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The Foreskin is Necessary
Paul M. Fleiss, M.D.
Published as "The Case Against Circumcision" in Mothering, p. 36-45, Winter 1997
Created as a Mothers Against Circumcision Web Page with permission from the author and Mothering.
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"Routine circumcision of babies in the United States did not begin until the Cold War era. Circumcision is almost unheard of in Europe, Southern America, and non-Muslim Asia. In fact, only 10 to 15 percent of men throughout the world are circumcised."
"The natural penis requires no special care. A child's foreskin, like his eyelids, is self-cleansing. Forcibly retracting a baby's foreskin can lead to irritation and infection. The best way to care for a child's intact penis is to leave it alone."
Western countries have no tradition of circumcision. In antiquity, the expansion of the Greek and Roman Empires brought Westerners into contact with the peoples of the Middle East, some of whom marked their children with circumcision and other sexual mutilations. To protect these children, the Greeks and Romans passed laws forbidding circumcision.1 Over the centuries, the Catholic Church has passed many similar laws.2,3 The traditional Western response to circumcision has been revulsion and indignation.
Circumcision started in America during the masturbation hysteria of the Victorian Era, when a few American doctors circumcised boys to punish them for masturbating. Victorian doctors knew very well that circumcision denudes, desensitizes, and disables the penis. Nevertheless, they were soon claiming that circumcision cured epilepsy, convulsions, paralysis, elephantiasis, tuberculosis, eczema, bed-wetting, hip-joint disease, fecal incontinence, rectal prolapse, wet dreams, hernia, headaches, nervousness, hysteria, poor eyesight, idiocy, mental retardation, and insanity.4
In fact, no procedure in the history of medicine has been claimed to cure and prevent more diseases than circumcision. As late as the 1970s, leading American medical textbooks still advocated routine circumcision as a way to prevent masturbation.5 The antisexual motivations behind an operation that entails cutting off part of the penis are obvious.
The radical practice of routinely circumcising babies did not begin until the Cold War era. This institutionalization of what amounted to compulsory circumcision was part of the same movement that pathologized and medicalized birth and actively discouraged breastfeeding. Private-sector, corporate-run hospitals institutionalized routine circumcision without ever consulting the American people. There was no public debate or referendum. It was only in the 1970s that a series of lawsuits forced hospitals to obtain parental consent to perform this contraindicated but highly profitable surgery. Circumcisers responded by inventing new "medical" reasons for circumcision in an attempt to scare parents into consenting.
Today the reasons given for circumcision have been updated to play on contemporary fears and anxieties; but one day they, too, will be considered irrational. Now that such current excuses as the claim that this procedure prevents cancer and sexually transmitted diseases have been thoroughly discredited, circumcisers will undoubtedly invent new ones. But if circumcisers were really motivated by purely medical considerations, the procedure would have died out long ago, along with leeching, skull-drilling, and castration. The fact that it has not suggests that the compulsion to circumcise came first, the "reasons," later.
Millions of years of evolution have fashioned the human body into a model of refinement, elegance, and efficiency, with every part having a function and purpose. Evolution has determined that mammals' genitals should be sheathed in a protective, responsive, multipurpose foreskin. Every normal human being is born with a foreskin. In females, it protects the glans of the clitoris; in males, it protects the glans of the penis. Thus, the foreskin is an essential part of human sexual anatomy.
Parents should enjoy the arrival of a new child with as few worries as possible. The birth of a son in the US, however, is often fraught with anxiety and confusion. Most parents are pressured to hand their baby sons over to a stranger, who, behind closed doors, straps babies down and cuts their foreskins off. The billion-dollar-a-year circumcision industry has bombarded Americans with confusing rhetoric and calculated scare tactics.
Information about the foreskin itself is almost always missing from discussions about circumcision. The mass circumcision campaigns of the past few decades have resulted in pandemic ignorance about this remarkable structure and its versatile role in human sexuality. Ignorance and false information about the foreskin are the rule in American medical literature, education, and practice. Most American medical textbooks depict the human penis, without explanation, as circumcised, as if it were so by nature.
The foreskin is a uniquely specialized, sensitive, functional organ of touch. No other part of the body serves the same purpose. As a modified extension of the penile shaft skin, the foreskin covers and usually extends beyond the glans before folding under itself and finding its circumferential point of attachment just behind the corona (the rim of the glans). The foreskin is, therefore, a double-layered organ. Its true length is twice the length of its external fold and comprises as much as 80 percent or more of the penile skin covering.6,7
The foreskin contains a rich concentration of blood vessels and nerve endings. It is lined with the peripenic muscle sheet, a smooth muscle layer with longitudinal fibers. These muscle fibers are whirled, forming a kind of sphincter that ensures optimum protection of the urinary tract from contaminants of all kinds.
