THE JOURNAL OF CONTEMPORARY HEALTH LAW AND POLICY, Volume 17: Pages 61-133,
Fall 2000.

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IV. CIRCUMCISION: A SPECIFIC APPLICATION OF THE CONSENT DOCTRINE

      The foregoing discussion of medical consent in general and in the special case of parental permission for procedures on children yields a framework for analyzing circumcision. For simplicity, the analysis below is limited to the standard case of neonatal circumcision on newborn boys with normal genitalia. In 1999, history was made when a United Kingdom family court addressed on the merits a proposed circumcision of a five-year-old boy for religious reasons and unambiguously concluded that an order for circumcision would not be granted as circumcision did not satisfy the “paramountcy of welfare” standard, i.e., it was not in the best interests of the child.134 Due in part to the pervasive presence of neonatal circumcision in American society, no case addressing the validity of parental permission for a routine circumcision has ever been decided in a United States court. Instead, courts have repeatedly demonstrated their determination to avoid any confrontation with the legal issues raised by neonatal circumcision. In 1987, a lawsuit challenging the legal validity of parental permission for neonatal circumcision was denied by a California trial court and subsequently affirmed by the state appeals court.135 The California Supreme Court denied the petition for review.136 More recently, the Eighth Circuit Court of Appeals affirmed a trial court’s invocation of lack of standing as a justification for refusing to consider a mother’s claim on behalf of her son who was circumcised with his father’s consent, but without her consent.137

      Currently, an ongoing contest in New Jersey is attracting national attention which - like Re J - involves two divorcing parents with opposite desires regarding circumcision of their male child, three-year old Matthew Price. The Price case, in which unlike the British case neither parent claims any religious motives for their desires regarding the circumcision of their son, may in the end become the first recorded case directly addressing the viability of parental consent to circumcision. Already, the New Jersey Supreme Court has ordered the trial court to hold a rehearing in the matter, and has appointed an experienced children’s rights attorney as guardian ad litem.138

      Despite well-settled precedent supporting the viability of such a claim, which though technically moot is “capable of repetition, yet evading review,”139 the court ruled, based on the fact that the plaintiff had already had a circumcision performed, that no remedy existed for the plaintiff and the court could not protect him from being circumcised.

      Because there is no possibility of obtaining consent from the patient, the issues then become whether parents can give effective permission for the procedure, and what legal and ethical obligations doctors may have in this situation. Doctors do have a strict obligation to ensure that parents receive all material information relating to the risks and benefits of circumcision in a manner that they can comprehend, that any parent giving permission is fully competent to evaluate the information provided and that the treatment’s potential consequences, and that parents are not in any way unduly influenced by the manner or timing of the disclosure.

      The requirements for surrogates are in some respects more stringent than those affecting a patient’s own consent. While in certain circumstances, patients may themselves be able to provide legally valid consent to prophylactic removal of their own healthy tissue, parents can never grant permission for prophylactic removal of healthy tissue from their children. The benefits of the proposed procedure must clearly outweigh short - and long term disadvantages, and spiritual costs and benefits may not be incorporated into this analysis. The decision must be made solely for the patient’s own benefit; even potentially life-saving assistance for a close family member cannot justify violating a non-consenting patient’s right to be free of intrusive medical procedures.

      Parents should thus be able to give effective permission for circumcision, and doctors should be permitted to perform a circumcision, only if the benefits clearly outweigh any attendant costs. As we shall see, the evidence does not support routine circumcision.

       A. Does routine circumcision provide urgently needed medical benefits?

      Circumcision does not correct an existing injury, disease or harmful malfunction. Thus, even if circumcision provides some medical benefit, there is no urgency to perform the procedure. General ethical and legal principles concerning surgery on children therefore dictate that the decision whether a male will be circumcised must be suspended until the male is capable of making the decision himself. This is even clearer if claimed medical benefits would not be realized until adulthood.

