Pediatrician's wife, American Academy of Pediatrics Annual Conference Hyatt-Regency Hotel, Chicago, April 14, 1996 Said:
Where Is My Foreskin?
The Case Against Circumcision
http://www.sexually
Paul M. Fleiss, MD
Western countries have no tradition of circumcision. In antiquity, the expansion of the Greek and Roman Empires brought Westerners into contact with the peoples of the Middle East, some ofwhom marked their children with circumcision and other sexual mutilations. To protect these children, the Greeks and Romans passed laws forbidding circumcision.
Circumcision started in America during the masturbation hysteria of the Victorian Era, when a few American doctors circumcised boys to punish them for masturbating. Victorian doctors knew verywell that circumcision denudes, desensitizes, and disables the penis. Nevertheless, they were soon claiming that circumcision curedepilepsy, convulsions, paralysis, elephantiasis, tuberculosis, eczema,bed-wetting, hip-joint disease, fecal incontinence, rectal prolapse,wet dreams, hernia, headaches, nervousness, hysteria, poor eyesight,idiocy, mental retardation, and insanity.[4]
In fact, no procedure in the history of medicine has beenclaimed to cure and prevent more diseases than circumcision. As late as the 1970s, leading American medical textbooks still advocatedroutine circumcision as a way to prevent masturbation.
The radical practice of routinely circumcising babies did notbegin until the Cold War era. This institutionalizatio
Today the reasons given for circumcision have been updated to play on contemporary fears and anxieties; but one day they, too, will be considered irrational. Now that such current excuses as the claim that this procedure prevents cancer and sexually transmitted diseases have been thoroughly discredited, circumcisers will undoubtedly invent new ones. But if circumcisers were really motivated by purely medicalconsideratio
Millions of years of evolution have fashioned the human bodyinto a model of refinement, elegance, and efficiency, with every part having a function and purpose. Evolution has determined that mammals' genitals should be sheathed in a protective, responsive, multipurposeforeski
Parents should enjoy the arrival of a new child with as few worries as possible. The birth of a son in the US, however, is often fraught with anxiety and confusion. Most parents are pressured to hand their baby sons over to a stranger, who, behind closed doors,straps babies down and cuts their foreskins off. The billion-dollar-
Information about the foreskin itself is almost always missing from discussions about circumcision. The mass circumcision campaigns of the past few decades have resulted in pandemic ignorance about this remarkable structure and its versatile role in human sexuality.Ignorance and false information about the foreskin are the rule inAmerican medical literature, education, and practice. Most American medical textbooks depict the human penis, without explanation, as circumcised, as if it were so by nature.
What Is the Foreskin?
The foreskin is a uniquely specialized, sensitive, functional organ of touch. No other part of the body serves the same purpose. Asa modified extension of the penile shaft skin, the foreskin covers and usually extends beyond the glans before folding under itself and finding its circumferential point of attachment just behind the corona(the rim of the glans). The foreskin is, therefore, a double-layered organ. Its true length is twice the length of its external fold,comprising 80 percent or more of the penile skin covering,[6] or at least 25 percent of the flaccid penis's length.
The foreskin contains a rich concentration of blood vessels and nerve endings. It is lined with the peripenic muscle sheet, a smooth muscle layer with longitudinal fibers. These muscle fibers are whorled, forming a kind of sphincter that ensures optimum protection of the urinary tract from contaminants of all kinds.
Like the under surface of the eyelids or the inside of the cheek, the under surface of the foreskin consists of mucous membrane.It is divided into two distinct zones: the soft mucosa and the ridge dmucosa. The soft mucosa lies against the glans penis and containsectopic sebaceous glands that secrete emollients, lubricants, andprotective antibodies. Similar glands are found in the eyelids and mouth.
Adjacent to the soft mucosa and just behind the lips of the foreskin is the ridged mucosa. This exquisitely sensitive structure consists of tightly pleated concentric bands, like the elastic band sat the top of a sock. These expandable pleats allow the foreskin lipsto open and roll back, exposing the glans. The ridged mucosa gives the foreskin its characteristic taper.
On the underside of the glans, the foreskin's point of attachment is advanced toward the meat us (urethral opening) and forms a band like ligament called the frenulum. It is identical to the frenulum that secures the tongue to the floor of the mouth. The foreskin's frenulum holds it in place over the glans, and, in conjunction with the smooth muscle fibers, helps return the retracted foreskin to its usual forward position over the glans.
