Changes

* [[Phimosis]]: as mentioned earlier, true [[phimosis]] is rare and can be treated effectively without surgery. According to a study by Blalock et.al. (2003)<ref>{{REFjournal |last=Blalock HJ, Vemulakonda V, Ritchey ML, Ribbeck M. |title=Outpatient management of [[phimosis]] Following newborn circumcision. '' |journal=J Urol'' |date=2003; |volume=169( |issue=6): |pages=2332-4.2334 |accessdate=}}</ref>, 2.9% of those circumcised develop a post-operative [[phimosis]], in which the circumcision scar constricts. In intact patients, the rate of [[phimosis]] is only 1% (see also the study by Jakob Øster above). Therefore, circumcision is not a preventive measure for [[phimosis]].

* As mentioned above, the [[foreskin]] keeps the [[Glans penis|glans]] moist. This subpreputial moisture contains, among other substances, the enzyme lysozyme, which breaks up the cell wall of bacteria, thereby providing a natural antibacterial screen. This explains the results of several studies, such as Laumann et.al.<ref>{{REFjournal |last=Laumann EO, Masi CM, Zuckerman EW. |first= |title=Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. '' |journal=JAMA'' |date=1997; |volume=277: |issue= |pages=1052-7.1057 |url= |accessdate=}}</ref>, which found a higher rate of infection with bacterial venereal diseases in circumcised than in intact men.* The studies by Fleiss ''et.al''. (1998<ref>{{REFjournal |last=Fleiss PM, Hodges FM, Van Howe RS. |first= |title=Immunological functions of the human prepuce. '' |journal=Sex Transm Inf'' |date=1998; |volume=74: |issue= |pages=364-7.367 |url= |accessdate=}}</ref> support this. According to the [[AAP]], the general sexual behaviour of the male - such as frequent change in partners and the use of condoms - has a much higher impact on sexually transmitted diseases then the circumcision status.<ref>{{REFjournal |last=Task Force on Circumcision. |first= |title=Circumcision policy statement. '' |journal=Pediatrics'' |date=1999; |volume=103( |issue=3): |pages=686-93.693 |url= |accessdate=}}</ref>