Like the undersurface of the eyelids or the inside of the cheek, the undersurface of the foreskin consists of mucous membrane. It is divided into two distinct zones: the soft mucosa and the ridged mucosa. The soft mucosa lies against the glans penis and contains ectopic sebaceous glands that secrete emollients, lubricants, and protective antibodies. Similar glands are found in the eyelids and mouth.
Adjacent to the soft mucosa and just behind the lips of the foreskin is the ridged mucosa. This exquisitely sensitive structure consists of tightly pleated concentric bands, like the elastic bands at the top of a sock. These expandable pleats allow the foreskin lips to open and roll back, exposing the glans. The ridged mucosa gives the foreskin its characteristic taper.
On the underside of the glans, the foreskin's point of attachment is advanced toward the meatus (urethral opening) and forms a bandlike ligament called the frenulum. It is identical to the frenulum that secures the tongue to the floor of the mouth. The foreskin's frenulum holds it in place over the glans, and, in conjunction with the smooth muscle fibers, helps return the retracted foreskin to its usual forward position over the glans.
At birth, the foreskin is usually attached to the glans, very much as a fingernail is attached to a finger. By puberty, the penis will usually have completed its development, and the foreskin will have separated from the glans.8 This separation occurs in its own time; there is no set age by which the foreskin and glans must be separated. One wise doctor described the process thus, "The foreskin therefore can be likened to a rosebud which remains closed and muzzled. Like a rosebud, it will only blossom when the time is right. No one opens a rosebud to make it blossom."9
Even if the glans and foreskin separate naturally in infancy, the foreskin lips can normally dilate only enough to allow the passage of urine. This ideal feature protects the glans from premature exposure to the external environment.
The penis develops naturally throughout childhood. Eventually, the child will, on his own, make the wondrous discovery that his foreskin will retract. There is no reason for parents, physicians, or other caregivers to manipulate a child's penis. The only person to retract a child's foreskin should be the child himself, when he has discovered that his foreskin is ready to retract.
Parents should be wary of anyone who tries to retract their child's foreskin, and especially wary of anyone who wants to cut it off. Human foreskins are in great demand for any number of commercial enterprises, and the marketing of purloined baby foreskins is a multimillion-dollar- a-year industry. Pharmaceutical and cosmetic companies use human foreskins as research material. Corporations such as Advanced Tissue Sciences, Organogenesis, and BioSurface Technology use human foreskins as the raw materials for a type of breathable bandage.10
The foreskin has numerous protective, sensory, and sexual functions.
The foreskin may have functions not yet recognized or understood. Scientists in Europe recently detected estrogen receptors in its basal epidermal cells.24 Researchers at the University of Manchester found that the human foreskin has apocrine glands.25 These specialized glands produce pheromones, nature's chemical messengers. Further studies are needed to fully understand these features of the foreskin and the role they play.
The natural penis requires no special care. A child's foreskin, like his eyelids, is self-cleansing. For the same reason it is inadvisable to lift the eyelids and wash the eyeballs, it is inadvisable to retract a child's foreskin and wash the glans. Immersion in plain water during the bath is all that is needed to keep the intact penis clean.26
The white emollient under the child's foreskin is called smegma. Smegma is probably the most misunderstood, most unjustifiably maligned substance in nature. Smegma is clean, not dirty, and is beneficial and necessary. It moisturizes the glans and keeps it smooth, soft, and supple. Its antibacterial and antiviral properties keep the penis clean and healthy. All mammals produce smegma. Thomas J. Ritter, MD, underscored its importance when he commented, "The animal kingdom would probably cease to exist without smegma."27
Studies suggest that it is best not to use soap on the glans or foreskin's inner fold.28 Forcibly retracting and washing a baby's foreskin destroys the beneficial bacterial flora that protect the penis from harmful germs and can lead to irritation and infection. The best way to care for a child's intact penis is to leave it alone. After puberty, males can gently rinse their glans and foreskin with warm water, according to their own self-determined needs.
Circumcision is almost unheard of in Europe, South America, and non-Muslim Asia. In fact, only 10 to 15 percent of men throughout the world are circumcised, the vast majority of whom are Muslim.29 The neonatal circumcision rate in the western US has now fallen to 34.2 percent.30 This relatively diminished rate may surprise American men born during the era when nearly 90 percent of baby boys were circumcised automatically, with or without their parents' consent.