      At most, some contend that circumcision is a prophylactic measure, to prevent urinary tract infection (UTI) in boys, penile cancer and sexually transmitted diseases (STDs) in adult males.140 Thus, the only claimed benefit that males would realize before adulthood is a reduced rate of UTI. It cannot plausibly be maintained that this is an urgently needed medical benefit. Moreover, even if urgency were not required, and even if the claimed prophylactic benefit were significant, that benefit would at a minimum, have to clearly outweigh any harm that circumcision might cause in order to overcome the general, well-established presumption against incursion on a non-consenting person’s physical integrity.

      In addition, as explained below, the claims that circumcision has prophylactic value have been essentially refuted. These claims are the latest in a long history of claimed benefits from circumcision that have proven to be illusory. In 1896, for example, the medical profession contended that circumcision helps avoid “phimosis, paraphimosis, redundancy (where the prepuce more than covers the glans), adhesions, papillomate, eczema (acute and chronic), oedema, chancre, chancroid, cicatrices, inflammatory thickening, elephantiasis, naevus, epithelioma, gangrene, tuberculosis, preputial calculi, hip-joint disease, hernia, …[o]nanism, seminal emissions, enuresis, dysuria, retention, general nervousness, impotence, convulsions, hystero-epilepsy.”141 All of these claims were ultimately shown to lack scientific foundation. More recent justifications likewise have been shown to lack scientific merit.142 The evidence regarding the current claims is evaluated below.

          1. Phimosis, balanitis, and hygiene concerns do not justify routine circumcision

      Although commonly given as justifications for neonatal circumcision,143 there is no scientific evidence to support these claims. The incidence of phimosis following circumcision (0.3% to 1.0%)144 is approximately the same as far males never circumcised (0.6% to 0.9%).145 In comparative studies the incidence of phimosis and balanitis was not significantly different between those circumcised and those not circumcised.146

      While it has likewise been asserted that a circumcised penis is more hygienic, no studies in the medical literature exist to support such a claim. To the contrary, circumcised boys under the age of three years have been found to have more problems associated with poor hygiene than intact boys.147

          2. Urinary tract infections do not justify routine circumcision

      Of the claimed benefits of circumcision, only one - reduction of UTI - would occur during childhood, before a male is able to decide for himself whether to undergo the procedure. Some studies have suggested a weak association between having a foreskin and developing a UTI148 a large proportion of UTIs are the result of anatomical defects of the urinary tract and kidney.149. The connection however, is extremely tenuous; one study calculates that roughly 195 boys would require circumcision to prevent one UTI occurrence.150 Even a study by a leading circumcision advocate estimated that circumcision prevents UTI is less than one percent of boys who undergo the procedure.151 Unfortunately, no one has yet made a viable attempt at producing data demonstrably free of influence from the numerous potential confounding variables. Until a study takes into account the influence of rooming in,152 breast feeding,153 level of parental education,154 prenatal maternal UTI,155 premature birth,156 history of UTI in a first degree relative,157 hygienic practices,158previous bacterial or viral infection,159 previous course of antibiotics,160race,161 urine collection method162 and diagnostic criteria,163 so definitive conclusions are possible regarding the protective effects of neonatal circumcision. This list of other possible variables suggests that even if circumcision did have an effect on UTI, a comparable or greater prophylactic effect could be accomplished by less drastic and less intrusive means - for example, by simply teaching parents and children proper hygiene and by encouraging mothers to breastfeed.

      Moreover, most UTIs are minor are are easily treated with oral antibiotics. The foreskin has been linked to the more serious infections that reach the kidneys.164 The most common infection-related claim by defenders of circumcision is that males not circumcised will develop renal failure.165 However, that claim is unsupportable.166 There is no reliable data on the rate of renal failure on children in the United States.167 Two Swedish studies have yielded more reliable information.168 The first study showed that UTI was not responsible for any of the renal failures among children in Sweden.169 The second study showed that UTI was responsible for only five percent of renal failures among children.170 Using the highest recorded Swedish national rate of renal failure in children and assuming all cases of renal failure from boys could be prevented by neonatal circumcision, it would take 476,190 circumcisions to prevent one renal failure. Those 476,190 would, as a statistical matter, cause at least 952 life-threatening complications.171 Circumcising to prevent renal failure is thus clearly irrational.