* Due to the inevitable loss of sensitivity as a result of circumcision, there is also the temptation to go without condoms, in order not to lose even more sensitivity.<ref>{{REFjournal |last=Hooykaas C, van der Velde FW, van der Linden MM. et al. |first= |title=The importance of ethnicity as a risk factor for STDs and sexual behaviour among heterosexuals. '' |journal=Genitourin Med'' |date=1991; |volume=67( |issue=5): |pages=378-83.383 |url= |accessdate=}}</ref><ref>{{REFjournal |last=Michael RT, Wadsworth J, Feinleib J, ''et al''. |first= |title=Private sexual behavior, public opinion, and public health policy related to sexually transmitted diseases: a US-British comparison. '' |journal=Am J Public Health'' |date=1998; |volume=88( |issue=5): |pages=749-54.754 |url= |accessdate=}}</ref><ref>{{REFjournal |last=Laumann EO, Masi CM, Zuckerman EW. |first= |title=Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. '' |journal=JAMA'' |date=1997; |volume=277: |issue= |pages=1052-7.1057 |url= |accessdate=}}</ref>* Two studies that have been published in early 2007<ref>{{REFjournal |last=Gray RH and colleagues. |first= |title=Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. |journal=Lancet. |date=2007: |volume=369; |issue= |pages=657-666. |url= |accessdate=}}</ref><ref>{{REFjournal |last=[[Robert C. Bailey|Bailey RC]] and colleagues. |first= |title=Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. '' |journal=Lancet''. |date=2007: |volume=369; |issue= |pages=643-656. |url= |accessdate=}}</ref>, which investigated the effectiveness of circumcision as a means of reducing the spread of HIV from infected women to heterosexual men in African high risk areas, have been repeatedly subjected to strong criticism. Both studies were ended prematurely, which distorted the results. The men who had been circumcised for the study had to stay sexually inactive during the wound healing, which gave the intact control group more relative opportunity to become infected. The fact that the USA has both the highest rate of circumcised males in the western world, as well as the highest HIV infection rate, makes the studies look dubious. Besides that, several other studies concluded that circumcision does not have a significant impact on the risk of infection with HIV.<ref>{{REFjournal |last=Grosskurth H, Mosha F, Todd J, et al. |first= |title=A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. '' |journal=AIDS'' |date=1995; |volume=9( |issue=8): |pages=927-34.934 |url= |accessdate=}}</ref><ref>{{REFjournal |last=Barongo LR, Borgdorff MW, Mosha FF, ''et al''. |first= |title=The epidemiology of HIV-1 infection in urban areas, roadside settlements and rural villages in Mwanza Region, Tanzania. '' |journal=AIDS'' |date=1992; |volume=6( |issue=12): |pages=1521-8.1528 |url= |accessdate=}}</ref><ref>{{REFconference |last=Changedia SM, Gilada IS. |first= |title=Role of male circumcision in HIV transmission insignificant in conjugal relationship (abstract no. ThPeC7420). |url= |place=Barcelona, Spain |source=Presented at the Fourteenth International AIDS Conference, Barcelona, Spain, July |date=7-12, July 2002. |accessdate=}}</ref><ref>{{REFconference |last=Connolly CA, Shishana O, Simbayi L, Colvin M. |first= |title=HIV and circumcision in South Africa (Abstract No. MoPeC3491). |url= |place=Bangkok, Thailand |source=Presented at the 15th International AIDS Conference, Bangkok, Thailand, July |date=11-16, July 2004. |accessdate=}}</ref><ref>{{REFconference |last=Thomas AG, Bakhireva LN, Brodine SK, Shaffer RA. |first= |title=Prevalence of male circumcision and its association with HIV and sexually transmitted infections in a U.S. navy population (Abstract no. TuPeC4861). |url= |place=Bangkok, Thailand |source=Presented at the 15th International AIDS Conference, Bangkok, Thailand, July |date=11-16, July 2004. |accessdate=}}</ref>* Urinary tract infections (UTI): a UTI can be effectively treated with antibiotics, this was also proven by studies<ref>{{REFjournal |last=McCracken |first=G. |title=Options in antimicrobial management of urinary tract infections in infants and children. '' |journal=Pediatr Infect Dis J'' |date=1989; |volume=8( |issue=8):552–55. |pages=552-555 |url= |accessdate=}}</ref><ref>{{REFjournal |last=Larcombe |first=J. |title=Urinary tract infection in children. '' |journal=BMJ'' |date=1999; |volume=319:1173–5. |issue= |pages=1173-1175 |url= |accessdate=}}</ref>. A Swedish study <ref>{{REFjournal |last=Mårild S, Jodal U. |first= |title=Incidence rate of first–time symptomatic urinary tract infection in children under 6 years of age. '' |journal=Acta Paediatr'' |date=1998; |volume=87( |issue=5):549–52. |pages=549-552 |url= |accessdate=}}</ref> found that, during the first 6 years of life, the incidence of UTIs in boys was 1.8%, but in girls was 6.6%. UTIs are less common in boys after the first year of life. Mueller ''et.al''. <ref>{{REFjournal |last=Mueller ER, Steinhardt, G., Naseer S. |first= |title=The incidence of genitourinary abnormalities in circumcised and uncircumcised boys presenting with an initial urinary tract infection by 6 months of age. '' |journal=Pediatrics'' |date=1997; |volume=100 (Supplement): |issue= |pages=580. |url= |accessdate=}}</ref> did not find a significant difference in UTI rates between circumcised and intact boys with normal urinary tract anatomy.* Other studies suggest that circumcision is more likely to raise than to lower the generally low risk of acquiring UTI: multiple studies from Israel showed a strong correlation between ritual circumcision on the 8th day of life and postoperative UTI.<ref>{{REFjournal |last=Menahem |first=S. |title=Complications arising from ritual circumcision: pathogenesis and possible prevention. '' |journal=Isr J Med Sci'' |date=1981; |volume=17( |issue=1):45–8. |pages=45-48 |url= |accessdate=}}</ref><ref>{{REFjournal |last=Cohen HA, Drucker MM, Vainer S, et al. |first= |title=Postcircumcision urinary tract infection. |journal=Clin Pediatr |date=1992; |volume=31( |issue=6):322–4. |pages=322-324 |url= |accessdate=}}</ref><ref>{{REFjournal |last=Goldman M, Barr J, Bistritzer T, Aladjem M. |first= |title=Urinary tract infection following ritual Jewish circumcision '' |journal=Isr J Med Sci'' |date=1996; |volume=32:1098–102. |issue= |pages=1098-1102 |url= |accessdate=}}</ref>

