This list contains key references cited for further reading in the main pages of the site. It makes no claim to be comprehensive but it does aim to include the most significant and influential papers published since 1945. Where possible an abstract or relevant quotation is included.
When you follow a reference link from the main pages, the target reference should always be the one appearing at the top of the page. Multiple publications from one author are grouped together as one link.
Awojobi. O.A., 1992 Sutureless circumcision. Tropical Doctor 22(3), 124
I was trained to perform circumcisions in infants using the bone cutter and excising the prepuce flush with it. This method is often accompanied by haemorrhage from the dorsal vessels, requiring ligatures, when the cutter is removed and the skin retracted to expose the glans. However, excision of the prepuce 0.5cm distal to the bone cutter prevents opening up of the vessels at the level of the constriction produced by the bone cutter.
Badger, J., 1988 Some light under the foreskin Australian Forum 2, (6), 11-19
"During the late 1960s and early 1970s, a great debate raged in the Australian medical press on the pros and cons of circumcision. One of the most curious features of this debate was that it was clear that the learned doctors on both sides of the fence had one thing in common - they had never seen an adult uncircumcised penis! ....
"Since that time circumcision has become much less common in Australia, so that now there will be a substantial number of sexually active young Australians who still have a foreskin. Hard facts about circumcision are still as scarce, however, and so is any general knowledge about people's attitudes to the operation. We have therefore constructed the great Forum circumcision questionnaire to try and dispel some of the ignorance. This questionnaire is for all - male and female, young and old, experienced and inexperienced, straight or gay. Please fill it in, pass the other half to your lover, friend brother or sister, and give photocopies to anyone else who is interested, and make sure that they all get sent back to us. The results will be published in a future Forum, and will at last tell the world - and the medical profession - what you think about circumcision, and how it has affected your private life."
Badger, J. 1989 Circumcision - what you think. Australian Forum 2 (11), 10-29
"At last, after long sessions analysing your responses, here it is - the report on the Great Forum Circumcision Questionnaire. Thanks to all of you who sent in forms, and especially those who wrote letters to amplify their answers. Special thanks, too to those who took the trouble to pass copies to their friends."
Badger, J., 1989 The great circumcision report, part 2. Australian Forum 2 (12), 5-13
"Last issue we looked in detail at the 180 responses we received to the Great Forum Circumcision Questionnaire, and uncovered some fascinating and surprising facts about your attitudes to circumcision and its effects on sexuality. In the second instalment we look at some general questions which arose, and at how our findings compare with modern medical research."
Boon, M.E., I. Susanti, M.J. Tasche & L.P. Kok, 1989. Human papillomavirus (HPV) associated male and femal genital carcinomas in a Hindu population. The male as vector and victim. Cancer, 64, 550-565
Epidemiologic, histologic and immunohistochemical data concerning male (penile) and female (cervical and vulvar/vaginal) genital carcinomas in a Hindu population are reported. The data are from Bali, an Indonesian Hindu island in a country with a predominantly Muslim population. In contrast to the surrounding Muslim population, circumcision is rare in the people of Bali, and the rate of phimosis in grown men is very high. The Balinese epidemiologic data of 1985 to 1986 were compared with 1986 data from The Netherlands. In Bali, cervical carcinoma was the most frequent carcinoma in women, and vulvar/vaginal carcinoma ranked seven. These carcinomas were much less frequent in The Netherlands. In Balinese men, penile carcinoma is the second most frequent carcinoma, whereas it is rarely diagnosed in The Netherlands. Penile carcinomas are found in Bali in younger age groups than in The Netherlands. Based on the immunohistochemical staining results, it is estimated that over 75% of the studied Balinese genital carcinomas contain human papillomavirus (HPV). The data presented in this paper may indicate that the cofactor of impeded postcoital hygiene can be of great importance for male and female HPV-associated genital carcinogenesis. It is clear that Balinese men, in particular men with extreme phimosis, are both vectors and victims of HPV. In The Netherlands the man is exclusively the vector of HPV.
Bryk F., 1934 Circumcision in Man and Woman. (tr. Felix Berger). New York: American Ethnological Press: 342 pp. (Facsimile reprint New York: AMS Press, 1974).
