17,156
edits
Changes
Jump to navigation
Jump to search
=== Pain ===
In the past, advocates of circumcision claimed that a newborn child's nerve system was not yet fully developed, and that as a result, the child felt no [[pain]] during the circumcision procedure. Anand & Hickey (1987) have shown that newborn children do in fact feel [[pain]], and more acutely than adults.<ref name="anand-hickey1987">{{REFjournal
|last=Anand
|first=
|author-link=
|last2=Hickey
|first2=
|author2-link=
|etal=no
|title=Pain and its effects in the human neonate and fetus
|trans-title=
|language=
|journal=New Engl J Med
|location=
|date=1987-11-19
|volume=317
|issue=21
|pages=1321-9
|url=https://www.cirp.org/library/pain/anand/
|quote=
|pubmedID=3317037
|pubmedCID=
|DOI=
|accessdate=2019-11-08
}}</ref> This has led American health associations to recommend doctors take measures to reduce the pain of circumcision in infants.
The [https://www.cirp.org/library/statements/aap1999/|AAP Circumcision Policy Statement] (1999) states quite clearly that ''"There is considerable evidence that newborns who are [[circumcised]] without analgesia experience pain and physiologic stress"''. Furthermore, the pain is quite severe, and requires injections for proper pain management. Sucrose and Acetaminophen ''"cannot be recommended as the sole method of analgesia"''. Topical cream is no longer thought sufficient as ''"the analgesic effect is limited during the phases associated with extensive tissue trauma such as...tightening of the clamp"''.<ref>{{REFjournal
|last=
|first=
|title=American Academy of Pediatrics: Circumcision Policy Statement; Task Force on Circumcision
|journal=Pediatrics
|date=1999-03
|volume=103
|issue=3
|pages=686-93
|url=https://pediatrics.aappublications.org/content/103/3/686#sec-9
|accessdate=2019-11-26
|note=Statement Reaffirmed Sept. 1, 2005
}}</ref>
The [[AAFP]] (2002) states quite simply in their [https://www.cirp.org/library/statements/aafp2002/| position paper], ''"Newborns experience pain during circumcision".''<ref>{{REFweb
|title=Circumcision: Position Paper on Neonatal Circumcision. Board Approved: August 2007 Reaffirmed
|website=Official American Academy of Family Physicians Website
|url=http://www.aafp.org/online/en/home/clinical/clinicalrecs/children/circumcision.html
|accessdate=2011-05-02
}}</ref> This is not a debatable fact, and yet, it is not widely accepted, even by some doctors. It might be hard for some doctors to accept, as they may have been taught that the infant does not feel [[pain]], and may have performed countless circumcisions with this idea. Usage of anesthesia for infant circumcision is still by no means the rule.
Penile injections of anesthetic are now recommended by all of the major medical institutions. In their [http://www.ama-assn.org/ama/no-index/about-ama/13585.shtml Report 10 of the Council on Scientific Affairs], the AMA states ''"When the decision is made to proceed with circumcision, local anesthesia should be provided for the procedure. Ring block or dorsal penile blocks [injections] are most effective. [[EMLA]] cream has limited utility"''. Alarmingly, ''"Despite the clear evidence that newborn males generate brisk pain responses during circumcision, a recent survey of residency training programs found that 26% of programs that taught circumcision provided no instruction on the use of local anesthesia". The AMA reports that "Of physicians performing circumcision, 45% use anesthesia, 71% of pediatricians, 56% of family practitioners, and 25% of obstetricians"''.<ref>{{REFweb
|title=Report 10 of the Council on Scientific Affairs (I-99): Neonatal Circumcision
|website=American Medical Association Official Website
|url=http://www.ama-assn.org/ama/no-index/about-ama/13585.shtml
|accessdate=2011-05-04
}}</ref>
The AAP's [http://www.healthychildren.org/English/ages-stages/prenatal/decisions-to-make/pages/Where-We-Stand-Circumcision.aspx Heatlhy Children website] suggests ''"Your pediatrician (or your obstetrician) should discuss the forms of analgesia that are available"''.<ref>{{REFweb
|title=Where We Stand: Circumcision
|publisher=[[AAP]]
|date=2011-03-23
|url=http://www.healthychildren.org/English/ages-stages/prenatal/decisions-to-make/pages/Where-We-Stand-Circumcision.aspx
|accessdate=2019-10-12
}}</ref> Be that as it may, few forms of analgesia are recommended. There are basically two types of injections to choose from, and the website does not go into the difference between a 'dorsal nerve block' and a 'ring block' injection.
