News in depth: The details behind the headlines

News in brief is useful, but sometimes you want to know more. This page will contain the details and background information that brief news reports have to leave out.

OECD figures show USA doing badly on child health

The following figures from the recent OECD publication, Doing Better for Children, shows that the USA, despite spending more on health than anywhere else, is not doing well at all.

Infant mortality – deaths per 1000 live births

OECD average: 5.4;  USA: 6.8

This might not seem so bad, except that the only countries scoring worse than the USA were the Slovak Republic on 7.2 and Mexico and Turkey off the scale at 18.8 and 23.6 respectively.

Low birth weight – % of children born less than 2.5 kg

OECD average: 6.6;  USA: 8.1

Breast-feeding - % of children breast-fed at some point during infancy

OECD average: 86;  USA: 74

Vaccination for pertussis (whooping cough) – % vaccinated

OECD average: 93.8;  USA: 85.7

When it comes to vaccination for measles, however, the USA is right on the OECD average of 91.5 per cent.

Child mortality – deaths per 100,000, males 0-19 years

OECD average: 66;  USA: 83

This is significantly higher than the average, and what makes it more telling is that the only countries that scored worse were Britain (91), Portugal (102), Belgium (103) and Mexico (121).

Teen pregnancy – births per 1000 women, 15-19 years

When it comes to teenagers giving birth, the USA is right off the scale, with an incidence exceeded only by Mexico.

OECD average: 15.5

Four countries scored higher than this: Britain with 24.8; Turkey with 39.7; USA with  49.8; and Mexico with 65.8.

Source: OECD, Doing Better for Children (September 2009)

Significance of these figures

The significance of these figures is that they are a bucket of cold water on the idea that circumcision improves child health. The only OECD countries that practise widespread circumcision of infants or young children are the United States and Turkey. In the USA between 50 and 60 per cent of male infants are circumcised, and in Turkey (largely Muslim) the practise of circumcising boys between the ages of six to eight is nearly universal. As a result of American influence, circumcision is also common in South Korea, but there it is usually done on boys around the age of twelve.

If circumcision was, as its promoters insist, an advantage or benefit to children that made them more healthy than those not circumcised, you would expect that countries with the most circumcision would have the healthiest children. These figures tell a different tale. Poor health outcomes in Turkey and Mexico can be explained by underdevelopment and poverty, but is a surprise to see the richest and most powerful country in the world pretty much on a level with them. It is obvious that the high level of circumcision in the United States is not making children healthier; indeed, on these figures, American children are significantly less healthy than their uncircumcised counterparts in Europe.

The countries that score best on all these indicators are the European nations, plus Japan, Australia and New Zealand, where circumcision is unknown or rare.

You could not go so far as to argue from these figures that lack of circumcision improved child health outcomes, but they are convincing (or as the circumcision promoters like to say, “compelling”) evidence that circumcision does nothing to improve child health. The huge sums wasted altering baby boys’ penises would be better spent on raising the incidence of breast-feeding and educating mothers in basic child-care.

The high rate of teen pregnancy is probably a consequence of the refusal of American religious conservatives to provide teenagers with appropriate sex education, and especially of the Bush presidency’s determination to push so-called “abstinence education” in its place. These programs have been the subject of a rigorous evaluation by Mathematica Policy Research, which found no difference in sexual behaviour, STD acquisition or condom use between those who had done the course and a control group who had missed out, and only a small difference in sexual knowledge. (The control group knew a bit more.) There was one small difference between the two groups: very slightly more of those who had done the course had enjoyed four or more sexual partners in the period following their training. (They had evidently learned something.)

Source:  Christopher Trenholm et al, Impacts of four Title V, Section 510 Abstinence Education Programs, Final Report (Mathematica Policy Research, April 2007)

Circumcision does not reduce adult STD rates

There is also evidence that circumcision does nothing to lower the incidence of sexually transmitted infections among sexually active teenagers and adults.

In a study of the world’s eighteen major democracies focused on the connection between religious belief or non-belief and sexual health, Gregory Paul found that the more secular societies tended to have lower rates of murder, suicide, STDs, abortion and teen pregnancy than the more religious, and that among the developed nations the United States was remarkable in boasting the highest incidence both of these problems and of religious fervour. Although the late twentieth century STD epidemic has been curtailed in all prosperous democracies, he writes, rates of adolescent gonorrhoea infection remain six to three hundred times higher in the United States than in the secular democracies of Europe and Japan. The U.S.A. also experiences uniquely high adolescent and adult syphilis infection rates, while in strongly secular Scandinavia the two main curable STDs have been almost eliminated. “Increasing adolescent abortion rates show a positive correlation with increasing belief and worship of a creator, and a negative correlation with increasing non-theism and acceptance of evolution; again rates are uniquely high in the U.S.” [1]

It will be observed that Paul’s findings also provide evidence that in developed countries less circumcision means less venereal disease. The European countries with low rates of STD infection discussed above are precisely those which do not practise circumcision, a fact which throws serious doubt on the proposition that it provides meaningful protection in the sexual minefield. Indeed, a writer in the South African Medical Journal has commented that “the social experiment of circumcision to prevent STDs, including HIV, has already failed in the USA, which has the highest rate of non-therapeutic infant circumcision in industrialised countries and the highest rate of HIV in the  developed world.” [2]

1.  Gregory S. Paul, Cross-national correlations of quantifiable societal health with popular religiosity and secularism in the prosperous democracies, Journal of Religion and Society, Vol. 7, 2005.

2.  D. Sidler, J. Smith, H. Rode, Neonatal circumcision does not reduce HIV/AIDS infection rates; A. and J. Myers, Editorial: Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable, both in South African Medical Journal, Vol. 98, No. 10, October 2008.

Vaccine against HIV shows promise

A medical trial in Thailand has raised hopes of a major breakthrough in the fight against Aids after scientists said an experimental vaccine had reduced the risk of HIV infection by a third. The world's largest HIV/AIDS vaccine trial of more than 16,000 volunteers was the first in which infection has been prevented, according to the US army, which sponsored the trial with the National Institute of Allergy and Infectious Diseases.

A combination of two vaccines was tested on HIV-negative Thai men and women aged 18 to 30 at average risk of becoming infected. All the volunteers were given counselling and condoms to help them avoid HIV. Then half were randomly picked to receive the vaccine, while the other half got dummy shots. Until the trial ended, nobody knew who had been given the genuine vaccine and who had not.

