{{Long NPOV}} {{cleanup|December 2005}} Numerous medical studies have tried to assess the effects of circumcision. Several professional medical organizations are putting the '''evidence of medical benefits and risks of Circumcision''' under and increasing level of scrutiny. ==Possible Risks of Circumcision== '''The complications listed here are known to have occurred at least once, and have been reported in medical journals. They ''may or may not'' occur in a particular operation.''' Circumcision is a surgical operation, therefore the complications from it are many and varied. Williams & Kapila state: "the literature abounds with reports of morbidity and even death as a result of circumcision."http://www.cirp.org/library/complications/williams-kapila/ The complications may be immediate or delayed. The immediate complications may be further classified into surgical mishap, Hemorrhage, Infection and anesthetic risk. ===Immediate Complications=== * Surgical mishap : Mistakes are an unfortunate possible complication of any surgery. Surgical mishaps that have been documented with circumcision include penile denudationhttp://www.cirp.org/library/complications/sotolongo1/, excision of part or all of the Glans penishttp://www.cirp.org/library/complications/sherman1/, urethral fistulahttp://www.cirp.org/library/complications/baskin/ and penile necrosis which results in loss of the entire penis. * Hemorrhage : Bleeding after circumcision is usually minor and easily controlled, but in rare occasions, may progress to shock due to blood loss (Hypovolemic_shock) or death (Exsanguination) http://www.cirp.org/library/death/hiss1/http://www.circumstitions.com/death-exsang.html . * Infection : Infections are usually minor and local, but in rare cases may progress to Urinary_tract_infectionhttp://www.cirp.org/library/disease/UTI/goldman/, life-threatening Systemic_infections, Meningitishttp://www.cirp.org/library/complications/scurlock1/ or death. * Anesthetic risk : Anesthetic risk includes Methaemglobinaemiahttp://www.cirp.org/library/complications/arda1/http://www.cirp.org/library/complications/couper1/ . Infection and bleeding are by far the most common complications. Other immediate complications are extremely rare. ===Delayed Complications=== * Urinary_retention http://bmj.bmjjournals.com/cgi/content/extract/309/6955/660; * The slowing down of venous blood flow (Venous_stasis) http://www.cmaj.ca/cgi/content/full/169/3/216; * Tightness of the foreskin, which prevents it from being moved back over the head of the penis (Phimosis)http://www.cirp.org/library/complications/blalock1/; * Concealed penis http://www.cirp.org/library/complications/trier1/; * Adhesions http://www.cirp.org/library/complications/gracely1/; * Skin bridge http://www.cirp.org/library/complications/naimer2/; * Painful erections. (source?) Some suggest that the opening to the urethra (Meatus) may also be affected, leading to inflammation (Meatitis)http://www.cirp.org/library/complications/brennemann1/, meatal ulcerationhttp://www.cirp.org/library/complications/freud1/, and narrowing of the urethra (meatal stenosishttp://www.cirp.org/library/complications/kunz1/http://www.cirp.org/library/complications/persad/. === Pain, stress, trauma, and interference with breastfeeding initiation === The American_Academy_of_Pediatrics' policy states: :Some common painful minor procedures, such as circumcision, do not always receive the warranted attention to comfort issues. Available research indicates that newborn circumcisions are a significant source of Pain during the procedure and are associated with irritability and feeding disturbances during the days afterward. Opportunities for alleviating pain exist before, during, and after the procedure, and many interventions are effective.http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b108/3/793 :-- ''The Assessment and Management of Acute Pain in Infants, Children and Adolescents'', 2001. Many studies have examined adverse effects of the procedure; some employing various forms of pain relief. A few of these findings are summarised in the following table.

Study1	Effects noted	Unstated
Marshall (1982) http://www.cirp.org/library/birth/marshall2/	Brief and transitory effects on mother-infant interactions observed during hospital feeding sessions.
No pain relief
Howard (1994) http://www.cirp.org/library/pain/howard/	Significant increases in Heart_rate, Respiratory_rate, and crying. Deteriorated feeding behaviour.
Taddio (1997) http://www.cirp.org/library/pain/taddio2/	Stronger pain response during vaccination 4 to 6 months later.
Lander (1997) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=9417009&query;_hl=1	Sustained elevation of heart rate and high-pitched cry. Choking and apnea in 2 infants.
Acetaminophen (Tylenol/Paracetamol)
Howard (1994) http://www.cirp.org/library/pain/howard/	Significant increases in heart rate, respiratory rate, and crying. Deteriorated feeding behaviour. Improved comfort after postoperative period.
Taddio (1997) http://www.cirp.org/library/pain/taddio2/	Stronger pain response during vaccination 4 to 6 months later, though attenuated as compared to Placebo.
EMLA (topical anaesthetic)
Lander (1997) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=9417009&query;_hl=1	Significantly less crying and lower heart rates.
Dorsal penile nerve block (DPNB)
Kirya (1978)	Consistent elimination of pain
Lander (1997) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=9417009&query;_hl=1	Significantly less crying and lower heart rates. Not effective during foreskin separation and incision.