Retraction of the Foreskin
At birth, the foreskin is usually attached to the glans, very much as a fingernail is attached to a finger. By puberty, the penis will usually have completed its development, and the foreskin will have separated from the glans.[8] This separation occurs in its own time; there is no set age by which the foreskin and glans must be separated. One wise doctor described the process thus, "The foreskin therefore can be likened to a rosebud which remains closed and muzzled. Like a rosebud, it will only blossom when the time is right.No one opens a rosebud to make it blossom."[9]
Even if the glans and foreskin separate naturally in infancy,the foreskin lips can normally dilate only enough to allow the passage of urine. This ideal feature protects the glans from premature exposure to the external environment.
The penis develops naturally throughout childhood. Eventually,the child will, on his own, make the wondrous discovery that his foreskin will retract. There is no reason for parents, physicians, or other caregivers to manipulate a child's penis. The only person to retract a child's foreskin should be the child himself, when he has discovered that his foreskin is ready to retract.
Parents should be wary of anyone who tries to retract their child's foreskin, and especially wary of anyone who wants to cut it off. Human foreskins are in great demand for any number of commercial enterprises, and the marketing of purloined baby foreskins is a multi million-dollar-
What Are the Foreskin's Functions?
The foreskin has numerous protective, sensory, and sexual functions.
* 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 of the surface of the glans.
* Immunological Defense: The mucous membranes that line allbody 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. Plasma cells in the foreskin's mucosal lining secrete immunoglobulins, antibodies that defend against infections.
* 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.[15] These specialized nerve endings can discernmotion, subtle changes in temperature, and fine gradations oftexture.[16, 17, 18, 19, 20, 21, 22, 23]
* 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 overthe 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 allthe 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 isthe 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 enablesthe penis to slip in and out of the vagina nonabrasively inside its own slick sheath of self-lubricating, movable skin. The female isthus stimulated by moving pressure rather than by friction only, as when the male's foreskin is missing.
The foreskin fosters intimacy between the two partners byenveloping the glans and maintaining it as an internal organ. The sexual experience is enhanced when the foreskin slips back to allowthe male's internal organ, the glans, to meet the female's internalorgan, the cervix--a moment of supreme intimacy and beauty.
The foreskin may have functions not yet recognized or understood. Scientists in Europe recently detected estrogen receptorsin its basal epidermal cells.[24] Researchers at the University of Manchester found that the human foreskin has apocrine glands.[25]These specialized glands produce pheromones, nature's chemical messengers. Further studies are needed to fully understand these features of the foreskin and the role they play.
Care of the Foreskin
The natural penis requires no special care. A child's foreskin, like his eyelids, is self-cleansing. For the same reason itis inadvisable to lift the eyelids and wash the eyeballs, it isinadvisable to retract a child's foreskin and wash the glans.Immersion in plain water during the bath is all that is needed to keep the intact penis clean.[26]
The white emollient under the child's foreskin is called smegma. Smegma is probably the most misunderstood, most unjustifiably maligned substance in nature. Smegma is clean, not dirty, and is beneficial and necessary. It moisturizes the glans and keeps it smooth, soft, and supple. Its antibacterial and antiviral properties keep the penis clean and healthy. All mammals produce smegma. Thomas J. Ritter, MD, underscored its importance when he commented, "The animal kingdom would probably cease to exist without smegma."[27]
Studies suggest that it is best not to use soap on the glansor foreskin's inner fold.[23] Forcibly retracting and washing a baby's foreskin destroys the beneficial bacterial flora that protect the penis from harmful germs and can lead to irritation and infection.The best way to care for a child's intact penis is to leave it alone.After puberty, males can gently rinse their glans and foreskin with warm water, according to their own self-determined needs.
How Common Is Circumcision?
Circumcision is almost unheard of in Europe, South America,and non-Muslim Asia. In fact, only 10 to 15 percent of men throughout the world are circumcised. The vast majority of whom are Muslim.[29]The neonatal circumcision rate in the western US has now fallen to34.2 percent.[30] This relatively diminished rate may surpriseAmerican men born during the era when nearly 90 percent of baby boyswere circumcised automatically, with or without their parents'consent.
How Does Circumcision Harm?
The "medical" debate about the "potential health benefits" ofcircumcision rarely addresses its real effects.