The "medical" debate about the "potential health benefits" of circumcision rarely addresses its real effects.
Depending on the amount of skin cut off and how the scar forms, the circumcised penis may be permanently twisted, or curve or bow during erection.33 The contraction of the scar tissue may pull the shaft into the abdomen, in effect shortening the penis or burying it completely.34
Circumcision also severs the lymph vessels, interrupting the circulation of lymph and sometimes causing lymphedema, a painful, disfiguring condition in which the remaining skin of the penis swells with trapped lymph fluid.
The circumcision wound is larger than most people imagine. It is not just the circular point of union between the outer and inner layers of the remaining skin. Before a baby is circumcised, his foreskin must be torn from his glans, literally skinning it alive. This creates a large open area of raw, bleeding flesh, covered at best with a layer of undeveloped proto-mucosa. Germs can easily enter the damaged tissue and bloodstream through the raw glans and, even more easily, through the incision itself.
Even after the wound has healed, the externalized glans and meatus are still forced into constant unnatural contact with urine, feces, chemically treated diapers, and other contaminants.
Female partners of circumcised men do not report a lower rate of cervical cancer,40 nor does circumcision prevent penile cancer.41 A recent study shows that the penile cancer rate is higher in the US than in Denmark, where circumcision, except among Middle-Eastern immigrant workers, is almost unheard of.42 Indeed, researchers should investigate the possibility that circumcision has actually increased the rate of these diseases.
Circumcision does not prevent acquisition or transmission of sexually transmitted diseases (STDs). In fact, the US has both the highest percentage of sexually active circumcised males in the Western world and the highest rates of sexually transmitted diseases, including AIDS. Rigorously controlled prospective studies show that circumcised American men are at a greater risk for bacterial and viral STDs, especially gonorrhea,43 nongonoccal urethritis,44 human papilloma virus,45 herpes simplex virus type 2,46 and chlamydia.47
Medical journals have published numerous accounts of babies who have had part or all of their glans cut off while they were being circumcised.53, 54, 55 Other fully conscious, unanesthetized babies have had their entire penis burned off with an electrocautery gun.56, 57, 58 The September 1989 Journal of Urology published an account of four such cases.59 The article described the sex-change operation as "feminizing genitoplasty," performed on these babies in an attempt to change them into girls. The March 1997 Archives of Pediatrics and Adolescent Medicine described one young person's horror on learning that "she" had been born a normal male, but that a circumciser had burned his penis off when he was a baby.60 Many other similar cases have been documented.61, 62 Infant circumcision has a reported death rate of one in 500,000.63, 64
Numerous other studies have proven that circumcision disrupts the mother-infant bond during the crucial period after birth. Research has also shown that circumcision disrupts feeding patterns. In a study at the Washington University School of Medicine, most babies would not nurse right after they were circumcised, and those who did would not look into their mothers' eyes.66
Physicians have a duty to refuse to perform circumcision. They also must educate parents who, out of ignorance or misguidance, request this surgery for their sons. The healthcare professional's obligation is to protect the interests of the child. It is unethical in the extreme to force upon a child an amputation he almost certainly would never have chosen for himself.
To be intact, as nature intended, is best. The vast majority of males who are given the choice value their wholeness and keep their foreskins, for the same reason they keep their other organs of perception. Parents in Europe and non-Muslim Asia never have forced their boys to be circumcised. It would no more occur to them to cut off part of their boys' penises than it would to cut off part of their ears. Respecting a child's right to keep his genitals intact is normal and natural. It is conservative in the best sense of the word.
A circumcised father who has mixed feelings about his intact newborn son may require gentle, compassionate psychological counseling to help him come to terms with his loss and to overcome his anxieties about normal male genitalia. In such cases, the mother should steadfastly protect her child, inviting her husband to share this protective role and helping him diffuse his negative feelings. Most parents want what is best for their baby. Wise parents listen to their hearts and trust their instinct to protect their baby from harm. The experience of the ages has shown that babies thrive best in a trusting atmosphere of love, gentleness, respect, acceptance, nurturing, and intimacy. Cutting off a baby's foreskin shatters this trust. Circumcision wounds and harms the baby and the person the baby will become. Parents who respect their son's wholeness are bequeathing to him his birthright-his body, perfect and beautiful in its entirety.
