Circumcision

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Circumcision

  1. 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. 2. Objectives: To Understand: <ul><li>What circumcision is </li></ul><ul><li>Where circumcision is practiced </li></ul><ul><li>Why it came to be practiced </li></ul><ul><li>How it is done </li></ul><ul><li>Potential complications to infants and children </li></ul><ul><li>The anatomical structures removed </li></ul><ul><li>The lasting effects in adults </li></ul><ul><li>Where to go for more information </li></ul>
  3. 3. Genital Cutting <ul><li>Is defined as the alteration or amputation of healthy tissue from an individual’s genitalia </li></ul><ul><li>Has been performed by some U.S. physicians since the turn of the century </li></ul><ul><li>Has been a ritual in some cultures for thousands of years </li></ul>
  4. 4. Where Genital Cutting Occurs Today Female Male
  5. 5. Female Genital Cutting <ul><li>Approximately 2% of women are circumcised worldwide </li></ul><ul><li>Benefits asserted by practitioners include </li></ul><ul><ul><li>Hygienic benefits for the woman </li></ul></ul><ul><ul><li>Safety benefits for her children </li></ul></ul><ul><ul><li>Esthetic or pleasurable benefits for her mate </li></ul></ul><ul><li>World Health Organization defines female genital mutilation (FGM): </li></ul><ul><ul><li>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 . </li></ul></ul><ul><ul><li>Type I (~80%) – excision of prepuce and or part or all of clitoral tip </li></ul></ul><ul><ul><li>Type II - excision of clitoral tip with partial or total excision of labia minora </li></ul></ul><ul><ul><li>Type III (~15%) – excision of part or all of external genitalia and stitching/narrowing of vaginal opening (infibulation or pharaonic circumcision) </li></ul></ul><ul><ul><li>Type IV – other alteration to the female genital organs </li></ul></ul>
  6. 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. 7. Medical Claims for Male Genital Cutting <ul><li>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.” </li></ul><ul><ul><ul><li>Athol A. W. Johnson On An Injurious Habit Occasionally Met with in Infancy and Early Childhood, The Lancet, vol. 1 (7 April 1860) </li></ul></ul></ul><ul><li>1860’s and 70’s Epilepsy, phimosis, penile cancer, masturbation, paralysis, hip-joint disease, digestive disorders </li></ul><ul><li>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 </li></ul><ul><li>1940’s Most venereal diseases </li></ul><ul><li>1980’s HIV </li></ul><ul><li>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. </li></ul>
  8. 8. Circumcision Preparation – the Restraint
  9. 9. Infant Circumcision A B C F E D
  10. 10. Surgical Complications - Penile Structure <ul><li>Scarring always occurs </li></ul><ul><li>Uneven circumcision is common </li></ul><ul><li>15% of examined circumcised males had penile adhesions in Ref. [1] </li></ul><ul><li>Lymphedema [2] </li></ul><ul><li>Skin bridges [3-5] </li></ul><ul><li>Urethral fistulas, hypospadius and epispadius (a) [6-14] </li></ul><ul><li>Buried, concealed, and hidden penis (c) [15-27] </li></ul><ul><li>Penile amputation (d) [28-44] </li></ul>
  11. 11. Infant & Child Postoperative Complications <ul><li>Difficulty breastfeeding. </li></ul><ul><li>Aggravated response to pain in infants months later. [45] </li></ul><ul><li>Infection. Incidence in neonatal circumcisions was 0.4% [46], in older boys as high as 10% [47] </li></ul><ul><li>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 </li></ul><ul><li>Necrosis. Necrosis and slough of the glans or even entire penis has been reported following circumcision.[52-54] Rates unknown, probably rare </li></ul><ul><li>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 </li></ul><ul><li>Severe permanent disability or death. Rates unknown, probably rare [61,62] </li></ul>
