Difference between revisions of "Pain"

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<b>However, none of the above three procedures totally eliminate pain. A baby boy will still experience some pain despite any of those analgesic procedures. Prevention of pain requires protecting a boy from elective neonatal non-therapeutic circumcision. Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or trauma.</b>
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<big><b>However, none of the above three procedures totally eliminate pain. A baby boy will still experience some pain despite any of those analgesic procedures. Prevention of pain requires protecting a boy from elective neonatal non-therapeutic circumcision. Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or trauma.</b></big>
  
 
==Attitudes and practices regarding analgesia for newborn circumcision==
 
==Attitudes and practices regarding analgesia for newborn circumcision==

Revision as of 04:55, 15 June 2021

The pain of circumcision is extreme and traumatizing.

Infant circumcision

Intraoperative pain

Circumcision is most-commonly performed on newborn infants as a non-therapeutic cultural body re-configuration. At that tender age, the foreskin normally is fused with the underlying glans penis by a synechial membrane that is common to both parts.[1]

There are four painful steps in every infant circumcision:

  1. Before circumcision surgery can commence, the surgeon must first forcibly separate these two highly innervated body parts in an exquisitely painful procedure by forcing a blunt probe between the two parts to destroy, rip and tear the synechia apart.[2]
  2. Next, in another painful step, a dorsal slit must be cut in the foreskin, so that a special clamp can be installed.
  3. The foreskin is erogenous tissue,[3] so it is highly innervated.[4] Nervous tissue requires a large blood supply, so the foreskin is richly vascularized with many blood vessels,[5] therefore the foreskin must be crushed with one of several special clamps in yet another painful step before the circumcision can be carried out.[6]
  4. Finally, in another, painful step, the foreskin must be cut away.

Lander et al. (1997) conducted a comparison neonatal non-therapeutic circumcision without anesthesia (current practice in 1997), ring block, dorsal penile nerve block, and a topical eutectic mixture of local anesthetics (EMLA).[7]

With no anesthesia, the infants screamed continuously. Newborns in the untreated placebo group exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the circumcision and following. Two newborns in the placebo group became ill following circumcision (choking and apnea). One experienced projectile vomiting.[7]

EMLA was the least effective pain control. Dorsal penile nerve block (DPNB) was more effective, and ring block was the most effective. The authors reported "[w]ithout exception, newborns in this study who did not receive an analgesic suffered great distress during and following the circumcision, and they were exposed to unnecessary risk (from choking or apnea)." The authors were so alarmed that they terminated the no anesthesia arm of the study early.[7] None of the analgesic measures tested provided total pain relief.[8] Any infant boy who undergoes neonatal circumcision will experience some pain and trauma. Boys who escape circumcision would have no pain or trauma. The authors concluded that circumcision should be performed with anesthetic, however the text makes clear that they meant analgesia, since full anesthesia is unsafe for neonates.[7]

Post-surgical pain

Circumcision is an invasive cutting and amputation. Like other invasive operations, post-surgical pain persists after the surgery for days or weeks. Infant boys will not receive effective analgesia because their young age makes such drugs dangerous.

Howard et al. (1994) studied male infants after their neonatal circumcision. They recorded the comfort scores of the infants at numerous periods after circumcision. They also observed and recorded feeding behavior.

It was found that feeding behavior deteriorated significantly after circumcision. Some breastfeed infants were unable to breastfeed and required formula feeding after circumcision. Acetaminophen was found to be almost totally ineffective against the post-circumcision pain. It did have some effect six hours after the circumcision. The authors concluded "that circumcision of the newborn causes severe and persistent pain."[9]

Traumatic effect of infant circumcision

There is now substantial evidence that infant circumcision causes post traumatic stress disorder ̪(PTSD). Preverbal memory starts to function before birth and continues to function in the newborn period,[10] and infants are now known to feel pain intensely,[11] so all of the necessary requirements are present.[12]

Taddio & colleagues (1995)(1997) studied the effect of neonatal circumcision on the behavior of boys after surgery and at the time of vaccination. It was found that circumcised boys had a higher pain response at time of vaccination six months later as compared with intact boys,[13] [14] showing that the nervous system had been permanently sensitized to heightened pain sensation.