Paul M. Fleiss, MD, MPH, is assistant clinical professor of pediatrics at the University of Southern California Medical Center. He is the author of numerous scientific articles published in leading national and international medical journals.
Doctors Opposing Circumcision (DOC)
2442 N.W. Market Street, Suite 42 Seattle, WA 98107 206-368-8358 weber.u.washington.edu/~gcd/DOC/
The National Organization of Circumcision Information Resource Centers
PO Box 2512 San Anselmo, CA 94979-2512 415-488-9883 www.nocirc.org
The National Organization to Halt the Abuse and Routine Mutilation of Males
PO Box 460795 San Francisco, CA 94146-0795 415-826-9351 www.noharmm.org
Nurses for the Rights of the Child
369 Montezuma, Suite 354 Santa Fe, NM 87501 505-989-7377 www.cirp.org/nrc/
Available from bookstores, from the publishers, or via the Internet at NOHARMM's Online Bookstore
Bigelow, Jim, PhD. The Joy of Uncircumcising! Exploring Circumcision: History, Myths, Psychology, Restoration, Sexual Pleasure and Human Rights. 2nd ed. Aptos, CA: Hourglass, 1995.
Denniston, George C., MD, MPH, and Marilyn Fayre Milos, RN, eds. Sexual Mutilations: A Human Tragedy. (Proceedings of the Fourth International Symposium on Sexual Mutilations, Lausanne, Switzerland, 1996). New York: Plenum Press, 1997.
Goldman, Ronald, PhD Circumcision: The Hidden Trauma: How an American Cultural Practice Affects Infants and Ultimately Us All. Boston: Vanguard Publications, 1997.
Goldman, Ronald, PhD Questioning Circumcision: A Jewish Perspective. 2nd ed. Boston: Vanguard Publications, 1997.
O'Mara, Peggy, ed. Circumcision: The Rest of the Story-A Selection of Articles, Letters, and Resources 1979- 1993. Santa Fe, NM: Mothering,1993.
Ritter, Thomas J., MD, and George C. Denniston, MD. Say No to Circumcision! 40 Compelling Reasons Why You Should Respect His Birthright and Keep Your Son Whole, 2nd ed. Aptos, CA: Hourglass, 1996.
Whose Body, Whose Rights? Examining the Ethics and the Human Rights Issue of Infant Male Circumcision. Award-winning documentary. 56 min. VHS.
For World Wide Web ordering and preview: http://www.noharmm.org/wbwr.htm
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1. T. J. Ritter and G. C. Denniston, Say No to Circumcision: 40 Compelling Reasons, 2nd ed. (Aptos, CA: Hourglass, 1996),6-20.
2. "Incipit Libellus De Ecclesiasticis Disciplinis et Religione Christiana Collectus. Liber II.XC, XCI" in Patrologiæ Cursus Completus , vol. 132 (Paris: Apud Garnier Fratres, Editores et J. P. Migne Successores, 1880), 301-302.
3. S. Grayzel, The Church and the Jews in the XIIth Century, vol. 2, ed. K. R. Stow (Detroit, MI: Wayne State University Press, 1989), 246-247.
4. See Note 10, 17-40.
5. M. F. Campbell, "The Male Genital Tract and the Female Urethra," in Urology, eds. M. F. Campbell and J. H. Harrison, vol. 2, 3rd ed. (Philadelphia: W. B. Saunders, 1970), 1836.
6. See photographic series: J. A. Erickson, "Three Zones of Penile Skin." In M. M. Lander, "The Human Prepuce," in G. C. Denniston and M. F. Milos, eds., Sexual Mutilations: A Human Tragedy (New York: Plenum Press, 1997), 79-81.
7. M. Davenport, "Problems with the Penis and Prepuce: Natural History of the Foreskin" (photograph 1), British Medical Journal 312 (1996): 299-301.
8. J. Øster, "Further Fate of the Foreskin," Archives of Disease in Childhood 43 (1968): 200-203.
9. H. L. Tan, "Foreskin Fallacies and Phimosis," Annals of the Academy of Medicine, Singapore 14 (1985): 626-630.
10. F. A. Hodges, "Short History of the Institutionalization of Involuntary Sexual Mutilation in the United States," in G. C. Denniston and M. F. Milos, eds., Sexual Mutilations: A Human Tragedy (New York: Plenum Press, 1997), 35.
11. A. B. Hyman and M. H. Brownstein, "Tyson's 'Glands': Ectopic Sebaceous Glands and Papillomatosis Penis," Archives of Dermatology 99 (1969): 31-37.
