Infant Male Circumcision: A Medical Perspective

We gratefully acknowledge the expert advice of Professor Brian Morris on the scientific accuracy of this article. 

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Circumcision of males is a well-recognised religious practice, with an estimated 38% of men in the world having been circumcised.¹ But the topic of male circumcision has been vigorously debated in many scientific and mass media outlets in recent decades. Legal and ethical considerations have further highlighted the various and complex factors that fuel the debate and parental disagreements have taken the issue to be debated in courts of law.

Proponents of infant male circumcision present arguments based on the health benefits and on the fact of parental rights. In contrast, opponents of infant male circumcision argue for free will, choice and the sanctity of the human body. It has been argued that the decision for circumcision should be postponed to adulthood, allowing the person to make an informed decision about his own body. The argument is based on the idea that the circumcision of a child of non-consenting age may be a violation of his human rights. Indeed, the practice of infant circumcision has even been deemed by some to be a form of mutilation of males that is unjustifiable according to modern ethical standards.

In this era of evidence-based medicine, when the evidence regarding the risk versus benefit of any intervention can be objectively analysed, we seek to assess the impact of infant circumcision on the physical, mental and emotional wellbeing of male neonates, children, adolescents and adults. To this end, we look at circumcision from a medical perspective, weighing up the strength of evidence for and against infant male circumcision. We will critically assess the evidence based on the Hippocratic Oath, which states ‘I will prevent disease whenever I can, for prevention is preferable to cure’.

A Brief History of Male Circumcision

Circumcision of males is one of the oldest and most common of surgical procedures.  There is no consensus amongst anthropologists regarding the origin of circumcision. A study of archeological and artistic evidence of pre-historic times, such as drawings, engravings, and sculptures demonstrate evidence of circumcision.² Thus circumcision can be traced back to before Ancient Egyptian civilization, as there is evidence of it being practiced in Europe during the Paleolithic era.

The earliest Egyptian mummies (1300 BCE) were circumcised and wall paintings in Egypt suggest that circumcision was customary even several thousand years before then.³

Renowned University College London Professor Emeritus of Surgery, Harold Ellis, states, ‘Circumcision might well be claimed to be the most ancient “elective” operation and was practiced in Ancient Egypt by assistants to the priests on the priests and on members of Royal families.’  Commenting on a wall painting depicting the circumcision procedure, Prof Ellis says, ‘There is remarkable evidence for this carved on the tomb of a high-ranking royal official which was discovered in the Sakkara cemetery in Memphis and is dated between 2400 and 3000 BC. This represents two boys or young men being circumcised. The operators are employing a crude stone instrument.’⁴

Today, circumcision of males is a very common surgical procedure in Anglophone countries, most notably the in the US and the Middle East. It is also common in most of sub-Saharan Africa as well as in Polynesian and Melanesian cultures.⁵ The greater prevalence of this procedure in countries with hot climates seems to suggest that circumcision of the male perhaps arose as a practical step to improve hygiene. It is thought that later circumcision became ritualised as various cultures adopted it as routine.⁶

While cultural and hygienic reasons may have led to the first circumcisions, brief descriptions of adult circumcision for medical reasons were first mentioned in 19^th-century textbooks. A well-known surgeon of the time, John Abernethy,   described the use of a bistoury, a type of long and narrow surgical knife, to achieve circumcision in men suffering from an infective condition.⁷  With the discovery and widespread use of anaesthesia and antiseptics by the middle of the 19^th century, surgical procedures became more refined. The first reported circumcision in the surgical accounts of St Bartholomew’s Hospital was in 1865.⁸ The medical benefits of circumcision for a wide range of genitourinary problems were widely reported in Victorian times.^9,10,11 Since then, there has been tremendous progress in the surgical technique of circumcision, with many technological advances.