Given what is known from aforementioned official documents, the AAP website may be more informative and effective if it would say ''"Make sure your doctor knows of the ineffectiveness of anything short of local anesthesia, and make sure your baby is given an injection. This is your responsibility, because your doctor may or may not be up to date on the latest understandings of infant sensitivity to pain during circumcision."'' The AAP may be holding back, however, perhaps because this would upset the doctor/parent power relationship, and may cause too much questioning of doctors in general. One may not expect to find this kind of advice on such a website, and yet, anything less than this is a dangerously weak statement.
To control [[pain]], some physicians that circumcise use Tylenol, sugar,<ref>{{REFweb
|quote=To calm the baby during the procedure, a sugar filled gauze pacifier soaked with sweet juice is used, and soothing music is played in the room.
|url=http://www.pollockclinics.com/circumcision/circumcision-guide.html
|title=Parents' Guide to Circumcision
|last=
|first=
|publisher=
|date=
|accessdate=2011-04-08
}}</ref><ref>{{REFweb
|quote=During the circumcision, your son will receive sugar pacifiers to suck on which reduce his pain perceptions.
|url=http://www.pollockclinics.com/circumcision/circumcision-before.html
|title=Before the Circumcision
|last=
|first=
|publisher=
|date=2011-04-08
|accessdate=2011-04-08
}}</ref> a topical cream,<ref>{{REFweb
|quote=Then in our office, he will have topical anesthetic applied to his penis.
|url=http://www.pollockclinics.com/circumcision/circumcision-before.html
|title=Before the Circumcision
|last=
|first=
|publisher=
|date=2011-04-08
|accessdate=2011-04-08
}}</ref> and/or a local anaesthetic injection called a dorsal penile ring block.<ref>{{REFweb
|quote=We use extensive pain control methods including Tylenol, a sugar solution (to reduce pain perceptions), a topical freezing cream, and a local anesthetic injection.
|url=http://www.pollockclinics.com/circumcision/circumcision-guide.html
|title=Parents' Guide to Circumcision
|last=
|first=
|publisher=
|date=
|accessdate=2011-04-08
}}</ref> Topical anaesthetic only serves to numb the area to lessen the pain of the injection, but studies have shown that a dorsal penile ring block is not always effective in stopping the pain of circumcision.<ref name="Journal of Perinatology April/May 2002">{{REFjournal
|last=Taeusch
|first=H. William
|init=HW
|last2=Martinez
|first2=Alma M.
|init2=AM
|last3=Partridge
|first3=J. Colin
|init3=JC
|last4=Sniderman
|first4=Susan
|init4=S
|last5=Armstrong-Wells
|first5=Jennifer
|init5=J
|last6=Fuentes-Afflick
|first6=Elena
|init6=E
|title=Pain During Mogen or Plastibell Circumcision
|journal=Journal of Perinatology
|volume=22
|issue=3
|pages=214-8
|url=http://www.nature.com/jp/journal/v22/n3/full/7210653a.html
|quote=...more than half of the study group had what we considered excessive pain/discomfort over the course of the entire procedure.
|pubmedID=
|pubmedCID=
|DOI=
|note=April/May 2002
|date=2002-04
|accessdate=2011-04-08
}}</ref><ref name="Clinical Pediatrics August 1986">{{REFjournal
|last=Williamson
|first=Paul S.
|init=PS
|last2=Evans
|first2=Nolan Donovan
|init2=ND
|title=Neonatal Cortisol Response to Circumcision with Anesthesia
|journal=Clinical Pediatrics
|volume=25
|issue=8
|pages=412-6
|url=http://cpj.sagepub.com/content/25/8/412.abstract
|quote=The adrenal cortisol response to surgery was not significantly reduced by the administration of lidocaine.