<ref>{{REFjournal |last=Wolbarst |first=A. |title=Circumcision and penile cancer. '' |journal=Lancet'' |date=1932; |volume=1( |issue=5655):150–53. |pages=150-153 |url= |accessdate=}}</ref>. Today, it is known that sexually transmitted human papillomavirus (HPV) is a major risk factor<ref>{{REFjournal |last=McCance DJ, Kalache A, Ashdown K, ''et al''. |first= |title=Human papillomavirus types 16 and 18 in carcinomas of the penis from Brazil. '' |journal=Int J Cancer'' |date=1986; |volume=37( |issue=1):55–9. |pages=55-59 |url= |accessdate=}}</ref>, as well as smoking<ref>{{REFjournal |last=Harish K, Ravi R. |first= |title=The role of tobacco in penile carcinoma. '' |journal=Brit J Urol'' |date=1995; |volume=75( |issue=3):375–7. |pages=375-377 |url= |accessdate=}}</ref>. Studies have shown that there is no significant difference in the risk of getting penile cancer between circumcised and intact men. To prevent a single case of penile cancer, it would statistically take 600 to 900 circumcisions<ref>{{REFdocument |title=Position Paper on Neonatal Circumcision |url= |contribution= |last= |first= |publisher=American Academy of Family Physicians. Position Paper on Neonatal Circumcision. (Leawood, Kansas, (February ) |format= |date=2002-02-14, 2002). |accessdate=}}</ref>. The influence of circumcision on the infection risk of the female partner with cervical cancer has been refuted several times as well. HPV vaccination is an effective measure against carcinoma of the cervix.

* Especially in newborns, where the bodily pain reduction mechanisms are not yet fully developed, local anaesthesia is often insufficient for the operation. Even in conjunction with regional anaesthesia of the dorsal nerve of the [[penis]], the rate of failure to provide sufficient anaesthetic even for experienced anaesthetists is still 5-10%. The general anaesthesia that would be needed for newborns, however, poses significant risks for the child, and, therefore, is only likely to be used in emergencies. A surgical operation without proper pain control can lead to the development of a specific pain memory<ref>Prof. Dr. med. Boris Zernikow {{REFweb |url=http://www.spiegel.de/spiegel/vorab/experte-warnt-rituelle-beschneidung-veraendert-das-gehirn-der-kinder-a-849534.html |title=Kinderschmerz-Experte warnt: Rituelle Beschneidung verändert das Gehirn der Kinder |trans-title=Children's pain expert warns: Ritual circumcision changes the brain of children |language=German |last=Prof. Dr. med. Boris Zernikow |first= |publisher=Spiegel Online |website= |date=2012-08-12 |accessdate=2019-10-11 |format= |quote=}}</ref>. In unsedated and partially sedated infants increased secretion of the stress hormone cortisol could be observed for months after the operation. Overall, their pain threshold was lower and the risk of chronic pain increased. Regardless of these findings, infant circumcisions with insufficient or no anaesthetic are still common practice<ref>{{REFjournal |last=Garry |first=T. |title=Circumcision: a survey of fees and practices. '' |journal=OBG Management'' |date=1994. ( |volume=October): |issue= |pages=34-6.36 |url= |accessdate=}}</ref><ref>{{REFjournal |last=Howard CR, Howard FM, Garfunkel LC, de Blieck EA, Weitzman M. |first= |title=Neonatal circumcision and pain relief: current training practices. '' |journal=Pediatrics'' |date=1998; |volume=101: |issue= |pages=423-428. |url= |accessdate=}}</ref><ref>{{REFjournal |last=Stang HJ, Snellman LW. |first= |title=Circumcision practice patterns in the United States. '' |journal=Pediatrics'' |date=1998; |volume=101: |issue=e5. |pages= |url= |accessdate= |note=Link to [[AAP]] website}}</ref>. During procedures which take several minutes, babies tend to fall into a state of stupor, which in the past was falsely interpreted as peaceful sleep, nurturing the belief that babies felt no pain. Measurements taken in those cases revealed a typically 3- to 4-fold increase in cortisol levels, which equals a state of severe shock.<ref>{{REFjournal |last=Gunnar MR, Fisch RO, Korsvik S, Donhowe JM. |first= |title=The effects of circumcision on serum cortisol and behavior. '' |journal=Psychoneuroendocrinology'' |date=1981; |volume=6( |issue=3): |pages=269-75.275 |url= |accessdate=}}</ref>