Cameron DW, Simonsen JN, D'Costa LJ, et al. 1989 Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. Lancet; 2: 403-407.
To determine the frequency and risk factors for female to male sexual transmission of human immunodeficiency virus type 1 (HIV-1), a prospective study was carried out in 422 men who had acquired a sexually transmitted disease (STD) from a group of prostitutes with a prevalence of HIV-1 infection of 85%. The initial seroprevalence of HIV among the men was 12%. 24 of 293 (8.2%) initially seronegative men seroconverted to HIV-1. Newly acquired infection was independently associated with frequent prostitute contact (risk ratio 3.2, 95% confidence interval 1.2-8.1), with the acquisition of genital ulcer disease (risk ratio 4.7, 95% confidence interval 1.3-17.0), and with being uncircumcised (risk ratio 8.2, 95% confidence interval 3.0-23.0). 96% of documented seroconversions occurred in men with one or both of the latter two risk factors. In a subgroup of 73 seronegative men who reported a single prostitute sexual contact, the frequency of HIV-1 infection was 8.2% during 12 weeks of observation. No man without a genital ulcer seroconverted. A cumulative 43% of uncircumcised men who acquired an ulcer seroconverted to HIV-1 after a single sexual exposure. These data indicate an extremely high rate of female to male transmission of HIV-1 in the presence of STD and confirm a causal relation between lack of male circumcision, genital ulcer disease, and susceptibility to HIV-1 infection.
Castellsague X, Bosch X, Munoz N, Meijer C, Shah KV, de Sanjose, S, Eluf-Neto J, Ngelangel CA, Chichareon S, Smith JS, Herrero, R & Francheschi S. 2002
Male circumcision, penile human papilloma virus infection, and cervical cancer in female partners.
New England Journal of Medicine 346: 1105-1112.
Background It is uncertain whether male circumcision reduces the risks of penile human papillomavirus (HPV) infection in the man and of cervical cancer in his female partner.
Methods We pooled data on 1913 couples enrolled in one of seven case-control studies of cervical carcinoma in situ and cervical cancer in five countries. Circumcision status was self-reported,and the accuracy of the data was confirmed by physical examination at study sites.The presence or absence of penile HPV DNA was assessed by a polymerase-chain-reaction assay in 1520 men and yielded a valid result in the case of 1139 men (74.9 percent).
Results Penile HPV was detected in 166 of the 847 men (19.6 percent)and in 16 of the 292 men (5.5 percent). After adjustment for age at first intercourse,lifetime number of sexual ners,and other potential confounders,circumcised men were less likely than uncircumcised men to have HPV infection (odds ratio,0.37;95 percent confidence interval,0.16 to 0.85). Monogamous women whose male partners had six or more sexual partners and were circumcised had a lower risk of cervical cancer than women whose partners were uncircumcised (adjusted odds ratio,0.42;95 percent confidence interval, 0.23 to 0.79). Results were similar in the subgroup of men in whom circumcision was confirmed by medical examination.
Conclusions Male circumcision is associated with a reduced risk of penile HPV infection and,in the case of men with a history of multiple sexual partners, a reduced risk of cervical cancer in their current female partners.
Chartham, Robert. Advice to Men
From page 108:
"A study of 2,500 uncircumcised penises has revealed that that less than half (45%) have foreskins that completely cover the head of the relaxed penis, whereas in 32% the foreskin covered only half the head and in 23% did not cover it at all."
Cooper, GG GJ Thomson & PA Raine, 1983. Therapeutic retraction of the foreskin in childhood. Br. Med. J. (Clin. Res. Ed) 286(630), 186-187
Cox, G. 1995 De virginibus puerisque - the function of the foreskin from an evolutionary perspective. Medical Hypotheses 45, 617-621
The functional significance of the human male foreskin is considered in evolutionary terms. It is postulated that there is a lifetime reproductive advantage in delaying the age of first coitus, and hence of first childbirth, for some years after puberty, until the parents are better established as providers. Phimosis and preputial adhesions are common in human males because they have selective advantage, tending to impede and therefore delay the onset of sexual activity. The physical signs of female virginity have an analogous function, and have been selected for in the same way. This hypothesis also provides a consistent explanation for the world-wide tradition of circumcision and for the common practice of masturbation by human males.