A relatively small number of people became infected with HIV – 51 of the 8,197 people given the vaccine, and 74 of the 8,198 who received dummy shots – but the difference was statistically significant, which means scientists believe it could not have happened by chance. It worked out at a 31% lower risk of infection for the vaccine group. Colonel Jerome Kim, who helped to lead the $105m (£64m) study for the US army, said it was "the first evidence that we could have a safe and effective preventive vaccine".

Recent failures had led many scientists to believe that such a vaccine might not be achievable. In 2007, the drug company Merck abandoned what had looked at the time like the most promising avenue of research after disappointing trial results. Today the National Institute's director, Dr Anthony Fauci, warned it was "not the end of the road", but said he was surprised and very pleased by the outcome. "It gives me cautious optimism about the possibility of improving this result," he said. "This is something that we can do." Every day, 7,000 people worldwide are newly infected with HIV; 2 million died of AIDS in 2007, the UN agency UNAIDS estimates. The AIDS Vaccine Advocacy Coalition, an international group that has worked towards developing a vaccine, welcomed the results of the trial – the third major study since 1983, when HIV was identified as the cause of AIDS – as "a historic milestone". The executive director, Mitchell Warren, said: "There is little doubt that this finding will energise and redirect the AIDS vaccine field."

Frances Gotch, professor of immunology at Imperial College London, said the results appeared to be statistically significant and may have been the effect of the two different vaccines working in tandem to more powerful effect. "The fact that they have seen a response with people with such a low incidence of infection is impressive," Gotch, who is also the principal investigator for the International AIDS Vaccine Initiative, told the Guardian. "Of course it's not 100% of people [protected] but 31% could make an enormous difference in the world. I think this is something we can work with."

Thailand's ministry of public health conducted the study, which used strains of HIV common in Thailand. Scientists stressed it was not known whether such a vaccine would work against other strains elsewhere in the world. The study was done in Thailand because US army scientists carried out pivotal research in that country when the AIDS epidemic emerged there, isolating virus strains and providing genetic information on them to vaccine makers.

The study tested a two-vaccine combination in a "prime-boost" approach, where the first one primes the immune system to attack the HIV virus, and the second one strengthens the response. Alvac uses canarypox, a bird virus, altered so it can't cause human disease, to ferry synthetic versions of three HIV genes into the body. AIDSVax contains a genetically engineered version of a protein on HIV's surface. It is unclear whether vaccine makers will seek to license the two-vaccine combination in Thailand. Before the trial began, the US Food and Drug Administration said other studies would be needed before the vaccine could be considered for US licensing. The full results of the trial will be presented at an international AIDS vaccine conference in Paris in October.

The executive director of the Global HIV Vaccine Enterprise, an alliance of research bodies and funders like the Gates Foundation, said the results showed a vaccine was an achievable goal. "This is a historic day in the 26-year quest to develop an AIDS vaccine," said Dr Alan Bernstein. "This trial is the first demonstration in humans that, with more research, it will be possible to develop a vaccine that is fully protective against HIV."

Deborah Jack, chief executive of the National AIDS Trust in the UK, said a vaccine, by far the most effective way of tackling serious infectious diseases, was desperately needed.. More work was needed, but the promising findings "justify the continuing investments and efforts of the international community, including the UK government, to develop a vaccine." The Terrence Higgins Trust said it was treating the results with "cautious optimism". "This is the first step on a very long road," said the policy manager, Vicky Sheard. "There's a lot of research needed into how a vaccine can be rolled out, how costly it's going to be, whether it's going to be effective against different strains."

HIV breakthrough as scientists discover new vaccine to prevent infection
First evidence of possible vaccine as US military-backed medical trial in Thailand cuts HIV infection rate by a third

by Sarah Boseley and Haroon Siddique
Guardian (UK), 24 September 2009

Comment

It will be noted that this is a far more scientifically sound clinical trial than the African circumcision experiments.

• The number of subjects involved is much greater: one and half times more than the three African trials put together.
• The trials went on for much longer: three years versus 20 months.
• It was  genuine random trial in that the participants did not know who was given the vaccine and who was not. This means that differing behaviours between the two groups cannot have influenced the result.
• All participants were given the same counselling, unlike the African experiments, where only those who agreed to get circumcised were given counselling on safe sex and provided with condoms.
• Since a vaccine will equally protect men from infection by women, women from men, men from men, children from mothers, and anyone from IV infection, whether medical, pseudo-medical ("needle men") or recreational drug use, the degree of protection stands for much more than the circumcision trials' much touted "60%" protection of men from infection by women only.

On top of all this, compare the tone of cautious optimism here with the overheated fanfares in praise of circumcision that greeted the results of the African experiments. The vaccine trials represent the true scientific spirit, consistent with a remark by Charles Darwin that "caution is almost the soul of science".* For all their scientific pretensions, that is not the spirit that animates the circumcision promoters.

*  Letter to Anton Dohrn, 4 January 1870, quoted in Janet Browne, Charles Darwin: The Power of Place, p. 393

More circumcision death and injury in United States

$429,000 awarded for circumcision disfigurement

In August a Californian jury awarded $429,484 to an infant whose penis was disfigured for life by surgery. On Nov. 12, 2006, Evan Tank was circumcised by pediatrician Ralph Berberich, who accidentally cut the tip of Evan’s penis. Plaintiff’s counsel claimed that Berberich failed to remove adhesions tethering the foreskin to the glans, causing the glans to be pulled into the clamp along with the foreskin. Hence the glans was cut off along with the foreskin. Berberich countered that penis trauma is a recognized complication of the procedure and that Evan’s parents had accepted the risk The doctor argued that, rather than an error on his part, Evan probably had an unusual penile anatomy that caused his penis to be pulled into the clamp.

Source: Recorder (San Francisco) August 12, 2009

Interesting that the operator tried to blame the infant’s anatomy rather than admitting negligence in his own technique. The fact is that all penises are different; if surgeons are going to muck around with them, they ought to examine each one carefully before they charge in. It's also interesting that the operator tried to defend himself by admitting that (additional) damage to the penis was so common as to be "a recognised complication of the procedure". A bit like Russian roulette.

