Risks and complications of circumcision

 

INTRODUCTION

All medical procedures carry a risk that something will go wrong, and circumcision is no exception. Intactivists exploit this ruthlessly, regaling their audience with horror stories of botched circumcisions, alarming complications, and gruesome pictures of mangled or infected organs. And all backed up with frightening statistics “proving” harm and death on a disturbing scale.

So, are these claims justified, or are they mere scare mongering?

Firstly, it must be acknowledged that yes, there have been tragic accidents resulting in permanent maiming, even death, in the course of medical circumcisions. And less serious mishaps that required medical intervention to correct. But this must be put into perspective. Gory photos of circumcisions gone wrong can be matched by equally gruesome photos of foreskins gone wrong (gangrene, infections, paraphimosis, penile cancer …). Yet we accept risks with other medical procedures. Children sometimes suffer life-threatening reactions to vaccines, for example. In Canada, in 2004, a total of 8409 adverse events were reported stemming from vaccinations. Most were minor, and self-resolving, such as a rash or fever, but they included 38 cases of anaphylaxis, 37 cases of convulsions, 4 of brain infections and, for the period 1997 – 2004, three deaths (Public Health Agency of Canada, 2006).

Nevertheless we submit ourselves and our children to vaccination because the risk of suffering a potentially serious illness as a consequence of not being vaccinated is much higher. In short, getting vaccinated wins in a risk-benefit analysis, i.e. the benefits outweigh the risks. And the consequences of failing to understand this are depressingly apparent every time easily preventable diseases like measles and whooping cough make comebacks because parents refuse vaccination for their children. Often, the disturbing reason is that parents have been duped by anti-vaccination pseudoscience hyping up the alleged harm of vaccines, whilst ignoring the benefits.

Intactivists are no different to anti-vaxxers in this regard. They exaggerate the risks whilst downplaying, or completely ignoring, the benefits. But when all the evidence is evaluated a story very different from the intactivists’ narrative emerges. In high-HIV settings the consensus is that medical circumcision wins a risk-benefit (and cost-benefit) analysis. Infant circumcision even more so (it is cheaper, quicker, safer, easier, and confers benefits throughout infancy and childhood as well). Consequently, medical early infant circumcision is now being rolled out in HIV-epidemic settings with the approval of the WHO, CDC, UNAIDS, PEPFAR, Bill & Melinda Gates Foundation, UNICEF and the various local medical and governmental organizations dealing with this terrible epidemic.

So, what about circumcision in low-HIV countries? The American Academy of Pediatrics (AAP) conducted an extensive review (Blank et al., 2012) and concluded “that the health benefits of newborn male circumcision outweigh the risks and justify access to this procedure for families who choose it.” But the AAP Task Force stopped short of recommending it should be done routinely for all male infants, leaving the final decision to the parents.

Predictably this caused howls of outrage from the anti-circumcision lobby, and critiques, counter-critiques, counter-counter critiques, etc. filled the medical literature for several years after the new policy was published. (If you have time, the Journal of Medical Ethics carried the most extensive series, and it is revealing to see how the intactivists, led by Prof. Robert S. Van Howe, switched to ad hominem attacks on their chief critic Prof. Brian Morris, after their technical criticisms were exposed as vacuous). Some of the authors of the AAP’s policy were even subjected to personal harassment.

Two years later draft policy recommendations by the Centers for Disease Control (CDC) contained similar conclusions to those of the AAP. This led to the CDC being swamped with anti-circumcision comments when they put the draft report to public consultation. The intactivist lobby put out a “call to arms” on social media, and about 3,000 of the faithful responded, bombarding the CDC with repetitive and pseudoscientific objections, swamping a more modest number of pro-circumcision respondents. The list may be viewed here: http://cdc.intactivist.net/?page=1&limit=100 As with the AAP, a round of critique and counter-critique also followed in the published literature (e.g. Morris et al., (2017), and references therein).

More recently the Canadian Pediatrics Society (CPS) reviewed the data and decided that infant circumcision’s benefits did not exceed the risk, instead stating that these were “closely balanced”, although they did not say circumcision should be denied (Sorokan et al., 2015). But their position statement was not nearly as comprehensive as the AAP’s. Notably it used weak data for some of the risks and benefits, and failed to refer to the extensive data in the largest survey of infant circumcision complications in a developed world setting (El Bcheraoui et al., 2014). When a team from Australia, the USA, and Canada performed a risk:benefit analysis using better data (giving preference to randomized controlled trials, and meta-analyses) they found that the benefits of early infant medical circumcision exceeded the risks by a very large margin (Morris et al., 2016).