* Circumcision denudes: Depending on the amount of skin cutoff, circumcision robs a male of as much as 80 percent or more of his penile skin. Depending on the foreskin's length, cutting it off makes the penis as much as 25 percent or more shorter. Careful anatomical investigations have shown that circumcision cuts off more than 3 feetof veins, arteries, and capillaries, 240 feet of nerves, and more than20,000 nerve endings.[31]
* Circumcision desensitizes: Circumcision desensitizes thepenis radically. Foreskin amputation means severing the rich nerve network and all the nerve receptors in the foreskin itself.Circumcision almost always damages or destroys the frenulum. The loss of the protective foreskin desensitizes the glans. Because the membrane covering the permanently externalized glans is now subjected to constant abrasion and irritation, it keratinizes, becoming dry and tough. The nerve endings in the glans, which in the intact penis arejust beneath the surface of the mucous membrane, are now buried bysuccessive layers of keratinization. The denuded glans takes on a dull, grayish, sclerotic appearance.
* Circumcision disables: The amputation of so much penile skin permanently immobilizes whatever skin remains, preventing it from gliding freely over the shaft and glans. This loss of mobility destroys the mechanism by which the glans is normally stimulated.When the circumcised penis becomes erect, the immobilized remaining skin is stretched, sometimes so tightly that not enough skin is left to cover the erect shaft. Hair-bearing skin from the groin and scrotum is often pulled onto the shaft, where hair is not normally found. The surgically externalized mucous membrane of the glans hasno sebaceous glands. Without the protection and emollients of theforeskin, it dries out, making it susceptible to cracking andbleeding.
* Circumcision disfigures: Circumcision alters the appearance of the penis drastically. It permanently externalizes the glans,normally an internal organ. Circumcision leaves a large circumferential surgical scar on the penile shaft. Because circumcision usually necessitates tearing the foreskin from the glans, pieces ofthe glans may be torn off, too, leaving it pitted and scarred. Shreds of foreskin may adhere to the raw glans, forming tags and bridges of dangling, displaced skin.[32]
Depending on the amount of skin cut off and how the scar forms, the circumcised penis may be permanently twisted, or curve orbow during erection.[33] The contraction of the scar tissue may pull the shaft into the abdomen, in effect shortening the penis or buryingit completely.[
* Circumcision disrupts circulation: Circumcision interrupts the normal circulation of blood throughout the penile skin system and glans. The blood flowing into major penile arteries is obstructed bythe line of scar tissue at the point of incision, creating backflowinstead of feeding the branches and capillary networks beyond thescar. Deprived of blood, the meatus may contract and scarify,obstructing the flow of urine.[35] This condition, known as meatalstenosis, often requires corrective surgery. Meatal stenosis is foundalmost exclusively among boys who have been circumcised.
Circumcision also severs the lymph vessels, interrupting thecirculation of lymph and sometimes causing lymphedema, a painful,disfiguring condition in which the remaining skin of the penis swells with trapped lymph fluid.
* Circumcision harms the developing brain: Recent studies published in leading medical journals have reported that circumcision has long lasting detrimental effects on the developing brain,[36]adversely altering the brain's perception centers. Circumcised boys have a lower pain threshold than girls or intact boys.[37]Developmen
* Circumcision is unhygienic and unhealthy: One of the most common myths about circumcision is that it makes the penis cleaner and easier to take care of. This is not true. Eyes without eyelids would not be cleaner; neither would a penis without its foreskin. The artificially externalized glans and meatus of the circumcised penis are constantly exposed to abrasion and dirt, making the circumcised penis, in fact, more unclean. The loss of the protective foreskinl eaves the urinary tract vulnerable to invasion by bacterial and viral pathogens.
The circumcision wound is larger than most people imagine. Itis not just the circular point of union between the outer and inner layers of the remaining skin. Before a baby is circumcised, his foreskin must be torn from his glans, literally skinning it alive.This creates a large open area of raw, bleeding flesh, covered at best with a layer of undeveloped proto mucosa. Germs can easily enter the damaged tissue and bloodstream through the raw glans and, even more easily, through the incision itself.
Even after the wound has healed, the externalized glans andmeatus are still forced into constant unnatural contact with urine,feces, chemically treated diapers, and other contaminants.
Female partners of circumcised men do not report a lower rate of cervical cancer,[40] nor does circumcision prevent penile cancer.[41] A recent study shows that the penile cancer rate is higher in the US than in Denmark, where circumcision, except among Middle Eastern immigrant workers, is almost unheard of.[42] Indeed,researchers should investigate the possibility that circumcision has actually increased the rate of these diseases.