Parents sue over baby’s death after circumcision

The parents of a 6-week-old boy who bled to death after a circumcision at Rosebud’s Indian Health Service Hospital last year are suing the government for wrongful death. According to documents filed Wednesday in federal court, Eric Keefe underwent a circumcision on June 13, 2008. His mother gave him Motrin and Tylenol for pain and he suffered massive blood loss at home that night, dying at the hospital the next morning. His parents, Forrest and Mary Keefe of Wood, say Dr. Douglas Lehmann failed to inform them of the type of pain medication they should have used. The Keefes are seeking $2 million for personal injury and wrongful death. Sturgis lawyer Mick Strain, who represents the plaintiffs, said he and the parents wouldn’t talk about the case until it is tried or settled. The file lists no attorney for the government.

Source: Argus Leader [South Dakota], September 18, 2009

$2.3 million awarded for botched circumcision

A Fulton County jury (Georgia, U.S.A.) has awarded $1.8 million in damages to a boy whose penis was severed in a botched circumcision. The state court jury gave another $500,000 to the boy’s mother in the decision rendered Friday. The case involves a child, identified only as D.P. Jr., who was born at South Fulton Medical Center in 2004. In a suit filed two years later, his mother contended that the doctor who circumcised him removed too much tissue and that his pediatrician failed to respond when a nurse complained of excessive bleeding. The tip of the penis was placed in a biohazard bag and might have been reattached if a urologist had attended to the boy within eight hours, one of the mother’s lawyers, David J. Llewellyn of Atlanta [and ARC] said.

The jury found that both the pediatrician, Dr. Cheryl Kendall, and the physician who performed the circumcision, Dr. Haiba Sonyika, were negligent. South Fulton Medical Center was absolved of liability. The pediatrician’s lawyer, Roger Harris, said he disagreed that the jury’s decision indicated that Dr. Kendall was negligent because she didn’t go to the hospital. He hinted at an appeal. “We believe there was error committed during the course of the trial,” he said. Dr. Sonyika’s lawyer could not be reached for comment.

Llewellyn said the money awarded by the jury is to cover the cost of medical treatments and psychiatric counseling for the boy and his family. The jury did not award punitive damages. The Atlanta Journal-Constitution is not naming the mother to avoid identifying the child. “This case does point out one of the dangers of circumcision that every parent must seriously consider when having the procedure done,” Llewellyn said. He contended that parents are not told of the risks of the procedure.

Source: Atlanta Journal-Constitution, Monday, March 30, 2009

Claim for circumcision damage in Chicago

A Northwestern Memorial Hospital obstetrician is being sued for allegedly botching a circumcision of a 1-day-old baby and cutting off a portion of the infant's penis, according to WBBM-AM 780. The suit, filed Tuesday in Cook County Circuit Court by David Burden on behalf of his son Daniel Burden, claims that on Oct. 5, 2007, one day after Daniel was born, Dr. Marc Feldstein performed a circumcision on the boy. However, rather than removing only the foreskin, the doctor cut and removed a portion of the baby's penis, the suit said. After the procedure, baby Daniel was transferred to Children's Memorial Hospital to have emergency corrective surgery. Burden accuses Dr. Feldstein, Northwestern Women's Health Associates and Northwestern Memorial Hospital of medical negligence. The suit asks for more than $50,000.

Chicago Breaking News Centre, 15 April 2009

A fifth of African HIV infections caused by medical procedures

New research confirms earlier claims that up to one in five HIV cases in Africa are infected during medical and surgical procedures by medical staff using dirty needles and non-sterile clinical equipment.

Dr Potterat said that “The studies now show directly that many Africans are at risk from a wide range of common skin puncturing practices that may involve contaminated instruments and materials. By uncritically accepting the orthodox view that HIV is almost exclusively transmitted by sex, public health workers and researchers are complicit in prolonging avoidable suffering.” He and 11 other scientists have published a series of papers in the International Journal of STD and AIDS, to coincide with World Aids Day on 1 December (Vol. 20, No. 12, December 2009).

In one of the studies, patients at the University of Calabar Teaching Hospital in south eastern Nigeria who contracted HIV were significantly more likely to have had blood tests, vaccinations, blood transfusions or surgical procedures. Half of the patients who received tetanus vaccinations reported seeing needles being reused.

Another study in the journal, published by the British Association of Sexual Health and HIV, an affiliate organisation of the Royal Society of Medicine, looked at rates of HIV infection among children in Swaziland. HIV infections there are the highest in the world at 26 per cent of the adult population, reducing the country’s average life expectancy to 32 years. Using data from the Swaziland Demographic and Health Survey, the authors found that one in five Swazi children aged two to 12 who are infected with the virus have HIV-negative mothers.

These children had experienced many more medical injections and vaccinations than their uninfected brothers or sisters. Most of these related to anti-malaria health programmes. Africans are subject to a much higher proportion of injections and blood tests than patients in the West, according to a 1999 study for the World Health Organisation. That research found that a wide range of common symptoms such as colds, ear infections, fatigue and tonsillitis were treated with injections rather than oral medication. The study concluded that at least 50 per cent of these were unsafe, with needles being used repeatedly on one patient after another, without sterilisation.

“HIV priorities have been and continue to be misplaced,” said Stuart Brody, a professor at the University of the West of Scotland, in Paisley, who has researched the spread of HIV in Kenya through tetanus vaccinations. “The mindset is to pretend this is not an issue, perhaps because of the received wisdom or because you don’t get funding if you question it, but this does not save lives.”

But Dr Anna Thomas, head of economic and social development at ActionAid Kenya, said: “The use of unsterilised needles is one of the many issues affecting HIV/AIDS in Africa. “But the vast majority of the spread of HIV/AIDS is down to unsafe sex between men and women and that is where we need to continue to focus our efforts.”

CIA comment: If is true that 20 per cent of HIV infections are caused by unsafe medical and surgical practices (such as circumcision?) this “vast majority” cannot be more than 80 per cent of cases.

One in five HIV infections caused by medical staff
by William Payne and Mike Pflanz,  Telegraph (London), 17 November 2009

Australian study finds insignificant benefit from circumcision

Safety and Efficacy of Nontherapeutic Male Circumcision: A Systematic Review
Caryn L. Perera, BA, Grad Cert EBP, Franklin H. G. Bridgewater, MBBS, FRACS, Prema Thavaneswaran, BSc (Hons), PhD and Guy J. Maddern, PhD, FRACS

Annals of Family Medicine
Volume 8, Issue 1, January/February 2010

ABSTRACT

PURPOSE:  We wanted to assess the safety and efficacy of nontherapeutic male circumcision through a systematic review of the literature.

