional articles proposed female circumcision, though predominantly of adult females who consent to the surgery, including: Circumcision in the Female: Its Necessity and How to Perform It Benjamin E. Dawson, A.M., M.D. - Kansas City, Missouri President, Eclectic Medical University American Journal of Clinical Medicine, vol. 22, no. 6, p. 520-523, June 1915 Circumcision of the Female C.F. McDonald, M.D. - Milwaukee, Wisconsin GP, Vol. XVIII No. 3, p. 98-99, September, 1958
  • The history of medical rationales for circumcision begins with a concern for “moral hygiene” rather than the kind of hygiene associated with personal cleanliness. Bright's disease (acute glomerulonephritis, acute nephritic syndrome, acute nephritis): A vague and obsolete term for disease of the kidneys - acute or chronic. Usually refers to nonsuppurative inflammatory or degenerative kidney diseases characterized by proteinuria and hematuria and sometimes by edema, hypertension, and nitrogen retention. Prevalent in males; onset at any age; highest incidence between 3 and 7 years of age. R. Bright: Cases and observation, illustrative of renal disease accompanied with the secretion of albuminous urine. Guy’s Hospital Reports, London, 1836, 1: 338-400. Guy’s Hospital Reports, London, 1840, 5: 101-161.
  • In preparation for the procedure, the baby’s arms and legs are strapped to a board-like retaining device.
  • The baby’s foreskin is attached to the head of the penis by synechia in the same way that the fingernail is attached to the finger. Pictures A-C display the Gomco Clamp method. Pictures D-F display the Plastibell technique. In frame F, the umbilical cord remnant and clamp are visible and the Plastibell device is left in place on the penis. Other methods often used by physicians include the Mogen clamp, and free-hand. Brief description of the Gomco Clamp method. Foreskin is detached from glans by running forceps around inside, tearing the connective membrane that at birth bonds it to the glans. The forceps is used to tightly squeeze skin down length of penis. This is to prevent bleeding. The first cut in the foreskin is made to allow room for the bell covering the glans to be placed. The bell is placed over the glans. A piece of metal is tightened to squeeze the foreskin against the bell. The foreskin is cut off with a scalpel. The bell is removed. A piece of gauze with petroleum on it is placed on the glans.
  • (a) Urethral fistula at frenulum (note probe), probably the result of incisional trauma. (b) Three-year-old boy with an almost transected glans from circumcision at birth, but parents did not note the abnormality until age 3. Urethra had been completely transected (arrow). (c) Neonate referred immediately after Gomco clamp circumcision in which all the skin of the shaft had been amputated. Caused by pulling too much skin up into the clamp and amputating it. May require a free skin graft. (d) Six-month-old baby was referred after loss of the entire penis from cautery used during circumcision. Evidently both corpora had thrombosed and sloughed, so no phallus remained. From the textbook Pediatric Trauma , edited by Robert J. Touloukian, M.D., Yale University School of Medicine (John Wiley & Sons). Epispadias - A urinary tube anatomic variation where the opening of the urethra (urethral meatus) is somewhere on the top side (dorsal surface) of the penis. Hypospadias - A urinary tube anatomic variation where the opening of the urethra (urethral meatus) is located on the underside (ventral surface) of the penis. Hypospadias and Epispadias can be inadvertently produced during circumcision by splitting the glans penis at the time of dorsal or ventral split preparatory to actual excision of the prepuce. In addition, inadvertent laceration of the penile or scrotal skin has been recorded. On occasion, the tip of the glans has been excised.
  • Meatitis – inflammation of the meatus, the opening of the urethra. Meatitis and meatal ulcer are rarely, if ever, seen in the uncircumcised boy. Meatal stenosis is far more common in circumcised adult men than in uncircumcised adult men 5 and is believed to result from meatitis in infancy. Caudal anesthesia is currently being employed in some centers, 32 and its use, like the use of all regional anesthetics has its own inherent complications. Additional Complications of Plastibell: When the Plastibell is utilized, the ring of the bell may migrate and by pressure necrosis produce a set of problems unique to this technique. If the ring may migrate and by pressure necrosis produce a set of problems unique to this technique. If the ring is too large it may migrate proximally and produce a groove in the shaft itself. 14,23,30,45,59,73 To avoid such complications, any retained Plastibell ring should be removed after several days if it has not fallen off spontaneously. Adopted from George W. Kaplan, M.D. Complications of Circumcision, UROLOGIC CLINICS OF NORTH AMERICA, 10 , 543-549 (1983). See also N. Williams and L. Kapila, Complications of Circumcision, BRITISH JOURNAL OF SURGERY, 80 , 1231-1236 (1993).
  • Both statements agree on all these issues. What we should ask ourselves is “Surgery on infants or no surgery on infants?” Rather than “Anesthetic or No Anesthetic?” American Academy of Pediatrics and Canadian Paediatric Society. Prevention and management of pain and stress in the neonate. Pediatrics 2000 Feb;105:454-61. Anand KJS. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med. 2001 Feb;155:173-80.
  • From Circumcision: Frequently Asked Questions Published by the American Association of Pediatrics (AAP) in 2001 http://www.medem.com/search/article_display.cfm?path=\TANQUERAY&mstr=/M_ContentItem/ZZZ13FOPIUC.html&soc=AAP&srch_typ=NAV_SERCH
  • Care of the intact penis is simpler than care of the circumcised penis.
  • The surface are of the adult foreskin is between 12 and 15 square inches. It contains 10,000-20,000 nerve endings, the same kinds of fine touch receptors (Meissner’s corpuscles) found in the clitoris. These receptors are found in volar regions, such as the fingertips and lips, and are only sparsely located in the head of the penis. The foreskin contains part of the dartos muscle (sometimes referred to as the Peripenic muscle). This muscle lies just beneath the skin and is the same muscle responsible for contraction of the scrotal skin. The dartos muscle is also responsible for tightening the tip of the foreskin in a manner similar to that of a sphincter. [1,2] Credits for the picture showing the frenulum, frenular delta, and ridged band to John A. Erickson, www.foreskin.org. Jefferson G . The peripenic muscle; some observations on the anatomy of phimosis. Surgery, Gynecology, and Obstetrics (Chicago) 1916; 23(2):177-181. Cold CJ, Taylor JR. The prepuce . BJU Int 1999;83 Suppl. 1:34-44.