  12. 12. Anesthetic or No Anesthetic? <ul><li>Anesthetic risks </li></ul><ul><ul><li>General anesthesia has led to deaths </li></ul></ul><ul><ul><li>Local anesthetic agents injected into the corpora cavernosa can produce impotence; the rate is unknown </li></ul></ul><ul><ul><li>Idiosyncratic reactions and overdosage </li></ul></ul><ul><ul><li>Epinephrine may produce local tissue problems or systemic toxicity </li></ul></ul><ul><li>Without anesthesia </li></ul><ul><ul><li>Decreased pO 2 </li></ul></ul><ul><ul><li>Increased serum cortisol </li></ul></ul><ul><ul><li>Increased withdrawal </li></ul></ul><ul><ul><li>One recorded instance precipitated a pneumothorax </li></ul></ul><ul><ul><li>Greater long-term increased response to painful stimuli [45] </li></ul></ul>
  13. 13. Consensus: Prevention and Management of Pain in the Newborn <ul><li>Compared with older age groups newborns </li></ul><ul><ul><li>may experience greater sensitivity to pain </li></ul></ul><ul><ul><li>such pain may have long-term consequences </li></ul></ul><ul><ul><li>a lack of behavioral response (for example, lack of crying) does not necessarily indicate a lack of pain </li></ul></ul><ul><li>Health care professionals should “prevent, reduce, or eliminate the stress and pain of neonates.” </li></ul><ul><ul><ul><li>Joint statement, American Academy of Pediatrics and Canadian Paediatric Society </li></ul></ul></ul>
  14. 14. Care of the Circumcised Penis <ul><li>After circumcision </li></ul><ul><ul><li>Tip of the penis may seem raw or yellowish </li></ul></ul><ul><ul><li>May have yellow discharge for up to a week </li></ul></ul><ul><ul><li>Change bandage at each diapering to reduce risk of infection </li></ul></ul><ul><ul><li>Use petroleum jelly or vitamin A&D ointment to keep bandages from sticking to wound </li></ul></ul><ul><ul><li>It takes 7 to 10 days for the penis to heal after circumcision </li></ul></ul><ul><li>Watch for </li></ul><ul><ul><li>Lack of urination within 6 to 8 hours after the circumcision </li></ul></ul><ul><ul><li>Persistent bleeding </li></ul></ul><ul><ul><li>Indications of infection: swelling, foul-smelling drainage, or redness around the tip of the penis that gets worse after 3 to 5 days </li></ul></ul>
  15. 15. Care of the Unaltered Penis <ul><li>Do not use force to retract foreskin </li></ul><ul><li>Foreskin becomes retractile usually before puberty </li></ul><ul><li>Do not wash with harsh soaps or abrasives </li></ul>
  16. 16. The Adult Foreskin <ul><li>The most erogenous tissue in the male body </li></ul><ul><li>12-15 square inches </li></ul><ul><li>10,000-20,000 nerve endings </li></ul><ul><li>240 feet of nerves </li></ul><ul><li>3-4 feet of blood vessels </li></ul><ul><li>Specialized structures </li></ul><ul><ul><li>Frenulum </li></ul></ul><ul><ul><li>Frenular delta </li></ul></ul><ul><ul><li>Ridged band (frenar band) </li></ul></ul><ul><ul><li>Dartos muscle </li></ul></ul>
  17. 17. Comparing Anatomy During Erection
  18. 18. The Adult Penis Intact or Cut
  19. 19. Protective Functions of the Foreskin <ul><li>Contains or emits </li></ul><ul><ul><li>Lysozyme (natural antibacterial agent) </li></ul></ul><ul><ul><li>Immunoglobulins (antibodies) </li></ul></ul><ul><ul><li>Langerhans cells (an immune system component) </li></ul></ul><ul><ul><li>Sebaceous glands and sebum (moisturizing oil) </li></ul></ul><ul><li>That may serve to </li></ul><ul><ul><li>Prevent mucosal tissue and glans from over-keratinizing </li></ul></ul><ul><ul><li>In infancy, protects the urethra against contamination, meatal stenosis, and Urinary Tract Infections (UTIs) </li></ul></ul><ul><li>The skin covering itself also </li></ul><ul><ul><li>Protects mucosal tissue and glans from injury </li></ul></ul><ul><ul><li>Protects the nerves of the mucosal tissue and glans </li></ul></ul><ul><ul><li>Protects the glans against sunburn, frostbite, and other environmental hazards </li></ul></ul>
