This is Chapter 3 of a statement available at http://www.doctorsopposingcircumcision.org/DOC/statement0.html
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Chapter Three: Alleged Medical Benefits of Circumcision
An infant boy is born with a healthy foreskin. Consequently, there are no medical indications for circumcision in the newborn period.1,2
Infant circumcision is a painful, stressful, and traumatic procedure that leaves the infant exhausted and debilitated to the extent that some are unable to suckle at the breast.3 Medical authorities accordingly recommend that circumcision be performed only on healthy and stable infants. In the absence of any medical indication, and with the surgical operation being performed only on healthy and stable infants, the Council on Scientific Affairs of the American Medical Association (AMA), therefore, properly describes elective infant circumcision as a “non-therapeutic” procedure.4 (Infant circumcision was downgraded from routine to elective in 1997, in a joint statement issued by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.5)
Claims for any health or medical benefit are restricted to a possible prophylactic benefit in later life. Circumcision of the newborn, in the opinion of a few, may prevent phimosis, infection with sexually transmitted diseases, urinary tract infection in the first year of life, penile cancer, and cervical cancer in sexual partners. These claims date from the era of opinion-based medicine, when, in the absence of any scientific evidence, medical doctors relied on the opinions of one another rather than on evidence. (e.g.6) We shall examine each of these claims.
Phimosis is the term used to describe the condition of being unable to retract the prepuce (foreskin).
Almost every newborn infant boy has a non-retractile foreskin. The condition of non-retractability occurs because 1) the foreskin is fused with the glans penis in the newborn, 2) because the foreskin of the newborn is too narrow to retract over the glans penis, or 3) frenulum breve. Non-retractable foreskin is not a disease but a normal developmental physiological stage in boys. The foreskin gradually becomes retractable between infancy and 18 years of age.7 About 1 percent of males, aged 18 and older, still have a non-retractile foreskin. The fusion of the foreskin with the glans penis spontaneously separates and no treatment is necessary. Frenulum breve, a rare condition, may be relieved by a minor incision in the frenulum (frenuloplasty).
Phimosis is not a life-theatening condition, and usually requires no treatment. When treatment is deemed necessary, phimosis may be treated by application of topical steroid ointment without surgical risk.8,9 Older boys and men may treat non-retractile foreskin with manual stretching to accomplish permanent tissue expansion.10,11 (See Chapter Seven)
Neonatal circumcision frequently results in a phimotic condition as the cicatrix caused by circumcision may contract in front of the glans penis, trapping it behind a phimotic ring. Blalock et al. (2003) report that phimosis occurs in 2.9 percent of circumcision patients.12 This exceeds, by a factor of three, the incidence of non-retractile foreskin reported by Øster (1968) at the end of puberty. It is clear, therefore, that circumcision cannot be recommended to prevent phimosis. The AAP statement of 1975 correctly noted that incomplete removal of the foreskin can result in post-circumcision phimosis.13 The AAP statement of 1989 misleadingly reported that circumcision “properly performed” prevents phimosis.14 By properly performed, the task force meant that sufficient skin must be removed to make it impossible for a circular scar to form in advance of the glans penis. Unfortunately, when that much tissue is removed, the patient is likely to suffer painful erections because insufficient skin is left to accommodate the expansion of the penis with tumesence. Circumcisions frequently are improperly performed because they are delegated to the most junior members of the staff.15 Also, knowledgable physicians are aware that skin tissue must be left to accommodate erections, so post-circumcision phimosis is not an uncommon complication. The use of male circumcision to prevent/cure phimosis is outmoded.
Sexually Transmitted Diseases
Abraham Leo Wolbarst, M.D., was an ardent defender and promoter of the practice of circumcision. After Holt (1913) criticized ritual circumcision because of the large number of cases of tuberculosis resulting in death acquired through infection of the open wound,16 Wolbarst (1914) came to the defense of ritual circumcision by extolling the alleged sanitary benefits of circumcision.6 Wolbarst did this by collecting opinions from other medical doctors, which he then published in an article in the Journal of the American Medical Association. He solicited opinions that circumcision prevented the venereal diseases of syphilis and chancroid. He then cited these opinions as evidence of the value of circumcision. Controlled studies were not available in that long-ago day. The United States military services, on the basis of such flimsy evidence, circumcised large numbers of men to prevent sexually transmitted diseases during two world wars.
