NOCIRC of North Carolina
CHARLOTTE CENTER
National Organization of Circumcision Information Resource Centers
 P.0. Box 471503
Charlotte, North Carolina 28247
(704) 367-2520 Fax: (704) 367-0107

PRESS RELEASE 

To: ABC and ABC Network Affiliates
For: Immediate Release
Contact:
Bevin Jett or Kenneth Baker, M.D., Medical Director
704-367-2520 or 704-289-2553 FAX: 704-283-1906
NOCIRC of North Carolina
P.O. Box 471503
Charlotte, NC 28247


NOCIRC of North Carolina Questions ABC's Investigative Effort:
Inaccuracies and Lack of Documented Data Cited in "20/20" Program Segment

ABC "20/20" (January 15,1999)
"The Unkindest Cut"

"An examination into whether routine infant circumcisions are medically beneficial or a barbaric act".

NOCIRC of North Carolina is the North Carolina State chapter of the National Organization of Circumcision Information Resource Centers (NOCIRC), a nonprofit health educational organization that presents the medical community and the general public with the latest documented medical evidence on routine infant circumcision. NOCIRC of North Carolina issues this press release and the following addendum to detail in full the inaccuracies and lack of documented medical information presented in ABC "20/20"'s recent airing of "The Unkindest Cut" on January 15, 1999.

While "20/20" did raise several important issues concerning routine infant circumcision, they presented only a superficial overview of this medical controversy and pointedly failed to deal with any issue in any depth. "20/20" also was derelict in giving erroneous medical and statistical information regarding routine infant circumcision in the United States.

Specifically, "20/20" obscured the pain issue, ignored the human rights issue, neglected to present the known risks and long-term harm of routine infant circumcision, and completely overlooked the malpractice issue in the case of Linda and Paul Barry (a featured couple whose son was circumcised against their wishes). "20/20" focused only on three "benefit myths" related to circumcision, yet never directly addressed the actual validity of these "myths" during their "investigative" circumcision program segment.


ABC "20/20"'s "investigative" report relied primarily on personal opinion or anecdotes from a handful of interview subjects, most who were firmly for or against this newborn surgical procedure. No documented studies on infant circumcision were presented to support either position on routine circumcision. Although "20/20" did try to appear as if they were providing medical testimony by consulting an "outside expert", Dr. Alexander Walker, this "outside expert" did not present any documented medical evidence in his summary evaluation. Instead, Dr. Walker was asked by Timothy Johnston, M.D., ABC's medical reporter, to use a subjective and intangible scale ranking system to judge the merit of routinely performing a painful and risky surgery with inherent long-term disadvantages on male newborns. Not surprisingly, Dr. Walker gave routine infant circumcision the lowest possible value in terms of benefit: a "1" on a scale of "1" to "10" ("10" representing highest benefit).

NOCIRC of North Carolina, however, objects to ABC's "20/20"'s trivial assessment of a painful and harmful routine newborn procedure and ABC's misrepresentation that "20/20" had actually investigated the circumcision issue in depth. Parents have the right to be presented with documented medical information, not just opinion and personal anecdote, in their evaluation of routine infant circumcision for their newborn sons. Parents should be able to rely on ABC and it's recognized newsmagazine, "20/20", for the most accurate and current medical data when "20/20" chooses to spotlight a medical topic, regardless of the cultural or religious aspects that may be connected with the selected medical issue.

ABC did not live up to this expectation. Recognizably, ABC is a mass broadcast medium that needs to present complicated medical data in a comprehensible format for its viewers. "20/20"'s story "The Unkindest Cut", however, served to mislead and misinform their viewing audience on the actual risks, harm, and long term disadvantages of routine infant circumcision.

In providing no actual medical data and using several pieces of misinformation, ABC "20/20"'s report slanted toward making circumcision seem "slightly" beneficial. NOCIRC of North Carolina challenges ABC to present a single statistically significant medical benefit for routine infant circumcision. We suspect that "20/20" specifically avoided statistical data in their report to avoid exposing the lack of any significant medical benefit to a newborn surgery that is so intrinsically tied to a cultural or religious importance for many individuals in the United States.