Taddio et al. (1997) concluded:

Although postsurgical central sensitisation (allodynia and hyperalgesia) can extend to sites of the body distal from the wound, suggesting a supraspinal effect, the long-term consequences of surgery done without anaesthesia are likely to include post-traumatic stress as well as pain. It is, therefore, possible that the greater vaccination response in the infants circumcised without anaesthesia may represent an infant analogue of a post-traumatic stress disorder triggered by a traumatic and painful event and re-experienced under similar circumstances of pain during vaccination.[14]

John Rhinehart, M. D., (1999) a clinical psychiatrist, reported finding numerous cases of PTSD in his adult male patients pursuant to infant circumcision.[15]

Effect of extreme pain on developing nervous system

Fitzgerald & Walker (2003) argued that extreme pain (such as that caused by circumcision) may alter developing nervous tissue in the very young.[16]

History

Investigating pain of circumcision

Paul Emil Flechsig (1847-1929) was an eminent nineteenth-century German neuroanatomist, psychiatrist and neuropathologist. He suggested in 1872 that infants could not feel pain because their nerves are not completely myelinated.[17] Incredible as it may seem today, his idea was accepted without question and without being tested.

As a result, medical doctors performed all manners of invasive, painful procedures on neonates without anesthesia or analgesia, including millions upon millions of painful circumcisions and even open heart surgery. Open heart surgery was performed with curare to paralyze the infant but without any anesthesia.

Flechsig's bizarre opinion was not questioned until the 1970s. Several lines empirical of research carried out in the 1970s suggested that infants can in fact feel intense pain.

  • Anders et al. (1970) showed that measurement of serum cortisol is a useful indicator of pain for psychological investigation in infancy.[18]
  • Emde et al. (1971) showed that the "stress" of circumcision caused an increase in the amount of non-REM sleep.[19]
  • Richards, Bernal & Brackbill (1976) reported behavioral differences between American boys (circumcised) and British boys (genitally intact).[20]
  • Luther, Kraybill & Potter (1976) compared the level of cortisol in infants before and after circumcision. They found a substantial rise in the cortisol levels in the infants, which they said was due to the "stress" of circumcision.[21]
  • Rawlings, Miller & Engel (1980) showed that as the pain of circumcision increased, oxygenation of the skin decreased.[22]
  • Gunnar et al. (1981) recorded serum cortisol and behavior state throughout the unanesthetized, non-therapeutic circumcision process. Serum cortisol levels and behavioral distress were found to be closely related. The authors stated:

Neonatal circumcision is performed without anesthesia and it is clearly stressful for the infant.

So great was Flechsig's influence, the authors were still unwilling to use the word pain and substituted the word stress.[23]

  • Marshall et al. (1982) studied mother-child interaction with regard to feeding behavior after circumcision without anesthesia. They found that circumcised boys had more interruptions of feeding in the 24-hour period of observation.[24]

Porter, Miller & Marshall (1986) studied the nature of pain cries during unanesthetized, non-therapeutic circumcision. the cries during circumcision were found to shorter, with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; and greater variability of the fundamental. Adult listeners judged these cries to have an unusual degree of urgency.[25]

Surgical operation on infants without anesthesia continued for well over a century, at least until 1987, when the American Academy of Pediatrics was forced to issue a CYA statement that called for the use of anesthesia.[26]

Anand & Hickey (1987) published a paper in the New England Journal of Medicine that totally demolished Flechsig's ridiculous claims and conclusively proved that newborn infants are capable of feeling intense pain. After publication of this paper, no doubt about pain sensation in infants remained. The article stated:

Numerous lines of evidence suggest that even in the human fetus, pain pathways as well as cortical and subcortical centers necessary for pain perception are well developed late in gestation, and the neurochemical systems now known to be associated with pain transmission and modulation are intact and functional. Physiologic responses to painful stimuli have been well documented in neonates of various gestational ages and are reflected in hormonal, metabolic, and cardiorespiratory changes similar to but greater than those observed in adult subjects. Other responses in newborn infants are suggestive of integrated emotional and behavioral responses to pain and are retained in memory long enough to modify subsequent behavior patterns.[11]

Gunnar et al. (1988) examined the association between behavioral distress and adrenocortical activity. It was found that differences in behavioral distress did not reliably the level of adrenocortical activity. Moreover, it was found that while non-nutritive sucking reduces crying it did not reduce the adrenocortical response to the stressful stimulus of circumcision pain.[27]