  20. 20. Sexual Functions of the Foreskin <ul><li>Erotic pleasure, via the ridged band (aka. frenar or frenular band) [63-71] </li></ul><ul><li>Contains most of the specialized fine-touch nerve endings (Meissner's corpuscles) in the penis [63-71] </li></ul><ul><li>Store pheromones and release them on arousal </li></ul><ul><li>Store and release natural lubricants </li></ul><ul><li>Make the glans a visual signal of sexual arousal </li></ul><ul><li>Supply skin to cover the shaft in erection </li></ul><ul><li>Reduce friction in intercourse and masturbation </li></ul><ul><li>Prevent dyspareunia (painful intercourse) </li></ul><ul><li>Stimulate partner's genitalia </li></ul><ul><li>Retain lubrication within the vagina </li></ul>
  21. 21. Current Claims of Circumcision Benefits <ul><li>Medical </li></ul><ul><ul><li>Reduce penile cancer incidence </li></ul></ul><ul><ul><li>Reduce UTI occurrence rate </li></ul></ul><ul><ul><li>Reduce STD transmission rates </li></ul></ul><ul><ul><li>Reduce cervical cancer rate in female partner </li></ul></ul><ul><li>The most commonly cited benefits: </li></ul><ul><ul><li>Preferred appearance </li></ul></ul><ul><ul><li>Circumcised penis does not require rinsing </li></ul></ul>
  22. 22. Circumcision is Associated with <ul><li>Decreased pleasurable sensation for the man [72-74] </li></ul><ul><li>Increased erectile problems [75-76] </li></ul><ul><li>Increased sexual problems for female partners [77] </li></ul><ul><li>Psychological problems, including anger, grief, difficulty with trust, inhibited intimacy, communication challenges [78] </li></ul><ul><li>Increased diversity of sexual behaviors [79,80] </li></ul><ul><li>Increased resistance to condom use [80] </li></ul><ul><li>No difference in STD transmission rate [79] </li></ul><ul><li>Increased risk of UTIs [81-83] </li></ul><ul><li>No difference in cervical cancer rates for sexual partners [84] </li></ul><ul><li>“ Circumcision is not considered to be beneficial in preventing or reducing the risk of penile cancer,” American Cancer Society (1999) </li></ul>
  23. 23. <ul><li>“ Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.” </li></ul><ul><li>-- American Academy of Pediatrics 1999 </li></ul><ul><li>“ There is no medical indication for routine male circumcision…. The foreskin requires no special care during infancy. It should be left alone.” </li></ul><ul><li>-- The Royal Australasian College of Physicians 2002 </li></ul>Two Position Statements
  24. 24. Genital Cutting <ul><li>Is practiced on about 15% of males and 2% of females worldwide </li></ul><ul><li>Is the amputation of functional genital tissue </li></ul><ul><li>Was introduced into medicine to alter sexuality </li></ul><ul><li>Is painful </li></ul><ul><li>Has risks of surgical complication </li></ul><ul><li>Leaves recipients with lifelong detrimental effects </li></ul><ul><li>Does not promote health </li></ul>
  25. 25. Further Resources <ul><li>Circumcision information </li></ul><ul><ul><li>www.cirp.org – Collected scientific journal articles </li></ul></ul><ul><ul><li>www.nocirc.org – International symposia on genital integrity </li></ul></ul><ul><ul><li>www.doctorsopposingcircumcision.org </li></ul></ul><ul><li>Local education and advocacy </li></ul><ul><ul><li>www.notjustskin.org – Maryland Circumcision Information Resource Center </li></ul></ul><ul><li>Healing </li></ul><ul><ul><li>www.norm.org – National Organization of Restoring Men </li></ul></ul>