|pubmedID=
|pubmedCID=
|DOI=
|date=1986-08
|accessdate=2011-04-08
}}</ref> During circumcision, somp physicians give children sugar pacifiers to "reduce the perception of pain",<ref>{{REFweb
|quote=During the circumcision, your son will receive sugar pacifiers to suck on which reduce his pain perceptions.
|url=http://www.pollockclinics.com/circumcision/circumcision-before.html
|title=Before the Circumcision
|last=
|first=
|publisher=
|date=2011-04-08
|accessdate=2011-04-08
}}</ref> but in at least one study, data shows that giving sugar to a child doesn't help to reduce the perception of pain in the child.<ref name="Lancet, The 2010-10-09">{{REFjournal
|last=Slater
|first=Rebeccah
|init=R
|first2=Laura
|init2=L
|last2=Cornelissen
|first3=Lorenzo
|init3=L
|last3=Fabrizi
|first4=Debbie
|init4=D
|last4=Patten
|first5=Jan
|init5=J
|last5=Yoxen
|first6=Alan
|init6=A
|last6=Worley
|first7=Stewart
|init7=S
|last7=Boyd
|first8=Judith
|init8=J
|last8=Meek
|first9=Maria
|init9=M
|last9=Prof. Fitzgerald
|title=Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomised controlled trial
|journal=The Lancet
|volume=376
|issue=9748
|pages=1225-32
|url=http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2961303-7/fulltext
|quote=Our data suggest that oral sucrose does not significantly affect activity in neonatal brain or spinal cord nociceptive circuits, and therefore might not be an effective analgesic drug. The ability of sucrose to reduce clinical observational scores after noxious events in newborn infants should not be interpreted as pain relief.
|pubmedID=
|pubmedCID=
|DOI=
|date=2010-10-09
|accessdate=2011-04-08
}}</ref> Post-operative pain and the pain the child must endure during recovery is hardly, if ever, addressed by professionals.
It has been shown that an infant's response to [[pain]] can be altered for years as a consequence of circumcision.<ref>{{TaddioA etal 1995}}</ref><ref>{{TaddioA KatzJ IlersichAL KorenG 1997}}</ref>
{{Box|Boxtext=<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>}}
=== Sexual effects ===
Circumcision and frenectomy remove tissues with heightened erogenous sensitivity.<ref name="cepeda2023" /> <ref name="winkleman1959">{{WinkelmannRK 1959}}</ref> They concluded, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well."
The [[amputation]] of the prepuce results in the loss of the majority of fine-touch neuroreceptors found in the [[penis]], leaving only the uninhibited protopathic sensibility of the artificially externalized [[glans penis]]. The imbalance caused by not having the input from the now ablated fine-touch receptors may be a leading cause of the changes in sexual behavior noted in [[circumcised]] human males.<ref>{{REFjournal
|last=Van Howe
|init=RS
|author-link=Robert S. Van Howe
|last2=Cold
|init2=CJ
|title=Advantages and Disadvantages of Neonatal Circumcision
|journal=The Journal of the American Medical Association
|volume=277
|issue=13
|pages=1052-7
|url=http://www.ncbi.nlm.nih.gov/pubmed/9218663
|quote=
|pubmedID=9218663
|pubmedCID=
|DOI=
|date=1997-04-02
|accessdate=
}}</ref>
Histology of the male circumcision scar shows [[amputation]] neuromas, Schwann cell proliferation and the bulbous collection of variably sized neurites. [[Amputation]] neuromas do not mediate normal sensation and are notorious for generating pain.<ref name="ColdCJ TaylorJR 1999"/>
See [[Sexual effects of circumcision]] for more information.
Relocate sections.
The [[Circumcision methods]] are discussed in a separate article.