Although by 1989 it was totally clear that infants can feel intense pain, the 1989 American Academy of Pediatrics Circumcision Task Force, under the leadership of the infamous Edgar J. Schoen, M. D., declined to recommend the use of analgesics for non-therapeutic neonatal circumcision, thereby condemning million of newborn baby boys to a painful, stressful circumcision.[28]

Finding an ethical way to do painful non-therapeutic circumcision

The finacially and psychologically vested circumcision industry suddenly found itself in a predicament. It was now suddenly proven beyond any shadow of a doubt that newborn baby boys can feel intense pain. Medical ethics and the standard of care now necessitated pain relief, however it is dangerous to give general anesthesia to neonates. Wallerstein (1985) had proposed that routine (non-therapeutic) circumcision of baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,[29] however this clearly would not do for the avid pro-circumcision lobby. No circumcision equals no fee for surgery. The financial gain from discontinuing non-therapeutic circumcision is just too high to discard. Bollinger (2012) estimated that the total annual cost of non-therapeutic circumcision to Americans is $3,647,000,000.[30] The avaricious American circumcision industry is simply not willing to give that lucrative income up, so a way to make non-therapeutic circumcisions in infancy acceptable had to be found.

Three methods were proposed:

  • Application of EMLA Cream topical anesthetic. EMLA is a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%. EMLA Cream (lidocaine 2.5% and prilocaine 2.5%), applied to intact skin under occlusive dressing, provides dermal analgesia by the release of lidocaine and prilocaine from the cream into the epidermal and dermal layers of the skin and by the accumulation of lidocaine and prilocaine in the vicinity of dermal pain receptors and nerve endings.[31]
  • Dorsal Penile Nerve Block (DPNB) as proposed by Kirya & Werthman (1978).[32]
  • Ring Block. Broadman et al. (1987) proposed ring block for neonatal non-therapeutic circumcision.[33] Ring block is considered the most effective analgesic procedure for neonatal non-therapeutic circumcision. Infant boys feel less pain and suffer less trauma than with the other two pain reduction procedures.[7] [34]

The standard of care now requires analgesia if elective neonatal non-therapeutic circumcision is to be carried out.[26] [35]

However, none of the above three procedures totally eliminate pain. A baby boy will still experience some pain despite any of those analgesic procedures. Prevention of pain requires protecting a boy from elective neonatal non-therapeutic circumcision. Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or trauma.

Attitudes and practices regarding analgesia for newborn circumcision

Historic attitudes and practices

Wellington & Rieder (1993) conducted a survey of physicians in London, Ontario. They found that only 4 percent used DPNB. They concluded:

Despite evidence that neonates perceive pain and that there is a physiologic stress response to circumcision which can be reduced if analgesia is employed, the vast majority of physicians performing newborn circumcisions either do not employ analgesics or employ analgesics of questionable efficacy. Lack of familiarity with the use of analgesics among neonates and with dorsal penile block in particular are the most common reasons cited for lack of analgesic use. Educational efforts and research into less invasive techniques of analgesia for newborn circumcision are urgently required.[36]

Ryan & Finer (1994) carried out a training program for physicians in the newborn nurseries of the Womens' Pavilion, Royal Alexandra Hospital, Edmonton, Alberta, Canada. After a training program, they found that 66 percent of physicians who perform non-therapeutic neonatal circumcisions had started to use analgesia during the procedure. This applies to one hospital in Canada.[37] (Non-therapeutic neonatal circumcisions are no longer performed in Canadian hospitals.)[38]

Maxwell & Yaster (1999) called on physicians to use analgesia during neonatal non-therapeutic circumcision surgery, saying:

DESPITE THE DEBATE that continues over the benefits and risks of nonritual neonatal circumcision, it remains a commonly performed surgical procedure in the United States. To the best of our knowledge, it is the only surgical procedure that is routinely performed without first administering analgesia or anesthesia. This unconscionable state of affairs exists, despite the overwhelming evidence that newborns, even those born prematurely, are capable of experiencing pain. Indeed, anyone present during a circumcision realizes that the newborn feels and responds to pain and will attempt to withdraw if unrestrained. In addition, this pain has physiologic correlates: elevated heart rate and blood pressure, lowered arterial oxygen saturation, and elevated levels of adrenocortical hormones. During the past 15 years, results of a multitude of studies have demonstrated that effective analgesia can prevent this pain and ameliorate the associated stress response. Furthermore, the failure to provide anesthesia or analgesia has been shown to cause not only short-term physiologic perturbations but also longer-term behavioral changes.[39]