  26. 26. References 1 <ul><li>Penile Adhesions </li></ul><ul><li>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. </li></ul><ul><li>Lymphedema. Penile lymphedema may occur following circumcision especially if the wound separates or becomes infected. Skin grafting may be required for resolution. </li></ul><ul><li>Shulman, J. Ben-Hur, N., and Neuman, Z.: Surgical complications of circumcision. Am. J. Dis. Child ., 127:149; 1964. </li></ul><ul><li>Skin Bridges </li></ul><ul><li>Klauber GT, Boyle J. Preputial skin-bridging. Complication of circumcision. Urology 1974; 3: 722-3. </li></ul><ul><li>Sathaye VU, Goswami AK, Sharma SK. Skin bridge - a complication of paediatric circumcision. Br J Urol 1990; 66: 214. </li></ul><ul><li>Ritchey ML, Bloom DA. Re: Skin bridge--a complication of paediatric circumcision. Br J Urol 1991; 68: 331. </li></ul><ul><li>Urethral Fistula </li></ul><ul><li>Johnson S. Persistent urethral fistula following circumcision: report of a case. US Naval Med Bull 1949; 49: 120-2. </li></ul><ul><li>Limaye RD, Hancock RA. Penile urethral fistula as a complication of circumcision. J Pediatr 1968; 72: 105-6. </li></ul><ul><li>Lackey JT, Mannion RA, Kerr JE. Urethral fistula following circumcision. JAMA 1968; 206: 2318. </li></ul><ul><li>Lackey JT, Mannion RA, Kerr JE. Subglanular urethral fistula from infant circumcision. J Indiana State Med Assoc 1969; 62: 1305-6. </li></ul><ul><li>Shiraki, IW. Congenital megalourethra with urethracutaneous fistula following circumcision: a case report. J Urol 1973: 109: 723. </li></ul><ul><li>Lau, JTK, Ong GB. Subglandular urethral fistula following circumcision: repair by the advancement method. J Urol 1981; 126: 702-703. </li></ul><ul><li>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. </li></ul><ul><li>Palmer SY, Colodny AH. Congenital urethrocutaneous fistulas. Urology . 1994; 44: 149-50. </li></ul><ul><li>Baskin LS. Canning DA. Snyder III HM. Duckett JW Jr. Surgical repair of urethral circumcision injuries. Journal d'Urologie 1997;158(6):2269-2271. </li></ul>
  27. 27. References 2 <ul><li>Buried, Concealed, and Hidden Penis </li></ul><ul><li>Stewart DH. The toad in the hole circumcision -- a surgical bugbear. Boston Med Surg J 1924; 191: 1216-8. </li></ul><ul><li>Talarico RD, Jasaitis JE. Concealed penis: a complication of neonatal circumcision. J Urol 1973; 110: 732-3. </li></ul><ul><li>Trier WC, Drach GW. Concealed penis. Another complication of circumcision. Am J Dis Child 1973; 125: 276-7. </li></ul><ul><li>Radhakrishnan J, Reyes HM. Penoplasty for buried penis secondary to &quot;radical&quot; circumcision. J Pediatr Surg 1984; 19: 629-31. </li></ul><ul><li>Kon M. A rare complication following circumcision: the concealed penis. J Urol 1983; 130: 573-4. </li></ul><ul><li>Donahoe PK, Keating MA. Preputial unfurling to correct the buried penis. J Pediatr Surg 1986; 21: 1055-7. </li></ul><ul><li>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. </li></ul><ul><li>Shapiro SR. Surgical treatment of the &quot;buried&quot; penis. Urology 1987; 30: 554-9. </li></ul><ul><li>Horton CE, Vorstman B, Teasley D, Winslow B. Hidden penis release: adjunctive suprapubic lipectomy. Ann Plast Surg 1987; 19: 131-4. </li></ul><ul><li>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. </li></ul><ul><li>Bergeson PS. et al. The Inconspicuous Penis. Department of General Pediatrics and Urology, Phoenix Children's Hospital. Pediatrics 1993; 92: 794-9. </li></ul><ul><li>Alter GJ, Horton CE Jr; Horton CE Jr. Buried penis as a contraindication for circumcision. J Am Coll Surg 1994; 178: 487-90. </li></ul><ul><li>Alter G. Buried Penis. (link to http://www.altermd.com/pconstruct/urethral.htm) </li></ul><ul><li>Penile Amputation </li></ul><ul><li>Brimhall JB. Amputation of the penis following a unique method of preventing hemorrhage after circumcision. St Paul Med J 1902; 4: 490. </li></ul><ul><li>Lerner BL. Amputation of the penis as a complication of circumcision. Med Rec Ann 1952;46:229-31. </li></ul>