Modern evidence-based medicine, however, is unable to support Wolbarst’s overblown claims. Cook et al. (1994) were unable to show a definite benefit for circumcision—finding a slight tendency for non-circumcised men to have more syphilis and gonorrhea, but less tendency to have genital warts.17 Donovan et al. (1994) reported no significant difference between non-circumcised and circumcised men.18 Van Howe (1999) found circumcised men may be slightly more likely to have urethritis and uncircumcised males may be more prone to genital ulcer disease (GUD).19 Dickson et al. (2008) found more STD in circumcised men but the difference was not statistically significant.20 The Fetus and Newborn Committee of the Canadian Paediatric Society found that “circumcision had no significant effect on the incidence of common STDs.”21 The AAP Task Force (1999) reported that “behavior factors appear to be far more important than circumcision status.”22 The medical evidence does not support the practice of neonatal circumcision to prevent STDs.
de Vincenzi & Mertens (1994) performed a meta-analysis of the then-existing literature, regarding circumcision and HIV infection. They concluded, at that time, there was insufficient evidence to recommend male circumcision to prevent HIV transmission.23 The Council on Scientific Affairs of the AMA (1999) concluded that “behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision status, and circumcision cannot be responsibly viewed as “protecting” against such infections.”4 The Cochrane Library review of the medical evidence (2003) concluded that there is insufficient evidence to recommend circumcision to prevent HIV infection.24 Thomas (2004) found no evidence that circumcision is protective against HIV in a U.S. Navy population.25Talbott (2007) reports that it is the percentage of female sex workers in the female population, not the incidence of male circumcision, that determines the level of HIV infection.26 Dowsett & Couch (2007) examined the results of three randomized controlled trials (RCTs), but they still found insufficient evidence to recommend circumcision to prevent HIV infection.27 Green et al. (2008) reviewed the evidence regarding circumcision to prevent HIV infection and found “insufficient data” as well as countervailing data. They concluded:
“The world community must cautiously review and carefully consider the long-term consequences of mass circumcision campaigns, from the risk of increasing deaths and infections to human rights violations. In the rush to save lives, many may instead be lost and human rights trampled in the stampede. Circumcision is not the panacea the world has been waiting for in the battle to stem the HIV crisis.”28
The Lancet published two coordinated randomized controlled trials (RCTs) on February 24, 2007.29,30 One should note that the lead authors of these RCTs are natives of Australia, Canada, or the United States, all of which, now or formerly, are or were circumcising cultures. These men may well have suffered circumcision as infants. Siegfried et al.(2003) comment that such men are likely to carry “strong beliefs and opinions” in favor of circumcision.24 They may be compelled, therefore, to produce literature to support their culture of origin. (See Chapter Six for discussion of the effect of circumcision upon medical literature.) These authors wrote papers advocating male circumcision to prevent HIV infection prior to undertaking these RCTs. The severe criticism that these papers have received suggests that something other than pure medical science is at work. Researcher bias cannot be ruled out.
The epidemic of HIV infection in the United States is concentrated among men who have sex with men (MSM). Two studies find that male circumcision is ineffective at preventing HIV among MSM.31,32
Moreover, RCTs carried out among adults in Africa are not relevant to children in North America. Even if the African RCTs were accurate, the incidence of infection and the risk of infection in North America are many times less than in Africa. Moreover, children do not engage in sexual intercourse so they are not at risk of HIV infection by sexual transmission. The African RCTs are not applicable to North America. Moreover, the RCTs have been shown to have such severe methodological flaws as to make them useless for formulation of public health policy. Van Howe & Storms (2011) show that male circumcision increases the incidence of HIV infection.33 Boyle & Hill (2011) report numerous fatal methodological flaws and say the use of the three RCTs by the World Health Organization to establish public health policy recommendations is inappropriate.34 Both teams of researchers report a higher incidence of HIV infection among circumcised men than among non-circumcised men in numerous sub-Saharan African nations.33 34
Condoms are an effective means of preventing sexually transmitted disease, including HIV.35
Urinary Tract Infections
Ginsburg & McCracken (1982), who studied urinary tract infection (UTI) in male infants at Parkland Hospital in Dallas, noted that 95% of the infant male UTI patients were not circumcised.36 They speculated that lack of circumcision may have contributed to the infection in some way. However, Parkland Hospital, a public hospital, did not perform neonatal circumcisions, even if patients demanded it,37 so most of the client population at Parkland must have been noncircumcised—a fact apparently overlooked by Ginsburg & McCracken.