ABC grossly misquoted the national 60.2% circumcision rate (source: National Center for Health Statistics) when "20/20" stated that the national infant circumcision rate was "almost 80%". "20/20" also stated that "today most hospitals do use anesthesia". While most U.S. hospitals today will allow anesthesia use at a physician's request, the majority of physicians in the U.S. do not personally use anesthesia because of the risks entailed with anesthesia use on newborns. Barbara Walters highly "editorialized" the content of the 1989 American Academy of Pediatrics (AAP) position statement on circumcision by stating in her closing remarks that "the American Academy of Pediatrics said that there were medical benefits of circumcision." Ms. Walters specifically omitted AAP's cautionary wording within the full text of the AAP statement: "Newborn circumcision has potential medical benefits and advantages, as well as (inherent) disadvantages and risks." (The word "inherent" has been added by the AAP since 1989.) Ms. Walters also failed to note that the AAP described the "medical benefits" of circumcision only as "potential", while the "disadvantages and risks" are described by the AAP as "inherent" with each circumcision procedure.

The human rights issue is inseparable from the ethics of performing routine infant circumcision, since infant circumcision is primarily a genital cosmetic or religious procedure that is always performed without the patient's consent. ABC "20/20" chose not to interview anyone from the numerous groups in the United States trying to protect children from non-therapeutic circumcision procedures: NOCIRC, Nurses for the Rights of the Child (NRC), Attorneys for the Rights of the Child (ARC), Circumcision Resource Center (CRC), Jewish Associates of CRC, Mothers Against Circumcision (MAC), National Organization to Halt the Abuse and Routine Mutilation of Males (NOHARMM), and National Organization of Restoring Men (NORM). "20/20" also elected not to present the perspective of thousands of circumcised adult men who today are expressing the physical and/or psychological harm that they have experienced from the routine infant circumcisions performed widely in the early to mid-20th century.

NOCIRC of NC would welcome for ABC "20/20" do a follow-up story that not only would include well-documented medical studies, but would also address the undeniable human rights violation that the United States practices in performing routine infant circumcisions. The United States remains alone as the only industrialized country in the world that performs this medically unnecessary, risky, painful, and diminishing genital alteration on the majority of it unsuspecting and unwilling newborn baby boys for non-therapeutic and non-religious reasons. 

(The following addendum is a listing of studies and statistical information incorrectly reported or omitted in the ABC "20/20" report on infant circumcision.)

ADDENDUM to:
NOCIRC of North Carolina's January 21, 1999 Press Release

ABC "20/20" (January 15,1999)
"The Unkindest Cut"

For the past three decades it has been recognized in the medical community and by the Academy of Pediatrics that any potential medical benefit to routine infant circumcision is statistically small or insignificant and is outweighed by the negative factors incurred with the practice of routine infant circumcision.

ABC "20/20" in their January 15, 1999 program story on infant circumcision portrayed the segment as an investigation into the controversy surrounding routine infant circumcision, although no statistical data or documented medical evidence was offered as to the potential medical benefits or risk and harm incurred in the practice of routine infant circumcision.

The National Organization of Circumcision Information Resource Centers of North Carolina (NOCIRC of NC) specifically addresses the inaccuracies or omission of information in the ABC "20/20" circumcision report as follows:

ABC "20/20" stated that "nearly 80% of American newborn boys are circumcised".

The National Center for Health Statistics (NCHS) of the Department of Heath and Human Services, U.S. Federal Government, compiles statistics on the number of circumcisions performed annually in the entire nation. The NCHS states that the circumcision rates for infants in 1994, 1995, and 1996 were 62.7%, 64.1%, and 60.2%, respectively. [1] (Data for 1997 and 1998 is not yet available.) The NHSC is considered by most media groups and medical personnel to be the standard for use in quoting national health statistics. "20/20" did not cite the source for their quoted "80%" U.S. infant circumcision rate.