  28. 28. References 3 <ul><li>Penile Amputation Continued </li></ul><ul><li>Levitt SB, Smith RB, Ship AG. Iatrogenic microphallus secondary to circumcision. Urology 1976; 8: 472-4. </li></ul><ul><li>Izzidien AY. Successful replantation of a traumatically amputated penis in a neonate. Journal of Pediatric Surgery April 1981,16(2):202-203. </li></ul><ul><li>Hanash KA. Plastic reconstruction of partially amputated penis at circumcision. Urology 1981; 18(3): 291-3. </li></ul><ul><li>Azmy A, Boddy SA, Ransley PG. Successful reconstruction following circumcision with diathermy. Br J Urol 1985; 57: 587-8. </li></ul><ul><li>Yilmaz AF, Sarikaya S, Yildiz S, et al. Rare complication of circumcision: penile amputation and reattachment. European Urology (Basel) 1993; 23(3): 423-424. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Strimling BS. Partial amputation of glans penis during Mogen clamp circumcision. Pediatrics 1996; 97: 906-7. </li></ul><ul><li>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. </li></ul><ul><li>Sherman J, Borer JG, Horowitz M, Glassberg KI. Circumcision: successful glanular reconstruction and survival following amputation. J Urol 1996; 156: 842. </li></ul><ul><li>Van Howe RS. Re: circumcision: successful glanular reconstruction and survival following traumatic amputation (Letter). J Urol . 1997;158:550. </li></ul><ul><li>Coskunfirat OK, Sayiklkan S, Velidedeoglu H.. Glans and penile skin amputation as a complication of circumcision (letter). Ann Plast Surg 1999;43(4):457. </li></ul><ul><li>Siegel-Itzkovich J. Baby's penis reattached after botched circumcision. BMJ 2000;321:529. </li></ul><ul><li>Park JK, Min JK, Kim HJ. Reimplantation of an amputated penis in prepubertal boys. J Urol 2001;165:586-7. </li></ul>
  29. 29. References 4 <ul><li>Pain Response </li></ul><ul><li>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). </li></ul><ul><li>Infection </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Meatitis </li></ul><ul><li>Daley, M. C.: Circumcision. J.A.M.A ., 214:2195, 1970. </li></ul><ul><li>Lairdner, D. [sic, should be Gairdner] : The fate of the foreskin. A study of circumcision. Br. Med. J ., 2:1433, 1949. </li></ul><ul><li>Mackenzie, A. R.: Meatal ulceration following neonatal circumcision. Obstet Gynecol ., 28:221, 1966. </li></ul><ul><li>Patel, H.: The problem of routine circumcision. Can. Med. Assoc. J ., 95:576, 1966. </li></ul><ul><li>Necrosis </li></ul><ul><li>Davidson, F.: Yeasts and circumcision in the male. Br. J. Ven. Dis ., 53:121-122, 1977. </li></ul><ul><li>Money, J.: Ablatio penis: normal male infant reassigned as a girl. Arch Sex. Behav ., 4:65-71. 1975. </li></ul><ul><li>Sterenberg. N., Golan, J., and Ben-Hur, N.: Necrosis of the glans penis following neonatal circumcision. Plast. Reconstr. Surg ., 68:237-239, 1981. </li></ul><ul><li>Major Morbidity </li></ul><ul><li>Thorek, P., and Egel, P.: Reconstruction of the penis with split-thickness skin graft. Plast. Reconstruc. Surg ., 4: 469, 1969. </li></ul><ul><li>Woodside, J. R. Necrotizing fascitis after circumcision. Am. J. Dis. Child ., 134:301, 1980. </li></ul><ul><li>Annunziato, D. and Goldman, L. M.: Staphylococcal scalded skin syndrome. A complication of circumcision. Am. J. Dis. Child 132:1178-1188; 1978. </li></ul><ul><li>Sussman, S. J., Schiller, R. P., and Shaskikumar, V. L.: Fournier's syndrome and review of the literature. Am. J. Dis. Child . </li></ul>