This had been shown earlier in a Mayo Clinic Proceedings article that estimated that the benefits exceeded the risks by a factor of 100 to 1, with half of non-circumcised males experiencing a foreskin-related problem over the course of their lives; the procedure was also shown to be cost-saving (Morris et al., 2014).

Of course, intactivists will counter that these last references are to works by authors who are famously pro-circumcision, and (they would argue) biased (as if intactivists aren’t). They also point to position statements from other (mostly European) medical bodies apparently opposing infant circumcision (the Dutch one being a favourite). But they overlook some important points.

The statements opposing circumcision are generally out of date and incomplete, failing to consider the extensive high quality published medical evidence, instead being based on ideology, rather than science. Nevertheless even these do not deny that circumcision is useful in high-HIV settings. And none make the extravagant claims intactivists do about circumcision harming sexual function and pleasure, and none say it should be banned. It is also telling that of the three medical bodies to have attempted an up to date review of the data, two found in favour (AAP & CDC), and one thought it “closely balanced” (CPS).

Whatever one thinks of the more optimistic benefit to risk ratios estimated by circumcision proponents, it is not difficult to show that the ratio is heavily skewed in circumcision’s favor. The most common indications for medically necessitated circumcisions are dermatological – phimosis, paraphimosis and lichen sclerosis. Whilst less serious cases can often be treated conservatively (with steroid creams, for example) there remain intransigent cases that refuse to resolve, or which recur, necessitating surgical intervention, including full circumcision. Millions of boys and men around the world have had to be separated from their foreskins to provide relief from these painful, and potentially dangerous, conditions.

Estimates of the proportion of males needing a circumcision later in life vary, but are generally in the range of 5 – 10 %. A study conducted in Denmark, a strongly anti-circumcision society, and often cited by intactivists, because it gives one of the lowest rates of medically indicated circumcision, found that between 5.2 and 5.7 % of boys sought treatment for foreskin problems, and 1.7 % needed surgery of some sort (not always circumcision) on their foreskins by age 18 (Sneppen & Thorup, 2016). These figures, it should be noted, are underestimates owing to “the strict foreskin-preserving culture in Denmark” and the exclusion of boys already circumcised for non-therapeutic reasons. In addition, it excludes males needing circumcision after age 18.

The most comprehensive survey (sample size = 1.4 million) of complication rates from infant circumcision in a developed country (the USA) found the overall rate to be less than 0.5 % (El Bcheraoui et al., 2014). These were overwhelmingly minor problems that could be treated simply, without recourse to further surgery. In fact, only about 2000 per million circumcisions (0.2 %) required surgical correction, again involving mostly simple procedures that lead to complete resolution of the problem. In short, if these data are representative of developed countries, then in those settings foreskins go wrong over ten times more often than circumcisions do, and a male is around an order of magnitude more likely to need surgery for a foreskin gone wrong, than for a circumcision gone wrong. And, it should be noted, circumcisions outside the neonatal period are 10 to 20 times riskier (El Bcheraoui et al., 2014), more expensive, and more distressing to the patient, as well as meaning that the patient has to suffer the problem, often for years, before being cured by circumcision.

And that is just for dermatological problems, using the most conservative data favored by intactivists for those problems. Add in all the other problems foreskins can cause (urinary tract infections, sexually transmitted infections, other infections, genital cancers, etc.) and the 100 to 1 benefit to risk ratio estimate might well be true.

From causing autism to affecting breastfeeding, intactivists have a host of bogus arguments to bolster their claims that circumcision is harmful. Those relating to sexual function and sensation deserve a section on their own (http://circfacts.org/function-sensation/ ). Others that do not fall into this category are dealt with individually below. As usual they are all pure pseudoscience, designed to frighten parents into not circumcising their sons. In short, scare tactics.