Ring block
Lander (1997) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=9417009&query;_hl=1	Significantly less crying and lower heart rates. Equally effective through all stages of the circumcision

''¹ Studies investigating several forms of pain relief have one entry for each form.'' Howard ''et al'' report that neonatal circumcision without Anaesthesia and using Acetaminophen (Tylenol) results in deteriorated breast-feeding immedately after circumcision.http://www.cirp.org/library/pain/howard/ They commented: :Numerous studies have shown that circumcision causes severe intraoperative pain as measured by changes in crying, heart rate, respiratory rate, transcutaneous PO₂, and cortisol levels ...[]... Neonatal circumcision are often performed on the day of discharge with many neonates leaving the hospital 3 to 6 hours postoperatively. Thus the observed deterioration in ability to breast-feed may potentially contribute to breast-feeding failure. Furthermore some neonates in this study required formula supplementation because of maternal frustration with attempts at breast-feeding, or because the neonate was judged unable to breast-feed postoperatively. This finding is disconcerting because early formula supplementation is associated with decreased breast-feeding duration. Howard ''et al.'' concluded that: :Acetaminophen was not found to ameliorate either the intra-operative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the postoperative period.http://www.cirp.org/library/pain/howard/ Many other studies have investigated the pain caused by circumcision, and the effectiveness of different forms of analgesia and anaesthesia. Taddio ''et al'' reported behavioural changes (heightened pain responses) during vaccinations in children circumcised with EMLA cream and with no anaethesia at the 99.9+% statistical confidence level (p<0.001) four to six months after their circumcision, suggesting a persistent effect on pain response. http://www.cirp.org/library/pain/taddio2/ The researchers commented: : "Study of the vaccination pain response of infants who had received more effective circumcision pain management (i.e., dorsal penile nerve block and adequate postoperative pain management) would be interesting." Kirya and Werthmann investigated the effect of Dorsal_penile_nerve block (DPNB), describing it as "painless".http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=660375&query;_hl=1 However, Lander ''et al'' found that DPNB is less effective than ring block.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=9417009&query;_hl=1 Marshall ''et al'' report that the stress of Neonatal_circumcision may alter feeding behaviour and some male infants may be unable to breastfeed after circumcision.http://www.cirp.org/library/birth/marshall2/ They commented: :Despite differences between control and experimental infants shortly after surgery, by 24 h post-operatively no significant differences were observed between the groups. The behavioral effects of circumcision in the present study were immediate but brief. This should be comforting information to those who provide care for newborns and for their parents.http://www.cirp.org/library/birth/marshall2/ Marshall ''et al'' did not report whether anaesthesia was used. ==Possible benefits of circumcision== === Prostate cancer === Early ecological studies suggested that circumcision has a protective effect against Prostate_cancer. Ravich and Ravich report on patients operated on for prostatic obstruction. In Jews, 1.8% of obstructions were cancerous, compared with 19% of non-Jews.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=14853120 Apt made similar observations in Sweden, concluding that uncircumcised males were at approximately twice the risk. Although ecological studies are considered unreliable, later case-control studies have confirmed this association. Ross ''et al.'' reported on two case-control studies, both in Southern California. Both studies included 142 cases. In both studies, circumcised men were at reduced risk (relative risk of 0.5 in whites and 0.6 in blacks).http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=3471995 Mandel & Schuman reported on a case-control study with 250 cases. When compared to controls drawn from their neighborhood, circumcised men were less likely to develop prostate cancer (odds ratio 0.82).http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=3553301 Ewings & Bowie performed a case-control study of 159 cases of prostate cancer, and found that circumcised men were at a reduced risk (odds ratio 0.62).http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=8761387 Prostate cancer is the second most common cancer in men. The lifetime risk of developing it is 1 in 5.http://www.hsc.stonybrook.edu/som/urology/urology_cp_prostatecancer.cfm. Nevertheless, prostate cancer is about twice as common in the United States (where circumcision is routine) than in Europe, and 8 times more common in the United States than in Japan. http://www.jncicancerspectrum.oupjournals.org/cgi/statContent/cspectfstat;99 Neither the American Cancer Society nor any of the professional medical organizations with official policy statements on circumcision mention a relationship between prostate cancer and circumcision status. === Penile cancer === Penile_cancer is a rare form of Cancer. Annually, there is one case in 100 000 men in developed countries. http://jncicancerspectrum.oxfordjournals.org/cgi/statContent/cspectfstat%3b101 http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_penile_cancer_35.asp?sitearea= The overall five-year survival rate for all stages of penile cancer is about 50 per cent. The American_Cancer_Society made this statment in their website: : The large variations in penile cancer rates throughout the world strongly suggest that penile cancer is a preventable disease. The best way to reduce the risk of penile cancer is to avoid known risk factors whenever possible. :In the past, circumcision has been suggested as a way to prevent penile cancer. This suggestion was based on studies that reported much lower penile cancer rates among circumcised men than among uncircumcised men. However, most researchers now believe those studies were flawed because they failed to consider other factors that are now known to affect penile cancer risk. :For example, some recent studies suggest that circumcised men tend to have certain other lifestyle factors associated with lower penile cancer risk: they are less likely to have many sexual partners, less likely to smoke, and more likely to have better personal hygiene habits. Most public health researchers believe that the penile cancer risk among uncircumcised men without known risk factors living in the United States is extremely low. The current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer. http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_Can_penile_cancer_be_prevented_35.asp?rnav=cri : (last revised 1_January 2005) In September 2004, the American_Medical_Association and the Royal_Australasian_College_of_Physicians stated that the use of infant circumcision to prevent Penile_cancer alone in adulthood is not justified. http://www.ama-assn.org/ama/pub/category/13585.html http://www.racp.edu.au/hpu/paed/circumcision/print.htm Nevertheless, other researchers have come to a different conclusion. One 1980 study estimated that the lifetime risk of an uncircumcised man developing invasive penile cancer (IPC) is one in 600 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=7377156&dopt;=Abstract. This was more than 3 times higher than for males neonatally circumcised. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=11144896&dopt;=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=8380060&dopt;=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=8260177&dopt;=Abstract Childhood circumcision has been associated with a reduced incidence of penile cancer in numerous studies. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=11196386&dopt;=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=11144896&dopt;=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=7377156&dopt;=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=11405332&dopt;=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=10643514&dopt;=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=10699138&dopt;=Abstract An absence of circumcision has been associated with a higher incidence of Human_Papilloma_Virus infection in males in several studies. HPV infection is a known risk factor in the development of penile cancer.http://content.nejm.org/cgi/pmidlookup?view=short&pmid;=11948269http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=15388997http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=12238658 ====Images of Invasive Penile Cancer in Uncircumcised Men==== * http://www.dermis.net/bilder/CD52/img0084.jpghttp://www.dermis.net/bilder/CD55/img0066.jpghttp://www.dermis.net/bilder/CD16/img0038.jpghttp://www.dermis.net/bilder/CD14/img0092.jpghttp://www.dermis.net/bilder/CD16/img0037.jpg or alternative links: * http://www.circs.org/reviews/penile_cancer/photos/PenileCancer01.jpghttp://www.circs.org/reviews/penile_cancer/photos/PenileCancer02.jpghttp://www.circs.org/reviews/penile_cancer/photos/PenileCancer03.jpghttp://www.circs.org/reviews/penile_cancer/photos/PenileCancer04.jpghttp://www.circs.org/reviews/penile_cancer/photos/PenileCancer05.jpg ===Phimosis=== Phimosis is the inability to retract the prepuce over the glans penis after separation from the glans has occurred. The foreskin is joined to the glans, and is naturally unretractable when a baby is born. But there are differences of opinion about how long this should continue, and how the foreskin should be treated if it remains too tight for too long. Gairdnerhttp://www.cirp.org/library/general/gairdner/ published data regarding the age of first foreskin retraction in 1949 that is now thought by some to be incorrect. However, these data are still presented in medical textbooks and taught in medical schools.http://www.mja.com.au/public/issues/178_11_020603/matters_arising_020603-1.html Many doctors, therefore, are misinformed about the natural developent of the foreskin, and this contributes to the mis-diagnosis of the normal non-retractile foreskin of childhood as pathological disease. Rickwood ''et al.'' write in their 2000 paper "Towards evidence based circumcision of English boys" in the ''British Medical Journal'' http://bmj.com/cgi/content/full/321/7264/792: :''Too many English boys, especially those under 5 years of age, are still being circumcised because of misdiagnosis of phimosis. What is phimosis? At birth, the foreskin is almost invariably non-retractable, but this state is transient and resolves in nearly all boys as they mature through puberty. Such normality, with an unscarred and pliant preputial orifice, is clearly distinguishable from pathological phimosis, a condition unambiguously characterised by secondary cicatrisation of the orifice, usually due to Balanitis_xerotica_obliterans. This problem, the only absolute indication for circumcision, affects some 0.6% of boys, peaks in incidence at 11 years of age, and is rarely encountered before the age of 5. (...) Strictly, only some 0.6% of boys with pathological phimosis need to be circumcised, although more relaxed criteria would allow for a similar proportion affected by recurrent balanoposthitis.'' A 1968 Danish study of 9,545 boys, which distinguished between phimosis and preputial adhesion, found that both conditions steadily declined with age. Phimosis was 8% among 6-7 year olds but only 1% among 16-17 year olds. Similarly, preputial adhesion was 63% among 6-7 year olds but only 3% among 16-17 year olds. The author, Jakob Øster, concluded: :''Phimosis is seen to be uncommon in schoolboys, and the indications for operation even rarer if the normal development of the prepuce is patiently awaited. When this policy is pursued, in the majority of cases of phimosis, it is seen to be a physiological condition which gradually disappears as the tissues develop. http://www.cirp.org/library/general/oster/'' It has been observed that Øster's study may not be representative of wider populations. http://www.mja.com.au/public/issues/178_11_020603/matters_arising_020603-3.html The true incidence of phimosis is controversial. Osmond found that 14% of British soldiers suffered, and Schoeberlein noted that 9.2% of uncircumcised German men suffered from phimosishttp://www.mja.com.au/public/issues/178_11_020603/matters_arising_020603-3.html. Reporting on a New Zealand study, Fergusson ''et al'' found that 3.7% of boys suffered from phimosis.http://www.circs.org/library/fergusson/index.html Phimosis is a complication of circumcision, that can occur when too little foreskin is removed.http://www.cirp.org/library/complications/blalock1/ Images of phimosis.http://147.46.43.65/~circum/hwimage/phimosis2.jpghttp://www.midori-clinic.or.jp/phimosis/palaphi.jpghttp://www.male-initiation.net/library/drawings/DORSAL/abefore.gifhttp://www.vghtpe.gov.tw/~peds/lecture/phimosis/42.jpg === Human Papilloma Virus (HPV) and cervical cancer === The claim that circumcision reduces cervical cancer in female partners was first put forward by Wynder ''et al.'' in 1954, with smegma (a white secretion of the Sebaceous_glands of the foreskin ) as the hypothesized causative agent. Several studies were performed during the mid-20th century to investigate whether smegma has carcinogenic properties. Pratt-Thomas ''et al.'' in 1956, found that horse smegma had a carcinogenic effect on laboratory mice. Heins ''et al,'' 1958 found that human smegma had a carcinogenic effect on laboratory mice. http://www.circs.org/library/heins/index.html However, a 1963 study by Reddy and Baruah was unable to reproduce the effect, leading the authors to conclude that the carcinogenic effect must be weak. In 1962, Stern and Neely did not observe that circumcision in the male partner had a protective effect. http://www.cirp.org/library/disease/cancer/stern1/. In 1982, Punyaratabandhu ''et al.'' reported a protective effect in Thai women.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=7119622 In 1991, Kjaer ''et al.'' reported an apparently protective effect in Dutch women, that failed to achieve statistical significance.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=2019457 In 1993, Agarwal ''et al.'' observed a significantly protective effect among Indian women.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=8348498 The study, "Male Circumcision, Penile [[Human Papilloma Virus] Infection, and Cervical Cancer in Female Partners]," published in the ''The New England Journal of Medicine'' in April 2002, found that male circumcision reduces the risks of penile human papillomavirus (HPV) infection in the man and of Cervical_cancer in his female partner. The subsequent study Condom use and other factors affecting penile human papillomavirus detection in men attending a sexually transmitted disease clinic confirmed the findings with regard to the protective effect of male circumcision against infection by penile human papillomavirus. Some now believe that the link between the higher incidence of Cervical_cancer in female partners of uncircumcised men is through the higher incidence of penile human papillomavirus (HPV) to which uncircumcised men are prone.