This flawed observation prompted Wiswell et al. to produce retrospective studies regarding UTI in circumcised infant males as compared with uncircumcised males. The studies all have serious methodological flaws, including failure to control for confounding factors, which include maternal infection, perinatal anoxia, high or low birthweight, prematurity of birth, rooming in, method of urine sample collection, type of hygienic care, and breastfeeding. The Fetus and Newborn Committee of the Canadian Paediatric Society (1989) examined data provided by Wiswell et al. and reported that they found Wiswell’s data to be “not sufficiently compelling to justify a change in their existing policy that circumcision is unnecessary and should not be performed.”38 Altshul (1990) pointed out that the studies had only shown association, not cause and effect.39 Thompson (1990) found that “unequivocable proof that lack of circumcision is a risk factor for increased urinary tract infection is currently unavailable.”40 Chessare (1993) compared the alleged advantage of preventing UTI with the disadvantages of complications and found that, even if Wiswell was correct in his claims, non-circumcision would still produce the highest medical utility.41
Evidence from Israel establishes a compelling association between ritual circumcision on the eighth day and immediate post-circumcision UTI.42-44
Mueller et al. (1997) reported no difference in the incidence of UTI in circumcised and non-circumcised boys with normal urinary tract anatomy.45
To put this matter into perspective, a Swedish study by Mårild et al. (1998), where infant circumcision is not practiced, found that, in the first six years of life, the incidence of UTI in boys was 1.8 percent, but in girls it was 6.6 percent.46 UTI infection in boys was rare after the first year of life. When UTI does occur, it is easily treated medically. McCracken (1989) and Larcombe (1999) report UTI infections respond rapidly to anti-microbial therapy.,47,48
The Task Force on Circumcision of the American Academy of Pediatrics, in their “evidence-based” statement, reported serious methodological flaws in all existing studies, and declined to recommend circumcision to reduce UTI.22The Royal Australasian College of Physicians (RACP) says routine non-therapeutic circumcision “cannot be justified on the basis of preventing a UTI.”49
The consensus of medical opinion is that circumcision is of little, if any, value in reducing UTI. Risk, complications, an disadvantages of circumcision outweigh any reduction in UTI. The notion that neonatal male circumcsion can prevent UTI increasingly is being viewed as a medical myth – one started by Ginsburg & McCracken’s failure to recognize that the client population at Parkland Hospital in Dallas was mostly noncircumcised.
Medical authorities now recommend breastfeeding, not circumcision, to reduce UTI in infancy.50,51 Moreover, Hansen (2004),52 and Mårild & others (2004)53 report that breastfeeding continues to have a protective effect even after weaning.
Kwak et al. (2004) report that circumcision after anti-reflux surgery to prevent UTI is not effective. 54
Abraham L. Wolbarst, the noted early 20th-century circumcision promoter, started the myth that neonatal circumcision absolutely prevented penile cancer, at a time (1932) when the etiology of cancer was not well understood.55His claims were accepted as fact, and unfortunately, one still finds such statements in the medical literature today. It was not long, however, until doctors started to report cases of cancer in circumcised men that did not fit with Wolbarst’s inflated claims.56 Wolbarst’s report was incorrect. Maden et al. (1993) reported 41 cases of penile cancer in circumcised men.57 Certainly, it was becoming clear that circumcision did not prevent penile cancer.