References
Blank, S., Brady, M., Buerk, E., Carlo, W., Diekema, D., Freedman, A., Maxwell, L., Wegner, S. (2012) Technical Report: Male Circumcision, Pediatrics, 130(3), e756-e785. On-line: http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1990

El Bcheraoui, C., Zhang, X, Copper, C.S., Rose, C.E., Kilmarx, P.H., Chen, R.T. (2014) Rates of adverse events associated with male circumcision in US medical settings, 2001 to 2010. JAMA Pediatrics, 168(7), 625-34. On-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4578797/

Morris, B.J., Bailis, S.A., Wiswell, T.E. (2014) Circumcision rates in the United States: Rising or falling? What effect might the new affirmative pediatric policy statement have? Mayo Clinic Proc., 89(5), 677-86.  Summarised here: http://circfacts.org/wp-content/uploads/2016/11/Circ-Risk-Benefits.pdf

Morris, B.J., Klausner, J.D., Krieger, J.N., Willcox, B.J., Crouse, P.D., Pollock, N. (2016) Canadian Pediatric Society position statement on newborn circumcision: a risk-benefit analysis revisited. Can. J. Urology, 23(5), 8495-8502. On-line: https://pollockclinics.com/wp-content/uploads/2016/11/can-jl-urol-8495.pdf
Follow-up correspondence on-line: http://www.canjurol.com/html/free-articles/V24I1_19_FREE_Letter_Editor_Feb17.pdf and http://www.canjurol.com/html/free-articles/V24I1_19_FREE_Reply_Authors_Feb17.pdf

Morris, B.J., Krieger, J.N., Klausener, J.D. (2017) CDC’s male circumcision recommendations represent a key public health measure. Global Health: Science and Practice, 5(1), 15-27. On-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478224/

Public Health Agency of Canada (2006) Canadian National Report on Immunization, 2006. On-line: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/06vol32/32s3/5vacc-eng.php

Sneppen, I. & Thorup, J. (2016) Foreskin morbidity in uncircumcised males. Pediatrics, 137(5). On-line: http://pediatrics.aappublications.org/content/137/5/e20154340.long

Sorokan, S.T., Finlay, J.C., Jeffries, A.L. (2015) Position statement. Canadian Paediatric Society. Newborn male circumcision. Paediatr., Child Health, 20(6), 311-5. On-line: https://www.cps.ca/en/documents/position/circumcision

 

Circumcision causes alexithymia

Alexithymia is a personality trait in which people have difficulty identifying and describing their own, or other people’s, emotions. Its causes remain unclear and, like many personality traits, are likely a complex interaction of genetics and environment. The assertion that it may be linked to circumcision comes from just one paper, by a pair of well-known intactivists: Bollinger & Van Howe (2011).

This same paper also claimed a connection between circumcision and use of an erectile dysfunction drug, not erectile dysfunction itself. The aspect is dealt with in detail elsewhere on this site (http://circfacts.org/function-sensation/#sens8 ) where it is explained that the study sample was likely biased as a result of the inappropriate way the participants were recruited – by an advertisement with a “loaded” title “Male circumcision trauma survey” on websites with histories of promoting anti-circumcision material. This alone seriously compromised the study.

The authors speculated that early trauma (such as pain from infant circumcision) affects the brain, thereby leading to alexithymia, but their own results do not bear this out. As pointed out in a critique (Morris & Waskett, 2012) the overall rate of alexithymia in the sample was higher than for the general population, confirming the biased nature of the sample, there was no association between age of circumcision and alexithymia, and the authors even admitted that “Circumcision pain itself did not seem to effect [sic] acquiring alexithymia”. In reply Bollinger & Van Howe argued that circumcision itself was associated with alexithymia (Bollinger & Van Howe, 2012). But if the circumcision was not traumatic (because anesthesia was used) then that undermines their hypothesis that trauma causes alexithymia! Even their own citations do not all support their hypothesis. One (Taylor et al., 1997) describes alexithymia as “a stable personality trait rather than just a consequence of psychological distress”.

In their defence, Bollinger & Van Howe acknowledged that their sample may be biased, and that their findings were “preliminary” and needed to be replicated (Bollinger & Van Howe, 2012). While true, it should be noted that single, preliminary, weak studies by biased authors on biased samples are no basis for forming firm conclusions. Science depends heavily on replication, until a consensus is reached. Many single-study hypotheses fall by the wayside for this reason. This is one of them. No study on alexithymia and circumcision has been published since.