The American Academy of Pediatrics convened a new task force on circumcision under the chair of Carole M. Lannon, M. D. That task force reversed the position previously taken under Edgar J. Schoen. It clearly stated that non-therapeutic infant circumcision is "not essential to the child’s current well-being." It provided an extensive discussion of procedural analgesia and said, quite strongly, that, if a circumcision is done, procedural analgesia should be provided.[35]

Kraft (2003) reported that "many health care practitioners routinely perform this procedure without the use of any or with inadequate or ineffective analgesia and anesthesia."[40]

Contemporary attitudes and practices

Little is known about current attitudes and practices regarding the use of analgesia in circumcision of the newborn. Application of analgesia prior to neonatal nontherapeutic circumcision takes additional physician time, so there may be a tendency to skip it.

Video

Infant circumcision procedure

Please note how the infant's lips quiver with pain.

Adolescent and adult circumcision

Adolescent and adult circumcision is usually carried out under total anesthesia, either by local or regional nerve block or by general anesthesia,[41] so the pain of the surgery is not usually a concern. That does not mean that the operation is pain free. It is not.

  • There is, of course, post-surgical pain, which may be relieved by a potent oral analgesic. One should have a two-week supply of analgesic medicine.
  • The recovery period for adolescent and adult circumcision is usually placed at six weeks. During that period of time, many patients experience pain when they they have involuntary nocturnal erections and the erection tightens the residual skin and pulls at the incision and suture.[42] In a few cases, the erections may cause wound dehiscence which requires additional surgery to re-close the surgical wound.
  • That is not the only source of pain. Circumcision amputates the protective foreskin. In cases of phimosis, the glans penis may never have been exposed before, so there frequently is severe pain when the glans penis touches anything. Many men complain that they are unable to wear trousers for an extended period of time. Only time and keratinization can ease this pain.
  • Circumcision is inexact surgery. Surgeons have to guess at how much skin to amputate, so they frequently get it wrong. If sufficient skin is not available to permit penis expansion during times of erection, then taut, painful erections are the result. This complication may be treated by tissue expansion. The tension may also cause wound dehiscence, which would cause additional pain.
  • Neuromas may form at the circumcision scar. Cold & Taylor (1999) reported that they are "notorious for generating pain.".[43]

See also

External links

  • REFweb Hill, George (11 September 2006). Pain of circumcision and pain control, Circumcision Reference Library. Retrieved 8 November 2020.
    Quote: Circumcision is the most stressful surgical procedure commonly performed on newborns.