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=15388997 http://sti.bmjjournals.com/cgi/content/full/78/3/215 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=11948269 In predominantly non-circumcising Great_Britain, the incidence of cervical cancer has reached epidemic proportions. In a study published in The_Lancet ,"The cervical cancer epidemic that screening has prevented in the UK," scientists from the London_School_of_Hygiene_and_Tropical_Medicine found that cervical screening was responsible for preventing many deaths from cervical cancer. In their estimation, one in 65 of all British women born since 1950 would have died from cancer of the cervix without the screenings. In 2000, cervical cancer deaths in Great Britain were 3.9 per 100,000 patient-years, compared with 3.3 in the USA, 2.8 in Canada, and 2.4 in Australia. http://www.wrongdiagnosis.com/c/cervical_cancer/deaths.htm A new HPV vaccine is expected to substantially reduce the risk of cervical cancer when it becomes available.http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4DSGXJN-3H&_coverDate=11%2F13%2F2004&_alid=233121028&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=4886&_sort=d&view;=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5;=0f3169e01fa5c87298ac7b9f84436e73 According to Dr. Xavier Castellsagué, "...it would not make sense to promote circumcision as a way to control cervical cancer in the United States, where Pap_smears usually detect it at a treatable stage." === Circumcision and Urinary tract infection (UTI) === Infections of the urinary tract (kidneys, ureters, bladder and urethra) can lead to kidney damage if undetected, but can generally be treated effectively with antibiotics. Recent studies find a three to seven times increased risk of UTIs in uncircumcised male infants within the first year of life. A 1998 Canadian population based cohort study by To et al. http://www.cirp.org/library/disease/UTI/to2/, for example, reported a relative risk of 3.7. The overall incidence of UTIs in infants was low, 1.88 and 7.02 per 1000 respectively. According to the American Medical Association, "There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI)." Some of these studies have nevertheless been extensively criticized for their methodology. The American_Academy_of_Pediatrics noted in its 1999 circumcision policy statement: : Few of the studies that have evaluated the association between UTI in male infants and circumcision status have looked at potential confounders (such as prematurity, breastfeeding, and method of urine collection) in a rigorous way. For example, because premature infants appear to be at increased risk for UTI, the inclusion of hospitalized premature infants in a study population may act as a confounder by suggesting an increased risk of UTI in uncircumcised infants. Premature infants usually are not circumcised because of their fragile health status. In another example, breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status. http://www.aap.org/policy/re9850.html More recently, however, randomized controlled trialshttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=11793114 and other studies have confirmed the protective effect of circumcisionhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=11772190 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=11156067 http://pediatrics.aappublications.org/cgi/content/full/105/4/789. UTIs are usually detected through urine tests. Depending on the method of urine collection, there is a varying risk of false positives through contamination. The bacteria detected may in fact come from the foreskin itself, not the urinary tract. In spite of this, an increased risk of UTI in uncircumcised males is generally considered plausible, a higher likelihood of bacterial colonization being the proposed mechanism. However, studies of UTI and circumcision do not classify groups of circumcised males according to their mothers' handling of the foreskin, making it impossible to infer any link with specific hygienic practices. It is generally recommended not to retract the foreskin of an infant during hygiene http://www.cirp.org/library/normal/aap/. Hodges and Fleiss claim that "it has been proven that retraction and washing of the infant foreskin can cause urinary tract infections by irritating the mucous membranes and destroying the naturally occurring beneficial flora which protects against pathogens." More recent research has shown that in fact fewer pathogens are present in circumcised males. UTIs in boys are most common during the first years of lifehttp://pediatrics.aappublications.org/cgi/content/full/104/2/222. Based upon their data, To et al. estimate that 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life. The American Academy of Pediatrics recommends breastfeeding to reduce the risk of UTI in children,http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b100/6/1035 but does not recommend circumcision for this purpose. === Circumcision and HIV/AIDS === Preliminary findings from one study found that circumcision may reduce the transmission of AIDS by as much as 70%. This is a dramatic finding and caused the data and safety monitoring board overseeing the research to end it nine months early so that the control group could be offered circumcision. However, for reasons that have not been disclosed, The Lancet, a prestigious British medical journal, has declined to publish the findings. It is expected that the findings will be presented to an International AIDS Society Conference in Brazil in July 2005. http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2005/07/06/MNGANDJFVK1.DTL Two other randomized controlled trials are still underway (see below). In 1989 the Cameron study was published and reported an 8.2 times higher risk of HIV infection among uncircumcised men. Since then some 38 studies have covered the issue of the protective effect accruing through male circumcision against female-to-male HIV transmission through vaginal sex. (No study has indicated that circumcision provides protection against male-to-female transmission, or transmission from the active partner to the passive partner in homosexual oral or anal intercourse.) The USAID document Male Circumcision:Current Epidemiological and Field Evidence summarized research as at September 2002. It states: :A systematic review and meta-analysis of 28 published studies by the London School of Hygiene and Tropical Medicine, published in the journal AIDS in 2000, found that circumcised men are less than half as likely to be infected by HIV as uncircumcised men. A subanalysis of 10 African studies found a 71 percent reduction among higher-risk men. A September 2002 update considered the results of these 28 studies plus an additional 10 studies and, after controlling for various potentially confounding religious, cultural, behavioral, and other factors, had similarly robust findings. Recent laboratory studies in Chicago found HIV uptake in the inner foreskin tissue to be up to nine times more efficient than in a control sample of cervical tissue.http://www.psi.org/resources/pubs/male-circ.pdf However, the Cochrane Library for Evidence-based Medicine's review of the data (2004) reported: :We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV.http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003362/frame.html Neither UNAIDS nor the Centers for Disease Control of the United States Public Health Service have accepted male circumcision as a proven method of epidemic control. The Royal Australian College of Physicians (2002) said: :There is increasing evidence, particularly from sub-Saharan Africa, which suggests an increased risk of female to male transmission of HIV in uncircumcised men. However, how much circumcision could contribute to ameliorate the current epidemic of HIV is uncertain. Whatever the future direction of this debate it can not be seen as an argument in favour of universal neonatal circumcision in countries with a low prevalence of HIV. [78] (http://www.racp.edu.au/hpu/paed/circumcision/STDs.htm) The USAID office of HIV/AIDS said: "male circumcision should not be actively promoted for HIV prevention unless and until the RCTs (Randomized controlled trials) confirm MC to be effective in reducing HIV infection".http://www.psi.org/resources/pubs/male-circ.pdf Three randomized controlled trials (RCT's) are underway in Kenya, South Africa, and Uganda over a three to five year period, with the first results due in 2007. However, other studies have found an association between circumcision and the prevalence of HIV in communities. Other researchers have contested the findings