      In short, if circumcision does reduce UTI, it is a woefully ineffective method, especially when weighed against the very significant complications and other disadvantages which are discussed below in further detail. Contrary to the retrospective data gathered elsewhere, a prospective study of 603 Japanese boys, none of whom were circumcised, found that none had ever had a UTI.172 This result casts much doubt upon the American studies from which one would have predicted that between six and twenty-four of these boys (1-4%) would have a UTI. The Japanese study suggests that either Japanese hygiene is vastly superior or that the American studies are flawed.

          3. Penile cancer does not justify circumcision

      Accurate data on the rates of penile cancer in circumcised and intact men in the United States is not available. There have been no epidemiologic studies of the rate of penile cancer in circumcised males, nor has there been any studies that distinguished on the basis of circumcision status. Claims that routine circumcision has lowered penile cancer rates are therefore difficult to support. Countries such as Japan,173 Norway,174 Finland175 and Denmark,176 in which circumcision is rare, have penile cancer rates that are lower than the estimated rates in the United States.177 In any event, the rate of penile cancer in all western countries is extremely low; among all males in Japan, Finland, Norway, and Denmark, countries that employ national cancer registries, for example, the rate of cancer ranges form 0.5 to 0.8 per 100,000. In the United States, where the cancer incidences are based on estimates, the incidence of penile cancer is approximately 0.8 per 100,000. and accounts for only 0.16% of all cancers in American males.178

      By way of comparison, the combined rate of ovarian and breast cancer in women is 264 times higher than the rate of penile cancer in men, and breast cancer is much more common in men than penile cancer.179 As noted above, clear incontrovertible evidence demonstrates that prophylactic removal of breast and/or ovarian tissue would reduce the likelihood of developing cancer enough to add months to the life expectancy of women with genetic markers for breast cancer.180 Yet as also noted above, the substantial potential benefit of an oophorectomy and/or mastectomy is universally regarded as inadequate to justify such prophylactic surgery, except in a woman at high-risk for ovarian or breast cancer.181 It would be unthinkable to perform the surgery on a young girl. If a female were ever to undergo such prophylactic surgery it could not occur until after she both reached adulthood and gave informed consent for the procedure. Even if it were correct that circumcision reduces the risk of penile cancer to a statistically significant degree, it would still be clearly unjustified to use circumcision as a prophylactic. Even if the highest estimates of reduced risk were accurate, it would take over 260,000 circumcisions to prevent a single case of penile cancer. It follows that in 260,000 circumcisions one would expect 520 life-threatening complications.182 Routinely amputating healthy tissue in quest of such remote and speculative benefits is irrational and violates both medical ethics and human rights.183

          4. Sexually transmitted disease prevention does not justify routine circumcision

      The role of circumcision in preventing STDs is even less clear. For each sexually transmitted infection, including HIV, there are contradictory medical studies.184 Because the epidemiology of STDs involves a mixture of biological, sociological and psychological factors, it is impossible to isolate the foreskin as a factor in the spread of STDs. The available medical literature suggests certain trends, but nothing definitive. Circumcised men actually appear more likely to contract urethritis (such as gonorrhea or chlamydia) or viral infections (such as herpes simplex or human papillomavirus). Intact men, on the other hand, appear slightly more prone to genital ulcers (such as chancroid).185 The role of circumcision in the transmission of HIV is far from decided.186

      Although several African studies have suggested that circumcision reduces the risk of HIV infection, several others have failed to document any significant influence.187 A few population studies have found circumcision to increase the risk of HIV infection.188 Meta-analysis of the published studies has revealed a significant degree of between study heterogeneity. The one trend noted is that a foreskin may place an African man who engages in high-risk sexual behaviors at increased risk for HIV infection.189 For the general population, circumcision does not appear to have an impact.190 Even proponents of circumcision acknowledge that the African experience with HIV does not apply in first world countries.191 The most effective timing of circumcision is also under dispute. One African study documented that males circumcised before fifteen years of age were at increased risk of contracting HIV,192 while those circumcised after twelve years of age were at a lower risk.193 Because genital discharge is more prevalent than genital ulcers, the one consistent trend, from several recent population surveys, is that circumcised men are at greater risk for contracting a STD.194 It is therefore inappropriate to cite avoidance of STDs as a justification for circumcision.