Craig JC. Knight JF. Sureshkumar P. Mantz E. Roy LP., 1996. Effect of circumcision on incidence of urinary tract infection in preschool boys. Journal of Pediatrics. 128:23-27
OBJECTIVE: To determine whether circumcision decreases the risk of symptomatic urinary tract infection (UTI) in boys less than 5 years of age.
STUDY DESIGN: A case-control study (1993 to 1995) in the setting of a large ambulatory pediatric service. Case subjects and control subjects were drawn from the same population. One hundred forty-four boys less than 5 years of age (median age, 5.8 months) who had a microbiologically proven symptomatic UTI (case subjects), were compared with 742 boys (median age, 21.0 months) who did not have a UTI (control subjects). The proportion of case and control subjects who were circumcised in each group was compared with the use of the chi-square test, with the strength of association between circumcision and UTI expressed in terms of an odds ratio. To determine whether age was a confounder or an effect-modifier, we stratified the groups by age (< 1 year; > or = 1 year) and analyzed by the method of Mantel-Haenszel.
RESULTS: Of the 144 preschool boys with UTI, 2 (1.4%) were circumcised, compared with 47 (6.3%) of the 742 control subjects (chi-square value = 5.6; p = 0.02; odds ratio, 0.21; 95% confidence intervals, 0.06 to 0.76). There was no evidence that age was a confounder or modified the protective effect of circumcision on the development of UTI (Mantel-Haenszel chi-square value = 6.0; p = 0.01; combined odds ratio, 0.18; 95% confidence intervals, 0.05 to 0.71; Breslow-Day test of homogeneity chi-square value = 0.6; p = 0.4).
CONCLUSIONS: Circumcision decreases the risk of symptomatic UTI in preschool boys. The protective effect is independent of age.
Crowley IP. Kesner KM, 1990. Ritual circumcision (Umkhwetha) amongst the Xhosa of the Ciskei. Br J Urol. 66, 318-21
The Umkhwetha is an ancient custom of ritual circumcision still practiced by the Xhosa people of Southern Africa. In 45 consecutive youths who required hospital admission the mortality rate was 9%. The complications seen over the years are reviewed and their management discussed.
Danielsson, B. Love in the South Seas. (tr. F. Lyon). London: Allen & Unwin, 1956: 240pp.
From page 91:
"The form of circumcision which the Polynesians practised differed considerably from the Jewish, and should perhaps rather be called by the medical terms incision or superincision. Instead of removing the foreskin altogether in the Jewish manner only a long slit was made in the upper side of it. The 'operation' was quite painless and simple, and was considered necessary; public opinion, indeed, was so strong that all boys without exception submitted to it on reaching the age of puberty."
Donovan, B., I. Bassett, N.J. Bodsworth, 1994. Male circumcision and common sexually transmissible diseases in a developed nation setting. Genitourinary Medicine 70,
Objective - to determine whether the circumcision status of men affected their likelihood of acquiring sexually transmitted diseases (STDs).
Design - A cross-sectional study employing an anonymous questionnaire, clinical examination and type specific serology for herpes simplex virus tye 2 (HSV2).
Setting - a public STD clinic in Sydney, Australia
Subjects - 300 consecutive heterosexual male patients
Main outcome measures - Associations between circumcision status and past or present diagnoses od STDs including HSV-2 serology and clinical pattern of genital herpes.
Results - 185 (62%) of the men were circumcised and they reported similar ages, education levels and lifetime partner numbers as men who were uncircumcised. There was no significant association between the presence or absence of the male prepuce and the number diagnosed with genital herpes, genital warts, and non-gonococcal urethritis. Men who were uncircumcised were no more likely to be seropositive for HSV-2 and reported symptomatic genital herpes outbreaks of the same frequency and severity as men who were circumcised. Gonorrhoea, syphilis and acute hepatitis B were reported too infrequently to reliably exclude any association with circumcision status. Human immunodeficiency virus (rare among heterosexula men in the clinic) was an exclusion criterion.
Conclusions - from the findings of this study, circumcision of men has no significant effect on the incidence of common STDs in this developed nation setting. However, these findings may not necessarily extend to other settings where hygiene is poorer and the spectrum of common STDs is different.