ABC "20/20" presented the fact that circumcision was extremely painful for a newborn and noted, during a video clip of a locally anesthetized baby undergoing a circumcision, that the baby still cried out during the most painful parts of the procedure. "20/20" did not mention a compelling 1997 Canadian study at the University of Alberta that showed infants who did not receive anesthesia experienced not only severe pain, but also an increased risk of choking and difficulty in breathing. Additionally the Canadian study concluded that anesthesia is difficult to administer in newborns and is usually not effective during the most painful parts of the procedure. The Canadian researchers found circumcision so traumatic that they decided to end the study early for ethical reasons. [2]

The effects of pain during and after circumcision have been noted for several decades. A 1984 study at the University of California, San Diego, noted that, "changes in heart rate, respiratory rate, transcutaneous pO2, adrenal cortical hormone secretion, sleep patterns, and behavioral patterns have been shown to be altered during and/or following circumcision of the full-term neonate" and, "Behavioral differences were still evident on the day following the procedure".[3] An earlier 1975 study also demonstrated that the effects of circumcision are long lasting.[4] A more recent 1997 study at the Hospital for Sick Children in Toronto reiterated this long-term effect of circumcision pain by demonstrating that non-anesthetized circumcisions on newborns "may induce long-lasting changes in infant pain behavior because of alterations in the infant's central neural processing of painful stimuli."[5] Other studies have shown that "feeding behavior after circumcision deteriorated in neonates" following circumcision [6] and that the effects from circumcision pain [7] interferes with maternal bonding. [8, 9]

This extreme pain and resulting negative impact is experienced by the majority of infants undergoing routine infant circumcision today in the United States. ABC "20/20" misleadingly implied that since "most hospitals do use anesthesia", that most circumcised infants received anesthesia. A 1998 study found this not to be the case: only 25 percent of OB/GYNs (the doctor most likely to perform the circumcision) [10], 56 percent of family practitioners, and 71 percent of pediatricians surveyed regularly used anesthesia.[11] It is now argued that to not provide anesthetic relief during a circumcision procedure is cruel and unethical, [12, 13] but many doctors still refuse to use anesthesia. Physicians cite 'concern over adverse drug effects' (54%) followed by 'procedure does not warrant anesthesia' (44%)" as the most common explanations for not using anesthesia. [14]

Different types of anesthesia provide different levels of pain relief. EMLA (a topical cream) has been shown to be only slightly effective [15] and is now determined to be unsafe to use on children under 6 months of age. [16] Although widely used, the dorsal penile nerve block (DPNB) does not offer adequate relief during the most painful parts of the procedure; a ring block has now been shown to be more effective than EMLA or DPNB during the circumcision procedure. [17]

While it is widely agreed that circumcision is too traumatic to administer without anesthesia, ABC "20/20" did not present the standard risks involved with giving a newborn anesthesia, local or general. The recent October 1998 death of a baby at Rainbow Children's Hospital in Cleveland, Ohio from anesthesia during a repair of a circumcision complication is representative of the most serious of the potential risks of anesthesia use in infant circumcision, but this child's death was not noted in the "20/20" report. [18] The two most recent (1997 and 1998) pain studies (cited above) and the Cleveland mortality case were widely reported in the general media during this past (1998) calendar year. 

ABC "20/20" did not address the significant rate of complications from circumcisions.

A 1995 case involving a penile amputation during a circumcision noted that, "the potential for complications during circumcision is real and ranges from the insignificant to the tragic. The fairly high rate (1.5 to 15%) reflects the fact that the procedure is often performed by an inexperienced individual without attention to basic surgical principles." [19]

The most common circumcision complications are hemorrhaging and sepsis.[20] Other circumcision complications include incorrect removal of tissue, skin bridges, urinary retention, meatitis, chordee, cysts, lymphedema, fistulas, necrosis, and inadvertent creation of hypospadias and epispadias. [21] Incorrect tissue removal and the circumcision scar formation can result in the circumcised penis being permanently twisted, curved or bowed during erection. [22] The non-elastic and contracting scar tissue can pull the shaft into the abdomen, and in effect shorten or bury the entire penile shaft, [23] a condition generally known as the "inconspicuous" penis. [24] Penile nerve damage can result by errors in application of anesthesia. [25] Extreme sepsis or operator error has caused numerous incidents of penile amputation. [26, 27, 28, 29, 30, 31]