12. A. Ahmed and A. W. Jones, "Apocrine Cystadenoma: A Report of Two Cases Occurring on the Prepuce," British Journal of Dermatology 81 (1969): 899-901.
13. G. N. Weiss et al., "The Distribution and Density of Langerhans Cells in the Human Prepuce: Site of a Diminished Immune Response?" Israel Journal of Medical Sciences 29 (1993): 42-43.
14. P. J. Flower et al., "An Immunopathologic Study of the Bovine Prepuce," Veterinary Pathology 20 (1983):189-202.
15. Z. Halata and B. L. Munger, "The Neuroanatomical Basis for the Protopathic Sensibility of the Human Glans Penis," Brain Research 371 (1986): 205-230.
16. J. R. Taylor et al., "The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision. British Journal of Urology 77 (1996): 291-295.
17. H. C. Bazett et al., "Depth, Distribution and Probable Identification in the Prepuce of Sensory End-Organs Concerned in Sensations of Temperature and Touch; Thermometric Conductivity," Archives of Neurology and Psychiatry 27 (1932): 489-517.
18. D. Ohmori, "Über die Entwicklung der Innervation der Genitalapparate als Peripheren Aufnahmeapparat der Genitalen Reflexe," Zeitschrift für Anatomie und Entwicklungsgeschichte 70 (1924): 347-410.
19. A. De Girolamo and A. Cecio, "Contributo alla Conoscenza dell'innervazione Sensitiva del Prepuzio Nell'uomo," Bollettino della Societa Italiana de Biologia Sperimentale 44 (1968): 1521-1522.
20. A. S. Dogiel, "Die Nervenendigungen in der Haut der äusseren Genitalorgane des Menschen," Archiv für Mikroskopische Anatomie 41 (1893): 585-612.
21. A. Bourlond and R. K. Winkelmann, "L'innervation du Prépuce chez le Nouveau-né," Archives Belges de Dermatologie et de Syphiligraphie 21 (1965): 139-153.
22. R. K. Winkelmann, "The Erogenous Zones: Their Nerve Supply and Its Significance," Proceedings of the Staff Meetings of the Mayo Clinic 34 (1959): 39-47.
23. R. K. Winkelmann, "The Cutaneous Innervation of Human Newborn Prepuce," Journal of Investigative Dermatology 26 (1956): 53-67.
24. R. Hausmann et al., "The Forensic Value of the Immunohistochemical Detection of Oestrogen Receptors in Vaginal Epithelium," International Journal of Legal Medicine 109 (1996): 10-30.
25. See Note 12.
26. American Academy of Pediatrics, Newborns: Care of the Uncircumcised Penis: Guidelines for Parents (Elk Grove Village, IL: American Academy of Pediatrics, 1994).
27. See Note 1.
28. See Note 1.
29. S. A. Aldeeb Abu-Sahlieh, "Jehovah, His Cousin Allah, and Sexual Mutilations," in Sexual Mutilations: A Human Tragedy, eds. G. C. Denniston and M. F. Milos (New York: Plenum Press, 1997), 41-62.
30. National Center for Health Statistics of the United States Department of Health and Human Services, 1994.
31. See Note 17.
32. G. T. Klauber and J. Boyle, "Preputial Skin-Bridging: Complication of Circumcision," Urology 3 (1974): 722-723.
33. J. P. Gearhart, "Complications of Pediatric Circumcision," in Urologic Complications, Medical and Surgical, Adult and Pediatric, ed. F. F. Marshall (Chicago: Year Book Medical Publishers, 1986), 387-396.
34. R. D. Talarico and J. E. Jasaitis, "Concealed Penis: A Complication of Neonatal Circumcision," Journal of Urology 110 (1973): 732-733.
35. R. Persad et al., "Clinical Presentation and Pathophysiology of Meatal Stenosis Following Circumcision," British Journal of Urology 75 (1995): 90-91.
36. A. Taddio et al., "Effect of Neonatal Circumcision on Pain Responses during Vaccination in Boys," Lancet 345 (1995): 291-292.
37. A. Taddio et al., "Effect of Neonatal Circumcision on Pain Response during Subsequent Routine Vaccination," Lancet 349 (1997): 599-603.
38. J. W. Prescott, "Genital Pain vs. Genital Pleasure: Why the One and Not the Other?" Truth Seeker 1 (1989): 14-21.
39.R. Goldman, Circumcision: The Hidden Trauma (Boston: Vanguard Publications, 1997), 139-175.
