About the Author
Sam Carnes RT(T) CMD is an intact man who is a medical professional and an intactivist. After finishing active duty military time in 2006, he went to IUPUI and received a Bachelor of Science in Radiation Therapy, graduating in 2010. He then went on to graduate school for a Graduate Certificate in Medical Dosimetry (radiation treatment planning for cancer patients). While working full time as a Medical Dosimetrist, he is also pursuing a Master of Science in Health Science. He is proud to be intact and happy to answer questions for new parents or anyone else who wants to learn about normal male anatomy and the problems with circumcision. Many find this information strange or intimidating because it is different from what they are used to hearing. However, being intact is the natural state and it is Sam’s goal to help make intact the norm here in the United States just as it is in practically everywhere else in the world. Sam can be reached at [email protected]
Healthcare spending is something many Americans worry about every day. As a country, our spending far exceeds that of every other nation. Reid (2010) says that “the one area where the United States unquestionably leads the world is in spending” (p. 9). That being said, everyone worries about trying to save money in this area, from the federal government, to state governments, to individuals. Obviously, it is such an important issue that it is hotly debated in political campaigns as well as among ordinary people on the street. Everyone wants to fix it, or at least to improve it, but no one can agree on exactly how to do this. One hears constant talk about government programs such as Social Security, Medicare, Medicaid, or Veterans Affairs either going bankrupt or at least being way over budget. The policies surrounding the creation and governance of Medicare, for example, partly caused the accelerated costs of healthcare in the United States (Morone & Ehlke, 2010, p. 130).
In an effort to cut spending, various cost saving measures have been employed. One such measure has been to defund circumcision and so, in some States, it is no longer covered by Medicaid. According to Andrews, Lazenby, Unal, and Simpson (2012), 18 States have done so thus far (p. 1). This has created much controversy. Some laud this as a good thing, believing the surgery to be cosmetic and completely unnecessary, and as Reid (2010) says, “The last thing we need is a legislative mandate to pay for treatment that is useless” (p. 155). Others, believing circumcision to be prophylactic and of great medical benefit, believe that discontinuing coverage will cause a surge in the infections and medical problems it is said to prevent as circumcision rates decline (Kacker, Frick, Gaydos, and Tobian, 2012, pp. 1-2).
Who is right? Obviously, saving money is a good thing, but it would be bad policy to stop coverage to save a little money now at the price of escalating costs in the future. To get an idea of what is at stake it is necessary to look at the issues surrounding circumcision. Does circumcision prevent disease? Do boys and men who are uncircumcised have more medical problems and have higher future medical costs or is this all a myth? To compare, it is necessary to look both at the United States population, which is largely circumcised, and the European population, which is largely uncircumcised. By comparing these two populations it can be better ascertained whether or not these fears are justified.
The Circumcision Controversy
Circumcision is a very ancient procedure which gained popularity in the United States only in the past 150 years. Many Americans assume that newborn males must be circumcised or else face many problems throughout life. They are unaware that this opinion is not shared by the majority worldwide. The medical community also is divided on the issue. Physicians in the United States tend to recommend the procedure and cite all of the claimed benefits while ignoring their colleagues abroad who disagree. Physicians from outside the United States tend to question the existence of these benefits, or at least, to question whether they outweigh both the possible complications from the procedure and the benefits an intact foreskin provides.
Many people are not well informed about circumcision. Most of the world is not circumcised but many Americans are surprised to learn this. In a study, participants were asked how they felt about circumcision “including the fact that 70% of the males worldwide are not circumcised” (Jia et al., 2009, p. 94). The knowledge level displayed was quite embarrassing with circumcised participants born and raised in the United States shocked to discover that they were in the minority. They also made comments in reference to the number of those uncircumcised worldwide such as “that is a lot of males and a lot of germs” (p. 94).
Due to the statement of the American Academy of Pediatrics (AAP) (1999) which said, “these data are not sufficient to recommend routine neonatal circumcision” (p. 691) it is becoming more common for circumcision to no longer be covered by insurance companies. Opponents argue that this will cost the system more in the long run due to increased health problems of those who are uncircumcised. They believe that lower circumcision rates are bad for the public health, claiming that those who are uncircumcised will have a disproportionately higher level of health problems in the future (Leibowitz, Desmond, & Belin, 2009, p. 144). They will cite the more recent AAP document (2012) which claims that the “current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it” (p. 585).