which indicate that circumcision reduces HIV transmission. For example, Van Howe, a leading anti-circumcision campaigner, produced a meta-analysis which presented circumcised men at a greater risk for HIV infection. He further speculated that circumcision may be responsible for the increased number of partners, and therefore, the increased risk. As reported by Geoffrey T. Falk, Van Howe has subsequently acknowledged that some of his statistics "were not as refined as they could have been" http://groups-beta.google.com/group/alt.circumcision/msg/07775bd5d88833c3. Van Howe's work was reviewed by O'Farrell and Egger who found methodological flaws in his work. Weiss, Quigley and Hayes carried out a new meta-analysis on circumcision and HIV and found as follows: :Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised. There have been other studies of note. Kelly ''et al.'' reported in "Age of male circumcision and risk of prevalent HIV infection in rural Uganda" that where circumcision was carried out before the age of 12 it results in a reduction to 0.39 of the odds of an uncircumcised man. The degree of protection changed according to the age at which circumcision was performed, however, with those circumcised at between 13 and 20 years at an odds ratio of 0.46, and those circumcised after the age of 20 at an odds ratio of 0.78. They concluded: "Prepubertal circumcision is associated with reduced HIV risk, whereas circumcision after age 20 years is not significantly protective against HIV-1 infection." With regard to the effects of behaviour on infection risk Buvé in USAID funded multi-site study on behalf of UNAIDS found that "In conclusion, differences in the rate of HIV spread between the East African and West African cities studied cannot be explained away by differences in sexual behaviour alone. In fact, behavioural differences seem to be outweighed by differences in HIV transmission probability." Bailey found in his study http://www.aegis.com/aidsline/2000/jul/a0071414.html that: :These results suggest that differences between circumcised and uncircumcised men in their sex practices and hygienic behaviors do not account for the higher risk of HIV infection found among uncircumcised men. Further consideration should be given to male circumcision as a prevention strategy in areas of high prevalence of HIV and other sexually transmitted diseases. Studies of the feasibility and acceptability of male circumcision in traditionally noncircumcising societies are warranted. Kiwanuka et al studied the relationship between religion and HIV in Rural Uganda and concluded: "Lower rates of HIV infection among Pentecostals appear to be associated with less Alcohol consumption, Sexual_abstinence and fewer sexual partners, whereas the low HIV prevalence in Muslims appears to be associated with low reported alcohol consumption and male circumcision." Muslims, despite having the lowest rate of sexual abstinence and the highest rate of having two or more sexual partners, had the lowest level of HIV infection compared with the other religious groups in the study (Catholics, Protestants, and Pentecostals). The factor in common between the Muslims (14.5% seropositive) and the Pentecostals (14.6% seropositive) was the lower alcohol consumption rate in these two groups than amongst Protestants (19.2%) and Catholics (19.9%). Studies have also been carried out as to the acceptability of male circumcison within traditionally non-circumcising communities. Kebaabetswe found that: :Male circumcision appears to be highly acceptable in Botswana. The option for safe circumcision should be made available to parents in Botswana for their male children. Circumcision might also be an acceptable option for adults and adolescents, if its efficacy as an HIV prevention strategy among sexually active people is supported by clinical trials. Lagarde found that "More than 70% of the non-circumcised men (NCM) stated that they would want to be circumcised if MC were proved to protect against sexually transmitted diseases (STD)." Lagarde cautioned that "Our results strongly suggest that interventions including MC should carefully address the false sense of security that it may provide." Bailey in his study Adult male circumcision in Kenya: safety and patient satisfaction looked at the possible adverse effects of introducing male circumcision on a public health scale and the post operative satisfaction levels of 380 circumcsions on 18-24 year old consenting men. As to satisfaction; "At 30 days post-surgery, 99.3% of men reported being very satisfied and 0.7% somewhat satisfied with circumcision. None were dissatisfied." And with regard to adverse effects; "All were mild or moderate and resolved within hours or several days of detection." In a recently published study in this regard in The_Lancet,'''Male circumcision and risk of HIV-1 and other sexually transmitted infections in India''', Reynolds and Bollinger found that male circumcision was strongly protective against HIV-1 infection with circumcised men being almost seven times less at risk of HIV infection than uncircumcised men.http://news.bbc.co.uk/1/hi/health/3570223.stm They further state that: :"The specificity of this relation suggests a biological rather than behavioural explanation for the protective effect of male circumcision against HIV-1." Baeten ''et al'' in a study published in The Journal of Infectious Diseases in 2005 found that uncircumcised men were at a greater than two-fold increased risk of acquiring HIV per sex act when compared with circumcised men. They conclude as follows: :"Moreover, our results strengthen the substantial body of evidence suggesting that variation in the prevalence of male circumcision may be a principal contributor to the spread of HIV-1 in Africa." Despite the strong evidence of a significant protective effect of infant male circumcision, "male circumcision should not be actively promoted for HIV prevention unless and until the RCTs (Randomized controlled trials) confirm MC to be effective in reducing HIV infection".http://www.psi.org/resources/pubs/male-circ.pdf ==== Recent Results ==== Recently, one of the more rigorous RCTs was cancelled July 6, 2005 when the study's preliminary results, disclosed by the Wall Street Journal, showed that circumcision reduced the risk of contracting HIV by 70 percent -- a level of protection far better than the 30 percent risk reduction set as a target for an AIDS vaccine. According to the newspaper account, the study under way in Orange Farm township, South Africa, was stopped because the results were so favorable. It was deemed unethical to continue the trial after an early peek at data showed that the uncircumcised men were so much more likely to become infected.http://www.aegis.org/news/wsj/2005/WJ050701.html The findings of the study - which reported that circumcision reduced the risk of contracting AIDS by 63% - were presented at the 3rd International IAS Society Conference on HIV Pathogenesis and Treatment, held in Rio de Janeiro, Brazil, 24-27 July 2005. http://www.ias-2005.org/planner/Abstracts.aspx?AID=2675 Two more randomized controlled trials (RCT's) are underway in Kenya and Uganda over a three to five year period, with the first results due in 2006. Although the trial shows promising protective effects of adult male circumcision in reducing HIV acquisition, UNAIDS emphasized that more research is needed to confirm the reproducibility of the findings of this trial and whether or not the results have more general application. UNAIDS believes that it is premature to recommend male circumcision as part of HIV prevention programmes.http://www.who.int/mediacentre/news/releases/2005/pr32/en/ This cautious approach is supported by the South African Cochrane Centre for evidence-based medicine. Evaluating earlier observational studies, the Cochrane review cites possible "researcher bias" and says these RCTs will have to be "carefully considered before circumcision is implemented as a public health measure