In 1932, Abraham Wolbarst, a New York urologist, demonstrated that invasive penile cancer almost never occurred in circumcised men and that the risk factor related to the timing of the circumcision.¹² WS Handley, a practising clinician, reported on the infrequency of carcinoma of the cervix in Jewish women and attributed it to the fact  that Jewish men were circumcised.¹³

The Religious Context of Infant Male Circumcision

In the Judeo-Christian tradition, the commandment to circumcise was first recorded in the chapters Genesis 17:10-14 and Leviticus 12:3 in the Old Testament and the Torah. It was the prophet Abraham^as who was given the commandment to carry out circumcision as a symbol of the covenant with God: ‘Every male child among you shall be circumcised; and you shall be circumcised in the flesh of your foreskins, and it shall be a sign of the covenant between Me and you.’¹⁴

Ishmael^as was the first-born of Abraham^as. Sarah^ra gave her maid Hagar^ra to her husband Abraham^as to be his wife, and she bore him a son whom he called Ishmael¹⁵. God made a covenant with Abraham^as and his seed¹⁶ and as a token of the covenant, laid down that every male child among them shall be circumcised. ‘Abraham said unto God, “O that Ishmael might live before Thee”’, and God responded: ‘As for Ishmael, I have heard thee: Behold, I have blessed him, and will make him fruitful, and will multiply him exceedingly; twelve princes shall he beget, and I will make him a great nation’.¹⁷ ‘In the self-same day was Abraham circumcised, and Ishmael his son.’^18.19

Consequently, the followers of Judaism have adhered to the practice of circumcision as a religious rite and symbol of their covenant with God through Abraham^as.

Later, many followers of the Christian faith abandoned this practice. The debate of the early followers of Jesus^as regarding circumcision is chronicled in Acts of the Apostles and various other epistles. Eventually, the Coptic church kept, and still keeps, circumcision as a religious requirement.²⁰

Commenting on the trend away from circumcision in Christianity, the Founder of the Ahmadiyya Muslim Community, Hazrat Mirza Ghulam Ahmad^as wrote: ‘Many other timeless commandments of the Torah were also violated, and the Christian faith underwent such a change that even if the Messiah^as himself were to return, he would fail to recognize it. It is most astonishing that the people who had been enjoined to follow the Torah, so brazenly flouted its commandments. For instance, it is nowhere written in the Gospels that though the eating of pork was made unlawful in the Torah, yet I [the Messiah] make it lawful for you; or that though the Torah prescribes circumcision, I repeal this commandment.’ ²¹

The Holy Qur’an does not give the commandment of circumcision directly but enjoins Muslims to follow the teachings and practices of the prophet Abraham^as.  The Qur’an describes the Prophet Abraham^as as ‘a righteous person and a Prophet.’²² The Qur’an further commands Muslims to ‘… follow ye the religion of Abraham who was ever inclined to God; he was not of those who set up gods with God.’²³

The practice of circumcision is described by the Holy Prophet^sa as an inherent requirement of human nature. His Companion Abu Huraira^ra narrates: ‘I heard the Prophet^sa saying, “Five practices are characteristics of the fitra (nature): circumcision, shaving pubic hair, cutting the moustaches short, clipping the nails, and depilating the hair of the armpits.’’’²⁴ It was the practice of the Holy Prophet^sa to perform the circumcision of the newborn on the seventh day. If a Muslim male is not circumcised at a young age, then it is permissible but not compulsory for him to be circumcised when he reaches adulthood. There is no evidence in Islamic jurisprudence that an adult who accepts Islam must be circumcised.²⁵ One of the companions of the Promised Messiah^as accepted Islam Ahmadiyyat from Sikhism. When he asked about circumcision, the Promised Messiah^as  advised him that circumcision is a sunnah (the practice of the Holy Prophet^sa) and not mandatory for adults who accept Islam. The philosophy behind all Islamic commandments in this regard is that such practices whose benefits outweigh the harm should be adopted while those where the harm exceeds the benefit should be abandoned.²⁶ 

The traditions of Hinduism prohibit circumcision and even any interference with a tight foreskin. Sikhism specifically bans circumcision in its holy book. Buddhists do not circumcise either, though this seems to be more on the philosophical tradition of not inflicting harm, rather than a specific religious prohibition.

Is Male Circumcision Medically Beneficial?

Male circumcision is the most common surgical procedure undertaken in the world today and an evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh its risks.  A highly cited scientific article, published in one of the most reputable medical journals in the world, reports that the circumcision of men protects against several conditions, including genital cancers, and a risk-benefit analysis concludes that the benefits of male circumcision exceed its risks by over 100 to 1.²⁷ The analysis found that half of all uncircumcised males will experience an adverse medical condition as a result of their foreskin.