  • A) Penis slightly tumescent. The area between the upper and lower lines is the foreskin's outside fold. The foreskin's outside fold is almost as long as the skin covering the penile shaft. The foreskin's inside fold, equal in length to and covered by the foreskin's outside fold, is not visible. Well over half of the total penile skin is foreskin. B) The foreskin retracted (manually) about an inch. The area between the upper (blue) line and the lower (green) line is the foreskin's mostly retracted outside fold. The area below the lower line is the first half-inch or so of the foreskin's partially retracted inside fold C) The foreskin retracted. The area between the upper and lower lines is the foreskin's retracted outside fold. The area below the lower line is the foreskin's retracted inside fold, gathered behind the coronal sulcus. D) The foreskin retracted farther. Almost the entire penile shaft is now covered with foreskin. The area between the upper and lower lines is the foreskin's retracted outside fold. The area between the lower line and the glans is the foreskin's retracted inside fold. If the skin were released, it would return to its position in (C). E) The foreskin retracted as far as it will comfortably go. The area between the lower (green) line (the only line now visible) and the glans is the foreskin's fully retracted inside fold. (One of the fingers holding the foreskin back is partially visible.) The entire penile shaft is now covered with foreskin. Well over half of the shaft is covered with the foreskin's retracted inside fold. Veins, arteries, capillaries, and smooth glans texture clearly visible. F) A circumcised penis. The scar that now forms the junction between the mucosal and shaft tissue is uneven. G) Arrows point to the end of the mucosal membrane, above which is the circumcision scar. Credits to John A. Erickson www.foreskin.org
  • Protection: Just as the eyelids protect the eyes, the foreskin protects the glans and keeps its surface soft, moist, and sensitive. It also maintains optimal warmth, pH balance, and cleanliness. The glans itself contains no sebaceous glands -- glands that produce the sebum, or oil, that moisturizes our skin. 11 The foreskin produces the sebum that maintains proper health for the surface of the glans. Immunological Defense: The mucous membranes that line all body orifices are the body's first line of immunological defense. Glands in the foreskin produce antibacterial and antiviral proteins such as lysozyme. 12 Lysozyme is also found in tears and mother's milk. Specialized epithelial Langerhans cells, an immune system component, abound in the foreskin's outer surface. 13 Plasma cells in the foreskin's mucosal lining secrete immunoglobulins, antibodies that defend against infection. 14 11. A. B. Hyman and M. H. Brownstein, "Tyson's 'Glands': Ectopic Sebaceous Glands and Papillomatosis Penis," Archives of Dermatology 99 (1969): 31-37 12. A. Ahmed and A. W. Jones, "Apocrine Cystadenoma: A Report of Two Cases Occurring on the Prepuce," British Journal of Dermatology 81 (1969): 899-901. 13. G. N. Weiss et al., "The Distribution and Density of Langerhans Cells in the Human Prepuce: Site of a Diminished immune Response?" Israel Journal of Medical Sciences 29 (1993): 42-43. 14. P. J. Flower et al, "An immunopathologic Study of the Bovine Prepuce," Veterinary Pathology 20 (1983):189-202.
  • Erogenous Sensitivity: The foreskin is as sensitive as the fingertips or the lips of the mouth. It contains a richer variety and greater concentration of specialized nerve receptors than any other part of the penis. 63 These specialized nerve endings can discern motion, subtle changes in temperature, and fine gradations of texture. 64-71 Coverage during Erection: As it becomes erect, the penile shaft becomes thicker and longer. The double-layered foreskin provides the skin necessary to accommodate the expanded organ and to allow the penile skin to glide freely, smoothly, and pleasurably over the shaft and glans. Self-stimulating Sexual Functions: The foreskin's double-layered sheath enables the penile shaft skin to glide back and forth over the penile shaft. The foreskin can normally be slipped all the way, or almost all the way, back to the base of the penis, and also slipped forward beyond the glans. This wide range of motion is the mechanism by which the penis and the orgasmic triggers in the foreskin, frenulum, and glans are stimulated. Sexual Functions in Intercourse: One of the foreskin's functions is to facilitate smooth, gentle movement between the mucosal surfaces of the two partners during intercourse. The foreskin enables the penis to slip in and out of the vagina nonabrasively inside its own slick sheath of self-lubricating, movable skin. The female is thus stimulated by moving pressure rather than by friction only, as when the male's foreskin is missing. See also K. Ohara, “The effect of male circumcision on the sexual enjoyment of the female partner” BJU INTERNATIONAL 83 Supplement 1 (1999): 79-84.
  • The incidence of penile cancer is 1 in 100,000. Urinary Tract Infections (UTIs) are more common in women than in intact or circumcised men. The myth that circumcision reduces the transmission rate of STDs is one of the most dangerous myths of all. The US aids epidemic occurred among men of whom almost 100% were circumcised. Worse, circumcision is associated with an increased resistance on the part of the male to use a condom. Condoms are effective at reducing STD transmission.
  • Policy Statement: American Academy of Pediatrics Task Force on Circumcision, (1999) Position Statement: Routine Circumcision of Normal Male Infants and Boys. Australian College of Paediatrics, (1996) An older statement from Australia “ Neonatal male circumcision has no medical indication. It is a traumatic procedure performed without anaesthesia to remove a normal and healthy prepuce.” -- Australian College of Paediatrics 1996
  • A few relevant organizations: Nurses for the Rights of the Child (NRC) Conscientious Objector Information for Nurses Betty Katz Sperlich, R.N., and Mary Conant, R.N. 369 Montezuma #354, Santa Fe, NM 87501 Tel: 505-989-7377 E-mail: wholebaby@nets.com Website: www.cirp.org/nrc Intersex Society of North America 4500 9th Avenue NE Suite 300, Seattle, WA 98105 Email: monica@isna.org Website: www.isna.org Lightfoot-Associates Information on Female Genital Mutilation Hanny Lightfoot-Klein, M.A. 4910 N. Calle Bosque, Tucson, AZ 85718 Tel: 520-529-2029, Fax: 520-529-9411 Circumcision Resource Center (CRC) Information and Resources Ronald Goldman, Ph.D. 232, Boston, MA 02133 Tel/Fax: 617-523-0088 E-mail: crc@circumcision.org Website: www.circumcision.org