References

Bollinger, D., Van Howe, R.S. (2011) Alexithymia and circumcision trauma: A preliminary investigation. Int. J. Men’s Health, 10(2), 184-95.

Bollinger, D., Van Howe, R.S. (2012) Preliminary results are preliminary, not “unfounded”: Reply to Morris and Waskett. Int. J. Men’s Health, 11(2), 181-5.

Morris, B.J., Waskett, J.H. (2012) Claims that circumcision increases alexithymia and erectile dysfunction are unfounded: A critique of Bollinger and Van Howe’s “Alexithymia and circumcision trauma: A preliminary investigation”. Int. J. Men’s Health, 11(2), 177-81.

Taylor, G.J., Bagby, R.M., Parker, J.D.A. (1997) Disorders of Affect Regulation: Alexythmia in Medical and Psychiatric Illness. Cambridge, U.K., Cambridge University Press.

 

Circumcision causes autism

Like the claim that circumcision may cause alexithymia (http://circfacts.org/medical-benefits/risks-complications/#risk1 ) the autism claim stems from a single paper co-authored by a well-known circumcision opponent, Morten Frisch: Frisch & Simonsen (2015a). This and the alexithymia claim belong to the same genre: that the pain of infant circumcision causes permanent, and harmful, neurological changes in the brain. Another example is the story that a brain scan by MRI found evidence of changes, a story since exposed as a likely hoax (http://circfacts.org/debunking-corner/#debk4 ). In its most ridiculous form, one sometimes sees, in comments threads, claims that such purported neurological changes account for the relatively high numbers of serial killers in the U.S.!

Whilst not for one moment suggesting deliberate deception on the part of Frisch & Simonsen (unlike the infamous attempt by the disgraced Dr Andrew Wakefield to link autism to the MMR – measles, mumps, rubella – vaccine) the study should be seen in the light of Prof. Frisch’s long-standing opposition to circumcision, and the habit of intactivists and their sympathizers, to gain credibility for their views by publishing weak studies that they can then cite in support of their agenda.

Whilst not suffering the selection bias of the alexithymia study, Frisch & Simonsen’s work falls far short of proving their case. As the old cliché goes, correlation is not causation. They studied the records of 342,877 Danish boys born between 1994 and 2003, looking for any association between circumcision and diagnoses of autism spectrum disorder (ASD). They concluded that there was an association between being circumcised as infants and ASD in boys under the age of 10. Curiously, the association was stronger for those boys circumcised more recently, i.e., those boys aged 4 years or less at the time of the study. The older ones showed a much weaker association, which seems odd, as one would expect diagnoses of ASD to increase with time, thereby increasing the sample size of affected boys and thus increasing the statistical significance of the association, if it existed.

While the study did attract criticism in the medical literature (Morris & Wiswell, 2015), which led to a reply (Frisch & Simonsen, 2015b), the most serious criticisms came from non-partisans in the circumcision debate. Ann Bauer, whose original study was part of the inspiration for Frisch & Simonsen’s study, weighed in on PubMed Commons (Bauer, 2015). Her original work (Bauer & Kriebel, 2013) actually investigated the possibility that there was a link between acetaminophen (paracetamol) and ASD, as there were indications that some susceptible infants could not metabolise this medication in the same way as older children, and adults. The use of a different metabolic pathway led to the generation of metabolic by-products with neurotoxic effects. Bauer and her colleagues used circumcision as a proxy for acetaminophen use (this analgesic is commonly given to infants to relieve discomfort following circumcision). And, indeed, the ecological data indicated an association was present. This coupled with a plausible mechanism, made acetaminophen, not circumcision, a more reasonable suspect for the association with circumcision in susceptible infants.

This possibility was mentioned by Frisch & Simonsen, but they were dismissive, preferring their own agenda instead. After all, they were out to attack circumcision, not acetaminophen, but Bauer pointed out that Frisch & Simonsen’s findings supported the acetaminophen hypothesis (Bauer, 2015). She pointed to a 1994 study finding that acetaminophen was effective in providing pain relief for newly circumcised infants and that in 1999 the American Academy of Pediatrics introduced guidelines for analgesia for circumcised infants. These guidelines included the use of acetaminophen. This offers an explanation for why the older boys in Frisch & Simonsen’s study (i.e., boys born before the introduction of the guidelines in 1999) showed only a weak association of circumcision with autism, but the younger ones (born after the 1999 guidelines were introduced and therefore likely to have been given acetaminophen) showed a stronger association.