A 1997 Wisconsin study showed that circumcised boys were significantly more likely (54% vs. 5%) to have skin adhesions, trapped debris, irritated urinary openings, and inflammation of the glans (head of the penis) than were boys with a foreskin, and that the circumcised penis requires more care than the intact penis during the first three years of life. This study also recommended against circumcision for cosmetic reasons due to the large variations in the appearance of the circumcised penis. [32]

ABC "20/20" introduced information that "anti-circumcision activists claim that there is a sexual reduction" with circumcision and offered a compelling video of Billy Ray Boyd, author of "Circumcision Exposed", demonstrating exactly how much tissue and nerve ending loss (240 feet of nerves and over 1,000 nerve endings) results from infant circumcision.

"20/20"'s counterpoint, however, was only to offer the opinion of one sex therapist who felt that based on personal experience with his own clients he didn't agree. Not only does circumcision cause keratinization (thickening of the surface layer tissue of the remaining penis glans), specialized tissue loss in circumcision results in less sensation and alteration of normal penile function in intercourse. [33] "20/20" did not mention a case study, which "20/20" was made aware of, that documents the personal opinions of over 500 men who feel they have reduced sensation or other complications resulting from circumcision. [34]

NOHARMM and NORM are two national organizations who have worked with over 10,000 men nationwide, both in documenting harm from circumcision and in providing information on foreskin restoration. Foreskin restoration has become an increasingly popular method for partially replacing the sensation loss caused by circumcision. "Many respondents [men undergoing foreskin restoration] (and their wives) reported that restoration resolved the unnatural dryness of the circumcised penis, which caused abrasion, pain or bleeding during intercourse, and that restoration offered unique pleasures, which enhanced sexual intimacy." [35] ABC was made aware of these organizations and these findings during the course of their "20/20" investigation, but declined to present this material in their circumcision story segment.

ABC's "20/20" presented three questions related to several "benefit myths" of circumcision, yet "20/20" never directly addressed the questions they asked in their program segment.

Below are listed "20/20"'s questions and the answers based on the most recent documented medical evidence:

  1. Do uncircumcised newborns have a greater risk of urinary tract infections (UTI's)? 
  2. Dr. Edgar Schoen, a relentless advocate for circumcision, and the chairperson of the American Academy of Pediatrics (AAP) Task Force on Circumcision in 1989, opened the door to the UTI debate by introducing studies into the 1989 AAP circumcision policy statement that suggested a UTI increase in intact infants. The AAP did note, however, in this same statement, that these studies were "retrospective in design and may have methodological flaws" and that "the study population may have been influenced by selection bias". [36} Unfortunately, many physicians have chosen to overlook this additional information regarding the unreliability of these studies in their effort to validate the routine surgical procedure of infant circumcision.
     

    Studies conducted since 1989 have not found significant increases of UTI's in intact males. [37, 38] A recent 1997 study found that most UTIs among males are not caused by the foreskin, but by an underlying defect in the urinary tract. [39] An extensive four year Canadian study (1993-1997) involving over 60,000 baby boys found that the rate of UTI's in intact children was dramatically less than previous reports (such as those included in the 1989 AAP statement) have suggested. Dr. Teresa To, the study's author, noted, "It appears that circumcising one's child solely for the benefit of lowering the risk of hospital admission for UTI (urinary tract infection) may be medically unnecessary." [40]

  3. Do uncircumcised men have a greater risk of sexually transmitted diseases (STDs), specifically HIV?

Older studies attempting to find a correlation between circumcision status and STD's are conflicting and, as the AAP reported in their 1989 statement, "inconclusive". [41] Recent studies now suggest that the presence of the foreskin may serve an immuniological function and offer some protection against the contraction of various STDs. These studies have shown that circumcised men have an increased risk of contracting urethritis, [42] gonorrhea, syphilis, genital warts [43] and chlamydia. [45] The United States, which has the highest rate of circumcision of any industrialized nation in the world, also has one of the highest rates of STD's in the world (a confirmed epidemic), including herpes, human papillomavirus infection, hepatitis B, and HIV infection. [46]