== Pain ==In the past, advocates of circumcision claimed that a newborn child's nerve system was not yet fully developed, and that as a result, the child felt no [[pain]] during the circumcision procedure. Anand & Hickey (1987) have shown that newborn children do in fact feel [[pain]], and more acutely than adults.<ref name="anand-hickey1987">{{REFjournal |last=Anand |first= |author-link= |last2=Hickey |first2= |author2-link= |etal=no |title=Pain and its effects in the human neonate and fetus |trans-title= |language= |journal=New Engl J Med |location= |date=1987-11-19 |volume=317 |issue=21 |pages=1321-9 |url=https://www.cirp.org/library/pain/anand/ |quote= |pubmedID=3317037 |pubmedCID= |DOI= |accessdate=2019-11-08}}</ref> This has led American health associations to recommend doctors take measures to reduce the pain of circumcision in infants. The [https://www.cirp.org/library/statements/aap1999/|AAP Circumcision Policy Statement] (1999) states quite clearly that ''"There is considerable evidence that newborns who are [[circumcised]] without analgesia experience pain and physiologic stress"''. Furthermore, the pain is quite severe, and requires injections for proper pain management. Sucrose and Acetaminophen ''"cannot be recommended as the sole method of analgesia"''. Topical cream is no longer thought sufficient as ''"the analgesic effect is limited during the phases associated with extensive tissue trauma such as...tightening of the clamp"''.<ref>{{REFjournal |last= |first= |title=American Academy of Pediatrics: Circumcision Policy Statement; Task Force on Circumcision |journal=Pediatrics |date=1999-03 |volume=103 |issue=3 |pages=686-93 |url=https://pediatrics.aappublications.org/content/103/3/686#sec-9 |accessdate=2019-11-26 |note=Statement Reaffirmed Sept. 1, 2005}}</ref> The [[AAFP]] (2002) states quite simply in their [https://www.cirp.org/library/statements/aafp2002/| position paper], ''"Newborns experience pain during circumcision".''<ref>{{REFweb |title=Circumcision: Position Paper on Neonatal Circumcision. Board Approved: August 2007 Reaffirmed |website=Official American Academy of Family Physicians Website |url=http://www.aafp.org/online/en/home/clinical/clinicalrecs/children/circumcision.html |accessdate=2011-05-02}}</ref> This is not a debatable fact, and yet, it is not widely accepted, even by some doctors. It might be hard for some doctors to accept, as they may have been taught that the infant does not feel [[pain]], and may have performed countless circumcisions with this idea. Usage of anesthesia for infant circumcision is still by no means the rule. Penile injections of anesthetic are now recommended by all of the major medical institutions. In their [http://www.ama-assn.org/ama/no-index/about-ama/13585.shtml Report 10 of the Council on Scientific Affairs], the AMA states ''"When the decision is made to proceed with circumcision, local anesthesia should be provided for the procedure. Ring block or dorsal penile blocks [injections] are most effective. [[EMLA]] cream has limited utility"''. Alarmingly, ''"Despite the clear evidence that newborn males generate brisk pain responses during circumcision, a recent survey of residency training programs found that 26% of programs that taught circumcision provided no instruction on the use of local anesthesia". The AMA reports that "Of physicians performing circumcision, 45% use anesthesia, 71% of pediatricians, 56% of family practitioners, and 25% of obstetricians"''.<ref>{{REFweb |title=Report 10 of the Council on Scientific Affairs (I-99): Neonatal Circumcision |website=American Medical Association Official Website |url=http://www.ama-assn.org/ama/no-index/about-ama/13585.shtml |accessdate=2011-05-04}}</ref> The AAP's [http://www.healthychildren.org/English/ages-stages/prenatal/decisions-to-make/pages/Where-We-Stand-Circumcision.aspx Heatlhy Children website] suggests ''"Your pediatrician (or your obstetrician) should discuss the forms of analgesia that are available"''.