for prevention of sexually transmitted HIV."http://www.cirp.org/library/disease/HIV/cochrane2003/ In assessing the impact of circumcision on the spread of sexually transmatted infections including HIV it must always be borne in mind that there are other risk factors. Thus, the United States has a high rate of STD infection and a high rate of circumcision compared with other advanced countries. http://www.medicinenet.com/script/main/art.asp?articlekey=41672 === Epididymitis in children === Epididymitis is a condition where the Epididymis becomes inflamed . It can be very painful, and can become a chronic condition, but medical treatment is well accepted and effective. http://www.duj.com/epididymitis.html http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Epididymitis?OpenDocument. One 1998 study found the rate of epididymitis in boys with foreskins was calculated to be significantly higher than in those without; it was found that an intact foreskin is an important etiological factor in boys with epididymitis. ===Decreased rate of penile problems=== A 1988 New Zealand study of penile problems by Fergusson ''et al'', in a birth cohort of more than 500 children from birth to 8 years of age found that: :''By 8 years, circumcised children had a rate of 11.1 problems per 100 children, and uncircumcised children had a rate of 18.8 per 100. The majority of these problems were for penile Inflammation including Balanitis, Meatitis, and inflammation of the Prepuce. However, the relationship between risks of penile problems and circumcision status varied with the child's age. During infancy, circumcised children had a significantly higher risk of problems than uncircumcised children, but after infancy the rate of penile problems was significantly higher among the uncircumcised. These associations were not changed when the results were adjusted statistically for the effects of a series of potentially confounding social and perinatal factors. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=3353186 The authors of this study acknowledged certain problem with the data: :''It is important to recognize that the data on medical attendance for penile problems was collected as part of a much larger longitudinal study of child health and development in which the primary concern was not with the issue of the longterm consequences of circumcision. This feature of the data collection process places a number of restrictions on the quality of the collected data. Specifically, data relating to immediate postcircumcision problems and penile problems that were treated at home without medical attention were not available. Also, diagnostic details of medical attendances for penile problems were limited. The net result of these imprecisions in the data collection process is that the incidence and prevalence of penile problems probably underestimated and the problems can only be described in terms of broad diagnostic categories. Nonetheless, we believe that the trends that emerge from the analysis are likely to reflect general differences in the medical histories of circumcised and uncircumcised children.http://www.circs.org/library/fergusson/index.html'' Van Howe observed that Fergusson ''et al.'' used parental complaints rather than direct examination in their retrospective study, so the study may have understated the number of boys with penile problems.http://www.cirp.org/library/complications/vanhowe/ ===Paraphimosis=== The American Academy of Family Physicians says: :"Paraphimosis is a urologic emergency, occurring in uncircumcised males, in which the Foreskin becomes trapped behind the Corona and forms a tight band of constricting tissue. Often iatrogenically induced, paraphimosis can be prevented by returning the prepuce to cover the glans following penile manipulation. Treatment often begins with reduction of edema, followed by a variety of options, including mechanical compression, pharmacologic therapy, puncture technique and dorsal slit. Prevention and early intervention are key elements in the management of paraphimosis. (Am Fam Physician 2000;62:2623-6,2628.)"http://aafp.org/afp/20001215/2623.html The article goes on to say that the cause is most often iatrogenic (caused by doctors). It further stated: :"Rare causes of paraphimosis include self-inflicted injury to the penis such as, piercing a penile ring into the glans and paraphimosis secondary to penile erections." Several different techniques are mentioned of dealing with this condition, and these are listed by the article in the American Family Physician, and also in the anti-circumcision web site CIRP. http://www.cirp.org/library/treatment/paraphimosis/ One procedure is minor surgery to make a small slit in the foreskin without removing any tissue.http://www.cirp.org/library/treatment/phimosis/saxena1/ Another method of treating paraphimosis is called the "Dundee technique." http://www.cirp.org/library/treatment/phimosis/reynard1/ Nevertheless, many physicians recommend circumcision for paraphimosis. Images of paraphimosis. http://www.aafp.org/afp/20001215/2623_f1.jpghttp://www.circlist.com/anatterms/anatimages/tcer015.jpg ===Balanitis=== '''Balanitis''' is inflammation of the glans penis. Balanitis involving the foreskin or prepuce is termed balanoposthitis. The most common complication of balanitis is phimosis, or inability to retract the foreskin from the glans penis.http://www.emedicine.com/emerg/topic51.htm and one study found that uncircumcised men were at more than five times the riskhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=2383029&dopt;=Abstract EMedicine says: "Uncircumcised men with poor personal hygiene are most affected by balanitis. Lack of aeration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema. Adherence of the foreskin to the inflamed and edematous glans penis causes phimosis."http://www.emedicine.com/emerg/topic51.htm O'Farrell ''et al.'' noted inferior hygiene among uncircumcised men.http://www.ncbi.nlm.nih.gov/entrez/cubby.fcgi?db=&cmd;=Search&term;=%22Quigley+M%22%5BAuthor%5D The researchers also reported an association between balanitis and inferior hygiene. Inflammation has numerous causes, including irritation by environmental substances, physical trauma, and infection by a wide variety of pathogens, including bacteria, virus, yeast, or fungus — each of which require a particular treatment. Good medical practice includes careful diagnosis with the aid of a good patient history, swabs and cultures, and pathologic examination of a biopsy. Only then can the proper treatment be prescribed.http://www.cirp.org/library/disease/balanitis/edwards1/ Many studies of balanitis do not examine the subjects' genital washing habits; a 1993 study by Birley et al. did so and found that excessive genital washing with soap may be a strong contributing factor to balanitis.http://www.cirp.org/library/disease/balanitis/birley/ Fakjian ''et al.'' studied 398 patients at a dermatology clinic in a cross-sectional study. 213 (53.5%) had been circumcised. "Balanitis was diagnosed in 2.3% of circumcised men and in 12.5% of uncircumcised men. In patients with diabetes mellitus, balanitis occurred with a prevalence of 34.8% in the uncircumcised population, compared with 0% in the circumcised population. Balanitis did occur with increased frequency in the diabetic population (16%), regardless of circumcision status, compared with the nondiabetic population (5.8%)." http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=2383029&dopt;=Abstract Balanitis_xerotica_obliterans is a skin condition causing white, atrophic patches on the glans or foreskin. It is much more common among uncircumcised males. '''Zoon's Balanitis''', illustrated here, also know as ''Balanitis Circumscripta Plasmacellularis'' or ''plasma cell balanitis'' (PCB) is an idiopathic, rare, benign penile dermatosis, usually of a middle-aged or older man http://www.emedicine.com/derm/topic45.htm. Circumcision is the usual treatment of choice but fusidic acid cream 2% has been curative in some cases. http://www.emedicine.com/derm/topic45.