HIV and Circumcision

The United States, while having the highest incidence of circumcision, also has the highest incidence of HIV infection among developed nations. [47] Angus Nicoll from the Communicable Disease Surveillance Centre in London stated in a 1997 paper that, "it is noticeable that being heavily circumcised has not prevented the USA from becoming the industrialised country most burdened with HIV, while the opposite is true for the UK." Nicholl cites the percentage rate of adult circumcised males in the UK at 21% (aged 16-59 years). (Currently less than 6% of British infants are circumcised.) [48]

Unfortunately most studies of HIV incidence in relation to circumcision are inconclusive and unreliable since cultural mores, socio-economic background, hygiene practices, and the prevalence of other STD infections are not excluded from consideration as a causative effect. [49] In an exhaustive 1994 review of 24 studies that attempted to show a relationship of HIV to circumcision status, de Vincenzi and Mertens concluded that, "...a lack of distinction between susceptibility and infectivity, inadequate control for confounding variables, potential selection bias and misclassification of exposure, inappropriate choice of a comparison group, and publication bias, may lead to under- or over-estimation of the association [between circumcision and HIV status]. It is difficult to predict the net effect of these sources of bias. Furthermore, the magnitude of the association varies strongly between studies and its crude measure is overestimated in some reports." [50]

A 1998 petition to the American Academy of Pediatrics Task Force on Circumcision with signatories representing over 60 organizations and institutions worldwide involved in AIDS education and awareness advised the AAP that "We do not consider routine circumcision to a valid or effective measure to prevent HIV transmission". [51]

3) Do circumcised men have a greater risk of cancer?

The theory that penile cancer is greater in uncircumcised men was disproved by a number of studies in the 1960's and 1970's. [52, 53, 54, 55, 56]

Hugh Singleton, M.D., National Vice President of Detection and Treatment, and Clark W. Heath, Jr., M.D., Vice President of Epidemiology and Surveillance Research, of the American Cancer Society, stated in a February 16, 1996 letter to the American Academy of Pediatrics: 

"[W]e would like to discourage the American Academy of Pediatrics from promoting routine circumcision as preventative measure for penile or cervical cancer. The American Cancer Society does not consider routine circumcision to be a valid or effective measure to prevent such cancers...Penile cancer rates in countries which do not practice circumcision are lower than those found in the United States. Fatalities caused by circumcision accidents may approximate the mortality rate from penile cancer...Perpetuating the mistaken belief that circumcision prevents cancer is inappropriate."

The American Cancer Society currently reiterates the context of this letter by stating "circumcision is not of value in preventing cancer of the penis" [57] on their current website.

Converted into a webpage and featured at MAC
by Mary G. Ray, Founder
Mothers Against Circumcision

with express permission from
Bevin Jett, Secretary
and Charlotte Center Director
NOCIRC of NC

FOOTNOTES

1. The National Center for Health Statistics (NCHS) of the Department of Heath and Human Services of the U.S. Federal Government (1996)

2. Lander, J. et al., "Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision," JAMA 1997;278:2157-2162.

3. Dixon S., Snyder J. Holve R., Bromberger P., "Behavioral Effects of Circumcision With and Without Anesthesia" J. Dev. Behav Peds 1984;5:246-250.

4. Richards MPM, Bernal J, Brackbill Y, "Early Behavior Differences: Gender or Circumcision." Dev Psychobiol 1975; 9:89-95

5. Taddio, A. et al., "Effect of Neonatal Circumcision on Pain Response during Subsequent Routine Vaccination," The Lancet 1997; 349:599-603.

6. Howard CR, Howard FM, Weitzman ML, "Acetominophen Analgesia in Neonatal Circumcision: The Effect on Pain." PEDIATRICS 1994; 93(4): 641-646.