<ref>{{REFweb |title=Where We Stand: Circumcision |publisher=[[AAP]] |date=2011-03-23 |url=http://www.healthychildren.org/English/ages-stages/prenatal/decisions-to-make/pages/Where-We-Stand-Circumcision.aspx |accessdate=2019-10-12}}</ref> Be that as it may, few forms of analgesia are recommended. There are basically two types of injections to choose from, and the website does not go into the difference between a 'dorsal nerve block' and a 'ring block' injection. Given what is known from aforementioned official documents, the AAP website may be more informative and effective if it would say ''"Make sure your doctor knows of the ineffectiveness of anything short of local anesthesia, and make sure your baby is given an injection. This is your responsibility, because your doctor may or may not be up to date on the latest understandings of infant sensitivity to pain during circumcision."'' The AAP may be holding back, however, perhaps because this would upset the doctor/parent power relationship, and may cause too much questioning of doctors in general. One may not expect to find this kind of advice on such a website, and yet, anything less than this is a dangerously weak statement. To control [[pain]], some physicians that circumcise use Tylenol, sugar,<ref>{{REFweb |quote=To calm the baby during the procedure, a sugar filled gauze pacifier soaked with sweet juice is used, and soothing music is played in the room. |url=http://www.pollockclinics.com/circumcision/circumcision-guide.html |title=Parents' Guide to Circumcision |last= |first= |publisher= |date= |accessdate=2011-04-08}}</ref><ref>{{REFweb |quote=During the circumcision, your son will receive sugar pacifiers to suck on which reduce his pain perceptions. |url=http://www.pollockclinics.com/circumcision/circumcision-before.html |title=Before the Circumcision |last= |first= |publisher= |date=2011-04-08 |accessdate=2011-04-08}}</ref> a topical cream,<ref>{{REFweb |quote=Then in our office, he will have topical anesthetic applied to his penis. |url=http://www.pollockclinics.com/circumcision/circumcision-before.html |title=Before the Circumcision |last= |first= |publisher= |date=2011-04-08 |accessdate=2011-04-08}}</ref> and/or a local anaesthetic injection called a dorsal penile ring block.<ref>{{REFweb |quote=We use extensive pain control methods including Tylenol, a sugar solution (to reduce pain perceptions), a topical freezing cream, and a local anesthetic injection. |url=http://www.pollockclinics.com/circumcision/circumcision-guide.html |title=Parents' Guide to Circumcision |last= |first= |publisher= |date= |accessdate=2011-04-08}}</ref> Topical anaesthetic only serves to numb the area to lessen the pain of the injection, but studies have shown that a dorsal penile ring block is not always effective in stopping the pain of circumcision.<ref name="Journal of Perinatology April/May 2002">{{REFjournal |last=Taeusch |first=H. William |init=HW |last2=Martinez |first2=Alma M. |init2=AM |last3=Partridge |first3=J. Colin |init3=JC |last4=Sniderman |first4=Susan |init4=S |last5=Armstrong-Wells |first5=Jennifer |init5=J |last6=Fuentes-Afflick |first6=Elena |init6=E |title=Pain During Mogen or Plastibell Circumcision |journal=Journal of Perinatology |volume=22 |issue=3 |pages=214-8 |url=http://www.nature.com/jp/journal/v22/n3/full/7210653a.html |quote=...more than half of the study group had what we considered excessive pain/discomfort over the course of the entire procedure. |pubmedID= |pubmedCID= |DOI= |note=April/May 2002 |date=2002-04 |accessdate=2011-04-08}}</ref><ref name="Clinical Pediatrics August 1986">{{REFjournal |last=Williamson |first=Paul S. |init=PS |last2=Evans |first2=Nolan Donovan |init2=ND |title=Neonatal Cortisol Response to Circumcision with Anesthesia |journal=Clinical Pediatrics |volume=25 |issue=8 |pages=412-6 |url=http://cpj.sagepub.com/content/25/8/412.abstract |quote=The adrenal cortisol response to surgery was not significantly reduced by the administration of lidocaine. |pubmedID= |pubmedCID= |DOI= |date=1986-08 |accessdate=2011-04-08}}</ref> During circumcision, somp physicians give children sugar pacifiers to "reduce the perception of pain",<ref>{{REFweb |quote=During the circumcision, your son will receive sugar pacifiers to suck on which reduce his pain perceptions. |url=http://www.pollockclinics.com/circumcision/circumcision-before.html |title=Before the Circumcision |last= |first= |publisher= |date=2011-04-08 |accessdate=2011-04-08}}</ref> but in at least one study, data shows that giving sugar to a child doesn't help to reduce the perception of pain in the child.