People give many reasons for circumcising their sons but what it boils down to is either cultural, religious, aesthetics, or for the perceived health benefits. A study found that males born and raised in the United States were the most in favor of circumcision with one comment being, “It is healthier for males to get circumcised” (Jia et al., 2009, p. 94-95). This belief in the health benefits has become deeply ingrained in American culture. But is this really the case or is it a myth? Is the healthcare system paying for something that has no benefit after all? Is it really true that circumcision reduces urinary tract infection (UTI), prevents phimosis and balanitis, reduces the incidence of penile cancer, and reduces the incidence of contracting STDs and HIV? To determine this one must look at the statistics and see the incidence of these diseases and issues in both a circumcised and an uncircumcised culture.
Hygiene and Phimosis
One argument in favor of circumcision is that it is said to improve penile hygiene. According to Wilson, Cumella, Parmenter, Stancliffe, & Shuttleworth (2009), “conditions such as urinary tract infections, cancer of the penis, acquired phimosis, paraphimosis, and candida infection (thrush) can result from poor hygiene” (p. 107). A vast majority of people in the United States believe that unless one retracts and cleans underneath the foreskin daily, it remains dirty and a haven for bacteria to grow. They believe that it is less hygienic for the glans to remain covered by the foreskin and will sometimes forcibly retract it before it is physiologically ready to do so, in order to maintain their view of proper hygiene. Since the foreskin often does not retract on its own until later in a boy’s development, medical professionals and parents who do this cause damage and often create the very problems they think they are preventing.
Phimosis is a condition in which the foreskin is narrowed at the opening, preventing retraction (Ahmed & Ellsworth, 2012, p. 12). It is claimed that this could be a source of infections, inadequate hygiene, and balanitis (Hunter, 2012, p. 37). According to Schoen (1997), the resulting inflammation of the glans and foreskin occurs in about 4% of uncircumcised boys with circumcision being the best method of prevention saying, “Although treatment can be conservative, late circumcision is often necessary for recurrent cases and medical management requires additional physician visits and treatment” (p. 258). What these authors fail to mention is that while phimosis may be a pathological condition when the condition persists into adulthood, in infants and young boys, and even into the late teenage years, it is a completely normal physiological process. As a boy develops, the foreskin gradually detaches from the glans penis. This occurs at anytime from infancy until young adulthood.
Circumcision and Urinary Tract Infection
One very common health reason given for circumcision is that it reduces urinary tract infections (UTI) which can occur in up to 4% of boys before they are one year old (The Royal Australasian College of Physicians [RACP], 2010, p. 10). Schoen (1997) claims, that there is a “greater than 10-fold increased risk of UTI in uncircumcised boys compared with their circumcised counterparts in the first year of life” and that “uncircumcised preschool boys and men are also at increased risk for UTI” (p. 258). According to the Centers for Disease Control and Prevention (CDC), “Overall, UTIs are not common among male infants, with estimates of the annual rate of UTI in uncircumcised infants being 0.70% versus 0.18% for circumcised infants” (Male Circumcision: Other Health Conditions section, para. 5). In opposition to Schoen, Malone (2005) states that studies have only “shown a three to seven times increased risk of UTI in uncircumcised compared with circumcised infants, with the greatest risk in infants under 1 year of age” (p. 773). Singh-Grewal, Macdessi, and Craig (2005) showed that it would take 111 circumcisions to prevent one UTI (p. 853). They also concluded:
The benefit of circumcision on UTI only outweighs the risk in boys who have had UTI previously and have a predisposition to repeated UTI. As this analysis has used a conservative circumcision complication rate of 2%, if the complication rate were in reality higher the risk–benefit analysis may not favour circumcision even in the higher risk populations (p. 858).