  30. 30. References 5 <ul><li>Major Morbidity Continued </li></ul><ul><li>Kirkpatrick, B. V., and Eitzman, D. V.: Neonatal septicemia after circumcision. Clin. Pediatr ., 13:767-768, 1974. </li></ul><ul><li>Procopis, P. G., and Kewley, G. D. Complication of circumcision. Med. J. Aust ., 1:15, 1982. </li></ul><ul><li>Death </li></ul><ul><li>Cleary, T. G., and Kohl, S.: Overwhelming infection with group B beta-hemolytic streptococcus associated with circumcision. Pediatrics , 64: 301-307, 1979. </li></ul><ul><li>Scurlock, J. M. and Pemberton, P. J.: Neonatal meningitis and circumcision. Med. J. Aust ., 1:332-334. </li></ul><ul><li>Innervation of the Foreskin </li></ul><ul><li>Z. Halata and B. L. Munger, &quot;The Neuroanatomical Basis for the Protopathic Sensibility of the Human Glans Penis,&quot; Brain Research 371 (1986): 205-230. </li></ul><ul><li>J. R. Taylor et al, &quot;The Prepuce: Specialized Mucosa of the Penis and its Loss to Circumcision,&quot; British Journal of Urology 77 (1996): 291-295. </li></ul><ul><li>H. C. Bazett et al, &quot;Depth, Distribution and Probable Identification in the Prepuce of Sensory End-Organs Concerned in Sensations of Temperature and Touch, Thermometric Conductivity,&quot; Archives of Neurology and Psychiatry 27 (1932): 489-517 </li></ul><ul><li>D. Ohmori, &quot;Uber die Entwicklung der Innervation der Genitalapparate als Peripheren Aufnahmeapparat der Genitalen Reflexe,&quot; Zeitschrift fur Anotomie und Entwicklungsgeschichte 70 (1924): 347-410. </li></ul><ul><li>A. De Girolamo and A. Cecio, &quot;Contributo alla Conoscenza dell'innervazione Sensitiva del Prepuzio Nell'uomo,' Bollettino della Societa Italiona de Biologia Sperimentale 44 (1968):1521-1522. </li></ul><ul><li>A. S. Dogiel, &quot;Die Nervenendigungen in der Haut der ausseren Genitalorgane des Menschen,&quot; Archiv fur Mikroskopische Anotomie 41 (1893): 585-612. </li></ul><ul><li>A. Bourlond and R. K. Winkelmann, &quot;Linnervation du Prepuce chez le Nouveau-ne&quot;, Archives Belges de Dermatologie et de Syphiligraphie 21 (1965):139-153. </li></ul><ul><li>R. K. Winkelmann, &quot;The Erogenous Zones: Their Nerve Supply and its Significance,&quot; Proceedings of the Staff Meetings of the Mayo Clinic 34 (1959): 39-47. </li></ul><ul><li>R. K. Winkelmann, &quot;The Cutaneous innervation of Human Newborn Prepuce,&quot; Journal of Investigative Dermatology 26 (1956): 53-67 </li></ul>
  31. 31. References 6 <ul><li>Decreased sensation </li></ul><ul><li>Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychological Reports 2001;88:1106-1106. </li></ul><ul><li>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. </li></ul><ul><li>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). </li></ul><ul><li>Erectile problems </li></ul><ul><li>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. </li></ul><ul><li>Stinson JM. Impotence and adult circumcision. J Nat Med Assoc 1973;65:161. </li></ul><ul><li>Sexual problems for female partner </li></ul><ul><li>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. </li></ul><ul><li>Psychological Problems </li></ul><ul><li>78. Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychological Reports 2001;88:1106-1106. </li></ul><ul><li>No difference in STD rate and wider set of sexual behaviors </li></ul><ul><li>79. Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13):1052-1057. </li></ul><ul><li>Wider set of sexual behaviors and increased resistance to condom use </li></ul><ul><li>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. </li></ul>
  32. 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. &quot;Cancer of the Cervix in Reference to Circumcision and Marital History,&quot; Journal of the American Medical Women's Association, vol. 17, no. 9 (September 1962): pp. 739-740.