References

  1. ↑ REFjournal Deibart GA. The separation of the prepuce in the human penis. Anat Rec. 1933; 57: 387-99. DOI. Retrieved 8 November 2020.
  2. ↑ REFjournal Oliver JE. Circumcision and cruelty to children. Br Med J. 1979; 2(6195): 933. PMID. PMC. DOI. Retrieved 8 November 2020.
    Quote: Without anaesthetic the operation in babies causes pain, intense and prolonged crying, air swallowing, vomiting sometimes followed by apnoea, and sometimes permanent local complications.
  3. ↑ REFjournal Falliers. Circumcision. JAMA. 21 December 1970; 214(12): 2194. Retrieved 8 November 2020.
  4. ↑ REFjournal Winkelmann RK. The cutaneous innervation of the human newborn prepuce. J Invest Dermatol. January 1956; 26(1): 53-67. Retrieved 8 November 2020.
  5. ↑ REFjournal Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Infect. October 1998; 74(5): 364-67. PMID. Retrieved 15 October 2019.
  6. ↑ REFjournal Circumcision procedure (Gomco Clamp method). Patient Care. 15 March 1978; 12: 82-85. Retrieved 8 November 2020.
  7. ↑ a b c d e REFjournal Lander J, Brady-Frerer B, Metcalfe JB, Nazerali S, Muttit S. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA. 24 December 1997; 278(24): 2157-64. PMID. Retrieved 10 November 2020.
  8. ↑ REFjournal Bellieni, Carlo V., Alagna, Maria G., Buonocore, Giuseppe. Analgesia for infants’ circumcision. Ital J Pediatr. 13 June 2013; 39: 39. PMID. PMC. DOI. Retrieved 29 May 2021.
  9. ↑ REFjournal Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics. April 1994; 93(4): 641-6. PMID. Retrieved 9 November 2020.
  10. ↑ REFjournal Hepper PG. Fetal memory: Does it exist? What does it do?. Acta Pædiatrica Supplement (Stockholm). October 1996; 416: 16-20. PMID. DOI. Retrieved 11 November 2020.
  11. ↑ a b REFjournal Anand KJS, Hickey PR, et al. Pain and its effects in the human neonate and fetus. N Engl J Med. 19 November 1987; 317(21): 1321-9. PMID. DOI. Retrieved 11 November 2020.
  12. ↑ REFjournal Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychol. 2002; 7(3): 329-43. PMID. DOI. Retrieved 11 November 2020.
  13. ↑ REFjournal Taddio A, Goldbach M, Ipp M, Stevens S, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet. 1995; 344: 291-2. PMID. DOI. Retrieved 10 November 2020.
  14. ↑ a b REFjournal Taddio A, Katz J, Ilersich AL, Gideon K. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1 March 1997; 342(9052): 599-603. PMID. DOI. Retrieved 11 November 2020.
  15. ↑ REFjournal Rhinehart J. Neonatal circumcision reconsidered. Tranactional Analysis Journal. July 1999; 29(3): 215-21. Retrieved 11 November 2020.
  16. ↑ REFbook Fitzgerald, Maria, Walker, Suellen (2003): The role of activity in developing pain pathways. Work: Proceedings of the 10th World Congress on Pain. Dostovsky JO, Carr DB, Koltzenburg M (eds) (ed.). Vol. 24. Seattle: ASP Press. Pp. 185-96. Retrieved 18 November 2020.
    Quote: In common with other areas of the central nervous system, synaptic development of spinal sensory connections is experience or activity dependent. Evidence from both animal and human studies shows that alterations in the patterns of sensory activity that can arise from tissue injury and pain in early life may disrupt normal synaptic organization within the somatosensory system. While these studies are incomplete and more investigation is needed in this area, the potential clinical importance of neonatal plasticity in pain development is clear.
  17. ↑ REFjournal Cope DK. Neonatal pain: the evolution of an idea.. The American Association of Anesthesiologists Newsletter. September 1998; Retrieved 12 November 2020.
  18. ↑ REFjournal Anders TF, Sachar EJ, Kream J, Roffwarg HP, Hellman L. Behavioral state and plasma cortisol response in the human neonate. Pediatrics. October 1970; 46(4): 532-7. PMID. Retrieved 13 November 2020.
  19. ↑ REFjournal Emde RN, Harmon RJ, Metcalf D, Koenig KL, Wagonfeld S. Stress and neonatal sleep. Psychosom Med. 1971; 33(6): 491-7.
  20. ↑ REFjournal Richards MPM, Bernal JF, Brackbill Y. Early behavioral differences: gender or circumcision?. Dev Psychobiol. January 1976; 9(1): 89-95. PMID. Retrieved 13 November 2020.