Here they are talking about those boys who seem prone to recurrent infections. They also admit that they are using a very low estimate, in other words a best case scenario, when looking at circumcision complication rate. It seems that the number of 111 circumcisions to prevent one UTI is significant. This is 111 surgeries with an estimated 2% complication rate to prevent one UTI that could be cleared up with a simple course of antibiotics. Why treat with surgery when a simpler treatment will work and additionally, will keep a boy or man with all of his body parts intact? Furthermore girls are more prone to UTIs overall and they are always treated with antibiotics, not circumcision. Roberts (2011), in the AAP’s Clinical Practice Guideline on UTIs, states that “the prevalence of UTI among febrile infant girls is more than twice that among febrile infant boys” (p. 598).
Physicians from many European countries came together and issued a document refuting four health-related reported benefits of circumcision claimed by the AAP (Frisch et al., 2013, pp. 796-800). The only possibly relevant argument was that of circumcision preventing urinary tract infections (UTIs) but even this argument “fails to meet the criteria to serve as a preventive measure for UTI” they said (p. 797). They pointed out that there have been no trials linking a lack of circumcision to UTIs, they are rarely serious, and evidence for any protective effect is weak (p. 797).They also show that the risk of complications from circumcision is higher than the chance of getting a UTI (p. 797). It is extremely telling that the rate of UTIs is similar between the United States and Europe even though the circumcision rates are vastly different (p. 797).
Circumcision and Penile Cancer
Penile cancer is a very rare disease. Some risk factors often given are: being uncircumcised, phimosis, and poor genital hygiene (Ahmed & Ellsworth, 2012, p. 14). Schoen (1997) states: “Evidence that circumcision protects against penile cancer is overwhelming” and that “newborn circumcision virtually eliminates this devastating threat” (p. 258). This seems to be quite a forceful statement for a disease that is so rare. He also claims that the incidence is vastly more common in uncircumcised men (p. 258). According to the American Cancer Society (2014), there will be 1,640 new cases of penile cancer in 2014. They report that “Penile cancer is very rare in North America and Europe. Penile cancer occurs in less than 1 man in 100,000 and accounts for less than 1% of cancers in men in the United States” (Penile Cancer section, para.1). According to a report from the National Cancer Intelligence Network (2013), the incidence number for penile cancer in England, Scotland, Wales and Northern Ireland was 1.3-2.0 per 100,000 for the 2008-2010 period (p. 3). The World Health Organization (WHO) (2007) lists the United Kingdom as being 6% overall for their circumcision rate (p. 8). With the vast difference in circumcision rate between the United States and the United Kingdom, one would expect a greater difference in penile cancer incidence than 1 versus 2 per 100,000, if circumcision was really a prominent factor.
Dr. Rowena Hitchcock (1997), of the Royal College of Surgeons of England, says that the paper by Dr. Schoen “reflects the influence of culture and habit on the interpretation of medical practice” (p. 260). She believes that this preference for circumcision is a cultural bias rather than sound medical practice (p. 260). She also brings up a very interesting point in noting that the incidence of penile cancer is comparable for the United States and Finland even though the rate of circumcision in Finland is less than 1% (p. 260). Another author notes that the incidence of penile cancer is actually slightly higher in the United States, where most men are circumcised, than in Denmark were most are not (Benetar & Benetar, 2003, p. 38). This calls into question the idea that being circumcised reduces one’s risk of this disease.
Circumcision and HIV Prevalence
One of the most often stated arguments today is that circumcision prevents, or at least dramatically reduces, one’s chance of contracting STDs and HIV. It is argued that “circumcision can significantly lower the risk of adult males acquiring HIV through heterosexual intercourse”
(p. 14). According to WHO (2007), “Three separate randomized controlled trials in South Africa demonstrated that circumcised men have a 48-60% reduced risk of becoming infected with HIV (p. 22). There is also an article which, while criticizing the methodology used in drawing conclusions from this series of trials, does not call into question the findings of the studies (Lie & Miller, 2011, pp. 34-40). Instead, they state that “we do have substantial data from observational research that complement and strengthen the results from the RCTs, [Randomized Controlled Trials] giving us sufficient confidence to recommend circumcisions as a public health intervention to prevent HIV infection” (p. 38).