True risk factors did not emerge until the 1980s. DNA from human papillomavirus (HPV) was identified in penile cancer cells.58 Infection with HPV (which is contracted by sexual intercourse) is an important risk factor. The use of tobacco is another important risk factor.59
Maden et al. (1993) improperly claimed that lack of circumcision was a risk factor,57 but Cold et al. (1997) discovered that Maden had not adjusted his data for age.60 When Maden’s data were properly adjusted for age, there was no difference in the risk for circumcised and non-circumcised men.60
Circumcision is ineffective for the prevention of penile cancer. Bissada et al. (1986) report that penile cancer forms on the circumcision scar.61 The American Academy of Family Physicians (AAFP) says 600 to 900 circumcisions would be necessary to prevent one case of penile cancer.62 The AAP says the risk of penile cancer in a non-circumcised man is “somewhat” higher than a circumcised man but remains low.22 The AMA says, because the disease is rare and occurs later in life, the use of circumcision as a preventive measure is not justified.4
Cancer of the Cervix in Partners
The risk factors for cervical cancer are infection with human papilloma virus (HPV)63 and smoking.64 Risk of infection with HPV is increased by early onset of sexual intercourse and multiple sex partners.65 There is no clear evidence that male circumcision decreases the risk of infection.
Male circumcision cannot be shown to prevent cervical cancer in female partners. The Royal Australasian College of Physicians (RACP) points out that vaccines are being developed to prevent infection with HPV. The RACP found no data to suggest that circumcision would be of additional benefit.49 When HPV vaccine comes into general use, it should nearly end the threat posed by cervical cancer.
Human papillomavirus vaccine to protect against HPV cervical cancer is now a reality and is being given to pre-teen girls.66
The claims of “potential benefits”, allegedly provided by medically unnecessary, non-therapeutic circumcision, lack any real support from medical science. United States medical literature, as compared with the medical literature of other nations, is highly biased in favor of male circumcision.67 The word “potential” means to exist in possibility but not in actuality. The scientific literature that supports such “potential” benefits is written mostly by doctors who were reared in circumcising cultures.68,69
- American Academy of Pediatrics, Committee on Fetus and Newborn. Standards and Recommendation for Hospital Care of Newborn infants. 5th ed. Evanston, IL: American Academy of Pediatrics, 1971:110.
- Foetus and Newborn Committee. FN 75-01 Circumcision in the newborn period. CPS News Bull Suppl 1975; 8(2):1–2. [Full Text]
- Howard CR, Howard FM, and Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994;93(4):641–6. [Full Text]
- Council on Scientific Affairs. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999. [Full Text]
- American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, Fourth Edition, November 1997.
- Wolbarst AL. Universal circumcision as a sanitary measure. JAMA 1914;LXII(2):92–7.
- Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish Schoolboys. Arch Dis Child 1968;43:200–3. [Full Text]
- Orsola A, Caffaratti J, Garat JM. Conservative treatment of phimosis in children using a topical steroid. Urology 2000;56(2):307–10. [Full Text]
- Ashfield JE, Nickel KR, Siemens DR, et al. Treatment of phimosis with topical steroids in 194 children. J Urol 2003;169(3):1106–8. [Abstract]
- Dunn HP. Non-surgical management of phimosis. Aust N Z J Surg 1989;59(12):963. [Full Text]
- Beaugé M. The causes of adolescent phimosis. Br J Sex Med 1997; Sept/Oct: 26. [Full Text]
- Blalock HJ, Vemulakonda V, Ritchey ML, Ribbeck M. Outpatient management of phimosis following newborn circumcision. J Urol 2003;169(6):2332–4. [Abstract]
- Thompson HC, King LR, Knox E, et al. Report of the ad hoc task force on circumcision. Pediatrics 1975;56(4):610–11. [Full Text]
- Task Force on Circumcision. Report of the Task Force of Circumcision. Pediatrics 1989;84(4):388–391. [Full Text]
- Fetus and Newborn Committee. Benefits and risks of circumcision: another view. Can Med Assoc J 1982; 126: 1399. [Full Text]
- Holt LE. Tuberculosis acquired through ritual circumcision. JAMA 1913;LXI(2):99–102. [Full Text]
- Cook LS, Koutsky LA, and Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health 1994;84(2):197–201. [Full Text]
- Donovan B, Bassett I, Bodsworth NJ. Male circumcision and common sexually transmissible diseases in a developed nation setting. Genitourin Med 1994; 70: 317–320. [Full Text]
- Van Howe RS. Does circumcision influence sexually transmitted diseases?: A literature review. BJU Int 1999; 83 Suppl 1; 52–62. [Full Text]
- Dickson NP, Van Rood T, Herbison P, Paul C. Circumcision and risk of sexually transmitted infections in a birth cohort. J Pediatr 2008;152:383–7. [Full Text]
- Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited. Can Med Assoc J 1996;154(6):769–80. [Full Text].