Emmett. AJ Z-plasty reconstruction for preputial stenosis - a surgical alternative to circumcision. Aust. Paediatric J. 18, 219-220
Gairdner, D. 1949. The fate of the foreskin. British Medical Journal 1949/2, 1433-1437
The development of the prepuce is incomplete in the newborn male child, and separation from the glans, rendering it retractable, does not usually occur until some time between 9 months and 3 years. True phimosis is extremely rare in infancy.
During the first year or two of life, when the infant is incontinent, the prepuce fulfils an essential function in protecting the glans. Its removal preposes to meatal ulceration.
The many and varied reasons commonly advanced for circumcising infants are critically examined. None are convincing.
Though early circumcision will prevent penile cancer, there is reason to suppose that keeping the prepuce clean would have its effect in preventing this disease.
In the light of these facts, a conservative attitude towards the prepuce is proposed, and a routine for its hygiene is suggested. If adopted this would eliminate the vast majority of the tens of thousands of circumcisions performed annually in this country, along with their yearly toll of some 16 child deaths.
Grossman. E.A. 1982. Circumcision: a Pictorial Atlas. Todd & Honeywell, Great Neck NY.
He Y. & XH Zhou, 1991. Balloon dilation treatment of phimosis in boys. Report of 512 cases. Chinese Medical Journal 104, 491-493
Five hundred and twelve boys, aged from 5 months to 12 years, with phimosis were treated by application of a specially designed balloon catheter (patented). 1% dicaine topical anesthesia was used. 3-6 months follow-up showed that all the patients were cured. The procedure is simple, safe and much less traumatizing than the conventional circumcision. The mechanisms of balloon dilation, the age-specificity and the anesthesia were discussed.
Izzien Al-Samarrai, A.Y. 1991. Plastibell circumcision. Journal of the Royal College of Surgeons of Edinburgh 36, 411
Circumcision is the commonest surgical procedure in Islamic countries. Using the Plastibell (Hollister Inc., Libertyville, Illinois, USA) it is an easy procedure and has minimal complications.
Jones D.R.and B.K Gray. 1989. A measured circumcision. Journal of the Royal College of Surgeons of Edinburgh 34, 283
"Circumcision is a common operation and a number of techniques have been described. The aim is to cut the foreskin at the correct length and angle so that it can be sutured to a neat rim of mucosa at the base of the glans without tension or excess skin."
Lafferty, PM FB MacGregor & WG Scobie, 1991. Management of foreskin problems. Archives of Disease in Childhood. 66, 696-697
One hundred consecutive cases of boys with foreskin problems referred to local paediatric surgeons in the Edinburgh area were studied. Fifty five underwent circumcision and the remainder were managed more conservatively with or without the use of local or general anaesthetic. Although sometimes avoiding general anaesthetic, the more conservative methods involved more frequent visits to the clinic, a larger number of complications, and a longer follow up period. Despite the vogue for conservatism, circumcision still has an important part to play in the management of troublesome foreskins in children.
Lang, K. 1986. Conservative therapy of phimosis. (in German) Monatsschrift Kinderheilkunde 134, 824-825
Worldwide in about ten percent of boys general circumcision is performed. The motivations are religious or other rites and ethnic customs, but no scientific medical indication exist for this intervention, even not the small group with inborn phimosis. For these until now only the surgical way is given by circumcision. In 56 cases of boys before puberty with severe phimosis 53 could be completely cured by combined parenteral HCG and local Corticoid treatment within 4-6 weeks. The longtime follow up study did not show any later side effect. The therapeutic scheme is given.
Leitch, I.O.W. 1970. Circumcision - a continuing enigma. Australian Paediatric Journal 6, 59-65
Lucas, M.G. 1984. A method of circumcision. British Journal of Urology 56, 551-553
"A case is made for a method of circumcision which is little known in the United Kingdom. ..... The aim is, with the foreskin retracted, to remove a strip of skin from its underlying loose connective tissue. ..... It takes rather longer to perform than a conventional circumcision but the extra time is justified by improved cosmetic and functional results."
Marshall, VF., 1953 Typical carcinoma of the penis in a male circumcised in infancy. Cancer 6, 1044-1045.
Masters, W.H. & V.E. Johnson, 1966. Human Sexual Response. Little, Brown & Co.