It is very interesting to look at the statistics for the prevalence of HIV. If circumcision truly reduced the incidence of HIV by 60% one would expect to see much lower rates in a country with a high circumcision rate. According to Sansom et al. (2010), the overall circumcision rate in the United States for those born between 1940 and 1979 is 79% (p. 2). According to the website avert.org, the prevalence of HIV is between 0.4 and 0.9% (“HIV & AIDS in USA,” n. d.). For all of Latin America the prevalence of HIV is 0.4%, while the circumcision rate given by WHO is <20% overall (“HIV & AIDS in Latin America,” n.d.; WHO, 2007, pp. 9, 12). The website circinfo.net further specifies the circumcision rates of some of the countries individually such as Mexico which varies between 10-30%, Brazil at 7%, and Colombia at 7% (“Rate of Circumcision,” n.d.). Circumcision rates throughout Europe are low. WHO lists the overall as being <20% and the United Kingdom specifically, as being 6% (pp. 8-9). Circinfo.net lists Spain as being 2%, Slovenia as 4.5%, Finland at 7%, and Denmark at 1.6% (“Rate of Circumcision,” n.d.). In Europe there was some variance between countries regarding HIV incidence. Eastern Europe had some countries that were higher such as the Ukraine (0.8%) and Estonia (1.3%). Central Europe was all 0.1% or less and Western Europe varied between 0.1% and 0.4% except for Portugal which had 0.7% (“European HIV & AIDS Statistics,” n. d.). Denmark is especially interesting because, while they have a 1.6% circumcision rate, avert.org gives the HIV incidence rate as 0.2% which is equal to Israel’s HIV prevalence and less than the United States; both countries with very high circumcision rates (“European HIV & AIDS Statistics,” n. d.). According to the arguments, countries with lower circumcision rates should have higher rates of HIV and yet they do not. The incidence in the United States is actually higher than the majority of the countries of Europe and Latin America! The Royal Dutch Medical Association (2010) states:
That the relationship between circumcision and transmission of HIV is at the very least unclear is illustrated by the fact that the US [United States] combines a high prevalence of STDs and HIV infections with a high percentage of routine circumcisions. The Dutch situation is precisely the reverse: a low prevalence of HIV/AIDS combined with a relatively low number of circumcisions. As such, behavioural factors appear to play a far more important role than whether or not one has a foreskin (pp. 7-8).
If circumcision is really supposed to greatly reduce these diseases, then the United States with its high circumcision rate should have much lower rates of STDs and HIV than the rest of the world. This has not proven true however. Is it not much more likely that promiscuity or some other unknown reason is the culprit? If having a foreskin was really the problem it seems that those countries where circumcision is much less common would have a corresponding increase in incidence of these diseases. The fact that this is not the case is a serious flaw to this argument. It would seem to indicate that these beliefs are a cultural bias rather than sound medical facts. The Royal Dutch Medical Association (2010) calls circumcision “a procedure in need of a justification” (p. 7).
In looking at the various research articles, it is interesting to note that many things are not based on facts. Many arrive at their basic assumptions, such as the 60% reduction in risk of acquiring HIV number, on data derived from circumcision trials conducted in Africa (Sansom et al., 2010, pp. 1-2). The situation in third world places such as Africa versus the United States or Europe is vastly different in terms of access to healthcare and hygiene practices. Even basics such as running water, food, and adequate shelter are not a given for many in these poorer countries. How can we guarantee that these African trials do not have an inherent bias built into them, whether intentionally or not? As an example, would it not be normal for a health care practitioner to practice cleanliness at the time of the procedure and also to instruct the patient in proper post-op care. This would include instruction in basic hygiene that might be taken for granted in more developed countries but is perhaps a novelty in the countries where these trials took place. Once having learned about cleanliness and proper hygiene, the practice could have continued and this is what created the reduction in HIV rates rather than from the circumcision itself. This at least raises reasonable doubt. Many other things seem to be estimated such as the age of acquiring HIV, the cost of treatment in the future, and life expectancy (Sansom et al., 2010, pp. 2-3). Much of the information seemed to come from mathematical models rather than by looking at the statistics of countries with various percentages of circumcision prevalence. The authors even admit, “The potential impact of circumcision is less well-understood in the United States, where the majority of HIV infection among U.S. males occurs through sexual contact with other males, and the prevalence of male circumcision already is high” (Sansom et al, 2010, p. 2). Yet Andrews et al. (2012) claims, “While there are inherent differences between these populations, there is no reason to believe circumcision would have radically different effects in different populations as findings from prospective studies in the US are consistent with the results from the African trials” (p. 6). The statistics do not support these claims. Furthermore, Van Howe (2004) says that while “several studies conducted in Africa have shown HIV to be more common in noncircumcised men; other studies have shown the opposite, whereas most have shown little or no difference” (p. 591). He furthermore says, “The HIV pandemic in Africa demonstrates distinct epidemiological differences from the outbreaks in North America or Europe” (p. 591).