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=PubMed&list;_uids=10101891&dopt;=Abstract '''Balanitis in childhood.''' Balanitis afflicts young boys generally only where a difficult to retract tight foreskin is present. Two studies found that uncircumcised boys were at approximately twice the risk of developing balanitishttp://www.circs.org/library/herzog/http://www.circs.org/library/fergusson/ Escala and Rickwood, in a 1989 examination of 100 cases of balanitis in childhood, concluded: "[T]he risk in any individual, uncircumcised boy appears to be no greater than 4%." http://www.cirp.org/library/disease/balanitis/escala1/, They recommend circumcision as a last resort only in cases of recurrent balanitis.http://www.cirp.org/library/disease/balanitis/escala1/ Images of balanitis http://zdravi.004.cz/z-balanitis/balanitis-cand.jpg http://www.stdservices.on.net/images/std/balanitis/slide10.jpg http://www.atlasdermatologico.com.br/ListaImagens/Balanitis_Candidomycetica1.JPG ===Skin diseases=== Researchers from the Imperial College School of Medicine, Chelsea & Westminster Hospital, London, England in a study Circumcision and genital dermatosesreported the results of their study of 357 patients referred for genital skin disease: : Most cases of inflammatory dermatoses were diagnosed in uncircumcised men, suggesting that circumcision protects against inflammatory dermatoses. The presence of the foreskin may promote inflammation by a koebnerization phenomenon, or the presence of infectious agents, as yet unidentified, may induce inflammation. The data suggest that circumcision prevents or protects against common infective penile dermatoses. Some American military doctors have recommended prophylactic circumcision because of the difficult conditions during wartime. For example, a United States Army report regarding World_War_II noted that in case of penile lesions, the foreskin may "invite secondary infection". The sexually transmitted disease Chancroid, now very uncommon, was also associated with phimosis, which could hardly occur in circumcised males, and "soldiers in combat were seldom able to practice personal hygiene". (Source: JF Patton, Medical Department, United States Army, Surgery in World War II, Urology, p. 64) == Sexual Effects == There have been many claims about the effect of circumcision on sexual function. Collins, in a study of 15 men found no post-circumcision difference in sex drive, erections, ejaculations, and overall satisfaction. Senkul found no significant effect in a study of 42 men circumcised for religious reasons, other than a 60% increase in time to ejaculation at the 98% statistical confidence level. Senkul said that delayed ejaculation may in fact be seen as a benefit. Fink found that medically necessitated circumcision resulted in worsened erectile function at the 99% confidence level, de-sensitization and/or delayed ejaculation at the 92% certainty level, but improved satisfaction at the 96% certainty level. In a pre- and post-circumcision survey of 95 men, Shen found that medical circumcision led to erectile dysfunction at the 99.9% level, "weakened erectile confidence" at the 96% level, and prolonged intercourse and "improved satisfaction" at the 96% level. In a study of 150 men circumcised as adults for penile problems, Masood ''et al'' reported a slight reduction in erectile function scores, from 22.41 before to 21.13 afterwards (60% confidence). 69% noted less pain during intercourse (95% confidence). 38% reported improved penile sensation (99% confidence), 18% reported worse penile sensation, while the remainder (44%) reported no change. 61% reported satisfaction with the results, while 17% felt it made things worse, and 22% expressed neutral sentiments. 44% of the patients (p = 0.04) and 38% of the partners (p = 0.02) thought the penis appearance improved after circumcision. The authors of the study concluded that the satisfaction rate was a 'poor outcome' and recommended discussing with prospective patients the results of this study during the informed consent process. An analysis of a national US survey by Laumann found that uncircumcised males had a higher overall rate of all seven types of sexual dysfunctions considered, especially after the age of 45 years, at a cumulative 93% statistical confidence level. He also found that circumcised men tend to engage in "more elaborated set of sexual practices" and that circumcision is associated with an increased incidence of sexually transmitted diseases, though this only reached statistical significance in the case of chlamydia. Concerning the differences in sexual practices, Laumann speculated "..differences in the association between circumcision status and sexual practice across ethnic groups suggest that cultural, rather than physiological forces may be responsible." http://www.circs.org/library/laumann/ A multinational study by Waldinger ''et al'' found that circumcised men took on average 6.7 minutes to ejaculate, compared with 6.0 minutes for uncircumcised men. This difference was not statistically significant. The comparison excluded Turkey, which was significantly different from the other countries studied. === Glans sensitivity === An examinination of 7 circumcised and 6 uncircumcised males discerned no difference in keratinization of the glans http://bmj.bmjjournals.com/cgi/content/full/320/7249/1592. Bleustein ''et al'' tested the sensitivity of the glans penis, and found no difference between circumcised and uncircumcised men http://www.circs.org/library/bleustein/, confirming an earlier study by Masters and Johnsonhttp://www.circs.org/library/masters/. Bleustein later followed up with a larger study, with the same finding.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=15833526&query;_hl=1 These studies relied on laboratory tests of sensation thresholds to mechanical or thermal stimuli, rather than on subjective reports of sexual sensation. Fink, in his survey of men circumcised as adults for medical (93%) or elective (7%) reasons, reported: "Adult circumcision appears to result in worsened erectile function (99% confidence), decreased penile sensitivity (92% confidence), no change in sexual activity (88% confidence) and improved satisfaction (96% confidence). Of the men 50% reported benefits and 38% reported harm. Overall, 62% of men were satisfied with having been circumcised." Fink attributes the improved satisfication to the respondee's aesthetic considerations and to a resolution of previous painful conditions. Fink grouped decreased sensitivity with ejaculation taking longer than the men desired. Only one question relating to ejaculation time had a significant result; the question directly addressing sensitivity had no significant difference. There is conflicting evidence whether this should be seen as evidence of decreased sensitivity or simply of delayed ejaculation. On the one hand, a study by Paick ''et al'' failed to find a correlation between increased vibrational sensitivity and premature ejaculation.