Furthermore, infant/neonatal circumcision affords protection against urinary tract infections, which are most common and severe during the first six months of life. Neonatal circumcision provides extensive protection against the risk of urinary tract infection in neonates.²⁸ Neonatal circumcision decreases the risk of urinary tract infection by 96% at six months of age.²⁹ The largest systematic review and meta-analysis of circumcision and lifetime risk of urinary tract infection reported that the risk of developing urinary tract infections was 32% in uncircumcised males as compared to 9% in circumcised males.³⁰ Recurrent urinary tract infections can lead to renal scarring and even renal failure. Circumcision prevents phimosis, swelling that leads to a painful condition. Also easily preventable by circumcision are inflammatory conditions such as balanitis, another painful condition common in uncircumcised boys and which may require circumcision for treatment. Some forms of balanitis can lead to secondary phimosis (a painful condition). Hygiene is easier to achieve if the male is circumcised.

Male circumcision protects against many, but not all, sexually transmitted infections, such as syphilis, genital herpes (HSV-2), chancroid, and oncogenic human papillomavirus (HPV).³¹ Male circumcision affords over 60% protection against HIV. Three large randomised clinical trials performed in sub-Saharan Africa consistently showed that male circumcision provided a high level of protection from HIV infection. It was the most cost-effective solution for prevention of HIV. The World Health Organization and the United Nations Programme on HIV/AIDS (UNAIDS) immediately endorsed the findings in 2007 and launched a campaign to promote male circumcision in HIV-endemic areas of sub-Saharan Africa. Follow-up studies have seen the level of the protective effect rise to 76%.^32,33

Male circumcision also affords protection against penile and to a lesser extent, prostate cancer.^34,35 Evidence of the protection against prostate cancer has been consolidated over the years.^36,37 The evidence that circumcision protects against prostate cancer is further supported by meta-analyses.³⁸ It has also been shown that the risk of dying of prostate cancer is much lower in countries where circumcision of men is common.³⁹

In addition, male circumcision appears to reduce the risk of cancer in a man’s sexual partner. A meta-analysis (a survey of many previously published studies) of 14 studies confirmed that male circumcision was associated with strong protection against cervical cancer.⁴⁰ Based on this robust evidence, the Centers for Disease Control advocate elective male circumcision to improve public health in the United States.⁴¹

What Age is Best for Male Circumcision?

Evaluation of current evidence by the American Academy of Pediatrics Task Force on circumcision indicates that the health benefits of newborn male circumcision outweigh any risks, and the benefits of newborn male circumcision justifies access to this procedure for those families who choose it.^42,43 This evidence led the American Academy of Pediatricians to recommend infant male circumcision for families who choose it for their sons. The Academy also recommended unbiased, evidence-based education of parents early in a pregnancy, as well as improved access, affordability, insurance coverage and provider training. The policy was endorsed by the American College of Obstetrician and Gynecologists.

Professor Brian Morris, at the University of Sydney in Australia, and expert colleagues performed a critical analysis of the extensive evidence in order to determine what might be the best age for circumcision. This led them to recommend early parent-approved infant male circumcision rather than delaying circumcision until the male is old enough to decide for himself.⁴⁴ They argued that circumcision in infancy is easier, lower-cost, more convenient, involves local (rather than the risk of general) anaesthesia and is associated with quicker healing and a better cosmetic outcome.

In contrast, circumcision of older boys or adults poses scheduling and possibly psychological barriers. While still a simple procedure, it is nevertheless a more substantial, longer, more costly operation and thus poses a higher risk of adverse events.⁴⁵ In addition, it also means many years in which uncircumcised boys remain unprotected from the adverse medical conditions that can affect those who have not been circumcised. Taken together, those observations provide a strong case favouring early infancy as being the best time to circumcise.

While children and infants, ‘lack the power to make rational choices and must therefore be guided by adults,’⁴⁶ responsible parenting demands that parents make decisions for the wellbeing of their offspring. This includes protecting them against infections and cancers. Waiting until adolescence or adulthood to allow the male to decide for himself not only deprives a young man of the benefits of the procedure during his childhood and early youth, but also exposes him to a higher risk of complications, embarrassment and inconvenience.