  33. 33. Additional Material <ul><ul><ul><li>Supplementary material is contained in the following slides </li></ul></ul></ul>
  34. 34. Early Quotes of Circumcision Benefits <ul><li>Clumsiness and bed-wetting </li></ul><ul><ul><li>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.” </li></ul></ul><ul><ul><ul><li>Lewis L. Sayer, MD, “Circumcision for the Cure of Enuresis,” Journal of the American Medical Association, Vol. 7, 1887. pp.631-633. </li></ul></ul></ul><ul><li>Neurological disorders </li></ul><ul><ul><li>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.” </li></ul></ul><ul><ul><ul><li>Charles E. Fisher, Circumcision, in A Hand-Book On the Diseases of Children and Their Homeopathic Treatment . Chicago: Medical Century Co., 1895. p.875. </li></ul></ul></ul>
  35. 35. The Trend Continues <ul><ul><ul><li>“ Measures more radical than circumcision would, if public opinion permitted their adoption, be a true kindness to patients of both sexes.” </li></ul></ul></ul><ul><ul><ul><ul><li>Jonathan Hutchinson, On Circumcision as Preventative of Masturbation , Archives of Surgery, vol. 2 (1891): pp. 267-268. </li></ul></ul></ul></ul><ul><ul><ul><li>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.&quot; </li></ul></ul></ul><ul><ul><ul><ul><li>W.G.Steele, MD. “Importance of Circumcision.” Medical World,Vol. 20 (1902): pp.518-519. </li></ul></ul></ul></ul>
  36. 36. Skin Bridges <ul><li>Abnormal bonding of penile skin as a result of circumcision </li></ul><ul><li>May result in physical and psychological discomfort </li></ul>
  37. 37. Legislation <ul><li>Female circumcision </li></ul><ul><ul><li>U.S. – Illegal to perform on a minor since 1996 [17 below] </li></ul></ul><ul><ul><li>Legislation criminalizing FC/FGM has been adopted in 16 countries, including 9 in Africa. [15 below] </li></ul></ul><ul><li>Male circumcision </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Finland – The consent of both parents is now required. </li></ul></ul><ul><li>Involuntary intersex gender assignment </li></ul><ul><ul><li>No legislation. </li></ul></ul>
  38. 38. Similar attitudes about Male and Female Circumcision <ul><li>Clitoridectomy and Infibulation in Africa </li></ul><ul><li>&quot;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.&quot; </li></ul><ul><li>&quot;The parts that are cut away are disgusting and hideous to look at. It is done for the beauty of the suture.&quot; </li></ul><ul><li>&quot;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.&quot; </li></ul><ul><li>&quot;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.&quot; </li></ul><ul><li>&quot;A circumcised woman is sexually more pleasing to her husband. The tighter she is sewn, the more pleasure he has.&quot; </li></ul><ul><li>&quot;Doctors do it, so it must be a good thing.&quot; </li></ul><ul><li>35 year old Sudanese woman: &quot;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?&quot; </li></ul>Infant Male Circumcision in North America &quot;It's only a little piece of skin. The baby does not feel any pain because his nervous system is not developed yet.“ &quot;An uncircumcised penis is a real turn-off. Its disgusting. It looks like the penis of an animal.&quot; &quot;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.&quot; &quot;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.&quot; &quot;Circumcised men make better lovers because they have more staying power than uncircumcised men.&quot; &quot;Doctors do it, so it must be a good thing.&quot; 35 years old American male: &quot;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?&quot;

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