       B. Harm caused by male circumcision

          1. Complications

      On the cost side, retrospective studies show that rates of immediate complications associated with neonatal circumcision are somewhere between 2.0%195 and 6.8%.196 One prospective study, looking at only for evidence of hemorrhage, found the rate of hemorrhage was 9.9%197 These estimates all exceed the 1.0% to 1.7% rate for complications for circumcisions performed after the first month of life.198 Complications range from hemorrhage - sometimes to the point of death and frequently necessitating a transfustion;199 minor infections;200 life-threatening infections sus as sepsis,201 meningitis,202 gangrene,203 staphylococcal scalded skin syndrome,204 erysipelas205 and scrotal absess;206 acute urinary retention leading to renal failure;207 penile ischemia;208 necrosis;209 buried penis;210 partial or complete penile amputation;211 iatrogenic hypospadias,212 total denudation of the penis;213 abdominal distension;214 pneumothorax;215 plastibell retention;216 urethral fistula;217 meatal ulceration;218 ruptured bladder;219 gastric rupture;220 tachycardia and heart failure;221 myocardial injury;222 iatrogenic burns;223 pulmonary embolism;224 phimosis;225 unilateral leg cyanosis;226 meatitis and meatal stenosis;227 penile hair tourniquet;228 to death.229

          2. Pain

      An additional and generally under appreciated cost is trauma to the newborn. Research has determined that newborns experience more pain from a give noxious stimuli than do older children and adults.230 The procedure is extremely painful.231 During circumcision, forceps or other probes are inserted into the delicate foreskin, where they are used to scrape, tear apart, and destroy the normal erogenous tissues. The baby’s sensitive foreskin is crushed, and the raw flesh is cut with scissors. Circumcision is usually followed by al alternation in sleep pattern marked by prolonged rapid eye movement sleep.232 The procedure frequently causes the newborn to withdraw from his environment thus interfering with his process of bonding with his mother and nursing.233 General anesthesia is considered too risky for use in the neonatal period, so most neonatal circumcisions are performed without anesthesia.234 Topical and local anesthetics, which blunt some of the pain do not adequately protect the infants. Experimental evidence indicates that newborns experience marked pain during circumcision, even when these agents are employed.235 In, 1997, researchers altered the number of subjects enrolled in an infant circumcision pain study because they concluded that inflicting pain on unanesthetized control patients was unethical.236

      Circumcision causes trauma to infants who are born with relatively few pain coping mechanisms.237 Pain causes irreversible changes in the infant’s developing brain, heightening his pain perception.238 These facts strongly support at least delaying circumcision until a male is older, when more can be done to avoid pain because the pain is more developed, thereby reducing the likelihood of permanent damage from the trauma. A prominent pediatric urologist has opined that postponing circumcision until after toilet training may also decrease the high rate of meatal stenosis in circumcised boys.239

          3. Loss of Function

      One recent study found that in circumcision approximately 50% of the penile skin sheath is removed, along with specialized nerves endings that are fundamental to normal sexual response.240 The sheath provides a natural lubricant and facilitates vaginal penetration during sexual intercourse.241 As a portion of the male reproductive apparatus, the foreskin clearly is not trivial.242

          4. Loss of immunological Protection and Physical Protection

      The human foreskin serves to protect the glans, an internal structure, from injury. The prepuce also serves valuable immunological functions by providing several defenses against infection.243 The infant’s prepuce has a pronounced tight tip with a sphincter, formed from the whorl of muscle tissue that stays closed to keep out foreign matter but opens to permit the outflow of urine.243 The sub-preputial wetness contains several secretions that act to destroy harmful microorganisms.245 The prepuce contains Langerhans cells, which provide the first line of mucosal immunity.246 Our understanding of mucosal immunity is still in its infancy.247

       C. Medical Considerations Strongly Disfavor Routine Circumcision

      Appropriate decision-making regarding the permissibility of infant circumcision requires balancing a neglible reduction of overall UTI and penile cancer rates against the significant disadvantages of the procedure - loss of functional and highly erogenous tissue, loss of immunological properties of the foreskin, risks of complications and the excruciating pain the newborn experiences. This balancing surely would yield the conclusion that the procedure is medically contra-indicated and not in the best interest of the infant patient.