  • Concatenation of references in reference slides Penile Adhesions 1.Katharine A. Gracely-Kilgore, R.N., M.S.N., C.P.N.P., “ Penile Adhesion: The Hidden Complication of Circumcision” NURSE PRACTITIONER, Volume 5 Number 9: Pages 22-4, May 1984. Lymphedema. Penile lymphedema may occur following circumcision especially if the wound separates or becomes infected. Skin grafting may be required for resolution. 2.Shulman, J. Ben-Hur, N., and Neuman, Z.: Surgical complications of circumcision. Am. J. Dis. Child ., 127:149; 1964. Skin Bridges Klauber GT, Boyle J. Preputial skin-bridging. Complication of circumcision. Urology 1974; 3: 722-3. Sathaye VU, Goswami AK, Sharma SK. Skin bridge - a complication of paediatric circumcision. Br J Urol 1990; 66: 214. Ritchey ML, Bloom DA. Re: Skin bridge--a complication of paediatric circumcision. Br J Urol 1991; 68: 331. Urethral Fistula Johnson S. Persistent urethral fistula following circumcision: report of a case. US Naval Med Bull 1949; 49: 120-2. Limaye RD, Hancock RA. Penile urethral fistula as a complication of circumcision. J Pediatr 1968; 72: 105-6. Lackey JT, Mannion RA, Kerr JE. Urethral fistula following circumcision. JAMA 1968; 206: 2318. Lackey JT, Mannion RA, Kerr JE. Subglanular urethral fistula from infant circumcision. J Indiana State Med Assoc 1969; 62: 1305-6. Shiraki, IW. Congenital megalourethra with urethracutaneous fistula following circumcision: a case report. J Urol 1973: 109: 723. Lau, JTK, Ong GB. Subglandular urethral fistula following circumcision: repair by the advancement method. J Urol 1981; 126: 702-703. Benchekroun A, Lakrissa A, Tazi A, Hafa D, Ouazzani N. Fistules urethrales apres circoncision: a propos de 15 cas. [Urethral fistulas after circumcision: apropos of 15 cases] Maroc Med 1981; 3: 715-8. Palmer SY, Colodny AH. Congenital urethrocutaneous fistulas. Urology . 1994; 44: 149-50. Baskin LS. Canning DA. Snyder III HM. Duckett JW Jr. Surgical repair of urethral circumcision injuries. Journal d'Urologie 1997;158(6):2269-2271. Buried, Concealed, and Hidden Penis Stewart DH. The toad in the hole circumcision -- a surgical bugbear. Boston Med Surg J 1924; 191: 1216-8. Talarico RD, Jasaitis JE. Concealed penis: a complication of neonatal circumcision. J Urol 1973; 110: 732-3. Trier WC, Drach GW. Concealed penis. Another complication of circumcision. Am J Dis Child 1973; 125: 276-7. Radhakrishnan J, Reyes HM. Penoplasty for buried penis secondary to "radical" circumcision. J Pediatr Surg 1984; 19: 629-31. Kon M. A rare complication following circumcision: the concealed penis. J Urol 1983; 130: 573-4. Donahoe PK, Keating MA. Preputial unfurling to correct the buried penis. J Pediatr Surg 1986; 21: 1055-7. Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF. Surgical correction of the buried penis: description of a classification system and a technique to correct the disorder. J Urol 1986; 136: 268-73. Shapiro SR. Surgical treatment of the "buried" penis. Urology 1987; 30: 554-9. Horton CE, Vorstman B, Teasley D, Winslow B. Hidden penis release: adjunctive suprapubic lipectomy. Ann Plast Surg 1987; 19: 131-4. van-der Zee JA, Hage JJ, Groen JM, Bouman FG. Een ernstige complicatie ten gevolge van rituele circumcisie van een 'begraven' penis. [A serious complication of ritual circumcision of a 'buried' penis] Ned Tijdschr Geneeskd 1991; 135: 1604-6. Bergeson PS. et al. The Inconspicuous Penis. Department of General Pediatrics and Urology, Phoenix Children's Hospital. Pediatrics 1993; 92: 794-9. Alter GJ, Horton CE Jr; Horton CE Jr. Buried penis as a contraindication for circumcision. J Am Coll Surg 1994; 178: 487-90. Alter G. Buried Penis. (link to http://www.altermd.com/pconstruct/urethral.htm) Penile Amputation Brimhall JB. Amputation of the penis following a unique method of preventing hemorrhage after circumcision. St Paul Med J 1902; 4: 490. Lerner BL. Amputation of the penis as a complication of circumcision. Med Rec Ann 1952;46:229-31. Levitt SB, Smith RB, Ship AG. Iatrogenic microphallus secondary to circumcision. Urology 1976; 8: 472-4. Izzidien AY. Successful replantation of a traumatically amputated penis in a neonate. Journal of Pediatric Surgery April 1981,16(2):202-203. Hanash KA. Plastic reconstruction of partially amputated penis at circumcision. Urology 1981; 18(3): 291-3. Azmy A, Boddy SA, Ransley PG. Successful reconstruction following circumcision with diathermy. Br J Urol 1985; 57: 587-8. Yilmaz AF, Sarikaya S, Yildiz S, et al. Rare complication of circumcision: penile amputation and reattachment. European Urology (Basel) 1993; 23(3): 423-424. Audry G, Buis J, Vazquez MP, Gruner M. Amputation of penis after circumcision--penoplasty using expandable prosthesis. Eur J Pediatr Surg 1994; 4: 44-5. Hanukoglu A, Danielli L, Katzir Z, Gorenstein A, Fried D. Serious complications of routine ritual circumcision in a neonate: hydro ureteronephrosis, amputation of glans penis, and hyponatraemia. Eur J Pediatr 1995; 154: 314-5. Gluckman GR et al. Newborn Penile Glans Amputation During Circumcision and Successful Reattachment. Journal of Urology (Baltimore), vol. 153 no. 3 Part 1 March 1995 pp. 778-779. Strimling BS. Partial amputation of glans penis during Mogen clamp circumcision. Pediatrics 1996; 97: 906-7. Neulander E, Walfisch S. Kaneti J. Amputation of distal penile glans during neonatal ritual circumcision -- a rare complication. Br J Urol 1996; 77: 924-5. Sherman J, Borer JG, Horowitz M, Glassberg KI. Circumcision: successful glanular reconstruction and survival following amputation. J Urol 1996; 156: 842. Van Howe RS. Re: circumcision: successful glanular reconstruction and survival following traumatic amputation (Letter). J Urol . 1997;158:550. Coskunfirat OK, Sayiklkan S, Velidedeoglu H.. Glans and penile skin amputation as a complication of circumcision (letter). Ann Plast Surg 1999;43(4):457. Siegel-Itzkovich J. Baby's penis reattached after botched circumcision. BMJ 2000;321:529. Park JK, Min JK, Kim HJ. Reimplantation of an amputated penis in prepubertal boys. J Urol 2001;165:586-7. Pain Response 45.Taddio A, Koren G et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet, Vol. 349: Pages 599-603 (March 1, 1997). Infection Gee, W. F., and Ansell, J. S.: Neonatal circumcision: A ten-year overview with comparison of the Gomco clamp and the Plastibell device. Pediatrics , 55:524, 1976. Fraser, I. A., Allen, M. J., Bagshaw, P. F., et al.: A randomized trial to assess childhood circumcision with the Plastibell device compared with a conventional dissection technique. Br. J. Surg ., 68:593-595, 1968. Meatitis Daley, M. C.: Circumcision. J.A.M.A ., 214:2195, 1970. Lairdner, D. [sic, should be Gairdner] : The fate of the foreskin. A study of circumcision. Br. Med. J ., 2:1433, 1949. Mackenzie, A. R.: Meatal ulceration following neonatal circumcision. Obstet Gynecol ., 28:221, 1966. Patel, H.: The problem of routine circumcision. Can. Med. Assoc. J ., 95:576, 1966. Necrosis Davidson, F.: Yeasts and circumcision in the male. Br. J. Ven. Dis ., 53:121-122, 1977. Money, J.: Ablatio penis: normal male infant reassigned as a girl. Arch Sex. Behav ., 4:65-71. 1975. Sterenberg. N., Golan, J., and Ben-Hur, N.: Necrosis of the glans penis following neonatal circumcision. Plast. Reconstr. Surg ., 68:237-239, 1981. Major Morbidity Thorek, P., and Egel, P.: Reconstruction of the penis with split-thickness skin graft. Plast. Reconstruc. Surg ., 4: 469, 1969. Woodside, J. R. Necrotizing fascitis after circumcision. Am. J. Dis. Child ., 134:301, 1980. Annunziato, D. and Goldman, L. M.: Staphylococcal scalded skin syndrome. A complication of circumcision. Am. J. Dis. Child 132:1178-1188; 1978. Sussman, S. J., Schiller, R. P., and Shaskikumar, V. L.: Fournier's syndrome and review of the literature. Am. J. Dis. Child . Kirkpatrick, B. V., and Eitzman, D. V.: Neonatal septicemia after circumcision. Clin. Pediatr ., 13:767-768, 1974. Procopis, P. G., and Kewley, G. D. Complication of circumcision. Med. J. Aust ., 1:15, 1982. Death Cleary, T. G., and Kohl, S.: Overwhelming infection with group B beta-hemolytic streptococcus associated with circumcision. Pediatrics , 64: 301-307, 1979. Scurlock, J. M. and Pemberton, P. J.: Neonatal meningitis and circumcision. Med. J. Aust ., 1:332-334. Innervation of the Foreskin Z. Halata and B. L. Munger, "The Neuroanatomical Basis for the Protopathic Sensibility of the Human Glans Penis," Brain Research 371 (1986): 205-230. J. R. Taylor et al, "The Prepuce: Specialized Mucosa of the Penis and its Loss to Circumcision," British Journal of Urology 77 (1996): 291-295. H. C. Bazett et al, "Depth, Distribution and Probable Identification in the Prepuce of Sensory End-Organs Concerned in Sensations of Temperature and Touch, Thermometric Conductivity," Archives of Neurology and Psychiatry 27 (1932): 489-517 D. Ohmori, "Uber die Entwicklung der Innervation der Genitalapparate als Peripheren Aufnahmeapparat der Genitalen Reflexe," Zeitschrift fur Anotomie und Entwicklungsgeschichte 70 (1924): 347-410. A. De Girolamo and A. Cecio, "Contributo alla Conoscenza dell'innervazione Sensitiva del Prepuzio Nell'uomo,' Bollettino della Societa Italiona de Biologia Sperimentale 44 (1968):1521-1522. A. S. Dogiel, "Die Nervenendigungen in der Haut der ausseren Genitalorgane des Menschen," Archiv fur Mikroskopische Anotomie 41 (1893): 585-612. A. Bourlond and R. K. Winkelmann, "Linnervation du Prepuce chez le Nouveau-ne", Archives Belges de Dermatologie et de Syphiligraphie 21 (1965):139-153. R. K. Winkelmann, "The Erogenous Zones: Their Nerve Supply and its Significance," Proceedings of the Staff Meetings of the Mayo Clinic 34 (1959): 39-47. R. K. Winkelmann, "The Cutaneous innervation of Human Newborn Prepuce," Journal of Investigative Dermatology 26 (1956): 53-67 Decreased sensation Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychological Reports 2001;88:1106-1106. Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5):2113-2116. Zwang G. Functional and erotic consequences of sexual mutilations. In: GC Denniston and MF Milos, eds. Sexual Mutilations: A Human Tragedy New York and London: Plenum Press, 1997 (ISBN 0-306-45589-7). Erectile problems Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5):2113-2116. Stinson JM. Impotence and adult circumcision. J Nat Med Assoc 1973;65:161. Sexual problems for female partner 77.O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1, 79-84. Negative feelings 78.Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychological Reports 2001;88:1106-1106. Wider set of sexual behaviors and increased resistance to condom use 79.Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13):1052-1057. No difference in STD rate 80.Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13):1052-1057. Urinary Tract Infection 81.Bollgren I, Winberg J. Letter. [Rebuttal of Edgar J. Schoen] Acta Paediatrica Scandinavia 1991; 80:575-7. 82.Amato D, Garduno-Espinosa J. Circumcision of the newborn male and the risk of urinary tract infection during the first year: A meta-analysis. Bol Med Infant Mex Volume 49, Number 10, October 1992, 652-658. 83.Craig JC et al. Effect of circumcision on incidence of urinary tract infection in preschool boys. From the Department of Nephrology, Royal Alexandra Hospital for Children, Sydney, Australia. Cervical Cancer 84.Elizabeth Stern; Peter M. Neely. "Cancer of the Cervix in Reference to Circumcision and Marital History," Journal of the American Medical Women's Association, vol. 17, no. 9 (September 1962): pp. 739-740.
  • Following its introduction, circumcision was purported to cure a variety of illnesses. Epilepsy, paralysis, idiocy, and almost any illness in a young male who had not already been circumcised might apparently be cured by circumcision. See “From Ritual to Science: The Medical Transformation of Circumcision in America”, David L. Gollaher, Journal of Social History Vol. 28 No. 1, pp. 5 – 36, Fall 1994. This article is available online at http://www.cirp.org/library/history/gollaher/.
  • Another quote: 1935 “all male children should be circumcised. … Nature intends that the adolescent male shall copulate as often and as promiscuously as possible, and to that end covers the sensitive glans so that it shall be ever ready to receive stimuli. … the glans of the circumcised rapidly assumes a leathery texture less sensitive than skin.” R.W. Cockshut. Circumcision. British Medical Journal, Vol.2 (1935): p.764.
  • More on Finland - Late in 1999, the Juridic Ombudsman of the Finnish Parliament, Riitta-Leena Paunio, noted that infant circumcision is not recommended without a medical reason and recommended that children should be consulted and should give their permission. She said the Finnish Parliament should weigh up the parents' religious rights over their children against the obligation of society to protect its children from ritualistic operations without immediate benefit to them. This decision is believed to be the first of its kind in any country. As an immediate result, the consent of both parents is now required. Countries that have adopted legislation criminalizing FC/FGM: Australia (six of eight states), Burkina Faso, Canada, Central African Republic, Côte d'Ivoire, Djibouti, Ghana, Guinea, New Zealand, Norway, Senegal, Sweden, Tanzania, Togo, the United Kingdom, and the United States. In addition, three states in Nigeria have criminalized the practice. [15] U.S. Law: On September 30, 1996, Congress enacted a provision criminalizing the practice of FC/FGM as part of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996. [17] With two exceptions, it provides that "whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years shall be fined under this title or imprisoned not more than 5 years, or both." [18] The statute exempts a surgical operation if such operation is "necessary to the health of the person on whom it is performed, and is performed by a person licensed in the place of its performance as a medical practitioner." [19] The term "health" in this exemption is to be interpreted narrowly. The statute states that "no account shall be taken of the effect on the person on whom the operation is to be performed of any belief on the part of that person, or any other person, that the operation is required as a matter of custom or ritual." [20] The statute also exempts an operation if it is "performed on a person in labor or who has just given birth and is performed for medical purposes connected with that labor or birth by a person licensed . . . as a medical practitioner, midwife, or person in training to become such a practitioner or midwife." [21] 15 The Center for Reproductive Rights, Female Circumcision/Female Genital Mutilation (FC/FGM): Global Laws and Policies Towards Elimination (2000). 17 See Illegal Immigration Reform and Immigrant Responsibility Act of 1996, Pub. L. 104-208, § 645, 110 Stat. 3009-546 (1996). WOMEN'S POLICY, INC., THE RECORD: GAINS AND LOSSES FOR WOMEN AND FAMILIES IN THE 104TH CONGRESS 95-96 (1997). 18 U.S.C.A. at § 116(a). 19 Id. at § 116(b)(1). 20 Id. at 116(c). 21 Id. at § 116(b)(2). See Legislation on Female Circumcision/ Female Genital Mutilation in the United States http://www.crlp.org/pub_art_fgmuslaws.html for more information
  • Compiled by Hanny Lightfoot-Klein, M.A. Some of her research is reprinted at www.fgmnetwork.org/Lightfoot-klein/ Hanny Lightfoot-Klein, The Sexual Experience and Marital Adjustment of Genitally Circumcised and Infibulated Females in The Sudan , The Journal of Sex Research 26 , 375-392 (1989). Hanny Lightfoot-Klein, PRISONERS OF RITUAL: SOME CONTEMPORARY DEVELOPMENTS IN THE HISTORY OF FEMALE GENITAL MUTILATION , presented at the Second International Symposium on Circumcision in San Francisco, April-30 - May 3, 1991. Additional quotes she reports about female circumcision "All the women in the world are circumcised. It is something that must be done. If there is pain, then that is part of a woman's lot in life." "An uncircumcised vulva is unclean and only the lowest prostitute would leave her daughter uncircumcised. No man would dream of marrying an unclean woman. He would be laughed at by everyone." Sudanese grandmother: "In some countries they only cut out the clitoris, but here we do it properly. We scrape our girls clean. If it is properly done, nothing is left, other than a scar. Everything has to be cut away." Additional quotes she reports about male circumcision "Men in all the 'civilized' world are circumcised.“ "An uncircumcised penis is dirty and only the lowest class of people with no concept of hygiene leave their boys uncircumcised." My own father, a physician, speaking of ritual circumcision inflicted upon my son: "It is a good thing that I was here to preside. He had quite a long foreskin. I made sure that we gave him a good tight circumcision."