* Postoperative bleeding of the wound. This can have severe consequences especially for very young infants, if they are not treated promptly. Their blood volume is only about 85 ml per kilogram of body weight, and even moderate blood loss can lead to hypovolaemia, hypovolaemic shock and even death.<ref>{{REFbook |last=Smart J, Nolan T. (Editors). '' |first= |year=2000 |title=Paediatric Handbook'', Sixth Edition. |url= |work= |editor= |edition=6 |volume= |chapter= |pages=82 |location=Victoria, Australia: |publisher=Blackwell Science Asia, 2000: p. 82 |isbn= |quote= |accessdate= |note=}}</ref><ref>Wetli CV. Case 93-1711. ''Autopsy of Demetrius Manker''. Miami: Dade County Medical Examiner Department, June 23, 1993.</ref><ref>{{REFjournal |last=Hiss J, Horowitz A, Kahana T. |first= |title=Fatal haemorrhage following male ritual circumcision. '' |journal=J Clin Forensic Med'' |date=2000; |volume=7: |issue= |pages=32-4.34 |url= |accessdate=}}</ref><ref>Newell TEC. ''Judgement of inquiry into the death of McWillis, Ryleigh Roman Bryan''. Burnaby, B.C.: B.C. Coroner's Service, Monday, 19 January 2004</ref>

* Postoperative [[phimosis]]: a phimotic ring can develop during scarring, which makes a re-circumcision necessary. According to a study by Blalock et.al.<ref>{{REFjournal |last=Blalock HJ, Vemulakonda V, Ritchey ML, Ribbeck M. |first= |title=Outpatient management of [[phimosis]] Following newborn circumcision. '' |journal=J Urol'' |date=2003; |volume=169( |issue=6): |pages=2332-4.2334 |url= |accessdate=}}</ref>, the prevalence is 2.9%, according to Leitch<ref>{{REFjournal |last=Leitch |first=IOW. |title=Circumcision - a continuing enigma. '' |journal=Aust Paediatr J'' |date=1970; |volume=6: |issue= |pages=59-65. |url= |accessdate=}}</ref> 5.5%.* Meatal stenosis, a pathological narrowing of the opening of the urethra, which mostly occurs in infancy and early childhood. It is one of the most common complications of infant circumcision. A study from 2006 found meatal stenosis exclusively in previously circumcised boys. The incidence rate after a circumcision is at approximately 10%.<ref>{{REFjournal |last=Van Howe |first=RS. |title=Incidence of meatal stenosis following neonatal circumcision in a primary care setting. '' |journal=Clin Pediatr'' (Phila). |date=Jan-Feb 2006; |volume=45( |issue=1): |pages=49-54. |url= |accessdate=}}</ref><ref>{{REFjournal |last=Stenram, A., Malmfors, G., & Okmian, L. (1986): |first= |title=Circumcision for [[phimosis]]: a follow-up study. '' |journal=Scandinavian journal of urology and nephrology'', |date=1986 |volume=20( |issue=2), |pages=89 PMID |url= |pubmedID=3749823. |accessdate=}} </ref><ref>{{REFweb |url=http://emedicine.medscape.com/article/1016016-overview |title=Meatal Stenosis |publisher=Medscape |accessdate=2019-10-11}}</ref>

* When the circumcision is followed by the ultra-orthodox Jewish ritual of Metzitzah B'Peh (which consists of sucking blood from the wound with the mouth), there is a risk of infection with herpes simplex type 1, which can lead to brain damage or death.<ref>{{REFweb |url=http://www.nytimes.com/2012/03/08/nyregion/infants-death-renews-debate-over-a-circumcision-ritual.html?_r=0 |title=Baby’s Death Renews Debate Over a Circumcision Ritual |last=Robbins |first=Liz |date=2012-03-07 |accessdate=2019-10-11}}</ref>

* An unavoidable late effect of any circumcision is the permanent loss of sexual sensitivity. This is partly due to the removal of sensory tissue. The [[foreskin]] contains very many nerve endings and touch receptors, which account for the major part of male sexual sensation. If the [[foreskin]] is removed, they can no longer provide sexual stimulation. It is also partly due to the fact that the surface of the [[Glans penis|glans]] reacts to the missing protection from friction and drying out by developing a callus layer. This reduces the sensitivity of the remaining nerves in the [[Glans penis|glans]] gradually over the years. The study conducted by Sorrells et.al.<ref>{{REFjournal |last=Sorrells ML, Snyder JL, Reiss MD, et al. |first= |title=Fine-touch pressure thresholds in the adult [[penis]]. |journal=BJU Int |date=2007; |volume=99: |issue= |pages=864-9.869 |url= |accessdate=}}</ref> found a significant reduction of sensitivity to touch for circumcised compared to intact [[penis]]es in adult males. Other studies revealed that circumcised men use condoms significantly less often than intact men, since they further limit the sexual sensitivity (see above).* Painful tension can occur when there is too little reserve skin left to support a full erection<ref>{{REFjournal |last=Taylor, J.R., Lockwood, A.P., & Taylor, A.J. (1996). |first= |title=The prepuce: „Specialized <q>Specialized mucosa of the [[penis]] and its loss to circumcision.“ </q> |journal=British Journal of Urology, |date=1996 |volume=77, |issue= |pages=291-295. |url= |accessdate=}}</ref>. This risk is partly dependent on the anatomy of the [[penis]]. While some [[penis]]es already have the majority of their full size when flaccid ([[Flesh Penis]], or "[[shower]]"), others are rather short when flaccid and double or more their size during an erection ([[Blood Penis]], or "[[grower]]"). Especially in children's circumcision, where the [[penis]] is not yet fully developed, the amount of reserve skin needed in adulthood cannot be estimated.* Erectile dysfunction: Both the damage inflicted to the blood vessels in the [[foreskin]] and the reduced sexual sensitivity can be causes for reduced erectile function with advancing age.<ref>{{REFjournal |last=Money, J., & Davison, J. (1983): |first= |title=Adult penile circumcision: Erotosexual and cosmetic sequelae. |journal=Journal of Sex Research, |date=1983 |volume=19, |issue= |pages=289-292 |url= |accessdate=}}</ref>