Circumcision does not prevent acquisition or transmission of sexually transmitted diseases (STDs). In fact, the US has both the highest percentage of sexually active circumcised males in the Western world and the highest rates of sexually transmitted diseases,including AIDS. Rigorously controlled prospective studies show that circumcised American men are at a greater risk for bacterial and viralSTDs, especially gonorrhea,[43] non gonoccal urethritis,[
* Circumcision is always risky: Circumcision always carries the risk of serious, even tragic, consequences. Its surgical complication rate is one in 500.[48] These complications include uncontrollable bleeding and fatal infections.[
Medical journals have published numerous accounts of babieswho have had part or all of their glans cut off while they were being circumcised.
* Circumcision harms mothers: Scientific studies have consistently shown that circumcision disrupts a child's behavioral development. Studies performed at the University of Colorado School of Medicine showed that circumcision is followed by prolonged,unrestful non-REM (rapid eye movement) sleep.[65] In response to thelengthy bombardment of their neural pathways with unbearable pain, thecircumcised babies withdrew into a kind of semi coma that lasted daysor even weeks.
Numerous other studies have proven that circumcision disruptsthe mother-infant bond during the crucial period after birth. Research has also shown that circumcision disrupts feeding patterns. In a study at the Washington University School of Medicine, most babies would not nurse right after they were circumcised, and those who did would not look into their mothers' eyes.[66]
* Circumcision violates patients' and human rights: No one has the right to cut off any part of someone else's genitals without that person's competent, fully informed consent. Since it is the infant who must bear the consequences, circumcision violates his legal rights both to refuse treatment and to seek alternative treatment. In 1995,the American Academy of Pediatrics Committee on Bioethics stated that only a competent patient can give patient consent or informed consent.[67] An infant is obviously too young to consent to anything.He must be protected from anyone who would take advantage of his defenselessness. The concept of informed parental permission allows for medical interventions in situations of clear and immediate medical necessity only, such as disease, trauma, or deformity. The human penis in its normal, uncircumcised state satisfies none of these requirements.
Physicians have a duty to refuse to perform circumcision. They also must educate parents who, out of ignorance or misguidance,
Common Sense
To be intact, as nature intended, is best. The vast majority of males who are given the choice value their wholeness and keep their foreskins, for the same reason they keep their other organs of perception. Parents in Europe and non-Muslim Asia never have forcedtheir boys to be circumcised. It would no more occur to them to cutoff part of their boys' penises than it would to cut off part of theirears. Respecting a child's right to keep his genitals intact isnormal and natural. It is conservative in the best sense of the word.
A circumcised father who has mixed feelings about his intact newborn son may require gentle, compassionate psychological counseling to help him come to terms with his loss and to overcome his anxieties about normal male genitalia. In such cases, the mother should steadfastly protect her child, inviting her husband to share this protective role and helping him diffuse his negative feelings. Most parents want what is best for their baby. Wise parents listen to their hearts and trust their instinct to protect their baby from harm. The experience of the ages has shown that babies thrive best in a trusting atmosphere of love, gentleness, respect, acceptance, nurturing, and intimacy. Cutting off a baby's foreskin shatters this trust.
Circumcision wounds and harms the baby and the person the baby will become. Parents who respect their son's wholeness are bequeathing to him his birthright--
Paul M. Fleiss, MD, MPH, is assistant clinical professor of pediatricsat the University of Southern California Medical Center. He is the author of numerous scientific articles published in leading nationaland international medical journals.
Notes
1. T. J. Ritter and G. C. Denniston, Say No to Circumcision: 40 Compelling Reasons, 2nd ed. (Aptos, CA Hourglass 1996), 6-20.
2. "Incipit Libellus De Ecclesiasticis Disciplinis et Religione Christiana Collectus. Liber II.XC, XCI" in Patrologiae Cursus Completus, vol. 132 (Paris: Apud Garnier Fratres, Editores et J. P. Migne Successores, 1880), 301-302.
3. S. Grayzel, The Church and the Jews in the Xllth Century, vol. 2, ed. K. R. Stow (Detroit, MI: Wayne State University Press, 1989), 246-247.
4. See Note 10, 17-40.
5. M. E Camphor "The Male Genital Tract and the Female Urethra," in Urology, eds. M. E. Campbell and J. H. Harrison, vol. 2, 3rd ed. (Philadelphia: W. B. Saunders, 1970), 1836.