Bauer noted that diagnoses of ASD have risen in recent years, particularly since the 1980s, but did not add that circumcision rates have declined (at least in developed countries), focussing instead on the introduction of acetaminophen. Nevertheless, this is an important point that further undermines Frisch & Simonsen’s hypothesis.

Other critics joined in. Ava Neyer, a primatologist with an autistic son, and who is used to fringe claims relating to the condition, understandably took an interest. Also, being opposed to infant circumcision herself (her boys were left “intact”) she can hardly be accused of bias. Yet she too was “suspicious” of Frisch & Simonsen’s work, and cautioned, “One study is not enough to state that circumcision can double the risk of autism, especially a flawed study like this. Science is a process, not a set of beliefs” (Neyer, 2015).

More significantly, Carsten Obel, Professor of General Child Health at Aarhus University, and who performs research into children’s mental disorders, commented in an article by journalist Kristian Sjøgren, “The jumping point here is causality. I would think that there could easily be another explanation for the connection that the study finds”. Obel said that the research needed to be repeated in other countries before one could be sure if the findings were true or not.

Criticism also came from Denmark’s National Autism Association, as reported by Sjøgren (2015). That organization said the study “does not in any way prove that there is a real causal link between circumcision and autism. The knowledge autism researchers today have unequivocally points to the fact that autism is a lifelong and congenital disability that is genetically conditioned and thus not a condition that can develop after birth.”

They continued, “Autism is one of the neurological research areas where you really lack many answers. Therefore, unfortunately, we meet professionals who believe they have solved the mystery of autism because they call autism together with their special interest in another research field for attention. It is clear that the new study is made by researchers who do not specialize in autism.”

Well said!

References
Bauer, A.Z., Kriebel, D. (2013) Prenatal and perinatal analgesic exposure and autism: an ecological link. Environmental Health, 12: 41, on-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3673819/

Bauer, A.Z. (2015) Comment. PubMed Commons. On-line: https://www.ncbi.nlm.nih.gov/pubmed/25573114 (scroll to bottom).

Frisch, M., Simonsen, A. (2015a) Ritual circumcision and risk of autism spectrum disorder in 0- to 9-year-old boys: national cohort study in Denmark. J. Roy. Soc. Med., 108(7), 266-79.

Frisch, M., Simonsen, A. (2015b) Circumcision-autism link needs thorough evaluation: Response to Morris and Wiswell. J. Roy. Soc. Med., 108(8), 297-8.

Morris, B.J., Wiswell, T.E. (2015) “Circumcision pain” unlikely to cause autism. J. Roy. Soc. Med., 108(8), 297.

Neyer, A. (2015) The problem with articles on autism risks and how to evaluate studies. Or why circumcision is unlikely to increase rates of autism. Blog post: https://chimericalcapuchin.wordpress.com/2015/01/10/the-problem-with-articles-on-autism-risks-and-how-to-evaluate-studies/

Sjøgren, K. (2015) [Researchers find link between autism and circumcision] videnskab.dk [science.dk]. On-line article: https://videnskab.dk/krop-sundhed/forskere-finder-sammenhaeng-mellem-autisme-og-omskaering [in Danish].

 

117 babies die each year from circumcision in the U.S.A.

This has become one of the most successful intactivist memes, judging by how frequently it and variants (“over 100 deaths a year”) are copied across the Internet. But, as with other “intactofacts”, it has no scientific basis.

It originated with an article by intactivist Dan Bollinger (2010). He assumed that the disparity in infant mortality rates (slightly higher for boys) was due to circumcision (boys get circumcised, girls don’t). On the basis of infant mortality and annual birth rate for each sex he calculated that approximately 117 more baby boys than girls die each year in the U.S. He then leapt to the unwarranted conclusion that these 117 extra deaths were from complications following circumcision.