- Task Force on Circumcision. Circumcision policy statement. Pediatrics 1999;103(3):686–93. [Full Text]
- de Vincenzi I, Mertens T. Male circumcision: a role in HIV prevention? AIDS 1994;8(2): 153–60. [Full Text]
- Siegfried N, Muller M, Volmink J, Deeks J, Egger M, Low N, Weiss H, Walker S, Williamson P. Male circumcision for prevention of heterosexual acquisition of HIV in men. In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software. [Full Text]
- Thomas AG, Bakhireva LN, Brodine SK, Shaffer RA Prevalence of male circumcision and its association with HIV and sexually transmitted infections in a U.S. Navy population. Abstract no. TuPeC4861. Presented at the XV International AIDS Conference, Bangkok, Thailand, July 11-16, 2004. [Abstract]
- Talbott JR. Size matters: the number of prostitutes and the global HIV/AIDS pandemic. PLoS ONE 2007;2(6): e543. [Full Text]
- Dowsett GW, Couch M. Male circumcision and HIV prevention: is there really enough of the right kind of evidence? Reprod Health Matters 2007;15(29):33–44. [Full Text]
- Green LW, McAllister RG, Peterson KW, Travis JW. Male circumcision is not the HIV ‘vaccine’ we have been waiting for! Future HIV Therapy 2008;2(3):193-9. doi:10.2217/17469600.2.3.193 [Full Text]
- Bailey RC, Moses S, Parker CB et al.: Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369(9562), 643–56.
- Gray RH, Kigozi G, Serwadda D et al.: Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369(9562), 657–66.
- Grulich, AE, Hendry O, Clark E, et al. Circumcision and male-to-male sexual transmission of HIV. AIDS 2001;15(9):1188–1189. [Full Text]
- Millet GA, Ding H, Lauby J, et al. Circumcision status and HIV infection among Black and Latino men who have sex with men in 3 US cities. J Acquir Immun Defic Syndr2007;46(5):643–50. [Abstract]
- Van Howe, Storms MS. How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa 2011; 2:e4 doi:10.4081/jphia.2011.e4. [Full Text]
- Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J Law Med (Melbourne) 2011;19:316-34. [Full Text]
- de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. N Engl J Med 1994;331(6):341–6. [Abstract]
- Ginsburg CM, McCracken, Jr. GH. Urinary tract infections in young infants. Pediatrics 1982;69(4):409–12. [Full Text]
- Wallerstein E. Circumcision: the uniquely American medical enigma. Urol Clin North Am 1985;12(1):123–132. [Full Text]
- Canadian Paediatric Society. Routine Circumcision, Ottawa: Canadian Paediatric Society, 1989. [Full Text]
- Altschul MS. The circumcision controversy (editorial). Am Fam Physician 1990;41:817–20. [Full Text]
- Thompson RS. Routine circumcision in the newborn: an opposing view. J Fam Pract 1990;31(2):189–96. [Full Text]
- Chessare JB. Circumcision: Is the risk of urinary tract infection really the pivotal issue?. Clin Pediatr 1992;31(2):100–4. [Full Text]
- Menahem S. Complications arising from ritual circumcision: pathogenesis and possible prevention. Isr J Med Sci 1981;17(1):45–8. [Full Text]
- Cohen HA, Drucker MM, Vainer S, et al. Postcircumcision urinary tract infection. Clin Pediatr 1992;31(6):322–4. [Abstract]
- Goldman M, Barr J, Bistritzer T, Aladjem M. Urinary tract infection following ritual Jewish circumcision Isr J Med Sci 1996;32:1098–102. [Full Text]