METHODS:  We systematically searched The York Centre for Reviews and Disseminations, Cochrane Library, PubMed, and EMBASE databases for randomized controlled trials published between January 1997 and August 2008. Studies reporting on circumcision in an operative setting in males of any age with no contraindications to or medical indications for circumcision were eligible for inclusion. The main comparator was intact genitalia. From 73 retrieved studies, 8 randomized controlled trials were ultimately included for analysis.

RESULTS:  Severe complications were uncommon. Analgesia/anesthesia during circumcision was promoted. The prevalence of self-reported genital ulcers was significantly lower in circumcised men than uncircumcised men (3.1% vs 5.8%; prevalence risk ratio 0.53; 95% confidence interval [CI], 0.43–0.64; P<.001). Circumcised sub-Saharan African men were at significantly lower risk of acquiring human immunodeficiency virus/acquired immune deficiency syndrome than were uncircumcised men (random effects odds ratio = 0.44, 95% CI, 0.32–0.59; P <.001). The evidence suggests that adult circumcision does not affect sexual satisfaction and function.

CONCLUSIONS:  Strong evidence suggests circumcision can prevent human immunodeficiency virus/acquired immune deficiency syndrome acquisition in sub-Saharan African men. These findings remain uncertain in men residing in other countries. The role of adult non-therapeutic male circumcision in preventing sexually transmitted infections, urinary tract infections, and penile cancer remains unclear. Current evidence fails to recommend widespread neonatal circumcision for these purposes.

Research Recommendation

Although approximately 30% of the global male population is circumcised, there is a paucity of high-quality evidence. Depending on the indication under investigation, prospective RCTs and case-control studies should be conducted to strengthen the evidence base and allow more informed conclusions on nontherapeutic male circumcision to be drawn.

Although the evidence for the efficacy of adult nontherapeutic male circumcision in preventing HIV/AIDS acquisition in sub-Saharan African men is strong, it is unclear whether these findings can be extrapolated to male populations in other countries. The role of adult nontherapeutic male circumcision in preventing sexually transmitted infection, urinary tract infection, and penile cancer is less clear, whereas the role of neonatal circumcision in preventing HIV/AIDS, sexually transmitted infection, urinary tract infection, and penile cancer is not presently supported by RCT evidence.

Patients who request circumcision in the belief that it bestows clinical benefits must be made aware of the lack of consensus and robust evidence, as well as the potential medical and psychosocial harms of the procedure. As the efficacy of prophylactic nontherapeutic male circumcision has not been comprehensively studied in neonates, it would be inappropriate to recommend widespread neonatal circumcision for this purpose.

Full text of the article may be read at Annals of Family Medicine

Comment

This level-headed article comes as a welcome breath of fresh air, and confirms the policy of the Royal Australasian College of Physicians to discourage medically unnecessary circumcision of minors. The bottom line is that (routine) preventive circumcision of minors offers no significant health benefit, carries significant risks, has an adverse effect on sexual sensation, and should not be performed.

There are two points that might be questioned.

First, the estimate of 30 per cent of men world-wide circumcised seems too high. Even allowing that most Muslims are circumcised (and there are probably many who are not), and that circumcision is common among tribal societies in Africa, it does not seem likely that the total could be much more than 25 per cent – though of course, fuelled by American dollars and those Microsoft millions, the World Health Organisation is certainly doing its best to make Africa foreskin-free. In fact, circumcision is rapidly becoming a practice confined to the underdeveloped world, where people who do not know any better have no choice but to obey those white witchdoctors.

Second, to conclude that “the evidence suggests that adult circumcision does not affect sexual satisfaction and function” suggests that the search for evidence has not been as thorough as it might have been. It is highly likely that circumcision in adulthood has a far less severe effect on sexual function and genital sensation than if it is done in infancy or childhood (for which reason maturity is a much better time to do it, if it must be done), but there are plenty of men, circumcised as adults, who report a significant loss of sexual feeling, and who bitterly regret their decision.

Further information on this site

Female genital mutilation happening in Australia

by Emily Bourke for AM

Health authorities in Australia say they are concerned about the growing number of women who have undergone some form of genital mutilation. Female circumcision is illegal in Australia, but experts say there is evidence that it is being practised here. More and more migrant women are also seeking help after having the procedure in their home countries.

Across Africa, the Middle East and parts of Asia, female genital mutilation is practised on about three million girls and women each year. The centuries-old custom has been outlawed in Australia since the 1990s. But that has not stopped it happening here, according to Dr Ted Weaver from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. "There is some evidence to suggest that it does happen in certain parts of Australia," he said. "It's hard to gauge the actual numbers because it's prohibited by legislation and it's something that is performed in an underground way. "But certainly there have been reports of children being taken to hospital after having the procedure done with complications from that procedure."

Melbourne's Royal Women's Hospital says it is seeing between 600 and 700 women each year who have experienced it in some form.
Somali-born Zeinab Mohamud, from the hospital's Family and Reproductive Rights Education Program, says much of her work involves untangling some outdated cultural traditions and religious misconceptions. "Some questions that we ask the women is 'why were you doing it?' and they will tell you, 'because of my religion'," she said. "We bring imams or priests to convince them that there is nothing from both books that says you have to do circumcision to girls. So why are you doing it?"

Ms Mohamud is optimistic the practice will end, but she fears migrant communities or individual women will be demonised. "Some people when they hear they say, 'how can that happen?' It's when something is cultural and the people have been doing it for so long, it's not easy to either eliminate it or to say, 'you have got a bad culture'," she said. "You have to work with them, listen to them. You have to know where they are coming from in order to help them."

Dr Ted Weaver agrees and he says ordering people against the practice would be inappropriate. "If we try and dictate and pontificate about this and not provide culturally appropriate care, we'll further disenfranchise those women," he said. "Any progress will be incremental. I don't think that it's something that will stop overnight. "But I think all we can do is advocate against it, speak out, try to educate women, try to empower women, certainly in this country, and we should do our best for international organisations that are also espousing the same message."