7. Emde R., Harmon R., Metcalf D. et al, "Stress and Neonatal Sleep" Psychosom Med 1971; 33:491-497.

8. Marshall, RE, Stratton, WC, Moore, JA, Boxerman, SB., "Circumcision I: Effects upon Newborn Behavior". Infant Behav Dev. 1980; 3:1-14

9. Marshall RE, Porter FL, Rogers AG, Moore J, Anderson B, Boxerman SB. "Circumcision II: Effects Upon Mother-infant Interaction". Early Human Development 1982; 7:367-374.

10. Howard J. Stang and Leonard W Snellman, "Survey Tells Who Is Making the Cuts", Pediatric News 1997;31 (7):34

11. Howard J. Stang and Leonard W. Snellman, "Circumcision Practice Patterns in the United States", PEDIATRICS 1998; 101(4): e5

12. Brady-Freyer B., "A Dilemma in Infant Research" University of Alberta Hospital, March 1995.

13. Walco GA, Cassidy RC, Schechter NL., "Pain, Hurt and Harm: The ethics of pain control in infants and children." N Engl J Med 1994; 331(8):541-544.

14. Howard J. Stang and Leonard W. Snellman, "Circumcision Practice Patterns in the United States", PEDIATRICS 1998;101(6): . e5

15.Benini F, Johnston CC, Faucher D, Aranda JV., "Topical Anesthesia During Circumcision in Newborn Infants. JAMA 1993; 270: 850-3

16. 1996 PHYSICIANS' DESK REFERENCE, p. 545-547.

17. Lander J, Brady-Freyer B, Metcalfe JB, et al., "Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision." JAMA 1997; 278:2158-2162.

18. James F. McCarty, "Routine Surgery Turns to Tragedy as Three Week Old Baby Boy Die" The Plain Dealer; October 20, 1998, pg. 1A

19. Gluckman GR et al., "Newborn Penile Glans Amputation During Circumcision and Successful Reattachment." Journal of Urology (Baltimore), 1995; 153: 3 Part 1 pp. 778-779

20. Williams N, Kapila L., "Complications of Circumcision". Br J Surg 1993; 80:1231-36.

21. Kaplan GW., "Complications of circumcision". Urol Clin N Amer 1983;10:543-549.

22. J. P. Gearhart, "Complications of Pediatric Circumcision," in Urologic Complications, Medical and Surgical, Adult and Pediatric, ed. F. F. Marshall (Chicago: Year Book Medical Publishers, 1986), 387-396.

23. R. D. Talarico and J. E. Jasaitis, "Concealed Penis: A Complication of Neonatal Circumcision," Journal of Urology 1973;110: 732-733.

24. Bergeson PS, Hopkin RJ, Bailey RB, McGill LC, and Piatt JP, "The Inconspicuous Penis", PEDIATRICS 1993; 92(6):794-799

25. Kaplan GW. "Complications of Circumcision". Urol Clin N Amer 1983;10:543-549.

26. Hanukoglu A, Danielli L, Katzir Z, Gorenstein A, Fried D. "Serious complications of routine ritual circumcision in a neonate: hydro ureteronephrosis, amputation of glans penis, and hyponatraemia". Eur J Pediatr 1995; 154: 314-5.

27. Audry G, Buis J, Vazquez MP, Gruner M. "Amputation of penis after circumcision--penoplasty using expandable prosthesis". Eur J Pediatr Surg 1994; 4: 44-5.

28. Yilmaz AF, Sarikaya S, Yildiz S, et al., "Rare Complication of Circumcision: Penile Amputation and Reattachment". European Urology (Basel) 1993; 23(3): 423-424

29. Azmy A, Boddy SA, Ransley PG., "Successful Reconstruction following Circumcision with Diathermy". Br J Urol 1985; 57:587-8.

30. Hanash KA., "Plastic Reconstruction of Partially Amputated Penis at Circumcision". Urology 198; 18(3): 291-3.

31. Izzidien AY., "Successful Replantation of a Traumatically Amputated Penis in a Neonate". Journal of Pediatric Surgery 198; 16:2, 202-203.