From p190 of Bantam Edition, 1980
"A limited number of the male study-subject population was exposed to a brief clinical experiment designed to disprove the false premise of the excessive sensitivity of the circumcised glans. The 35 uncircumcised males were matched at random with circumcised study subjects of similar ages. Routine neurologic testing for both exteroreceptive and light tactile discrimination were conducted on ventral and dorsal surfaces of the penile body, with particular attention directed towards the glans. No clinically significant diference could be detected between the circumcised and uncircumcised glans during these examinations."
Narayana AS, Olney LE, Loening SA, Weimar GW, Culp DA. 1982 Carcinoma of the penis: analysis of 219 cases. Cancer 49: 2185-2191.
Norman RW, Millard OH, Mack FG, Lannon SG., Belitsky P. 1983 Carcinoma of the penis: an 11-year review. Can. J. Surg. 26: 426-428.
Osmond, TE. 1953. Is routine circumcision advisable? Journal of the Royal Army Medical Corps 99, 254
The examination of large numbers of soldiers, most of them National Service men, provided a good opportunity to note the condition of the prepuce. The following table indicates the type of prepuce in 1,095 cases.
38% (416) Normal, i.e. the prepuce did not completely hide the glans penis
34% (377) Circumcised
20% (217) Long prepuce covering the glans penis but retractable
8% (85) Long prepuce which could not be retracted or only with difficulty;
in several cases the aperture in the prepuce was hardly more than pin-hole.
From the above figures it appears that 20% of these soldiers would have benefited from circumcision and 8% needed it; if the 377 circumcised men are excluded the respective percentages would be 35 and 14. In most of those with long prepuces there was a large collection of smegma, and this suggests that more teaching of hygiene is needed at centres where recruits are trained. The ignorance of these young soldiers is remarkable; many of them expressed surprise at the condition revealed when they retracted their foreskins; some of them had apparently never done so in their lives.
The foregoing is not meant to be a plea for the circumcision of every male baby; opinion seems generally against it, partly because it is impossible to decide at a very early age whether it is necessary. It is fairly generally agreed, however, that the circumcised are less likely to contract venereal disease than the uncircumcised and most young men are more liable to exposure in service than in civilian life; moreover the glans penis should be washed as often as the rest of the body. It does seem that all young National Service men should receive adequate instruction in personal hygiene when they first join, and those with foreskins which cannot be retracted should be advised to be circumcised.
Ohjimi T. & H. Ohjimi. 1981. Special surgical techniques for the relief of phimosis. J. Dermatol. Surg. Oncol. 7, 326-330
Patel, H. 1966. The problem of routine infant circumcision. Canadian Medical Association Journal 95, 576-581
One hundred male infants were studied at the Kingston General Hospital, Kingston, Ontario to determine the incidence and complications of routine circumcision. The parents were also interviewed concerning the cause of the operation. In these 100 infants, complications, usually minor, were very common, and included hemorrhage (35), meatal ulcers (31), infection (eight), phimosis (one) and meatal stenosis.
The reasons given for operation were prophylactic - to avoid the psychological trauma of later operations for infection, phimosis and "troubles" (40), cleanliness (11) and phimosis (four). The remaining cases were for social and other non-medical reasons. Attitudes of parents and physicians regarding circumcision varied from firm belief in its value to a casual approach. One half of the babies had partial circumcisions, confirming previous suspicions that non-Jewish males frequently had partial operations. Partial operations do not always guarantees cleanliness and probably do not eliminate the risk of penile carcinoma in all cases, if smegma is carcinogenic. Routine circumcision spare a few children psychologically traumatic operations at a later date and relieve parents of anxiety about the future of the uncircumcised child. This should be balanced against the complications, which, although usually minor, may occasionally be serious.
Rogers, BO. History of External Genital Surgery in C.E. Horton (ed) Plastic and reconstructive surgery of the genital area. Little, Brown & Co., Boston, 1973, pp 3-15
"Man's knowledge of methods to correct genital deformities began with circumcision. As a ritualistic operation, circumcision has been verified to exist in the earliest pre-dynastic mummies of Egypt and Nubia, and Sudhoff recognised circumcised penises in two early Egyptian sculptures."