<ref name="Lancet, The 2010-10-09">{{REFjournal |last=Slater |first=Rebeccah |init=R |first2=Laura |init2=L |last2=Cornelissen |first3=Lorenzo |init3=L |last3=Fabrizi |first4=Debbie |init4=D |last4=Patten |first5=Jan |init5=J |last5=Yoxen |first6=Alan |init6=A |last6=Worley |first7=Stewart |init7=S |last7=Boyd |first8=Judith |init8=J |last8=Meek |first9=Maria |init9=M |last9=Prof. Fitzgerald |title=Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomised controlled trial |journal=The Lancet |volume=376 |issue=9748 |pages=1225-32 |url=http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2961303-7/fulltext |quote=Our data suggest that oral sucrose does not significantly affect activity in neonatal brain or spinal cord nociceptive circuits, and therefore might not be an effective analgesic drug. The ability of sucrose to reduce clinical observational scores after noxious events in newborn infants should not be interpreted as pain relief. |pubmedID= |pubmedCID= |DOI= |date=2010-10-09 |accessdate=2011-04-08}}</ref> Post-operative pain and the pain the child must endure during recovery is hardly, if ever, addressed by professionals. It has been shown that an infant's response to [[pain]] can be altered for years as a consequence of circumcision.<ref>{{TaddioA etal 1995}}</ref><ref>{{TaddioA KatzJ IlersichAL KorenG 1997}}</ref> {{Box|Boxtext=<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>}}== Risks and late effects ==
Just like tonsil or appendix surgery, circumcision is a surgical intervention and brings the usual risks related to surgical operations, alongside several specific risks of complications and late effects. Uberoi et al. (2022) report "some men are experiencing a complex negative constellation of psychological, physical, and sexual associations that lead to significant emotional distress directed both internally and externally. The posts also reveal a discovery phenomenon wherein men discover the physical and psychological manifestations of the decisions made by others to modify their genitals."<ref name ="uberoi2022">{{REFjournal
|accessdate=2023-01-08
}}</ref>
=== Possible operative and postoperative complications ===
}}</ref>
}}
=== Sexual effects ===
Circumcision and frenectomy remove tissues with heightened erogenous sensitivity.<ref name="cepeda2023" /> <ref name="winkleman1959">{{WinkelmannRK 1959}}</ref> They concluded, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well." The [[amputation]] of the prepuce results in the loss of the majority of fine-touch neuroreceptors found in the [[penis]], leaving only the uninhibited protopathic sensibility of the artificially externalized [[glans penis]]. The imbalance caused by not having the input from the now ablated fine-touch receptors may be a leading cause of the changes in sexual behavior noted in [[circumcised]] human males.<ref>{{REFjournal |last=Van Howe |init=RS |author-link=Robert S. Van Howe |last2=Cold |init2=CJ |title=Advantages and Disadvantages of Neonatal Circumcision |journal=The Journal of the American Medical Association |volume=277 |issue=13 |pages=1052-7 |url=http://www.ncbi.nlm.nih.gov/pubmed/9218663 |quote= |pubmedID=9218663 |pubmedCID= |DOI= |date=1997-04-02 |accessdate=}}</ref> Histology of the male circumcision scar shows [[amputation]] neuromas, Schwann cell proliferation and the bulbous collection of variably sized neurites. [[Amputation]] neuromas do not mediate normal sensation and are notorious for generating pain.<ref name="ColdCJ TaylorJR 1999"/> See [[Sexual effects of circumcision]] for more information. === Psychological late effects ===
[[Psychological_issues_of_male_circumcision#Circumcision_trauma_in_adults| Psychological late effects]] are also possible after a circumcision, especially if the operation was carried out in childhood. On this occasion a variety of [[trauma]] may occur, which depend, among others, on age and circumstances of the circumcision. For example, whether the circumcision took place with or without sufficient anaesthesia, if the individual has been informed about the operation beforehand, if he was [[circumcised]] against his will or without his consent, and also, in the case of infant circumcision, if he was told about it during childhood or had to find it out coincidentally on his own.
== Complications ==
=== Death ===