Posted Sat Feb 6, 2010 11:15am AEDT

Comment

The ABC's report was in recognition of the United Nations' declaration of 6 February as International Day Against Female Genital Mutilation, but the UN's position has been condemned as sexist, misandrist (men-hating) and hypocritical by the International Coalition for Genital Integrity, which asks why the UN is concerned only with women and ignores the much larger number of boys and young men who are forced to submit to various forms of genital cutting. ICGI writes:

The United Nations says that female circumcision is now widely recognized as a violation of human rights. And so, the UN has declared February 6th as the “International Day Against FEMALE Genital Mutilation.” Instead, it should be declaring an “International Day Against HUMAN Genital Mutilation.” We say the UN is sexist and misandrist. The UN is also hypocritical. In 1989 the UN issued its Convention on the Rights of the Child, which “proclaimed and agreed that everyone is entitled to all the rights and freedoms set forth therein, without distinction of any kind, such as … sex.” Ironically, by declaring an International Day Against Female Genital Mutilation, the UN has also circumcised their Convention on the Rights of the Child.

The World Health Organization says female circumcision can cause severe bleeding, urinary and reproductive tract infections, and even death. All of these are also true for male circumcision.

If a small tattoo is mayhem, what is circumcision?

In Fresno, California, a father is facing the serious charge of mayhem for imposing a small tattoo on his 7-year-old son. Mayhem is an old offence, referring to any sort of serious maiming or mutilation of the body, and usually attracts a stiff sentence - as much as life imprisonment in California. But if a small mark on the skin, without cutting or loss of tissue, is mutilation, how would you describe the removal of the foreskin from the penis, and what sort of penalty should that attract when performed without need or consent on a minor?

A judge in Fresno, California (United States) recently raised the stakes in a case that has drawn widespread attention -- reinstating aggravated mayhem charges against two Bulldog gang members accused of inking a gang tattoo on a 7-year-old boy. Judge Gary Orozco's ruling means that the two men -- the boy's father and his friend -- could face life in prison rather than a maximum term of 16 years. The case also opens the door to a broader definition for child-abuse cases, according to the defense attorneys. Even Orozco acknowledged that the case raises the question of whether a parent ever has a right to subject children to potentially painful procedures such as getting pierced ears or being circumcised.

In court Friday, prosecutor William Lacy said Gonzalez held his son down against his will while Gorman inked a gang insignia on the boy's hip.
"He's crying and saying he didn't want it," said Lacy, who called the tattoo "a branding." Orozco agreed with Lacy's interpretation of the facts, saying the tattoo -- a quarter-size dog paw, which is a symbol of the Bulldog gang -- was painful to the child and left a permanent disfigurement on the boy's hip.

The ruling outraged Foster. He told Orozco that a mayhem charge should be reserved only for more serious cases. "It must be a cruel, savage and gory crime," he said. "A tattoo on a child, though a horrible decision, simply does not rise to mayhem." Foster's research showed that the mayhem charge evolved from the case of Lawrence Singleton, who raped a young runaway, chopped off her forearms with an ax and dumped her into a drainage culvert outside of Modesto to die. In other mayhem cases, a defendant was accused of putting out a cigarette on a victim's breasts or biting off the victim's ear. "It's absurd to compare a tattoo to these cases," Foster said. Attorney Manuel Nieto, who represents Gorman, said he also researched the issue and found that mayhem typically involves cases in which the defendant wants to punish or torture the victim.

Nieto said neither Gonzalez nor Gorman wanted to hurt the child or disfigure him. He said Gonzalez just wanted his son to have a tattoo like his father. Both Gorman and Gonzalez have several tattoos. Nieto likened Gonzalez's actions to a parent who has a daughter's ears pierced or a son circumcised. The child might not like the pain, but the parent has a right to do it, Nieto said.

Orozco said he doesn't know whether parents have a right to inflict pain on children against their will. Such acts, he said, could indeed be child abuse. Now it will be up to a jury to decide whether a tattoo constitutes mayhem.

Pablo Lopex, Charges reinstated in tattooing of boy, Fresno Bee (California), 29 January 2010

Earlier report, with photo of tiny tattoo

Circumcision increases risk of urethritis

Circumcision in Australia: Further evidence on its effects on sexual health and wellbeing
Jason A. Ferris, Juliet Richters, Marian K. Pitts, Julia M. Shelley, Judy M. Simpson, Richard Ryall, and Anthony M. A. Smith
Australian and New Zealand Journal of Public Health, Vol. 34 (2), April 2010, 160-64

OBJECTIVE: To report on the prevalence and demographic variation in circumcision in Australia and examine sexual health outcomes in comparison with earlier research.

METHODS: A representative household sample of 4,290 Australian men aged 16–64 years completed a computer-assisted telephone interview including questions on circumcision status, demographic variables, reported lifetime experience of selected sexually transmissible infections (STIs), experience of sexual difficulties in the previous 12 months, masturbation, and sexual practices at last heterosexual encounter.

RESULTS: More than half the men (58%) were circumcised. Circumcision was less common (33%) among men under 30 and more common (66%) among those born in Australia. After adjustment for age and number of partners, circumcision was unrelated to STI history except for non-specific urethritis (higher among circumcised men, OR=2.11, p<0.001) and penile candidiasis (lower among circumcised men, OR=0.49, p<0.001).

Circumcision was unrelated to any of the sexual difficulties we asked about (after adjusting for age) except that circumcised men were somewhat less likely to have worried during sex about whether their bodies looked unattractive (OR=0.77, p=0.04). No association between lack of circumcision and erection difficulties was detected. After correction for age, circumcised men were somewhat more likely to have masturbated alone in the previous 12 months (OR=1.20, p=0.02).

CONCLUSIONS: Circumcision appears to have minimal protective effects on sexual health in Australia.

Comment

One of the most interesting findings of the study is that circumcision nearly doubles a male’s risk of non-specific urethritis (NSU). This result is consistent with Jonathan Hutchinson’s notorious syphilis study of 1854, which showed (though this point was never mentioned by circumcision enthusiasts) that circumcised men had a higher risk of gonorrhoea. Since NSU is a urinary tract infection, the finding must also cast serious doubt on the claim that circumcision significantly reduces the risk of UTIs in male infants. A study published in the USA in 1987 also found that "lack of circumcision" did not increase the risk of gonoccocal urethritis, but that the foreskin had a protective effect against non-gonoccocal urethritis: Smith GL, Greenup R, Takafuji ET. Circumcision as a risk factor for urethritis in racial groups. Am J Public Health 1987;77:452-4.