Monetary Savings and Costs
The important question is whether circumcision costs money or saves it. Some people believe it to be a powerful preventative to disease indicating that it saves money. Nowhere is this being more loudly touted than in the realm of HIV, which is a very serious condition. Treatments are very costly and a person can live for many years with the condition. In an analysis, Andrews et al. (2012) used data in South Carolina to determine projected increased costs of treating HIV due to decreased rates of circumcision. They claim a “lifetime treatment cost of $377,360 for each additional HIV case projected” (p. 3). Further they say:
We estimate an additional 55 projected male cases of HIV and 47 female cases of HIV in this Medicaid birth year cohort. Using the 2009 reported cases of HIV/AIDS in South Carolina, this figure represents a 13% increase in annual incidence if no future Medicaid cohorts are circumcised. We project the total cost of these cases in 2010 dollars is $38,635,800 discounted to time of infection and $15,540,800 discounted to birth year. These figures account for lifetime treatment costs for the 2009 birth cohort (p. 4).
At the same time Andrews et al. (2012) states that “the cost to circumcise males in the 2009 Medicaid birth cohort in 2010 dollars at current reported circumcision rates is $4,856,200” (p. 4). This means they are claiming that in the state of South Carolina, it will cost the system an additional $33,779,600 each year in increased medical costs from HIV, as the price of not circumcising.
One might think that spending nearly $5,000,000 to save $34,000,000 sounds like a good deal. Van Howe (2004) however, using several types of analyses states that:
In every scenario, it was more costly to circumcise. Using the baseline analysis, neonatal circumcision and its sequelae cost $828.42 (3% discount) to $837.59 (5% discount) more than leaving the genitalia intact. Even for the MFS, [most favorable scenario] circumcision was more costly. In all scenarios, the cost of neonatal circumcision is higher than noncircumcision, regardless of the discount rate (pp. 591-592).
He goes on to say that “if neonatal circumcision were cost-free, were immediate complication-free, had no additional days of hospitalization, and had no immediate negative impact on health, neonatal circumcision would still be more costly” (p. 592). Since a greater numbers of UTIs is another common reason given for circumcision he adds, “To make neonatal circumcision cost-neutral, hospitalized urinary tract infections would need to cost $229,564” (p. 592). Obviously, not every UTI results in hospitalization. In fact, most are not serious enough to require that extent of treatment. A UTI is an infection and as such, a simple course of antibiotics will often clear it up quite quickly, just like any other infection. Even in those cases where a hospital stay may be required, it does not necessarily mean that the bill would be that large. Thus, any treatment for UTI that is less than $229,564 results in circumcision not being cost-neutral. Van Howe (2004) concludes:
The analysis is clear: Neonatal circumcision cannot be justified on economic or medical grounds. If the medical community is interested in preserving health and saving money, they should refrain from promoting, encouraging, or presenting neonatal circumcision as a medical option (p. 597).
So what do all of these statistics show? Intact men and boys have no more issues with their penises than their circumcised counterparts, despite the hype. For the most part, the statistics for the various problems associated with being uncircumcised are comparable, and in some cases are even lower in Europe, despite its much lower circumcision rate, than in the United States. Thus, looking at comparable cultures and levels of prosperity, the evidence indicates that routinely circumcising infant males does not save money. Many of the projected cost increases are mere conjecture using data obtained from faulty trials. Even if the trials had no inherent bias in them, the conditions between the United States and Africa are so different that to apply the statistics observed in Africa directly to situations in the United States, would show a lack of understanding of the issues as well be lacking in scientific rigor. It would make more sense to conduct such research in a country with a similar standard of living, particularly in the realm of health care. Just a cursory glance at the European statistics indicates that the foreskin does not cause more problems than any other part of the body when cared for appropriately. It is not a breeding ground for disease, but rather, is an important part of the male anatomy.