  • Transcript

    • 1. Circumcision: History, culture, and science of genital alteration. Ryan McAllister, Ph.D. Executive Director NOCIRC of the Capital Region www.notjustskin.org [email_address] Some explanatory text is included in the notes pages Revised 05 June 2003
    • 2. Objectives: To Understand:
      • What circumcision is
      • Where circumcision is practiced
      • Why it came to be practiced
      • How it is done
      • Potential complications to infants and children
      • The anatomical structures removed
      • The lasting effects in adults
      • Where to go for more information
    • 3. Genital Cutting
      • Is defined as the alteration or amputation of healthy tissue from an individual’s genitalia
      • Has been performed by some U.S. physicians since the turn of the century
      • Has been a ritual in some cultures for thousands of years
    • 4. Where Genital Cutting Occurs Today Female Male
    • 5. Female Genital Cutting
      • Approximately 2% of women are circumcised worldwide
      • Benefits asserted by practitioners include
        • Hygienic benefits for the woman
        • Safety benefits for her children
        • Esthetic or pleasurable benefits for her mate
      • World Health Organization defines female genital mutilation (FGM):
        • FGM - all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons .
        • Type I (~80%) – excision of prepuce and or part or all of clitoral tip
        • Type II - excision of clitoral tip with partial or total excision of labia minora
        • Type III (~15%) – excision of part or all of external genitalia and stitching/narrowing of vaginal opening (infibulation or pharaonic circumcision)
        • Type IV – other alteration to the female genital organs
    • 6. Female Genital Cutting in the U.S. Female Circumcision: Indications and a New Technique W.G. Rathmann, M.D. GP, vol. 20, no. 3,  pp 115-120 , September, 1959
    • 7. Medical Claims for Male Genital Cutting
      • Moral Hygiene “In cases of masturbation we must, I believe, break the habit by inducing such a condition of the parts as will cause too much local suffering to allow of the practice to be continued…. the operation, too, should not be performed under chloroform, so that the pain experienced may be associated with the habit we wish to eradicate.”
          • Athol A. W. Johnson On An Injurious Habit Occasionally Met with in Infancy and Early Childhood, The Lancet, vol. 1 (7 April 1860)
      • 1860’s and 70’s Epilepsy, phimosis, penile cancer, masturbation, paralysis, hip-joint disease, digestive disorders
      • 1880’s – 1900’s Curvature of the spine, dementia, clumsiness, bed-wetting, rheumatic disorders, asthma, Bright’s disease, syphilis, incontinence, constipation, general nervousness, restlessness, irritability, insomnia, night terrors
      • 1940’s Most venereal diseases
      • 1980’s HIV
      • From David L. Gollaher, “From Ritual to Science: The Medical Transformation of Circumcision in America,” Journal of Social History, Vol. 28, No. 1, pp. 5-36, 1994.
    • 8. Circumcision Preparation – the Restraint
    • 9. Infant Circumcision A B C F E D
    • 10. Surgical Complications - Penile Structure
      • Scarring always occurs
      • Uneven circumcision is common
      • 15% of examined circumcised males had penile adhesions in Ref. [1]
      • Lymphedema [2]
      • Skin bridges [3-5]
      • Urethral fistulas, hypospadius and epispadius (a) [6-14]
      • Buried, concealed, and hidden penis (c) [15-27]
      • Penile amputation (d) [28-44]
    • 11. Infant & Child Postoperative Complications
      • Difficulty breastfeeding.
      • Aggravated response to pain in infants months later. [45]
      • Infection. Incidence in neonatal circumcisions was 0.4% [46], in older boys as high as 10% [47]
      • Meatitis. With or without ulcer resulting from circumcision is reported between 8% and 31% [48-51], usually later in the first year, but while the child is still in diapers
      • Necrosis. Necrosis and slough of the glans or even entire penis has been reported following circumcision.[52-54] Rates unknown, probably rare
      • Major morbidity. Including major skin loss, [55] necrotizing fascitis, [56] staphylococcal scalded skin syndrome, [57] Fournier's gangrene, [58] generalized sepsis, [59] and meningitis. [60] Rates unknown, probably rare
      • Severe permanent disability or death. Rates unknown, probably rare [61,62]
    • 12. Anesthetic or No Anesthetic?
      • Anesthetic risks
        • General anesthesia has led to deaths
        • Local anesthetic agents injected into the corpora cavernosa can produce impotence; the rate is unknown
        • Idiosyncratic reactions and overdosage
        • Epinephrine may produce local tissue problems or systemic toxicity
      • Without anesthesia
        • Decreased pO 2
        • Increased serum cortisol
        • Increased withdrawal
        • One recorded instance precipitated a pneumothorax
        • Greater long-term increased response to painful stimuli [45]
    • 13. Consensus: Prevention and Management of Pain in the Newborn
      • Compared with older age groups newborns
        • may experience greater sensitivity to pain
        • such pain may have long-term consequences
        • a lack of behavioral response (for example, lack of crying) does not necessarily indicate a lack of pain
      • Health care professionals should “prevent, reduce, or eliminate the stress and pain of neonates.”