6. See photographic series: J. A. Erickson, "Three Zones of Penile Skin." In M. M. Lander, "The Human Prepuce," in G. C. Denniston and M. E. Milos, eds., Sexual Mutilations: A Human Tragedy (New York: Plenum Press, 1997), 79-81.
7. M. Davenport, "Problems with the Penis and Prepuce: Natural History of the Foreskin" (photograph 1), British Medical Journal 312 (1996): 299-301.
8. J. Oster, "Further Fate of the Foreskin," Archives of Disease in Childhood 43 (1968): 200-203.
9. H. L. Tan, "Foreskin Fallacies and Phimosis," Annals of the Academy of Medicine, Singapore 14 (1985): 626-630.
10. F. A. Hodges, "Short History of the Institutionalizatio
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 Demmatology 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.
15. Z. Halata and B. L. Munger, "The Neuroanatomical Basis for the Protopathic Sensibility of the Human Glans Penis," Brain Research 371 (1986): 205-230.
16. 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.
17. H. C. Bazett et al., "Depth, Distribution and Probable Identification in the Prepuce of Sensory End-Organs Concerned in Sensations of Temperature and Touch; Themometic Conductivity," Archives of Neurology and Psychiatry 27 (1932): 489-517.
18. D. Ohmori, "Ueber die Entwicklung der Innervation der Genitalapparate als Peripheren Aufnahmeapparat der Genitalen Reflexe," Zeitschriht fuer Anatomie and Entwicklungspeschic
19. A. De Girolamo and A. Cecio, "Contributo alla Conoscenza dell'innervazione Sensitiva del Prepuzio Nell'uomo," Bollettino delta Societa Italiana de Biologia Sperimentak 44 (1968): 1521-1522.
20. A. S. Dogiel, "Die Nervenendigungen in der Haut der aeusseren Genitalorgane des Menschen," Archiv fuer Mikroskopische Anatomie 41 (1893): 585-612.
21. A. Bourlond and R. K. Winkelmann, "L'innervation du Prepuce chez le Nouveau-ne," Archives Beiges de Demmatologie et de Syphiligraphie 21 (1965): 139-153.
22. 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.
23. R. K. Winkelmann, "The Cutaneous Innervation of Human Newborn Prepuce," Journal of Investigative Demtotology 26 (1956): 53-67.
24. R. Hausmann et al., "The Forensic Value of the Immunohistochemical Detection of Estrogen Receptors in Vaginal Epithelium," International Journal of Legal Medicine 109 (1996): 10-30.
25. See Note 12.
26. American Academy of Pediatrics, Newboms: Care of the Uncircumcised Penis Guidelines for Parents (Elk Grove Village, IL: American Academy of Pediatrics, 1994).
27. See Note 1.
28. See Note 1.
29. S. A. Aldeeb Abu-Sahlieh, Jehovah, His Cousin Allah, and Sexual Mutilations," in Sexual Mutilations A Human Tragedy, eds. G. C. Denniston and M. F. Milos (New York: Plenum Press, 1997), 41-62.
30. National Center for Health Statistics of the United States Department of Health and Human Services, 1994.
31. See Note 17.
32. G. I Klauber and J. Boyle, "Preputial Skin-Bridging: Complication of Circumcision," Urology 3 (1974): 722-723.
33. J. P. Gearhart, "Complications of Pediatric Circumcision," in Urologic Complications, Medical and Surgical, Adult and Pediatric, ed. E. E. Marshall (Chicago: Year Book Medical Publishers, 1986), 387-396.
34. R. D. Talarico and J. E. Jasaitis, "Concealed Penis: A Complication of Neonatal Circumcision," Journal of Urology 110 (1973): 732-733.
35. R. Persad et al., "Clinical Presentation and Pathophysiology of Meatal Stenosis Following Circumcision," British Journal of Urology 75 (1995): 90-91.
36. A. Taddio et al., "The Effect of Neonatal Circumcision on Pain Responses during Vaccination in Boys," Lancet 345 (1995): 291-292.
37. A. Taddio et al., "The Effect of Neonatal Circumcision on Pain Response during Subsequent Routine Vaccination," Lancet 349 (1997): 599-603.
38. J. W. Prescott, "Genital Pain vs. Genital Pleasure: Why the One and Not the Other" Truth Seeker 1 (1989): 14-21.
39. R. Goldman, Circumcision: The Hidden Trauma (Boston: Vanguard Publications, 1997), 139-175.
40. M. Terris et al, "Relation of Circumcision to Cancer of the Cervix," American Joumal of Obstetrics and Gynecology 117 (1973): 1056-1065.