Is Male Circumcision Medically Harmful?

Significant complications after circumcision in both infants and adults are extremely rare.⁴⁷  Most adverse events are technical, minor and easily treatable. A study of 1,400,920 males who underwent circumcision showed that the adverse event after circumcision was slightly less than 0.5% in infancy. The extremely rare serious adverse events of male circumcision are stricture (narrowing) of male genital organs and the need for surgery to repair an incomplete circumcision. Compared with boys circumcised at ages younger than one year, the incidences of probable adverse events were approximately twentyfold and tenfold greater for males circumcised from ages 1 to 9 years and at 10 years or older, respectively. Therefore, circumcision of males has a low complication rate especially if the procedure was performed during the first year of life.⁴⁸ Other studies also show that the complication rate after male circumcision of infants is 0.5% and in adults is 1.7% to 3.8%.⁴⁹

Moreover, there is no evidence of any long-term negative effects relating to circumcision in terms of personal satisfaction and intimate relationships.⁵⁰ Critical review of the evidence suggests that males who have been circumcised suffer no long-term adverse effect in terms of intimate functions or desires.^51,52,53,54

Despite some reports of psychological issues after circumcision,⁵⁵ there is no robust evidence of any long-term psychological or emotional consequences in the vast majority of men who undergo it. A recent survey found 29% of uncircumcised men wished they had been circumcised, compared with only 10% of circumcised men who wished that they had not been.⁵⁶

There is no evidence to suggest that the health benefits associated with circumcision of the male can be attained by other means such as the use of condoms, antibiotics and steroid creams.⁵⁷ Thus, based on high-quality studies published after vigorous peer-review processes, there is strong scientific evidence that demonstrates the clinical, ethical, psychological and cost benefits of infant male circumcision, especially in the neonatal period.

Male Circumcision: Public Health, Ethical and Legal Implications

Delaying male circumcision has a potentially detrimental effect on individual wellbeing and public health.⁵⁸ It is estimated that a 10% reduction in the circumcision rate will increase lifetime health care costs by $407 per male and $43 per female. In the present era of preventive medicine, with robust evidence in its favour, the practice of infant male circumcision fits the adage ‘prevention is better than cure’.

Addressing the legal and ethical aspects of infant male circumcision, Rivin, et al., in the Faculty of Law at the University of Washington in Seattle argues that a denial of male circumcision would be depriving the child of the highest attainable standard of health, given that the procedure prevents disease.⁵⁹ Withholding circumcision from a male infant may be against Article 18(1) OF the United Nations Convention on the Rights of the Child (CRC), which states, parents or, as the case may be, legal guardians, have the primary responsibility for the upbringing and development of the child. The best interests of the child will be their basic concern.” The legal right to offer circumcision to male infants because of its wide-ranging protection against multiple medical conditions and infections in infancy and childhood is well recognised.

Infant male circumcision is both ethical and legal, and supported by the United Nations Convention on the Rights of the Child. It has been argued that Article 24(3) of the United Nations Convention on the Rights of the Child (CRC)^60, which states that parties shall take all effective and appropriae measures with a view to abolishing traditional practices prejudicial to the health of children, might be interpreted as mandating circumcision, since not circumcising boys has been deemed as prejudicial to their health.⁶¹

The evidence in favour of infant male circumcision can robustly stand up to the four cardinal principles of contemporary medical ethics. The case of the principles of non-maleficence and beneficence has been made in the preceding sections.  An adult cannot consent to his own infant circumcision, therefore, the principle for respect for autonomy needs to be placed in the context of parental responsibility. To take steps to enhance public health and the health of individuals meets the principle of justice.  The positive impact of infantile male circumcision on the society and the individual, especially as regards the likelihood of adverse complications, supports the assertion that this practice does not violate human rights.⁶²

Infant Male Circumcision: Concluding Remarks

The modern version of the Hippocratic Oath actually states, ‘I will prevent disease whenever I can, for prevention is preferable to cure.’⁶³ Therefore, for the protection and well-being of minors, surgical procedures, even when associated with high complication rates, are justified. Examples include surgery for heart disease and cancer. Parents have a clear duty of care and are responsible for making informed decisions about their children’s health and well-being. These include interventions such as childhood vaccinations and infant male circumcision. Most parents have the best interests of their children at heart, and would not, for example, wait until their child reached adulthood before seeking corrective or cosmetic treatment for things such as the realignment of teeth, treatment of  cleft lips, tongue tie or hernia repairs.