The defunding of circumcision is a good cost saving measure. Statistics from cultures largely uncircumcised, such as Europe, do not show increased medical problems and costs. This indicates a cultural preference or bias rather than any real prophylactic effect. Instead of using healthcare dollars for unproven treatments, the money would be better spent on essential basic care for more people. The money saved by no longer covering circumcision is a mere drop in the bucket of the savings necessary to get our healthcare system under control, however. To truly decrease costs, many more changes would have to be made. First, we need to look at every treatment, procedure, medication, blood test, and so forth to determine if the practice is truly based on facts backed by evidence, rather than on custom and common practice. Next, we need to put laws in place that prohibit the many frivolous lawsuits that occur. These almost force doctors to order excessive tests and treatments in order to avoid accusations of malpractice and losing in a court of law, rather than being able to use sound judgment as to whether or not a test is truly indicated. Thirdly, we need to simplify the billing system. We have made this so complicated and truly convoluted that rather than being just one of the tasks that we do each day, we have to hire billing specialists. Even these specialists often disagree amongst themselves as to the meaning of various billing rules. Finally, we need to help provide adequate health care for our own citizens before spending money providing foreign aid. While it is laudable to want to help those in far away places, there is an old saying, “Charity begins at home.” How can we expect to help others when our own system is a mess, our costs are out of control, and millions of our own citizens do not have adequate health care? By applying these ideas we may perhaps be in a better position to pursue that elusive dream of a fair and equitable system of health care for all Americans.
Ahmed, A. & Ellsworth, P. (2012). To circ or not: A reappraisal. Urologic Nursing, 32(1), 10-19. Retrieved from http://www.suna.org/resources/urologic-nursing-journal/
American Academy of Pediatrics. (1999). Circumcision policy statement. Pediatrics, 130(3), 686-693. doi: 10.1542/peds.103.3.686
American Academy of Pediatrics. (2012). Circumcision policy statement. Pediatrics, 130(3), 585-586. doi:10.1542/peds.2012-1989
American Cancer Society. (2014). What are the key statistics about penile cancer? Retrieved from http://www.cancer.org/cancer/penilecancer/detailedguide/penile-cancer-key-statistics
Andrews, A. L., Lazenby, G. B., Unal, E. R., & Simpson, K. N. (2012). The cost of Medicaid savings: The potential detrimental public health impact of neonatal circumcision defunding. Infectious Diseases in Obstetrics & Gynecology, 1-7. doi:10.1155/2012/540295
Benatar, M., & Benatar, D. (2003). Between prophylaxis and child abuse: The ethics of neonatal male circumcision. American Journal of Bioethics, 3(2), 35-48. Retrieved from http://muse.jhu.edu/journals/american_journal_of_bioethics/
Centers for Disease Control and Prevention. (n.d.). Male Circumcision: Other health conditions. Retrieved from http://web.archive.org/web/20150108155833/http://www.cdc.gov/hiv/prevention/research/malecircumcision/otherconditions.html
European HIV & AIDS statistics. (n. d.). Retrieved from http://www.avert.org/european-hiv-aids-statistics.htm
Frisch, M., Aigrain, Y., Barauskas, V., Bjarnason, R., Czauderna, P., de Gier, R. E., & … Boddy, (2013). Cultural bias in the AAP’s 2012 technical report and policy statement on male circumcision. Pediatrics, 131(4), 796-800. doi:10.1542/peds.2012-2896
Hitchcock, R. (1997). Commentary. Archives of Diseases in Childhood, 77(3), 260. Retrieved from http://adc.bmj.com/
HIV & AIDS in Latin America. (n. d.). Retrieved from http://www.avert.org/hiv-aids-latin-america.htm
HIV & AIDS in USA. (n. d.). Retrieved from http://www.avert.org/hiv-aids-usa.htm
Hunter, D. (2012). Conditions affecting the foreskin. Nursing Standard, 26(37), 35-39. Retrieved from http://www.nursing-standard-journal.co.uk/
Jia, L., Hawley, S., Paschal, A., Fredrickson, D., St. Romain, T., & Cherven, P. (2009).