What is striking is how differently the media report these sorts of studies, depending on whether the foreskin has been found pathogenic, neutral or beneficial. There has been no coverage of this article in the Australian media, nor of the recent study by Adelaide researchers in Annals of Family Medicine, both of which conclude that circumcision is either useless for health or even harmful. But recall the numerous screaming headlines over the past decade every time some study or other showed that "lack of circumcision” was somehow associated with vastly increased risk of STDs, cancer, AIDS and tutti quanti. Actually, the reports rarely put it as cooly as that: usually they leave the impression, if they do not explicitly allege, that the mere presence of the foreskin is enough in itself to generate all these terrible diseases. Even a report on the Ferris/Richters study in 6Minutes does not escape the anti-foreskin prejudice: its headline is “Circumcision benefits not seen in Australia”, but why not write "Circumcision can double risk of urethritis"? And don’t forget to check out the responses to Prof. Morris’s comment.

It's interesting to compare the Canadian media, where newspapers reported the Adelaide study at length, and regularly carry opinion pieces critical of circumcision. In Australia, however, it seems to be impossible for anybody to utter a word against circumcision without being "balanced" - i.e. running through an exhaustive list of the "benefits" before muttering half-heartedly about a few remote risks or trivial disadvantages. Is everybody here too intimidated by Professor Voldemort and his “scientific” death eaters? If nothing else, they certainly seem to have mastered the Imperius and Confundus curses.

Circumcision ineffective against AIDS in developed countries

VIENNA, Austria, July 22 – Adult circumcision has been proposed as a possible HIV prevention strategy for gay men, but a new study by the University of Pittsburgh Graduate School of Public Health presented at the XVIII International AIDS Conference suggests it would have a very small effect on reducing HIV incidence in the United States.

Circumcision is thought to reduce the risk of HIV transmission by removing cells in the foreskin that are most susceptible to infection by the virus. Clinical trials conducted in Africa have found it reduces the risk of HIV in heterosexual men, yet there is little evidence that it can reduce transmission among American gay men. The study was based on surveys of 521 gay and bisexual men in San Francisco. Findings indicated that 115 men (21 percent) were HIV-positive and 327 (63 percent) had been circumcised. Of the remaining 69 men (13 percent), only three (0.5 percent) said they would be willing to participate in a clinical trial of circumcision and HIV prevention, and only four (0.7 percent) were willing to get circumcised if it was proven safe and effective in preventing HIV.

The researchers extrapolated these findings to the entire gay and bisexual male population of San Francisco, an estimated 65,700 people, and determined that only 500 men would potentially benefit from circumcision. "Circumcision in the U.S. already is very common, making it applicable to a limited number of men as a potential HIV prevention strategy in adulthood,” said Chongyi Wei, Dr.P.H., study author and post-doctoral associate, Pitt's Graduate School of Public Health. “Our study indicates that any potential benefit may likely be too small to justify implementing circumcision programs as an intervention for HIV prevention.”

Circumcising gay men would have limited impact on preventing HIV
by EurekAlert

Melbourne doctor suspended after plastibell circumcision goes wrong

Melbourne, 12 November 2010: A Melbourne doctor has been suspended for inflicting severe injuries on a 2-year old boy during a “routine” circumcision operation. The boy was circumcised by Dr Mohammed Mateen Ui Jabbar, using the plastibell device on 29 January 2008, as a result of which he suffered gross swelling and severe scarring of his penis. The boy was unable to urinate after the operation and was taken to the Royal Children’s Hospital, where he required surgery to remove the plastibell device and six further operations on his penis, including plastic surgery.

Dr Jabbar's disciplinary hearing at the Victorian Civil and Administrative Tribunal was held on 11-12 October, and the determination issued on 5 November. The case was reported in the Melbourne Herald-Sun on 11 November; the full determination can be read at the Australasian Legal Information Institute (Austlii).

This was the fourth time that Dr Jabbar had been reprimanded by the Victorian Medical Board, despite which he has been permitted to continue practising until his 3-month suspension takes effect on 22 November 2010. On previous occasions the doctor had been reprimanded for improperly touching a woman’s breasts and for prescribing testosterone for a male client without medical need. During an examination in 2006, the woman had asked for a routine skin inspection, but instead Dr Jabbar had squeezed her breasts and told her she needed cosmetic surgery because they were sagging but could be corrected with a breast lift or implants. On this occasion Dr Jabbar was reprimanded by the Medical Board and ordered to undergo counselling sessions.

The fate of the boy is similar to a case in Canada, where a baby boy died after circumcision with the plastibell device, which strangled his penis and blocked the urine passage.

The plastibell device is the most common method of circumcision used in Australia today. It consists of a kind of tourniquet that is tightened around the penis, thus strangling the foreskin, cutting of the blood supply and causing the tissue to die and fall off. It is similar to the rubber ring devices commonly used on farms to castrate calves and lambs. Some circumcision providers call this a bloodless or non-surgical method, but the truth is that any removal of tissue is surgery and will involve blood if the foreskin needs to be cut in order to apply the device. In another Canadian case a baby bled to death after a routine circumcision using the plastibell.

Complications from plastibell circumcision operations are quite common.

Sex discrimination – against boys

It is instructive to compare the mild censure given to Dr Jabbar with the criminal charges brought against Dr Graham Reeves, the “butcher of Bega”, for mutilating operations on women. At his trial in Sydney Dr Reeves attempted to defend his actions – involving the surgical removal of all or part of the external genitals of his female patients – by claiming that he was only doing it to save their lives. We might call this the circumcisers’ defence, since advocates of male circumcision likewise claim that they only circumcise boys in order to save them from future health problems or death from the terrible diseases they are sure to pick up if their foreskin is allowed to survive. It would appear that while doctors who harm women can end up on criminal charges, the most a doctor who harms boys can fear is a gentle slap on the wrist. One wonders how many other boys have suffered disfiguring injuries at the hands of Dr Jabbar.

Disciplinary action against medical practitioners

In 2010 State medical boards were replaced by a Commonwealth body, the Australian Health Practitioner Regulation Agency. Details of charges of misconduct brought against medical practitioners can be searched on its website.

Another reason not to circumcise: Australia faces big MRSA problem

THE growing incidence of methicillin-resistant Staphylococcus aureus (MRSA) in the community has highlighted the need for Australian clinical practice guidelines to be developed for its treatment, experts say. Associate Professor Graeme Nimmo, State Director of Microbiology for Pathology Queensland and president of the Australian Society for Antimicrobials (ASA), said the steady increase in the prevalence of community MRSA was of national concern and all doctors and members of the community needed to be aware of it. He said it now accounted for 15-20% of all S. aureus infections in Australia and that rate was increasing. “The prevalence has been increasing steadily in the past decade,” he said.