There is unbiased, factually robust clinical evidence suggesting that the neonatal period is the ideal window of opportunity for male circumcision.  In the present day and age, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatricians explicitly acknowledges that the benefits of male circumcision exceed its risks and advocate greater availability of male circumcision. So, the question now is whether it is ethically justifiable to withhold or delay the protective effect of neonatal male circumcision, especially in the face of strong scientific evidence favouring this procedure.

The current scientific evidence has proven the truthfulness of the teachings of Islam. The Holy Qur’an states, ‘Bring forward your proof if you are truthful.’⁶⁴  The scientific research detailed herein provides the evidence that neonatal circumcision, as commanded by religious teachings, has more benefits both long- and short-term and carries minimal harm. ‘Thus does Allah make His commandments clear to you that you may reflect.’ ⁶⁵

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About the Authors: Professor Amtul Razzaq Carmichael MD, FRCS (Gen Surg), MBBS, is a consultant specialist breast surgeon, with an interest in religious ethics.

Dr AS Sami is a trained surgeon with an interest in the history of surgical procedures.

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Endnotes

1. Brian Morris et al., “Estimation of Country-Specific and Global Prevalence of Male Circumcision,” Popul Health Metr 14, 4 (March 2016).

2. Javier C. Angulo and Marcos García-Díez, “Male Genital Representation in Paleolithic Art: Erection and Circumcision Before History,” Urology 74, no. 1 (2009):10-14.

3. Richard Lewinsohn, A History of Sexual Customs (New York: Harper & Row, 1971), 31-32.

4. Harold Ellis, The Cambridge Illustrated History of Surgery (Cambridge: Cambridge University Press, 2011).

5. Brian Morris et al., “Estimation of Country-Specific and Global Prevalence of Male Circumcision,” Popul Health Metr 14, 4 (March 2016).

6. Guy Cox and Brian J. Morris, “Why Circumcision: From Prehistory to the Twenty-First Century,” Surgical Guide to Circumcision, 2012, doi:10.1007/978-1-4471-2858-8_21.

7. John Abernethy, “The Conseqences of Gonorrhoea,” Lectures on Anatomy, Surgery and Pathology: Including Observations on the Nature and Treatment of Local Diseases, delivered at St. Bartholomew’s and Christ’s Hospitals, Chapt XXII, 163. The Strand, London: James Bulcock, 1828:315’6

8. GW Calendar, and A.Willet, “Brief Notes of the Surgical Practice of the Hospital,” St Bart’s Hosp Rep 1865; I: 35-62

9. P.C. Remondino, History of Circumcision from Earliest Times to the Present, (Philadelphia: F. A. Davis,1900), 200-5.

10. William Johnson Walsham, Surgery, Its Theory and Practice, (London: Churchill, 1903, 1034-6.

11. R. Warren,  Textbook of Surgery II (London: Churchill, 1915), 630-3.

12. Abrl. Wolbarst, “Circumcision And Penile Cancer.,” The Lancet 219, no. 5655 (1932): 150-153., doi:10.1016/s0140-6736(01)24346-3.

13. W. S. Handley, “Carcinoma of Cervix,” BMJ 1, no. 4594 (1949): 841-843.

14. The Bible, Genesis 17:10-11.

15.  The Bible, Genesis 16:3,15.

16. The Bible, Genesis 17:7.

17.  The Bible, Genesis 17:20.

18. The Bible, Genesis 77:26.

19. Sir Chaudhry Zafrullah Khan, “Judaism, Christianity, and Islam – a Trialogue,”https://www.alislam.org/library/links/00000218.html, Accessed 29/8/16.

20. Guy Cox and Brian J. Morris, “Why Circumcision: From Prehistory to the Twenty-First Century,” in Surgical Guide to Circumcision, eds. D.A. Bolnick et al. (London: Springer-Verlag, 2012), 243.