  21. ↑ REFjournal Talbert LM, Kraybill EN, Potter HD. Adrenal cortical response to circumcision in the neonate.. Obstet Gynecol. August 1976; 46(2): 208-10. PMID. Retrieved 13 November 2020.
  22. ↑ REFjournal Rawlings DJ, Miller PA, Engel RR. The effect of circumcision on transcutaneous PO2 in term infants. Am J Dis Child. July 1980; 134(7): 676-8. PMID. DOI. Retrieved 13 November 2020.
  23. ↑ REFjournal Gunnar MR, Fisch RO, Korsvick S, Donhowe JM. The effects of circumcision on serum cortisol and behavior.. Psychoneuroendocrinology. 1981; 6(3): 260-75. PMID. DOI. Retrieved 13 November 2020.
  24. ↑ REFjournal Marshall RE, Porter FL, Rogers AG, Moore J, Anderson B, Boxerman SB. Circumcision: II: Effects upon mother-infant interaction. Early Hum Dev. 1982; 7(4): 367-74. PMID. DOI. Retrieved 14 November 2020.
  25. ↑ REFjournal Porter FL, Miller RH, Marshal RE. Neonatal pain cries: effect of circumcision on acoustic features and perceived urgency. Child Dev. June 1986; 57(3): 790-802. PMID. DOI. Retrieved 15 November 2020.
  26. ↑ a b REFjournal Poland RL, Roberts RJ, Gutierrez-Mazorra JF, Fonkalsrud EW. Neonatal anesthesia. Pediatrics. September 1987; 80(3): 447. Retrieved 12 November 2020.
  27. ↑ REFjournal Gunnar M, Connors J, Isensee J, Wall L, et al. Adrenocortical activity and behavioral distress in human newborns. Dev Psychobiol. May 1988; 21(4): 297-310. PMID. DOI. Retrieved 15 November 2020.
  28. ↑ REFjournal Schoen EJ, Anderson G, Bohon C, Hinman Jr F, Poland RL, Wakeman ME. Report of the Task Force of Circumcision. Pediatrics. October 1989; 89(4): 388-91. PMID. Retrieved 18 November 2020.
  29. ↑ REFjournal Wallerstein E. Circumcision: the uniquely American medical enigma. Urol Clin North Am. 1985; 12(1): 123-32. PMID. Retrieved 15 November 2020.
  30. ↑ REFweb Bollinger, Dan (2012). High cost of circumcision Icons-mini-file pdf.svg, Academia. Retrieved 15 November 2020.
  31. ↑ REFweb (21 April 2020). EMLA, Drugs.com. Retrieved 21 November 2020.
  32. ↑ REFjournal Kirya C, Werthman Jr MW. Neonatal circumcision and penile dorsal nerve block—a painless procedure.. J Pediatr. June 1978; 92(6): 998-1000. PMID. DOI. Retrieved 16 November 2020.
  33. ↑ REFjournal Broadman LM, Hannallah RS, Belman AB, Elder PT, Ruttiman U, Epstein BS. Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penis. Anesthesiology. 31 August 1987; 67(3): 399-402. PMID. DOI. Retrieved 18 November 2020.
  34. ↑ REFjournal Stang HJ, Snnellman LW, Condon LM, Conroy MM, Liebo R, Brodersen L, Gunnar MR. Beyond dorsal penile nerve block: A more humane circumcision. Pediatrics. August 1997; 100(2): e3. PMID. DOI. Retrieved 18 November 2020.
  35. ↑ a b REFjournal Lannon CM, Bailey AGD, Fleischman AR, Kaplan G, et al. Circumcision policy statement. Pediatrics. September 1999; 103(3): 687-93. PMID. DOI. Retrieved 19 November 2020.
  36. ↑ REFjournal Wellington N, Rieder MJ. Attitudes and practices regarding analgesia for newborn circumcision. Pediatrics. October 1993; 92(4): 541-3. PMID. Retrieved 18 November 2020.
  37. ↑ REFjournal Ryan CA, Finer NN. Changing attitudes and practices regarding local analgesia for newborn circumcision.. Pedatrics. August 1994; 94(2): 230-3. PMID. Retrieved 19 November 2020.
  38. ↑ James Loewen (2019). Personal communication.
  39. ↑ REFjournal Maxwell, Yaster. Analgesia for neonatal circumcisionː No more studies, just do tt. Arch Pediatr Adolesc Med. May 1999; 153(5): 444-5. PMID. DOI. Retrieved 21 November 2020.
  40. ↑ REFjournal Kraft NL. A pictorial and video guide to circumcision without pain. Adv Neonatal Care. April 2003; 3(2): 50-62. PMID. DOI. Retrieved 18 November 2020.
  41. ↑ REFjournal Holman, John R., Stuessi, Keith A.. Adult circumcision. American Family Physician. 15 March 1999; 59(6): 1514-8. PMID. Retrieved 19 November 2020.
  42. ↑ REFjournal Dai, A-Juan, Li, Miao, Wang, Li-Li, Wang, Xiao-Hua, Huang, Yu-Hua. Improvement of erection related incision pain in circumcision patients using interrupted rapid eye movement sleep: A randomized controlled study. Urol J. 2018; 15(3): 126-31. PMID. DOI. Retrieved 28 November 2020.
  43. ↑ REFjournal Cold, C.J., Taylor, J.R.. The prepuce. BJU Int. 1 January 1999; 83 Suppl 1: 34-44. PMID. DOI. Retrieved 29 November 2020.
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