Professor Nimmo, who is also chair of the Australian Group for Antimicrobial Resistance, said MRSA appeared to be under control in hospitals, thanks to infection control initiatives. “Hospital strains [of MRSA] are not on the increase; in fact, they seem to be decreasing, but they are being replaced by the community ones,” he said.

Professor Keryn Christiansen, a past president of both the ASA and the International Society for Infectious Diseases (ASID), said community MRSA was a major problem, particularly as it was infecting young, healthy people. It was extremely important for GPs to be aware of the big problem of community-acquired MRSA and to be able to recognise these infections, which were characterised by “a lot of pus”, she said. “I see people who come into hospital who require drainage and they have gone to their GP who has just put them on standard anti-Staph therapy that has no effect on MRSA,” Professor Christiansen, clinical microbiologist at PathWest Laboratory Medicine, Royal Perth Hospital, WA, said.

The number one treatment was drainage of boils and abscesses, followed by broad-spectrum antibiotic therapy, culture and testing, and a change of antibiotics if MRSA was found on culture and sensitivity testing. Strains of particular concern that were becoming more common in Australia produced a toxin called Panton‒Valentine leukocidin (PVL), which caused more severe disease with a lot of pus formation and abscesses and required drainage and a longer hospital stay, Professor Christiansen said. “[PVL-positive MRSA] is sweeping across Australia and now accounts for around 20% of our community MRSA in WA and the vast majority of community MRSA on the east coast,” she said. “The other major worrying side of this is that the PVL-positive clones are infecting young, healthy people … in their teens, 20s and 30s.”

Comment by A/Prof Michael Guinness

Our experience exactly. I work in country NSW, where CA-MRSA has gone from nil in 2000 to 27% of all S.aureus isolated in 2009. Of shared concern is the greatly increased number of otherwise healthy young patients who are now being hospitalised for surgical management. … We have had four deaths so far ... how many more do they need before becoming proactive?

Source: MJA Insight, Monday 17 January 2011

Comment: Doctors’ surgeries or specialist clinics where minor procedures such as circumcisions are performed are prime sites for the presence of MRSA, and pose a real risk of infection any time the skin is cut or punctures. This is yet another reason why unnecessary surgeries such as non-therapeutic circumcision should be avoided.

Guardian (UK): Time to ban male circumcision?

If passed, article 50 will ban genital cutting for boys under 18 in San Francisco, with profound religious implications for Jews and Muslims. But isn't it time to oppose all circumcision?

by Neil Howard and Rebecca Steinfeld

San Francisco voters will decide later this year whether, like its female counterpart, male infant circumcision should be outlawed. If passed, article 50 — the "Genital Cutting of Male Minors" — would make it unlawful to circumcise, cut, or mutilate the foreskin, testicles, or penis of another person aged under 18. The bill includes an exemption for cases of medical necessity, but not for custom or ritual, which has profound implications for the many Jews and Muslims who consider it an essential part of their religious or cultural practice. Unsurprisingly, the bill has attracted considerable controversy. Some regard it as a modern manifestation of western antisemitism, while certain feminist groups consider the idea of comparing male and female genital cutting to be both offensive and unsubstantiated.

Neither the World Health Organisation nor the UN oppose male circumcision, and given that the procedure is so unquestioned that 33% of American boys still undergo it, one might think that they have a point. But is it really so simple? And are the differences between male and female circumcision really so straightforward?

According to research, the sexual damage caused by female and male genital cutting can be extensive. Female genital cutting, which can involve removal of the clitoris, may reduce the likelihood of orgasm and cause complications during childbirth. Similarly, male circumcision can result in excruciating pain, nerve destruction, infection, disfigurement and sometimes death. Like the clitoris, the foreskin serves a sexual purpose, and it protects the "head" of the penis from outside elements.

Both male and female genital cutting can have profound psychological consequences. Circumcised women often experience trauma, stress and anxiety, and can have relationship problems. Some circumcised men describe feelings of loss, anger, distrust, and grief, while others have reported problems with subsequent intimacy, long-term post-traumatic stress disorder, and a sense of powerlessness. With female genital cutting, the desire to control female sexuality remains key: believed to reduce a woman's libido, the practice is said to help her resist "illicit" sexual acts, thus aiding the maintenance of premarital virginity and marital fidelity.

Male circumcision has similarly been associated with managing sexuality. Maimonedes, the great Jewish sage, believed it counteracted "excessive lust", while as a secular practice in the US, it was first promoted as a means of preventing "harmful" masturbation. Now, the discourse of cleanliness is crucial – and one frequently hears that "a cut man is a cleaner man".

In Judaism, male circumcision, carried out eight days after birth, is essential, according to religious law; male circumcision is also practised in Islam, though the necessity of female genital cutting is contested among Muslims.

Clearly, significant similarities exist between male and female genital cutting, and the question asked by those behind article 50 is: why the legal difference between boys and girls?

What about the health argument, that male circumcision is "cleaner" and prevents HIV transmission? There is a body of research that claims a correlation between circumcision and reduced transmission rates, and this is not to be taken lightly, since it represents the strongest case for male genital cutting – at least in AIDS-ravaged regions. But such research is heavily contested. A 2007 study by Dowsett and Couch asserted that insufficient evidence exists to believe that circumcision does reduce transmission, while Gregorio et al's later analysis cast doubt on correlations between circumcision and transmission of HIV and STI's more generally.

Wouldn't a mass information campaign represent better public health policy than widespread pre-emptive circumcision? If we favour removal of body parts to reduce risk of disease, why not remove breasts to prevent breast cancer? Or pull teeth, in the name of cleanliness, to ward off plaque? Though health and hygiene are important, less intrusive and equally successful means clearly exist to ensure them.

What about religious freedom? Certainly, the ability to freely practise one's religion remains a vital component of any liberal democracy. But should this trump an individual's right to their bodily integrity? And shouldn't such a principle be extended to all those who, by virtue of their age, are too young to decide on which body parts they would or would not like to keep?

Some may point to state overreach here, suggesting that a ban on child ear-piercing will be next. But it is the irreversibility of circumcision that invalidates such comparisons. Instead of dismissing article 50 as either antisemitic or anti-feminist, therefore, we suggest that it should perhaps be considered as no more than the consistent application of legal principles to both sexes.