Unfortunately for Bollinger, the assumption on which he based his argument is unfounded. As was later pointed out (Morris et al., 2012) the same disparity is seen in other countries where male circumcision is not practiced (in fact it is even higher in non-circumcising Norway, and almost non-existent in circumcising Israel). So whatever causes it, it is not circumcision. In short, Bollinger’s argument is based on a false assumption, and so collapses entirely. It is even used on this site as an example of a false premise: http://circfacts.org/sloppy-logic/#slog15

A false premise was not the only problem with Bollinger’s paper. For an exposé of his other errors see: http://circumcisionnews.blogspot.co.uk/2010/05/fatally-flawed-bollingers-circumcision.html

In a variation of this theme, intactivists like to list individual cases of fatalities following circumcisions. But close examination of such cases shows that most have no relevance to medical circumcision in a clinical setting. Some were victims of ritual circumcisions by non-medical providers, others died of causes unrelated to circumcision, and some were from long ago (even 19th century!), when medical care was not as good as it is today. Many were older males falling victim to unhygienic and dangerous tribal circumcision rituals in Africa, crudely conducted by a shaman with a razor blade, spear tip or other sharp implement. To compare those cases to medical infant circumcision in a hospital is manifestly absurd, and is an exercise in “barrel-scraping” as intactivists desperately try to get the numbers of deaths up.

Such a list can be found here: http://www.cirp.org/library/death/ Even without investigating each case in detail, it is obvious from the ages, names and places that most are not medical circumcisions, and many involve youths and young men who were victims of dangerous African tribal rituals in which circumcision was performed by non-medical providers. Even where a case seems to be hospital related, it may not be. For example, Callis Osaghae is listed as dying in a hospital in Ireland in 2003. An uninformed reader, lacking time to follow up the source, might think this was therefore a medical circumcision that went wrong. No, it was not. Callis was circumcised by a non-licensed, non-medical practitioner with a razor blade at home, and he then bled to death. Goodluck Caubergs bled to death in 2010. But the intactivists don’t reveal that he was a victim of a midwife, untrained in surgery, and armed with a pair of scissors. She was subsequently jailed. Brayden Tyler Frazier, bled to death in Sacramento in 2013. But the intactivists don’t say he had haemophilia. And so on, and on, with misleading example after misleading example.

To examine every tragedy cited would be excessively time-consuming, but the folks at Circumcision Choice have already done this with a similar list. It turned out that nearly all the cases cited were NOT of newborns circumcised in medical settings in the U.S. To see their findings, go to the Circumcision Choice Facebook page and search the posts for “babies died”.

So how many infants do die as a result of complications from medical circumcisions in the U.S? It is such a vanishingly rare event that accurate data is hard to come by. Looking at the records of 136,086 boys born in U.S. Army hospitals from 1980 to 1985, 100,157 were circumcised, with 193 complications, few of them serious, and no deaths. There were 20 urinary tract infections (UTIs). In contrast, amongst the remaining 35,929 non-circumcised infants, there were 88 UTIs leading to two deaths (Wiswell & Geshke, 1989). (Circumcision, it should be noted, is highly protective against infant UTIs.) Expanding their search to the records of over 300,000 boys born in U.S. Army hospitals between 1970 and 1986 they still found no records of fatalities from circumcision, nor any in 650,000 boys circumcised in Texas from 1971to 1987. They could “find evidence for no more than two to three deaths per year that can be attributed to the procedure among the more than 1,200,000 boys that are circumcised.” The implication from their review is that an infant boy is more likely to die from a UTI that could most likely have been prevented by circumcision, than from a complication of circumcision. As bacteria responsible for UTIs are fast becoming antibiotic resistant, this situation will not improve. In short, infant circumcision may actually save more lives than it costs.

Instead of fixating on foreskins and peddling bogus statistics, perhaps intactivists should direct their energies instead at addressing the 11,300 babies that die within 24 hours of birth each year in the U.S. due largely to high teen pregnancy rates, poverty and lack of prenatal care, not circumcision: http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/SOWM-FULL-REPORT_2013.PDF

References

Bollinger, D. (2010) Lost boys: An estimate of U.S. circumcision-related infant deaths. J. Boyhood Studies, 4(1), 78-90.

Morris, B.J., Bailey, R.C., Klausner, J.D., Leibowitz, A., Wamai, R.G., Waskett, J.H., Banerjee, J., Halperin, D.T. Zoloth, J., Weiss, H.A., Hankins, C.A. (2012) A critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries. AIDS Care, 24(12), 1565-75.

Wiswell, T.E. Geshke, D.W. (1989) Risks from circumcision during the first month of life compared to those for uncircumcised boys. Pediatrics, 83(6), 1011-5.