Immigrants vs. non-immigrants: Attitudes toward and practices of non-therapeutic male circumcision in the United States of America. Journal of Cultural Diversity, 16(3), 92-98. Retrieved from http://tuckerpub.com/jcd.htm
Kacker, S., Frick, K. D., Gaydos, C. A., & Tobian, A. A. R. (2012). Costs and effectiveness of neonatal male circumcision. Archives of Pediatrics & Adolescent Medicine, 166(10): 910–918. doi: 10.1001/archpediatrics.2012.1440
Leibowitz, A., Desmond, K., & Belin, T. (2009). Determinants and policy implications of male circumcision in the United States. American Journal of Public Health, 99(1), 138-145. doi:10.2105/AJPH.2008.134403
Lie, R. K., & Miller, F. G. (2011). What counts as reliable evidence for public health policy: The case of circumcision for preventing HIV infection. BMC Medical Research Methodology, 11(1), 34-40. doi:10.1186/1471-2288-11-34
Malone, P. (2005). Circumcision for preventing urinary tract infection in boys: European view. Archives of Disease in Childhood, 90(8), 773-774. doi: 10.1136/adc.2004.066779
Morone, J. A., & Ehlke, D. C. (2013). Health politics and policy (5th ed.). Stamford, CT: Cengage Learning.
National Cancer Intelligence Network. (2013). Penile cancer incidence, mortality and survival rates in the United Kingdom. (2013). 1-6. Retrieved from www.ncin.org.uk/view?rid=1003
Rate of circumcision in adults and newborn. (n.d.). Retrieved from http://www.circinfo.net/rates_of_circumcision.html
Roberts, K. B. (2011). Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics, 128(3), 595-610. doi:10.1542/peds.2011-1330
Sansom, S. L., Prabhu, V. S., Hutchinson, A. B., Qian, A., Hall, H. I., Shrestha, R. K., … Taylor, W. (2010). Cost-effectiveness of newborn circumcision in reducing lifetime HIV risk among U.S. males. Plos One, 5(1), 1-8. doi:10.1371/journal.pone.0008723
Schoen, E. J. (1997). Benefits of newborn circumcision: Is Europe ignoring medical evidence? Archives of Disease in Childhood, 77(3), 258-260. Retrieved from http://adc.bmj.com/
Singh-Grewal, D., Macdessi, J., & Craig, J. (2005). Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomized trials and observational studies. Archives of Disease in Childhood, 90(8), 853-858. doi: 10.1136/adc.2004.049353
The Royal Australasian College of Physicians. (2010). Circumcision of Infant Males, 1-28. Sydney: RACP. Retrieved from http://web.archive.org/web/20150126154358/http://www.racp.edu.au/page/paedpolicy
The Royal Dutch Medical Association. (2010). Non-therapeutic circumcision of male minors. Utrecht: KNMG. Retrieved from http://knmg.artsennet.nl/Publicaties/KNMGpublicatie/ [link]
Van Howe, R. S. (2004). A cost-utility analysis of neonatal circumcision. Medical Decision Making, 24(6), 584-601. doi: 10.1177/0272989X04271039
Wilson, N., Cumella, S., Parmenter, T., Stancliffe, R., & Shuttleworth, R. (2009). Penile hygiene: Puberty, paraphimosis and personal care for men and boys with an intellectual disability. Journal of Intellectual Disability Research, 53(Part 2), 106-114. Retrieved from http://www.wiley.com/WileyCDA/WileyTitle/productCd-JIR.html
World Health Organization. (2007). Male circumcision: Global trends and determinants of prevalence, safety, and acceptability. Geneva: WHO Press. Retrieved from http://www.who.int/hiv/pub/malecircumcision/globaltrends/en/