21. Hazrat Mirza Ghulam Ahmad^as, Lecture Sialkot (Tilford, Surrey: Islam International Publications, 2007), 3.

22. The Holy Qur’an, 19:42.

23. The Holy Qur’an, 2:136.

24. Sahih Bukhari, Book #72, Hadith #779.

25. Correspondence from Darul Ufta’a, 83/17-3-18.

26. The Holy Qur’an 2: 220.

27. Brian J. Morris, Stefan A. Bailis, and Thomas E. Wiswell, “Circumcision Rates in the United States: Rising or Falling? What Effect Might the New Affirmative Pediatric Policy Statement Have?” Mayo Clinic Proceedings 89, no. 5 (2014): 677-686.

28. J. J. Zorc, “Clinical and Demographic Factors Associated With Urinary Tract Infection in Young Febrile Infants,” Pediatrics 116, no. 3 (2005): 644-648.

29. A. Nayir, “Circumcision for the Prevention of Significant Bacteriuria in Boys,” Pediatric Nephrology 16, no. 12 (2001): 1129-1134.

30. Brian J. Morris and Thomas E. Wiswell, “Circumcision and Lifetime Risk of Urinary Tract Infection: A Systematic Review and Meta-Analysis,” The Journal of Urology 189, no. 6 (2013): 2118-2124

31. Brian J. Morris et al., “Infant Male Circumcision: An Evidence-based Policy Statement,” Open Journal of Preventive Medicine 02, no. 01 (2012): 79-92.

32. Bertram Auvert et al., “Effect of the Orange Farm (South Africa) male circumcision roll-out (ANRS-12126) on the spread of HIV,” (6th IAS Conference on HIV Pathogenesis, Treatment and Prevention, Rome) 17-20 July 2011.

33.  F. X. Bosch, G. Albero, and X. Castellsague, “Male Circumcision, Human Papillomavirus and Cervical Cancer: From Evidence to Intervention,” Journal of Family Planning and Reproductive Health Care 35, no. 1 (2009): 5-7.

34. Brian J. Morris et al., “The Strong Protective Effect of Circumcision against Cancer of the Penis,” Advances in Urology 2011 (2011): 1-21.

35. Robert S. Van Howe, “Case Number And The Financial Impact Of Circumcision In Reducing Prostate Cancer,” BJU International 100, no. 5 (2007): 5-6.

36. Jonathan L. Wright, Daniel W. Lin, and Janet L. Stanford, “Circumcision and the Risk of Prostate Cancer,” Cancer 118, no. 18 (2012): 4437-4443.

37. Andrea R. Spence et al., “Circumcision and Prostate Cancer: A Population-based Case-control Study in Montréal, Canada,” BJU International 114, no. 6b (2014): E90-98.

38. N. Pabalan et al., “Association of Male Circumcision with Risk of Prostate Cancer: A Meta-analysis,” Prostate Cancer and Prostatic Diseases 18, no. 4 (2015): 352-357.

39. Brian Morris, Mitchells Wachtel, and Shengping Yang, “Countries with High Circumcision Prevalence Have Lower Prostate Cancer Mortality,” Asian Journal of Andrology 18, no. 1 (2016): 39-42.

40. F. X. Bosch, G. Albero, and X. Castellsague, “Male Circumcision, Human Papillomavirus and Cervical Cancer: From Evidence to Intervention,” Journal of Family Planning and Reproductive Health Care 35, no. 1 (2009): 5-7.

41. Centers for Disease Control and Prevention (CDC), Recommendations for Providers Counseling Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV Infection, STIs, and Other Health Outcomes, 2014, https://www.regulations.gov/#!documentDetail;D=CDC-2014-0012-0003.

42. American Academy of Pediatrics, “Male Circumcision: Task Force on Circumcision,” Pediatrics 130, no.3 (August 2012):e756-85, www.pediatrics.org/cgi/doi/10.1542/peds.2012-1990.

43. American Academy of Pediatrics, “Male Circumcision: Task Force on Circumcision,” Pediatrics 130, no.3 (August 2012):e756-85, www.pediatrics.org/cgi/doi/10.1542/peds.2012-1990.

44. Brian J. Morris et al., “A Snip in Time: What Is the Best Age to Circumcise?” BMC Pediatrics 12, no. 1 (2012): 20., doi:10.1186/1471-2431-12-20.