          • Joint statement, American Academy of Pediatrics and Canadian Paediatric Society
    • 14. Care of the Circumcised Penis
      • After circumcision
        • Tip of the penis may seem raw or yellowish
        • May have yellow discharge for up to a week
        • Change bandage at each diapering to reduce risk of infection
        • Use petroleum jelly or vitamin A&D ointment to keep bandages from sticking to wound
        • It takes 7 to 10 days for the penis to heal after circumcision
      • Watch for
        • Lack of urination within 6 to 8 hours after the circumcision
        • Persistent bleeding
        • Indications of infection: swelling, foul-smelling drainage, or redness around the tip of the penis that gets worse after 3 to 5 days
    • 15. Care of the Unaltered Penis
      • Do not use force to retract foreskin
      • Foreskin becomes retractile usually before puberty
      • Do not wash with harsh soaps or abrasives
    • 16. The Adult Foreskin
      • The most erogenous tissue in the male body
      • 12-15 square inches
      • 10,000-20,000 nerve endings
      • 240 feet of nerves
      • 3-4 feet of blood vessels
      • Specialized structures
        • Frenulum
        • Frenular delta
        • Ridged band (frenar band)
        • Dartos muscle
    • 17. Comparing Anatomy During Erection
    • 18. The Adult Penis Intact or Cut
    • 19. Protective Functions of the Foreskin
      • Contains or emits
        • Lysozyme (natural antibacterial agent)
        • Immunoglobulins (antibodies)
        • Langerhans cells (an immune system component)
        • Sebaceous glands and sebum (moisturizing oil)
      • That may serve to
        • Prevent mucosal tissue and glans from over-keratinizing
        • In infancy, protects the urethra against contamination, meatal stenosis, and Urinary Tract Infections (UTIs)
      • The skin covering itself also
        • Protects mucosal tissue and glans from injury
        • Protects the nerves of the mucosal tissue and glans
        • Protects the glans against sunburn, frostbite, and other environmental hazards
    • 20. Sexual Functions of the Foreskin
      • Erotic pleasure, via the ridged band (aka. frenar or frenular band) [63-71]
      • Contains most of the specialized fine-touch nerve endings (Meissner's corpuscles) in the penis [63-71]
      • Store pheromones and release them on arousal
      • Store and release natural lubricants
      • Make the glans a visual signal of sexual arousal
      • Supply skin to cover the shaft in erection
      • Reduce friction in intercourse and masturbation
      • Prevent dyspareunia (painful intercourse)
      • Stimulate partner's genitalia
      • Retain lubrication within the vagina
    • 21. Current Claims of Circumcision Benefits
      • Medical
        • Reduce penile cancer incidence
        • Reduce UTI occurrence rate
        • Reduce STD transmission rates
        • Reduce cervical cancer rate in female partner
      • The most commonly cited benefits:
        • Preferred appearance
        • Circumcised penis does not require rinsing
    • 22. Circumcision is Associated with
      • Decreased pleasurable sensation for the man [72-74]
      • Increased erectile problems [75-76]
      • Increased sexual problems for female partners [77]
      • Psychological problems, including anger, grief, difficulty with trust, inhibited intimacy, communication challenges [78]
      • Increased diversity of sexual behaviors [79,80]
      • Increased resistance to condom use [80]
      • No difference in STD transmission rate [79]
      • Increased risk of UTIs [81-83]
      • No difference in cervical cancer rates for sexual partners [84]
      • “ Circumcision is not considered to be beneficial in preventing or reducing the risk of penile cancer,” American Cancer Society (1999)
    • 23.
      • “ Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.”
      • -- American Academy of Pediatrics 1999
      • “ There is no medical indication for routine male circumcision…. The foreskin requires no special care during infancy. It should be left alone.”
      • -- The Royal Australasian College of Physicians 2002
      Two Position Statements
    • 24. Genital Cutting
      • Is practiced on about 15% of males and 2% of females worldwide
      • Is the amputation of functional genital tissue
      • Was introduced into medicine to alter sexuality
      • Is painful
      • Has risks of surgical complication
      • Leaves recipients with lifelong detrimental effects
      • Does not promote health
    • 25. Further Resources
      • Circumcision information
        • www.cirp.org – Collected scientific journal articles
        • www.nocirc.org – International symposia on genital integrity
        • www.doctorsopposingcircumcision.org
      • Local education and advocacy
        • www.notjustskin.org – Maryland Circumcision Information Resource Center
      • Healing
        • www.norm.org – National Organization of Restoring Men
    • 26. References 1
      • Penile Adhesions
      • Katharine A. Gracely-Kilgore, R.N., M.S.N., C.P.N.P., “ Penile Adhesion: The Hidden Complication of Circumcision” NURSE PRACTITIONER, Volume 5 Number 9: Pages 22-4, May 1984.
      • Lymphedema. Penile lymphedema may occur following circumcision especially if the wound separates or becomes infected. Skin grafting may be required for resolution.
      • Shulman, J. Ben-Hur, N., and Neuman, Z.: Surgical complications of circumcision. Am. J. Dis. Child ., 127:149; 1964.
      • Skin Bridges
      • Klauber GT, Boyle J. Preputial skin-bridging. Complication of circumcision. Urology 1974; 3: 722-3.
      • Sathaye VU, Goswami AK, Sharma SK. Skin bridge - a complication of paediatric circumcision. Br J Urol 1990; 66: 214.
      • Ritchey ML, Bloom DA. Re: Skin bridge--a complication of paediatric circumcision. Br J Urol 1991; 68: 331.
      • Urethral Fistula
      • Johnson S. Persistent urethral fistula following circumcision: report of a case. US Naval Med Bull 1949; 49: 120-2.
      • Limaye RD, Hancock RA. Penile urethral fistula as a complication of circumcision. J Pediatr 1968; 72: 105-6.
      • Lackey JT, Mannion RA, Kerr JE. Urethral fistula following circumcision. JAMA 1968; 206: 2318.
      • Lackey JT, Mannion RA, Kerr JE. Subglanular urethral fistula from infant circumcision. J Indiana State Med Assoc 1969; 62: 1305-6.
      • Shiraki, IW. Congenital megalourethra with urethracutaneous fistula following circumcision: a case report. J Urol 1973: 109: 723.
      • Lau, JTK, Ong GB. Subglandular urethral fistula following circumcision: repair by the advancement method. J Urol 1981; 126: 702-703.
      • Benchekroun A, Lakrissa A, Tazi A, Hafa D, Ouazzani N. Fistules urethrales apres circoncision: a propos de 15 cas. [Urethral fistulas after circumcision: apropos of 15 cases] Maroc Med 1981; 3: 715-8.
      • Palmer SY, Colodny AH. Congenital urethrocutaneous fistulas. Urology . 1994; 44: 149-50.
      • Baskin LS. Canning DA. Snyder III HM. Duckett JW Jr. Surgical repair of urethral circumcision injuries. Journal d'Urologie 1997;158(6):2269-2271.
    • 27. References 2
      • Buried, Concealed, and Hidden Penis
      • Stewart DH. The toad in the hole circumcision -- a surgical bugbear. Boston Med Surg J 1924; 191: 1216-8.
      • Talarico RD, Jasaitis JE. Concealed penis: a complication of neonatal circumcision. J Urol 1973; 110: 732-3.
      • Trier WC, Drach GW. Concealed penis. Another complication of circumcision. Am J Dis Child 1973; 125: 276-7.
      • Radhakrishnan J, Reyes HM. Penoplasty for buried penis secondary to "radical" circumcision. J Pediatr Surg 1984; 19: 629-31.
      • Kon M. A rare complication following circumcision: the concealed penis. J Urol 1983; 130: 573-4.
      • Donahoe PK, Keating MA. Preputial unfurling to correct the buried penis. J Pediatr Surg 1986; 21: 1055-7.
      • Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF. Surgical correction of the buried penis: description of a classification system and a technique to correct the disorder. J Urol 1986; 136: 268-73.
      • Shapiro SR. Surgical treatment of the "buried" penis. Urology 1987; 30: 554-9.
      • Horton CE, Vorstman B, Teasley D, Winslow B. Hidden penis release: adjunctive suprapubic lipectomy. Ann Plast Surg 1987; 19: 131-4.
      • van-der Zee JA, Hage JJ, Groen JM, Bouman FG. Een ernstige complicatie ten gevolge van rituele circumcisie van een 'begraven' penis. [A serious complication of ritual circumcision of a 'buried' penis] Ned Tijdschr Geneeskd 1991; 135: 1604-6.