* Vaginal dryness: Due to the loss of the natural gliding action, which comes from the mobility of the fore- and shaft skin, a much increased friction between [[penis]] and vagina occurs during intercourse. This can make intercourse painful for both partners and lead to abrasions<ref>{{REFjournal |last=[[Morten Frisch]], Morten Lindholm, Morten Grønbæk: |first= |title=Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. In: |journal=International Journal of Epidemiology Oktober |date=October 2011, |volume=40( |issue=5), S. |pages=1367-1381, doi: |url= |pubmedID=21672947 |DOI=10.1093/ije/dyr104, PMID 21672947. |accessdate=}}</ref><ref>{{REFjournal |last=Cortés-González, J., Arratia-Maqueo, J., & Gómez-Guerra, L. (2008): |first= |title=Does circumcision has an effect on female's perception of sexual satisfaction? |journal=Rev Invest Clin, |date=2008 |volume=60( |issue=3), |pages=227 PMID |url= |pubmedID=18807735. |accessdate=}}</ref> The prolonged time it takes circumcised men to reach orgasm, as well as the often longer and more vigorous thrusting movements - compared to intact men - play a part in this.<ref>{{REFjournal |last=Cold CJ, Taylor JR. |first= |title=The prepuce |journal=BJU Int |date=1999; |volume=83 |issue=Suppl. 1: |pages=34-44. |url= |accessdate=}}</ref><ref>{{REFjournal |last=Fink KS, Carson CC, DeVellis RF. |first= |title=Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. |journal=J Urol |date=2002; |volume=167( |issue=5): |pages=2113-2116. |url= |accessdate=}}</ref>

* It was observed that infants, following circumcision without pain control, had a disturbed bond with their mother<ref>{{REFjournal |last=Marshall RE, Porter FL, Rogers AG, ''et al''. [http://www.cirp.org/library/birth/marshall2/ |first= |title=Circumcision: II effects upon mother-infant interaction]. '' |journal=Early Hum Dev'' |date=1982; |volume=7( |issue=4): |pages=367-74374 |url=http://www.cirp.org/library/birth/marshall2/ |accessdate=}}</ref>, as well as problems with nurturing, up to the point of refusal to be fed. The sleeping habits of these babies were also disturbed, with prolonged non-REM sleep and increased waking.* In boys circumcised in childhood, post traumatic stress disorder (PTSD) could be diagnosed. In a study on Philippine boys, in whom no PTSD was found prior to the operation, 69% of the boys circumcised in the traditional ritual and 51% of those circumcised by standard medical procedures (including anaesthesia) fulfilled the DSM-IV criteria for PTSD following the operation.<ref>{{REFbook |last=Ramos |first=S, |last2=Boyle |first2=GJ. [ |year=2001 |title=Ritual and medical circumcision among Filipino boys: evidence of post-traumatic stress disorder |url=https://link.springer.com/chapter/10.1007/978-1-4757-3351-8_14 Ritual and medical circumcision among Filipino boys: evidence of post-traumatic stress disorder]. In: Denniston GC, Hodges FM, Milos MF (eds) '' |work=Understanding circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem''. |editor=Denniston GC, Hodges FM, Milos MF |edition= |volume= |chapter= |pages=253-270 |location=New York: |publisher=Kluwer Academic/Plenum Publishers, 2001: pp. 253-70. |isbn= |quote= |accessdate= |note=}}</ref>