41. C J. Cold et al., "Carcinoma in Situ of the Penis in a 76-Year-old Circumcised Man," Journal of Family Practice 44 (1997): 407-410.
42. M. Frisch et al., "Falling Incidence of Penis Cancer in an Uncircumcised Population (Denmark 1943-90)," British Medical Journal 311 (1995): 1471.
43. B. Donovan et al., "Male Circumcision and Common Sexually Transmissible Diseases in a Developed Nation Setting," Genitourinary Medicine 70 (1994): 317-320.
44. G L Smith et al., "Circumcision as a Risk Factor for Urethritis in Racial Groups,"American Journal of Public Health 77 (1987): 452-454.
45. L. S. Cook et al., "CIincal Presentation of Genital Warts among Circumcised and Uncircumcised Heterosexual Men Attending an Urban STD Clinic," Genitourinary Medicine 69 (1993): 262-264.
46. I. Bassett et al., "Herpes Simplex Virus Type 2 Infection of Heterosexual Men Attending a Sexual Health Centre," Medical Journal of Australia 160 (1994): 697-700.
47. E. O. Laumann et al., "Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice," Journal of the American Medical Association 277 (1997): 1052-1057.
48. W. E. Gee and J. S. Ansel, "Neonatal Circumcision: A Ten-year Overview With Comparison of the Gomco Clamp and the Plastibell Device," Pediatrics 58 (1976): 824-827.
49. G. W. Kaplan, "Complications of Circumcision," Urologic Clinics of North America 10 (1983): 543-549.
50. S. J. Sussman et al., "Fournier's Syndrome: Report of Three Cases and Review of the Literature," American Journal of Diseases of Children 132 (1978): 1189-1191.
51. B. V. Kirkpatrick and D. V. Eitzman, "Neonatal Septicemia after Circumcision," Clinical Pediatrics 13 (1974): 767-768.
52. J. M. Scurlock and R J. Pemberton, "Neonatal Meningitis and Circumcision," Medical Journal of Australia 1 (1977):332-334.
53. G. R. Gluckman et al., "Newborn Penile Glans Amputation during Circumcision and Successful Reattachment," Journal of Urology 153 (1995): 778-779.
54. B. S. Strimling, "Partial Amputation of Glans Penis during Mogen Clamp Circumcision,"Pediatrics 87 (1996): 906-907.
55. J. Shemman et al., Circumcision: Successful Glandular Reconstruction and Survival Following Traumatic Amputation," Journal of Urology 156 (1996): 842-844.
56. J. R. Sharpe and R. P. Finney, "Electrocautery Circumcision,"Urology 19 (1982): 228.
57. C. K. Pearlman, "Caution Advised on Electrocautery Circumcisions," Urology 19 (1982): 453.
58. C. K. Pearlman, "Reconstruction Following Iatrogenic Burn of the Penis" Journal of Pediatric Surgery 11 (1976): 121-122.
59. J. P. Gearhart and J. A. Rock, "Total Ablation of the Penis after Circumcision with Electrocautery: A Method of Management and Long-Term Followup," Journal of Urology 142 (1989): 799-801.
60. M. Diamond and H. K. Sigmundson, "Sex Reassignment at Birth: LongTerm Review and Clinical Implications," Archives of Pediatrics and Adolescent Medicine 151(1997): 298-304.
61. J. Money, "Ablatio Penis: Normal Male Infant Sex-Reassigned as a Girl," Archives of Sexual Behavior 4 (1975): 65-71.
62. D. A. Gilbert et al, "Phallic Construction in Prepubertal and Adolescent Boys," Journal of Urology 149 (1993): 1521-1526.
63. R. S. Thompson, "Routine Circumcision in the Newborn: An Opposing View," Journal of Family Practice 31 (1990): 189-196.
64. T. E. Wiswell, "Circumcision Circumspection," New England Journal of Medicine 336 (1997): 1244-1245.
65. R N. Emde et al., "Stress and Neonatal Sleep," Psychosomatic Medicine 33 (1971): 491-497.
66. R. E. Marshall et al., "Circumcision: II. Effects upon Mother-Infant Interaction," Early Human Development 7 (1982): 367-374.
67. Committee on Bioethics, "Informed Consent, Parental Permission, and Assent in Pediatric Practice," Pediatrics 95 (1995): 314-317.
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