Sharma U, Rath GJ, Singhal RM, Sharma LK, Prakash A. 1982 Megavoltage radiation therapy in carcinoma of the penis. Int. Surgery 67: 69-71.
Smith, G.L. R. Greenup & E.T. Takafuji , 1987. Circumcision as a risk factor for urethritis in racial groups. Am. J. Public Health 77, 452-454
A retrospective population-based case-control study of sexually transmitted urethritis was conducted at a large military base over a 21-month period. During the study, 9,514 patients were seen for sexually transmitted disease. The analysis was restricted to active duty males and showed that Blacks had 14.8 times the incidence rate of gonococcal urethritis (GCU) and 4.7 times the rate of nongonococcal urethritis (NGU) compared to Whites. There were slightly fewer cases of NGU than GCU. A case-control study of active duty soldiers showed that both Black and White circumcised subjects were 1.65 times as likely to have NGU as uncircumcised subjects (95% CI: 1.37-2.00). However, circumcision was not associated with an increased incidence of GCU.
Sorensen S.M. & M.R. Sorensen, 1988. Circumcision with the Plastibell device - a long-term follow-up. Int. Urol. Nephrol. 20, 159-166
Speert, H. 1953. Circumcision of the newborn. Obstetrics & Gynaecology 2, (2) 164-172
"On the other side of the ledger from the 1 death and few non-fatal accidents which have occurred as a result of neonatal circumcision are the 224 deaths from cancer of the penis in New York City during the years 1939-1950 or an anticipated number of 243 deaths for 1939-1951. The evidence seems strong that penile cancer deaths are preventable by circumcision in the neonatal period. The other alleged advantages of routine circumcision elude proof. Its value in penile cancer prophylaxis alone, in relation to its hazards, recommends this operation, dating from antiquity, to modern practice."
Szabo, Robert & R.V. Short. 2000. How does male circumcision protect against HIV infection? British Medical Journal 320, 1592-1594
The majority of men who are HIV positive have been infected through the penis. There is conclusive epidemiological evidence to show that uncircumcised men are at a much greater risk of becoming infected with HIV than circumcised men. The inner surface of the foreskin contains Langerhans' cells with HIV receptors; these cells are likely to be the primary point of viral entry into the penis of an uncircumcised man. Male circumcision should be seriously considered as an additional means of preventing HIV in all countries with a high prevalence of infection. The development of HIV receptor blockers, which could be applied to the penis or vagina before intercourse, might provide a new form of HIV prevention
Taguchi, Yosh, 1988. Private Parts - a health guide for men. McDonald Optima, 159pp
From page 25:
"When I was in training I remember a senior urologist telling me that, if called upon, any doctor could perform a circumcision. As specialists in the field, he suggested, we should be prepared to offer more. The procedure he recommended removes skin, but nothing more. An analogy can be made to a down-filled jacket. We can shorten the sleeve by slicing off the end, as in the 'bell-clamp' method, or we can cut the outer material and the lining and push the filling up the sleeve. By leaving behind the tissue between the outer and inner skin, we leave behind the vessels and nerves. Ther is less discomfort, less chance of bleeding, and an earlier return to normal function. One doctor, on whom I carried out such a circumcision, told me he was sexually functional in two weeks."
Tannahill Reay. Sex in History. London: Hamish Hamilton, 1980: 480pp.
Taylor, P.G. 1984. Case-control study of counselling against neonatal circumcision. Canadian Medical Association Journal 128, 814-817
Thesiger, W. Arabian Sands
' "There were eight of us and we were circumcised by one of the sheikhs of the Bait Khawar in the valley of the Kidyut. One of us was a Manahil, a grown man with a beard, the others were Bait Khawar. They were all older than I was. Before the operation our families rubbed our bodies with butter and saffron so that they shone. We were circumcised in turn sitting on a rock. Everyone had come to watch and there was a large crowd."
I asked him if he had been afraid, and he said, "Of course I was. Everyone is afraid when they know that they are going to be hurt, but they don't admit it. I was most afraid that I should flinch. As I was the youngest I was done first. The old man tied my foreskin very tightly with a piece of string and then left it to die. By God it hurt! It was almost a relief when he cut it off, though his knife was blunt and he went on hacking away for what seemed ages. One of the others fainted."