40. M. Terris et al., "Relation of Circumcision to Cancer of the Cervix," American Journal of Obstetrics and Gynecology 117 (1973): 1056-1065.
41. C. J. Cold et al., "Carcinoma in Situ of the Penis in a 76-Year-Old Circumcised Man," Journal of Family Practice 44 (1997): 407-410.
42. M. Frisch et al., "Falling Incidence of Penis Cancer in an Uncircumcised Population (Denmark 1943-90)," British Medical Journal 311 (1995): 1471.
43. B. Donovan et al., "Male Circumcision and Common Sexually Transmissible Diseases in a Developed Nation Setting," Genitourinary Medicine 70 (1994): 317-320.
44. G. L. Smith et al., "Circumcision as a Risk Factor for Urethritis in Racial Groups," American Journal of Public Health 77 (1987): 452-454.
45. L. S. Cook et al., "Clinical Presentation of Genital Warts among Circumcised and Uncircumcised Heterosexual Men Attending an Urban STD Clinic," Genitourinary Medicine 69 (1993): 262-264.
46. I. Bassett et al., "Herpes Simplex Virus Type 2 Infection of Heterosexual Men Attending a Sexual Health Centre," Medical Journal of Australia 160 (1994): 697-700.
47. E. O. Laumann et al., "Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice," Journal of the American Medical Association 277 (1997): 1052-1057.
48. W. F. Gee and J. S. Ansell, "Neonatal Circumcision: A Ten-Year Overview: With Comparison of the Gomco Clamp and the Plastibell Device," Pediatrics 58 (1976): 824-827.
49.G. W. Kaplan, "Complications of Circumcision," Urologic Clinics of North America 10 (1983): 543-549.
50. S. J. Sussman et al., "Fournier's Syndrome: Report of Three Cases and Review of the Literature," American Journal of Diseases of Children 132 (1978): 1189-1191.
51. B. V. Kirkpatrick and D. V. Eitzman, "Neonatal Septicemia after Circumcision," Clinical Pediatrics 13 (1974): 767-768.
52. J. M. Scurlock and P. J. Pemberton, "Neonatal Meningitis and Circumcision," Medical Journal of Australia 1 (1977): 332-334.
53. G. R. Gluckman et al., "Newborn Penile Glans Amputation during Circumcision and Successful Reattachment," Journal of Urology 153 (1995): 778-779.
54. B. S. Strimling, "Partial Amputation of Glans Penis during Mogen Clamp Circumcision," Pediatrics 87 (1996): 906-907.
55. J. Sherman et al., "Circumcision: Successful Glandular Reconstruction and Survival Following Traumatic Amputation," Journal of Urology 156 (1996): 842-844.
56. J. R. Sharpe and R. P. Finney, "Electrocautery Circumcision," Urology 19 (1982): 228.
57. C. K. Pearlman, "Caution Advised on Electrocautery Circumcisions," Urology 19 (1982): 453.
58. C. K. Pearlman, "Reconstruction Following Iatrogenic Burn of the Penis," Journal of Pediatric Surgery 11 (1976):121-122.
59. J. P. Gearhart and J. A. Rock, "Total Ablation of the Penis after Circumcision with Electrocautery: A Method of Management and Long-Term Followup," Journal of Urology 142 (1989):799-801.
60. M. Diamond and H. K. Sigmundson, "Sex Reassignment at Birth: Long-Term Review and Clinical Implications," Archives of Pediatrics and Adolescent Medicine 151 (1997): 298-304.
61. J. Money, "Ablatio Penis: Normal Male Infant Sex-Reassigned as a Girl," Archives of Sexual Behavior 4 (1975): 65-71.
62. D. A. Gilbert et al., "Phallic Construction in Prepubertal and Adolescent Boys," Journal of Urology 149 (1993): 1521-1526.
63. R. S. Thompson, "Routine Circumcision in the Newborn: An Opposing View," Journal of Family Practice 31 (1990): 189-196.
64. T. E. Wiswell, "Circumcision Circumspection," New England Journal of Medicine 336 (1997): 1244-1245.
65. R. N. Emde et al., "Stress and Neonatal Sleep," Psychosomatic Medicine 33 (1971): 491-497.
66. R. E. Marshall et al., "Circumcision: II. Effects upon Mother-Infant Interaction," Early Human Development 7 (1982): 367-374.
67. Committee on Bioethics, "Informed Consent, Parental Permission, and Assent in Pediatric Practice," Pediatrics 95 (1995): 314-317.
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