45. D.E. Coplen, “Rates of Adverse Events Associated With Male Circumcision in US Medical Settings, 2001 to 2010,” Yearbook of Urology 2014 (2014): 625-634., doi:10.1016/j.yuro.2014.07.025.

46. Robert Darby, “Risks, Benefits, Complications and Harms: Neglected Factors in the Current Debate on Non-Therapeutic Circumcision,” Kennedy Institute of Ethics Journal 25, no. 1 (2015): 1-34. See critique of Darby’s article in Morris BJ, Krieger JN, Klausner JD. Critical evaluation of unscientific arguments disparaging infant male circumcision. World J Clin Pediatr 2016;5:251-261.

47. Helen A. Weiss et al., “Complications of Circumcision in Male Neonates, Infants and Children: A Systematic Review,” BMC Urology 10, no. 1 (2010): 13.

48. D.E. Coplen, “Rates of Adverse Events Associated With Male Circumcision in US Medical Settings, 2001 to 2010,” Yearbook of Urology 2014 (2014): 625-634., doi:10.1016/j.yuro.2014.07.025.

49. John N. Krieger et al., “Adult Male Circumcision Outcomes: Experience in a Developing Country Setting,” Urologia Internationalis 78, no. 3 (2007): 235-240

50. John N. Krieger et al., “ORIGINAL RESEARCH—MENS SEXUAL HEALTH: Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya,” The Journal of Sexual Medicine 5, no. 11 (2008): 2610-2622.

51. Brian J. Morris and John N. Krieger, “Does Male Circumcision Affect Sexual Function, Sensitivity, or Satisfaction?—A Systematic Review,” The Journal of Sexual Medicine 10, no. 11 (2013): 2644-2657.

52. Ye Tian et al., “Effects of Circumcision on Male Sexual Functions: A Systematic Review and Meta-analysis,” Asian Journal of Andrology 15, no. 5 (2013): 662-666.,

53. Daniel Shabanzadeh, Signe Düring, & Cai Frimodt-Møller, “Male circumcision does not result in inferior perceived male sexual function – A systematic review,” Danish Medical Journal 63, no. 7, 2016.

54. John N. Krieger et al., “ORIGINAL RESEARCH—MENS SEXUAL HEALTH: Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya,” The Journal of Sexual Medicine 5, no. 11 (2008): 2610-2622.

55. Dirk Schultheiss et al., “Uncircumcision: A Historical Review of Preputial Restoration,” Plastic and Reconstructive Surgery 101, no. 7 (1998): 1990-1998.

56. YouGov, “Circumcision survey,” https://cdn.yougov.com/cumulus_uploads/document/ugf8jh0ufk/toplines_OPI_circumcision_20150202.pdf (2015).

57. Beth Rivin et al., “Critical Evaluation of Adler’s Challenge to the CDC’s Male Circumcision Recommendations,” International Journal Of Children’s Rights 24, no. 2 (2015): 265-303.

58. Seema Kacker et al., “Costs and Effectiveness of Neonatal Male Circumcision,” Archives of Pediatrics & Adolescent Medicine 166, no. 10 (2012): 910-918.

59. Michael J. Bates et al., “Recommendation by a Law Body to Ban Infant Male Circumcision Has Serious Worldwide Implications for Pediatric Practice and Human Rights,” BMC Pediatrics 13, no. 1 (2013): 1-9.

60. United Nations Human Rights Office of the High Commissioner for Human Rights, Convention on the Rights of the Child. 44/25, 20 November 1989: https://www.ohchr.org/en/professionalinterest/pages/crc.aspx. Retrieved from: https://www.un.org/documents/ga/res/44/a44r025.htm.

61. A.J. Jacobs, “The ethics of circumcision of male infants,” Isr Med Assoc J. 15, no. 1 (January 2013): 60–65.

62. Allan J. Jacobs and Kavita Shah Arora, “Ritual Male Infant Circumcision and Human Rights,” The American Journal of Bioethics 15, no. 2 (2015): 30-39.

63. R. Kelishadi, “To the Readers,” Int J Prev Med 1, no. 1 (2010): i.

64. The Holy Qur’an, 27:65.

65. The Holy Qur’an, 2:220.