32. Van Howe, R., "Variability in Penile Appearance and Penile Findings: A Prospective Study," BJU 1997; 80:776-782.

33. Milos MF eds., "Sexual Mutilations: A Human Tragedy" [Proceedings of the Fourth International Symposium on Sexual Mutilations, Lausanne, 1996]. New York: Plenum Press, 1997:125-9

34. Hammond T., "Long-Term Consequences of Neonatal Circumcision: A Preliminary Poll of Circumcised Males." in Denniston GC, Milos MF, eds., "Sexual Mutilations: A Human Tragedy" [Proceedings of the Fourth International Symposium on Sexual Mutilations, Lausanne 1996]. New York: Plenum Press, 1997:125-9

35. T. Hammond, BJU International (British Journal of Urology), 1999; 83, Suppl. 1: 85-92

36. American Academy of Pediatrics Policy Statement, PEDIATRICS 1989; 84:2,388-391

37. Altschul MS., "The Circumcision Controversy" (editorial). Am Fam Physician 1990; 41:817-820.

38. Hiroyuki Kayaba, Hiromi Tamura, Seiichi Kitajima, Yoshiyuki Fujiwara, Tetsuo Kato, "Analysis of Shape and Retractability of the Prepuce in 603 Japanese Boys", Journal of Urology 1996; 15:5; 1813-1815

39. Mueller ER, Steinhardt, G., Naseer S, et al. "The incidence of genitourinary abnormalities in circumcised and uncircumcised boys presenting with an initial urinary tract infection by 6 months of age". Pediatrics 1997; 100(Supplement);580 .

40. Teresa To, Mohammad Agha, Paul T Dick, William Feldman, "Cohort Study on Circumcision of Newborn Boys and Subsequent Risk of Urinary-tract Infection", The Lancet, 1998; 352:1813 -1816.

41. American Academy of Pediatrics Policy Statement, PEDIATRICS 1989; 84:2;388-391

42. Smith GL, Greenup R, Takafuji ET., "Circumcision as a Risk Factor for Urethritis in Racial Groups." Am J Public Health 1987; 77: 452-4.

43. Donovan B, Basset I, Bodsworth NJ., "Male Circumcision and Common Sexual Transmitted Diseases in a Developed Nation Setting". Genitourin Med 1994; 70:317-20.

44. Cook LS. Koutsky LA., Holmes KK., "Clinical Presentation of Genital Warts among Circumcised and Uncircumcised Heterosexual Men Attending an Urban STD clinic". Genitourin Med 1993; 69: 262-264.

45. Laumann EO, Masi CM, Zuckerman EW., "Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice". JAMA 1997; 277:1052-7.

46. Tanne JH, "US has epidemic of sexually transmitted disease". BMJ 1998; 317:1616.

47. World Health Organization. Global Programme on AIDS. Quarterly Report. July 3 1995

48. Barrie M. "Circumcision - A Definitive Overview". London: Beechgrove Press 1995:1-57

49. Van Howe RS. "Circumcision and HIV infection: Review of the literature and Meta-analysis". Int J STD AIDS 1998 10(1): in press

50. de Vincenzi I., Mertens T., "Male Circumcision: A Role in HIV prevention?" AIDS 1994; 8:153-160.

51. "Petition to the Task Force on Circumcision of the American Academy of Pediatrics", New York Circumcision Information Resource Center, 874 Broadway #1005, New York, NY,10003

52. D.G. Reddy; I.K. Baruah., "Carcinogenic Action of Human Smegma," Archives of Pathology 1963; 75(4): 414-420. ,

53. "Circumcision and Cancer of the Cervix." University of Aberdeen, Dept. of Obstetrics and Gynaecology. British Journal of Cancer 1965; Vol. XIX, No. 2

54. Preston, EN.,"Whither the Foreskin". JAMA 1970; 213(11):1853-1858

55. Terris, Wilson, Nelson., "Relation of Circumcision to Cancer of the Cervix." Am. J. Obstet. Gynecol., Dec. 15, 1973

56. Gellis SS. "Circumcision". Am J Dis Child 1978; 132: 1168-9

57. American Cancer Society, "Misleading Information": http://www2.cancer.org/zine/001/001_11051998_0.html