Article 3 of the European Convention on Human Rights outlaws the kind of "harm" that circumcision can cause; article 14 forbids the discrimination that prevents baby boys from enjoying the same protection of their genitalia as baby girls. In the 21st century, it is time to remember that men, too, can be victims of unjust hegemonic systems tolerated in the name of tradition, culture or religion. If we oppose female genital mutilation, has the time not come for us also to oppose male genital mutilation?

Neil Howard and Rebecca Steinfeld are doctoral students at Oxford University, specialising on issues related to gender in West Africa and the Middle East respectively.

Guardian (UK), 14 June 2011

Melbourne 2015: High incidence of circumcision complications

 

A study in Melbourne has found a disturbingly high incidence of circumcision complications requiring emergency treatment. Over a period of 29 months 167 boys were brought to the Royal Children’s Hospital casualty department suffering from circumcision-related injuries. The principal problems were: bleeding (53.9%), pain (38.3%), swelling (37.1%), redness (25.7%), decreased urine output (13.8%), fever (7.2%) and infection (6%). In addition, 29.9% were brought in because parents were shocked at the ugly post-circumcision appearance of the boy’s penis. About half the circumcisions (54%) had been performed for religious/cultural reasons, 30% for so-called medical reasons, and the remainder for reasons unknown. There was some difference in the incidence of complications between hospital-performed operations (40%) and those performed in the community, presumably by GPs and “specialist” clinic (60%), but not enough to justify the common assumption that hospital-performed operations are completely safe. The mean age of the boys was 3 years, but the boys circumcised by so-called community operators were much younger and had the highest incidence of complications.

Since the total number of circumcision operations performed is unknown, it is impossible to work out the rate of complications, but 167 emergency presentations in a 2-year period seems disturbingly high, especially as Victoria’s overall incidence of circumcision is about half that of Australia as a whole (12% nationally). Such injuries represent a cruel burden of pain, suffering and disfigurement on baby boys, and absorb significant public health resources – a situation that is doubly unfortunate as the original surgery was completely unnecessary. While over half (54%) of the circumcisions were performed for cultural/religious reasons (mainly the preference of Muslim parents), 30% of the procedures were for “medical reasons”. Given the age of the boys this figure seems highly dubious and probably reflects mistaken diagnoses of phimosis (usually curable with medications if genuine) or even fraudulent attempts to ensure the Medicare rebate or free hospital treatment.

Several other features of the study deserve comment.

The age of the boys undergoing hospital circumcision (median age 4.23 years, mean 5.6 years) is markedly higher than those circumcised in the community (median age 3.9 MONTHS, mean 1.4 YEAR). The authors do not adequately discuss this when comparing their associated complication frequencies. While some people will misinterpret this study to claim that hospital doctors are better at circumcision operations than GPs and other community operators, you could just as well argue that infant circumcisions are more often associated with complications than circumcision at older ages. However, both claims may be true or false, and this study does not settle the matter.

The study does not demonstrate markedly higher rates of complications following community-based compared hospital-based circumcisions. Since the study base is unknown, we cannot tell what proportions of all performed circumcisions (whether in hospitals or in the community) these 167 cases actually represent. Complications following hospital-based circumcisions are plausibly more likely to result in contacts to the hospital, because parents are routinely instructed by the operator/nurse to contact the emergency department in case of complications. On the other hand, we can only speculate as to what selected part of the total of community-based circumcisions will end up in the emergency department. Self-selection by parents and religious circumcisers of which boys with complications after community-based circumcisions should be referred to the emergency department may result in a skewed group of patients with relatively serious complications. This might partly explain the markedly higher hospital admission rate and greater proportion needing reoperation among community compared with hospital circumcisions.

A puzzling feature of Table 1 is that 18 (30%) of the hospital-based circumcisions were of boys from Muslim families, but only 6 (10%) were circumcised for cultural/religious reasons. This means that 12 boys from Muslim families who ended up in the emergency department had been circumcised in the hospital for “medical reasons”. While some such boys may plausibly be referred for the same (often ill-advised or mistaken) “medical reasons” as boys from non-Muslim families, it seems odd that twice the number of hospital-circumcised Muslim boys end up in the ED when the circumcision was performed for medical reasons as compared with cultural/religious reasons (12 vs 6).

Plastibell circumcision device criticized

The authors of the study also warn that the Plastibell circumcision device, used on nearly 60% of the boys who required emergency treatment, is not as safe as claimed by the circumcision providers and clinics that commonly use it. They identify 4 studies detailing complications arising from the device and comment: “While it is reported to be a quick and simple method preferred by many providers, these studies have revealed method-dependent concerns. This includes concern about what is the appropriate length of time for the device to be retained, an increase in infection and increase in analgesia requirement post-operatively. We identified that 54 boys (58.7%) were circumcised by this method in the community. There was particular concern and poor understanding about the appropriate length of time the Plastibell ring should remain in situ, which could be addressed in improved information for parents.”

Comment

The whole situation described in this report is very sad. Despite the claim of “medical reason”, very few (if any) of the original circumcision procedures were medically necessary (and thus in the best interests of he child), and the result has been a cruel burden of suffering borne by innocent children and, on top of that, avoidable demands on the public health system. Circumcision advocates are keen to prove that the earlier circumcision is done the safer, but this study suggests the opposite: that it was the youngest boys who suffered the greatest number of complications. From an ethical point of view it hardly matters, as any non-therapeutic circumcision of a minor is in violation of basic bioethical and human rights principles. A more relevant comparison would be between child and adult circumcision, as adults can make their own choices and give informed consent. It is sometimes claimed that “better training” of operators would lead to a lower incidence of complications, but the real problem is the complexity, variability and tiny size of the juvenile penis: there can be little doubt that the only truly effective way to avoid complications not to circumcise in the first place.

The authors of the study could have made more effort in their conclusions: it is hard to see that counseling parents as to the appearance of the penis following circumcision does the boys any good. They would have benefited from not being circumcised in the first place. What is needed is regulation of the circumcision industry, as recommended by the Tasmania Law Reform Institute report, and counseling of parents that circumcision is not necessary and not recommended.

Source: Grace Gold, Simon Young, Mike O’Brien, Franz E Babl. Complications following circumcision: Presentations to the emergency department. Journal of Paediatrics and Child Health 51 (December 2015): 1158–1163.

 

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