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=9884921 On the other hand, studies by Koos Slob ''et al.'' and several other groups cited therein demonstrated that ejaculation can be significantly delayed using a local anesthetic cream to numb the glans. Some men who undergo Foreskin_restoration claim that the procedure improves glans sensitivity. If one accepts the supposition that delayed ejaculation after circumcision arises from desensitization, then this claim is in seeming agreement with the post-circumcision surveys of Fink and Senkul. However, it is in apparent disagreement with the sensation threshold work of Bleustein ''et al'' (2003), Bleustein ''et al'' (2005) and Masters and Johnson. Some have suggested that much of this perceived "improved sensitivity" of the glans reported by foreskin restorers is psychosexual and psychosomatic and an example of the Placebo_effect, with no real change in glans sensitivity.http://bmj.bmjjournals.com/cgi/content/full/309/6955/679/a http://bmj.bmjjournals.com/cgi/eletters/309/6955/679/a#43129 Yang ''et al.'' concluded in their study into the innervated of the penile shaft and glans penis that: "The distinct pattern of innervation of the glans emphasizes the role of the glans as a sensory structure."http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=9698671 === Foreskin sensitivity === Traditionally, many believed that the foreskin was sexually sensitive http://www.cirp.org/library/cultural/maimonides/http://thriceholy.net/Texts/Circumcision.html and this belief has been documented by opponents of circumcision http://www.historyofcircumcision.net/index.php?option=com_content&task;=view&id;=32&Itemid;=55 http://www.circinfo.org/quote.html http://www.circumstitions.com/Pleasure.html. More recently, some researchers have also suggested that the foreskin may be sexually responsive http://www.cirp.org/library/anatomy/winkelmann2/ http://www.cirp.org/library/anatomy/winkelmann/ http://www.cirp.org/library/anatomy/lakshmanan/. Opponents of circumcision have also cited these studies, which report on the sensitivity or innervation of the prepuce. While there are no studies examining whether it or any other single part of the penis is specifically ''sexually'' sensitive, they claim a sexual role based upon the presence of nerve-endings in the foreskin sensitive to light touch, stroking and fluttering sensations. Not all agree, however. Genital integrity activist and author Kristen O'Hara argues that the glans is the "male clitoris", with the foreskin maintaining at best a supporting role during sexual intercourse.http://health.groups.yahoo.com/group/againstcirc/message/17199 Pathologist, John R. Taylor, a critic of circumcision, http://www.cirp.org/library/anatomy/taylor/ postulated that the relatively highly innervated and vascularised Ridged_band at the end of the foreskin, which is almost invariably removed in circumcision, is erogenous and plays a role in normal sexual function. He also speculated that the Gliding_action, possible only where sufficient loose penile shaft skin exists, serves to stimulate this band through contact with the corona of the glans penis during vaginal intercourse.http://www.cirp.org/library/anatomy/taylor2/ The gliding action was also mentioned by Lakshmanan, (1980) http://www.cirp.org/library/anatomy/lakshmanan/. No scientific confirmation of Taylor's speculation has been made. ===Female Arousal=== A study by psychologists Bensley & Boyle (2003) reported that vaginal dryness tends to be a problem when the male partner is circumcised.http://www.cirp.org/library/sex_function/bensley1/ Bensley ''et al.'' reported that the lack of a foreskin in the male partner produces symptoms similar to those of female arousal disorder. The authors hypothesized that the Gliding_action possibly involved in intercourse with an uncircumcised partner might help prevent the loss of vaginal lubrication. The researchers state that the respondents were self-selected, and that larger sample sizes are neededhttp://www.cirp.org/library/psych/boyle5/. Boyle ''et al.'' state that self-selection is unreliablehttp://www.cirp.org/library/psych/boyle6/. An earlier study (1988) of randomly selected young mothers in Iowa, where most men are circumcised, found that 76% found the circumcised penis more visually arousing.http://www.circs.org/library/williamson/index.html Although 88% of the women surveyed had only had experiences with circumcised penises, the pattern was repeated among the 24 women with dual experience. ==Costs and Benefits== Several researchers conducted cost-benefit analyses to see if infant circumcision justified the costs and the medical risks. Cadman ''et al.'' (1984) concluded that the expense of circumcision outweighed any money that might be saved by reducing the risk of penile cancer. Therefore, they argued, public funds should not pay for it http://www.cmaj.ca/cgi/content/abstract/131/11/1353. Lawler ''et al.'' (1991) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=1794670reported a net cost of $25.00 and a benefit of ten days of life. They concluded that there was no medical indication for or against circumcision. Ganiats ''et al.'' (1991) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db;=pubmed&dopt;=Abstract&list;_uids=1766331 reported that a net cost of $102 and it also cost 14 hours of healthy life. They found no medical basis on which to recommend for or against circumcision. Chessare (1992) compared circumcision preventing urinary tract infections against its risks http://www.cirp.org/library/disease/UTI/chessare/. He concluded that non-circumcision produced the “highest expected utility”, provided that the probability of developing a UTI was less than 0.29. Christakis ''et al.'' (2000) report that "Circumcision remains a relatively safe procedure. However, for some parents, the risks we report may outweigh the potential benefits." http://www.circs.org/library/christakis/index.html The American Academy of Pediatrics (1999) said: :"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child." Policy Statement, 1999 Clarifying their statement in 2000, the authors explained: :The Task Force found the evidence of low incidence, high-morbidity problems not sufficiently compelling to recommend circumcision as a routine procedure for all newborn males. However, the Task Force did recommend making all parents aware of the potential benefits and risks of circumcision and leaving it to the family to decide whether circumcision is in the best interests of their child. ... Circumcision falls into that group of procedures that have potential medical benefits and some risks and should be evaluated by each family in the context of their personal beliefs and values as well as their ethnic, cultural, and religious practices. The Task Force respects the role of parents as decision-makers for their newborns and recommends that physicians discuss with parents the potential benefits as well as risks of circumcision so that parents can decide whether circumcision is in the child's best interests. In June 2004 the College of Physicians and Surgeons of British Columbia said: :"Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention."[https://www.cpsbc.ca/cps/physician_resources/publications/resource_manual/malecircum] The most recent cost-utility study (2004) reported that the overall effect on male neonatal non-therapeutic circumcision on health is more likely to be negative rather than positive.http://mdm.sagepub.com/cgi/content/short/24/6/584 The author, Van Howe, is a fierce opponent of circumcision, and has presented at a Strategies for Intactivism conference in addition to NOCIRC symposia. He has also been criticised for bias, distortions and misrepresentation of the literature (The Pediatric Infectious Disease Journal: Volume 17(8) August 1998 pp 762-763). Some public and private health insurance providers have deleted coverage of elective non-therapeutic circumcision. In such cases, the person electing the procedure must bear the costs. ==See also== *Bioethics_of_neonatal_circumcision *Circumcision_advocacy *Genital_integrity (opponents of circumcision) *Circumcision_and_law *Foreskin_restoration *Male_circumcision ==External links== *American Academy of Pediatrics. Circumcision Policy Statement (RE9850). March 1999. *American Medical Association. Report 10 of the Council on Scientific Affairs (I-99), Neonatal Circumcision. Dec 1999. *British Medical Association. The Law & Ethics of Male Circumcision - Guidance for Doctors. March 2003. *Canadian Paediatric Society. Neonatal Circumcision Revisited. 1996 (reaffirmed March 2002) *The Royal Australasian College of Physicians. Policy Statement On Circumcision. Sep 2002. *Apt A. Circumcision and prostatic cancer. ''Acta Med Scand'' 1965; 178: 493-504. ==References== * Aaron J. Fink. ''Circumcision: A Parent's Decision for Life''. Kavanah Publishing Company,Inc., 1988. Category:Circumcision_debate