      • Bergeson PS. et al. The Inconspicuous Penis. Department of General Pediatrics and Urology, Phoenix Children's Hospital. Pediatrics 1993; 92: 794-9.
      • Alter GJ, Horton CE Jr; Horton CE Jr. Buried penis as a contraindication for circumcision. J Am Coll Surg 1994; 178: 487-90.
      • Alter G. Buried Penis. (link to http://www.altermd.com/pconstruct/urethral.htm)
      • Penile Amputation
      • Brimhall JB. Amputation of the penis following a unique method of preventing hemorrhage after circumcision. St Paul Med J 1902; 4: 490.
      • Lerner BL. Amputation of the penis as a complication of circumcision. Med Rec Ann 1952;46:229-31.
    • 28. References 3
      • Penile Amputation Continued
      • Levitt SB, Smith RB, Ship AG. Iatrogenic microphallus secondary to circumcision. Urology 1976; 8: 472-4.
      • Izzidien AY. Successful replantation of a traumatically amputated penis in a neonate. Journal of Pediatric Surgery April 1981,16(2):202-203.
      • Hanash KA. Plastic reconstruction of partially amputated penis at circumcision. Urology 1981; 18(3): 291-3.
      • Azmy A, Boddy SA, Ransley PG. Successful reconstruction following circumcision with diathermy. Br J Urol 1985; 57: 587-8.
      • Yilmaz AF, Sarikaya S, Yildiz S, et al. Rare complication of circumcision: penile amputation and reattachment. European Urology (Basel) 1993; 23(3): 423-424.
      • Audry G, Buis J, Vazquez MP, Gruner M. Amputation of penis after circumcision--penoplasty using expandable prosthesis. Eur J Pediatr Surg 1994; 4: 44-5.
      • Hanukoglu A, Danielli L, Katzir Z, Gorenstein A, Fried D. Serious complications of routine ritual circumcision in a neonate: hydro ureteronephrosis, amputation of glans penis, and hyponatraemia. Eur J Pediatr 1995; 154: 314-5.
      • Gluckman GR et al. Newborn Penile Glans Amputation During Circumcision and Successful Reattachment. Journal of Urology (Baltimore), vol. 153 no. 3 Part 1 March 1995 pp. 778-779.
      • Strimling BS. Partial amputation of glans penis during Mogen clamp circumcision. Pediatrics 1996; 97: 906-7.
      • Neulander E, Walfisch S. Kaneti J. Amputation of distal penile glans during neonatal ritual circumcision -- a rare complication. Br J Urol 1996; 77: 924-5.
      • Sherman J, Borer JG, Horowitz M, Glassberg KI. Circumcision: successful glanular reconstruction and survival following amputation. J Urol 1996; 156: 842.
      • Van Howe RS. Re: circumcision: successful glanular reconstruction and survival following traumatic amputation (Letter). J Urol . 1997;158:550.
      • Coskunfirat OK, Sayiklkan S, Velidedeoglu H.. Glans and penile skin amputation as a complication of circumcision (letter). Ann Plast Surg 1999;43(4):457.
      • Siegel-Itzkovich J. Baby's penis reattached after botched circumcision. BMJ 2000;321:529.
      • Park JK, Min JK, Kim HJ. Reimplantation of an amputated penis in prepubertal boys. J Urol 2001;165:586-7.
    • 29. References 4
      • Pain Response
      • 45. Taddio A, Koren G et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet, Vol. 349: Pages 599-603 (March 1, 1997).
      • Infection
      • Gee, W. F., and Ansell, J. S.: Neonatal circumcision: A ten-year overview with comparison of the Gomco clamp and the Plastibell device. Pediatrics , 55:524, 1976.
      • Fraser, I. A., Allen, M. J., Bagshaw, P. F., et al.: A randomized trial to assess childhood circumcision with the Plastibell device compared with a conventional dissection technique. Br. J. Surg ., 68:593-595, 1968.
      • Meatitis
      • Daley, M. C.: Circumcision. J.A.M.A ., 214:2195, 1970.
      • Lairdner, D. [sic, should be Gairdner] : The fate of the foreskin. A study of circumcision. Br. Med. J ., 2:1433, 1949.
      • Mackenzie, A. R.: Meatal ulceration following neonatal circumcision. Obstet Gynecol ., 28:221, 1966.
      • Patel, H.: The problem of routine circumcision. Can. Med. Assoc. J ., 95:576, 1966.
      • Necrosis
      • Davidson, F.: Yeasts and circumcision in the male. Br. J. Ven. Dis ., 53:121-122, 1977.
      • Money, J.: Ablatio penis: normal male infant reassigned as a girl. Arch Sex. Behav ., 4:65-71. 1975.
      • Sterenberg. N., Golan, J., and Ben-Hur, N.: Necrosis of the glans penis following neonatal circumcision. Plast. Reconstr. Surg ., 68:237-239, 1981.
      • Major Morbidity
      • Thorek, P., and Egel, P.: Reconstruction of the penis with split-thickness skin graft. Plast. Reconstruc. Surg ., 4: 469, 1969.
      • Woodside, J. R. Necrotizing fascitis after circumcision. Am. J. Dis. Child ., 134:301, 1980.
      • Annunziato, D. and Goldman, L. M.: Staphylococcal scalded skin syndrome. A complication of circumcision. Am. J. Dis. Child 132:1178-1188; 1978.
      • Sussman, S. J., Schiller, R. P., and Shaskikumar, V. L.: Fournier's syndrome and review of the literature. Am. J. Dis. Child .
    • 30. References 5
      • Major Morbidity Continued
      • Kirkpatrick, B. V., and Eitzman, D. V.: Neonatal septicemia after circumcision. Clin. Pediatr ., 13:767-768, 1974.
      • Procopis, P. G., and Kewley, G. D. Complication of circumcision. Med. J. Aust ., 1:15, 1982.
      • Death
      • Cleary, T. G., and Kohl, S.: Overwhelming infection with group B beta-hemolytic streptococcus associated with circumcision. Pediatrics , 64: 301-307, 1979.
      • Scurlock, J. M. and Pemberton, P. J.: Neonatal meningitis and circumcision. Med. J. Aust ., 1:332-334.
      • Innervation of the Foreskin
      • Z. Halata and B. L. Munger, "The Neuroanatomical Basis for the Protopathic Sensibility of the Human Glans Penis," Brain Research 371 (1986): 205-230.
      • J. R. Taylor et al, "The Prepuce: Specialized Mucosa of the Penis and its Loss to Circumcision," British Journal of Urology 77 (1996): 291-295.
      • H. C. Bazett et al, "Depth, Distribution and Probable Identification in the Prepuce of Sensory End-Organs Concerned in Sensations of Temperature and Touch, Thermometric Conductivity," Archives of Neurology and Psychiatry 27 (1932): 489-517
      • D. Ohmori, "Uber die Entwicklung der Innervation der Genitalapparate als Peripheren Aufnahmeapparat der Genitalen Reflexe," Zeitschrift fur Anotomie und Entwicklungsgeschichte 70 (1924): 347-410.
      • A. De Girolamo and A. Cecio, "Contributo alla Conoscenza dell'innervazione Sensitiva del Prepuzio Nell'uomo,' Bollettino della Societa Italiona de Biologia Sperimentale 44 (1968):1521-1522.