I interrupted to ask if they put anything on the wound. "Yes," he said, "a mixture of salt, ashes, and powdered camel dung -it stung like fire." '
Wahlin. N "Triple incision plasty" - a convenient procedure for preputial relief. Scandinavian Journal of Urology and Nephrology 26, 107-110
Circumcision is the accepted operation to treat phimosis. However, when the purpose is to achieve retractility of a narrow foreskin to avoid further scarring and phimotic development after recurrent balanitis, a preputial plasty might be sufficient. Several methods with single or multiple incisions have been introduced throughout the years. None of them seems to have gained general acceptance. Single plasties tend to give cosmetically unsatisfactory results with an apparent cleft or deformity, while the multiple ones, where the deformity is more or less spread around the circumference, are not always easily done, at least not in children. Still, circumcision seems to remain the standard procedure for preputial relief. A simple technique, where three longitudinal incisions are transversely sutured, is described. It has been used in a series of 63 consecutive patients with good results, and seems to offer a good compromise between simplicity and cosmetical demands.
Warner Ellen and Elliot Strashin, 1981. Benefits and risks of circumcision Canadian Medical Association Journal, 125, 967-976.
Circumcisions are performed either prophylactically in the neonatal period or therapeutically at a later age. About 10% of males not circumcised at birth will eventually require circumcision. The present neonatal circumcision rate is about 80% in the United States and 40% in Canada. The single most important determinant of whether a newborn male will be circumcised is the attitude of the attending physician. The literature was reviewed to determine the proven benefits of circumcision and to compare these with the known risks. Circumcising the newborn facilitates penile hygiene, prevents cancer of the penis and decreases the incidence of genital herpes in later life. Whether it decreases the incidence of cancer of the cervix is still uncertain. More important, neonatal circumcision is associated with much lower morbidity and mortality and with lower costs than therapeutic circumcision. Thus, prophylactic circumcision is recommended for the male population as a whole.
Weiss, Helen A., Quigley Maria A, Hayes, Richard J., 2000. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS (London) 14: 2361-2370
Objective: To systematically review studies of male circumcision and risk of HIV-1 infection in men in sub-Saharan Africa, and to summarize the findings in a meta-analysis.
Design: Meta-analysis of observational studies
Methods: A systematic literature review of studies published up to April 1999 that included circumcision as a risk factor for HIV-1 infection among males in sub-Saharan Africa was carried out. A random-effects meta-analysis was used to calculate a pooled relative risk (RR) and 95% confidence interval (CI) for all studies combined, and stratified by type of study population. Further analyses were conducted among those studies which adjusted for potential confounding factors.
Results: 27 studies were included. Of these, 21 showed a reduced risk of HIV among circumcised men. HIV risk among circumcised men was around half that in uncircumcised men (crude RR=0.52, CI 0.40-0.68). In the 15 studies that adjusted for potential confounding factors, the association was even stronger (adjusted RR=0.42, CI 0.34-0.54). The association was stronger among men at high risk of HIV (crude RR 0.27; adjusted RR=0.29, CI 0.20-0.41) than among men in general populations (crude RR 0.93; adjusted RR=0.56, CI 0.44-0.70).
Conclusions: Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly among men 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 do not traditionally circumcise.
Williamson, Marvel L. & Paul S. Williamson, 1988 Women's Preferences for Penile Circumcision In Sexual Partners. Journal of Sex Education & Therapy (Fall-Winter, 1988)
Regardless of pediatricians' attempts to negate routine newborn circumcision, U.S. circumcision rates remain constant. This study hypothesized that, because circumcision is usually a maternal choice and the circumcised penises are perceived by young women as more attractive, most women prefer circumcision for sexual reasons. Of 145 new mothers of sons responding to this survey, 71-83% preferred circumcised penises for each sexual activity listed. Visual appeal and sexual hygiene were predominate reasons for favoring circumcised sexual partners. Even among women having sexual experience only with uncircumcised partners, only half preferred uncircumcised penises for sexual partners. Eighty-nine percent of the sample had had their sons circumcised. This study furthers debate over whether circumcision decisions should be based solely on medical considerations limited to the newborn period.