- Mueller ER, Steinhardt, G., Naseer S. 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. [Abstract]
- Mårild S, Jodal U. Incidence rate of first–time symptomatic urinary tract infection in children under 6 years of age. Acta Paediatr 1998;87(5):549–52. [Abstract]
- McCracken G. Options in antimicrobial management of urinary tract infections in infants and children. Pediatr Infect Dis J 1989;8(8):552–55. [Full Text]
- Larcombe J. Urinary tract infection in children. BMJ 1999;319:1173–5. [Full Text]
- Beasley S, Darlow B, Craig J, et al. Position statement on circumcision.. Sydney: Royal Australasian College of Physicians, 2004. [Full Text]
- Outerbridge EW. Decreasing the risk of urinary tract infections (Letter). Paediatr Child Health 1998; 3(1):19. [Full Text]
- Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005;115(2):496–506. [Full Text]
- Hanson LÅ. Protective effects of breastfeeding against urinary tract infection. Acta Paediatr Scand 2004;93(2);154–6. [Full Text]
- Mårild S, Hansson S, Jodal U, Oden A, Svedberg K. Protective effect of breastfeeding against urinary tract infection. Acta Paediatr Scand 2004;93(2):164–8. [Full Text]
- Kwak C , Oh SJ. Lee A , Choi H. Effect of circumcision on urinary tract infection after successful antireflux surgery. BJU Int 2004;94(4):627–9. doi:10.1111/j.1464-410X.2004.05014.x [Full Text]
- Wolbarst A. Circumcision and penile cancer. Lancet 1932;1(5655):150–53.
- Boczko S, Freed S. Penile carcinoma in circumcised males. N Y State J Med 1979; 79(12):1903–4. [Full Text]
- Maden C, Sherman KJ, Beckmann AM, et al. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst 1993;85(1):19–24. [Abstract]
- McCance DJ, Kalache A, Ashdown K, et al. Human papillomavirus types 16 and 18 in carcinomas of the penis from Brazil. Int J Cancer 1986;37(1):55–9. [Abstract]
- Harish K, Ravi R. The role of tobacco in penile carcinoma. Brit J Urol 1995;75(3):375–7. [Full Text]
- Cold CR, Storms MR, Van Howe RS. Carcinoma in situ of the penis in a 76-year-old circumcised man. J Fam Pract 1997; 44:407–10. [Full Text]
- Bissada NK, Morcos RR, el-Senoussi M. Post-circumcision carcinoma of the penis. I. Clinical aspects. J Urol 1986;135(2):283–5. [Abstract]
- Commission on Clinical Policies and Research. Position Paper on Neonatal Circumcision. Leawood, Kansas: American Academy of Family Physicians, 2002. [Full Text]
- Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999;189(1):12–9. [Abstract]
- Wyatt SW, Lancaster M, Bottorff D, Ross F. History of tobacco use among Kentucky women diagnosed with invasive cervical cancer: 1997–1998. J Ky Med Assoc 2001;99(12):537–9. [Abstract]
- Poland RL. The question of routine neonatal circumcision. N Eng J Med 1990; 322:1312–5. [Full Text]
- The Future II Study Group. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. New Engl J Med 2007;356(19):1915–27, [Full Text]
- Fleiss PM. An analysis of bias regarding circumcision in American medical literature. In: Denniston GC, Hodges FM, Milos MF (eds.) Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. New York: Kluwer Academic/Plenum Publishers, 1999: pp. 379–402.
- Goldman R. The psychological impact of circumcision. BJU Int 1999;83 Suppl. 1:93–103. [Full Text]
- Hill G. The case against circumcision. J Mens Health Gend 2007;4(3):318–23. [Full Text]