      • A. S. Dogiel, "Die Nervenendigungen in der Haut der ausseren Genitalorgane des Menschen," Archiv fur Mikroskopische Anotomie 41 (1893): 585-612.
      • A. Bourlond and R. K. Winkelmann, "Linnervation du Prepuce chez le Nouveau-ne", Archives Belges de Dermatologie et de Syphiligraphie 21 (1965):139-153.
      • R. K. Winkelmann, "The Erogenous Zones: Their Nerve Supply and its Significance," Proceedings of the Staff Meetings of the Mayo Clinic 34 (1959): 39-47.
      • R. K. Winkelmann, "The Cutaneous innervation of Human Newborn Prepuce," Journal of Investigative Dermatology 26 (1956): 53-67
    • 31. References 6
      • Decreased sensation
      • Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychological Reports 2001;88:1106-1106.
      • Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5):2113-2116.
      • Zwang G. Functional and erotic consequences of sexual mutilations. In: GC Denniston and MF Milos, eds. Sexual Mutilations: A Human Tragedy New York and London: Plenum Press, 1997 (ISBN 0-306-45589-7).
      • Erectile problems
      • Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5):2113-2116.
      • Stinson JM. Impotence and adult circumcision. J Nat Med Assoc 1973;65:161.
      • Sexual problems for female partner
      • 77. O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1, 79-84.
      • Psychological Problems
      • 78. Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychological Reports 2001;88:1106-1106.
      • No difference in STD rate and wider set of sexual behaviors
      • 79. Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13):1052-1057.
      • Wider set of sexual behaviors and increased resistance to condom use
      • 80. Michael RT, Wadsworth J, Feinleib J, et al. Private sexual behavior, public opinion, and public health policy related to sexually transmitted diseases: a US-British comparison. Am J Public Health 1998;88(5):749-54.
    • 32. References 7 Urinary Tract Infection 81. Bollgren I, Winberg J. Letter. [Rebuttal of Edgar J. Schoen] Acta Paediatrica Scandinavia 1991; 80:575-7. 82. Amato D, Garduno-Espinosa J. Circumcision of the newborn male and the risk of urinary tract infection during the first year: A meta-analysis. Bol Med Infant Mex Volume 49, Number 10, October 1992, 652-658. 83. Craig JC et al. Effect of circumcision on incidence of urinary tract infection in preschool boys. From the Department of Nephrology, Royal Alexandra Hospital for Children, Sydney, Australia. Cervical Cancer 84. Elizabeth Stern; Peter M. Neely. "Cancer of the Cervix in Reference to Circumcision and Marital History," Journal of the American Medical Women's Association, vol. 17, no. 9 (September 1962): pp. 739-740.
    • 33. Additional Material
          • Supplementary material is contained in the following slides
    • 34. Early Quotes of Circumcision Benefits
      • Clumsiness and bed-wetting
        • 1887 “[His] Hip trouble is from falling down, an accident that children with tight foreskins are specially liable to, owing to the weakening of the muscles produced by the condition of the genitals.”
          • Lewis L. Sayer, MD, “Circumcision for the Cure of Enuresis,” Journal of the American Medical Association, Vol. 7, 1887. pp.631-633.
      • Neurological disorders
        • 1895 “In all cases in which male children are suffering nerve tension, confirmed derangement of the digestive organs, restlessness, irritability, and other disturbances of the nervous system, even to chorea, convulsions, and paralysis, or where through nerve waste the nutritive facilities of the general system are below par and structural diseases are occurring, circumcision should be considered as among the lines of treatment to be pursued.”
          • Charles E. Fisher, Circumcision, in A Hand-Book On the Diseases of Children and Their Homeopathic Treatment . Chicago: Medical Century Co., 1895. p.875.
    • 35. The Trend Continues
          • “ Measures more radical than circumcision would, if public opinion permitted their adoption, be a true kindness to patients of both sexes.”
            • Jonathan Hutchinson, On Circumcision as Preventative of Masturbation , Archives of Surgery, vol. 2 (1891): pp. 267-268.
          • 1902 “I have repeatedly seen such cases as convulsions, constant crying in infants, simulated hip joint diseases, backwardness in studies, enuresis, marasmus, muscular incoordination, paralysis, masturbation, neurasthenia, and even epilepsy, cured or greatly benefited by the proper performance of circumcision."
            • W.G.Steele, MD. “Importance of Circumcision.” Medical World,Vol. 20 (1902): pp.518-519.
    • 36. Skin Bridges
      • Abnormal bonding of penile skin as a result of circumcision
      • May result in physical and psychological discomfort
    • 37. Legislation
      • Female circumcision
        • U.S. – Illegal to perform on a minor since 1996 [17 below]
        • Legislation criminalizing FC/FGM has been adopted in 16 countries, including 9 in Africa. [15 below]
      • Male circumcision
        • Sweden – On June 1, 2001, the Swedish Parliament passed a law restricting circumcision to licensed practitioners, except for religious circumcision in the first two months of life.
        • Finland – The consent of both parents is now required.
      • Involuntary intersex gender assignment
        • No legislation.
    • 38. Similar attitudes about Male and Female Circumcision
      • Clitoridectomy and Infibulation in Africa
      • "She loses only a little piece of the clitoris, just the part that protrudes. The girl does not miss it. She can still feel, after all. There is hardly any pain. Women's pain thresholds are so much higher than men's."
      • "The parts that are cut away are disgusting and hideous to look at. It is done for the beauty of the suture."
      • "Female circumcision protects the health of a woman. Infibulation prevents the uterus from falling out [uterine prolapse]. It keeps her smelling so sweet that her husband will be pleased. If it is not done, she will stink and get worms in her vagina."
      • "Leaving a girl uncircumcised endangers both her husband and her baby. If the baby's head touches the uncut clitoris during birth, the baby will be born hydrocephalic [excess cranial fluid]. The milk of the mother will become poisonous. If a man's penis touches a woman's clitoris he will become impotent."
      • "A circumcised woman is sexually more pleasing to her husband. The tighter she is sewn, the more pleasure he has."
      • "Doctors do it, so it must be a good thing."
      • 35 year old Sudanese woman: "Yes, I have suffered from chronic pelvic infections and terrible pain for years now. You say that all if this is the result of my circumcision? But I was circumcised over 30 years ago! How can something that was done for me when I was four years old have anything to do with my health now?"
      Infant Male Circumcision in North America "It's only a little piece of skin. The baby does not feel any pain because his nervous system is not developed yet.“ "An uncircumcised penis is a real turn-off. Its disgusting. It looks like the penis of an animal." "An uncircumcised penis causes urinary infections and penile cancer. It generates smegma and smegma stinks. A circumcised penis is more hygienic and oral sex with an uncircumcised penis is disgusting to women." "Men have an obligation to their wives to give up their foreskin. An uncircumcised penis will cause cervical cancer in women. It also spreads disease." "Circumcised men make better lovers because they have more staying power than uncircumcised men." "Doctors do it, so it must be a good thing." 35 years old American male: "I have lost nearly all interest in sex. You might say that I'm becoming impotent. I don't seem to have much sensation in my penis anymore, and it is becoming more and more difficult for me to reach orgasm. You say that this is the result of my circumcision? That doesn't make any sense. I was circumcised 35 years ago, when I was a little boy. How can that affect me in any way now?"

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