Wiswell TE, Smith FR, Bass JW. 1985 Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics; 75, 901-903.
Wiswell TE. Enzenauer RW. Holton ME. Cornish JD. Hankins CT. 1987 Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infections in early infancy. Pediatrics; 79: 338-342.
The results of an investigation examining the circumcision frequency rate and its effect on the incidence of urinary tract infections in a large, widely dispersed population base during the 10-year period since the 1975 report of the American Academy of Pediatrics Ad Hoc Task Force on Circumcision are reported. Our study population included the 427,698 infants born in all United States Army hospitals, worldwide, from Jan 1, 1975, through Dec 31, 1984. There was an initial plateau in the circumcision frequency rate at approximately 85% during the first 4 years of the study period. In the subsequent 6 years there was a steady, significant decrease (P less than .001) of 1.4% to 4.0% per year through 1984, when the circumcision frequency rate reached its nadir of 70.5%. There was a concomitant increase in the total number of urinary tract infections among male infants (P less than .02) as the circumcision rate declined. This increase was due to the increase in the overall number of uncircumcised boys (who had a greater than 11-fold increased infection rate compared with circumcised boys). During the first half of the study period, there was a female predominance for urinary tract infections from birth onward. As the number of circumcised boys decreased (with a resultant increase in the total number of boys with infection), the male to female ratio of urinary tract infections during the first 3 months of life reversed, reflecting a movement toward a male predominance for infection in early infancy. This is the first, well-documented report of a decreasing rate of circumcisions performed on the American male population.
Wiswell TE. Geschke DW. 1989 Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics; 83: 1011-1015.
The records of 136,086 boys born in US Army hospitals from 1980 to 1985 were reviewed for indexed complications related to circumcision status during the first month of life. For 100,157 circumcised boys, there were 193 complications (0.19%). These included 62 local infections, eight cases of bacteremia, 83 incidences of hemorrhage (31 requiring ligature and three requiring transfusion), 25 instances of surgical trauma, and 20 urinary tract infections. There were no deaths or reported losses of the glans or entire penis. By contrast, the complications in the 35,929 uncircumcised infants were all related to urinary tract infections. Of the 88 boys with such infections (0.24%), 32 had concomitant bacteremia, three had meningitis, two had renal failure, and two died. The frequencies of urinary tract infection (P less than .0001) and bacteremia (P less than .0002) were significantly higher in the uncircumcised boys. Serious complications from routine prepuce removal are rare and relatively minor. Circumcision may be beneficial in reducing the occurrence of urinary tract infections and their associated sequelae.
Wiswell, T.E. H.L. Tencer, C.A. Welch & J.L. Chamberlain, 1993. Circumcision in children beyond the neonatal period. Pediatrics 92, 791-793
OBJECTIVE. Although many boys are circumcised after the newborn period, there are limited data concerning the proportion of uncircumcised infants who subsequently have the procedure, as well as minimal information about characteristics of this population.
POPULATION. Data and medical records of boys born in US Army hospitals from 1985 through 1992 were reviewed. General information regarding a portion of the 32,072 boys who were not circumcised during their neonatal hospitalization, but subsequently had the procedure, is reported. In addition, specific details are presented about 476 boys who were circumcised after their birth hospitalization.
RESULTS. The postneonatal circumcision frequency rate of these children increased significantly over this period (P < .0001), particularly after the 1989 American Academy of Pediatrics statement on circumcision. In general, most boys were not circumcised as neonates because of parental choice (55%) or because of a complicated neonatal course (32%). "Sleeve" and "freehand" resection were the most common methods of circumcision (93%), and general anesthesia was used in 91% of the boys. The mean age at postneonatal circumcision was 2.92 years. Common reasons for the ensuing procedure included parental choice (39%), coincidence with other surgery (27%), recurrent balanoposthitis (23%), and urinary tract infections (7%). Complications occurred in 8 of the 476 boys whose specific records were reviewed. These included excessive bleeding (3), malignant hyperthermia (2), aspiration pneumonia (1), large hematoma development (1), and postoperative fever (1).
CONCLUSIONS. An increasing number of boys are circumcised beyond the neonatal period, and the procedure performed at this time can be associated with substantial complications. This information may be of use when performing informed-consent counseling for neonatal circumcision.