      Numerous medical bodies around the world have recognized that routine infant circumcision is not medically justifiable. For example, in 1996, the Australian Association of Pediatric Surgeons announced that it does not support routine infant circumcision, because it is “inappropriate and unnecessary.”248 In 1997, the Australian Medical Association stated that neonatal circumcision should be discouraged by the medical profession.249 In 1991, the Australian College of Pediatrics likewise discouraged the practice of neonatal circumcision.250 The National Health and Research Council of Australia has stated that neonatal circumcision has “no medical indication” and that “the hazards of the operation outweigh…any possible advantages.”251 The British Medical Association has recommended that male circumcision be done only when medically necessary, stating that complications, including death, may result from this generally unnecessary surgery.252 In 1996, the Canadian Pediatric Society recommended that “[c]ircumcision of newborns should not be routinely performed.”253 Significantly, even though circumcision is the most frequently performed operation on children in the United States, a recent review article in an American journal discussing optimal times for performing various urological procedures on children did not mention circumcision.254

      The AAP has issued a series of statements regarding circumcision. Remarkably, even though the procedure is widespread in the United States and performed by many of the organization’s members, the AAP has never endorsed routine infant circumcision. In 1975, the AAP Task Force on Circumcision issued its first policy statement on circumcision, concluding that “[t]here is not absolute medical indication for routine circumcision of the newborn.”255 In 1999, the AAP admitted that scientific evidence does not support routine neonatal circumcision.256 Apparently unprepared, however, to accept the necessary conclusion that this prevalence practice should stop, the AAP merely stressed the importance of giving parents of male infants accurate and unbiased information and the opportunity to discuss the decision with a doctor.257 In 1991, the American Academy of Family Physicians took no position other than to state that it was a parental decision.258 Numerous medical bodies have stated their opposition to neonatal circumcision, or have at least acknowledged that the practice is not medically sound.259 Not a single national or international medical organization in the world recommends the procedure.

      D. Can parental permission for circumcision be effective?

      Given the foregoing, one might wonder how parental permission for routine circumcision could ever be effective, even if physicians comply with the requirements of informed permission. Like all surgical procedures, circumcision should not be subject to authorization by a surrogate for an incompetent person urless it is medically necessary. While there is some dispute in the American medical community today as whether routine circumcision provides any medical benefit, absolutely no one in the medical community seriously maintains that it is medically necessary or that it corrects an existing injury, disease, or malfunction.260 Accordingly, the Queensland Law Reform Commission in Australia recently stated that “consent by parents to [neonatal circumcision] being performed may be invalid in the light of the common law’s restrictions on the ability of parents to consent to the non-therapeutic circumcision of children.”261

      Both a best interests and a substituted judgment approach support this conclusion. Recent cost-utility analyses for neonatal circumcision that take as a given the supposed benefits with respect to only UTIs, but also cancer and STDs’ have concluded that over the course of a lifetime, circumcision on the whole either impairs health262 or has virtually no medical benefit.263 The evidence presented by weighing the costs and benefits suggests that circumcision is, in terms of the physical well-being of a boy, not in his best interests and not something to which a rational and fully informed person would be expected to consent. The inference of what the infant male would choose for himself, if able, receives further support from the actual choice of intact adult males. If the ultimate goal of medical decision-making for an incompetent person is to determine what the person would decide for himself, if able, the best evidence may be what similarly situated competent persons actually decide for themselves. Of males circumcised in the United States, only 3 in 1,000 choose to have this surgery performed later in life, suggesting that the overwhelming majority believe that the risks and sequelae of becoming circumcised outweigh any supposed benefits.264 If doctors followed the AAP Committee’s recommendation to delay the decision until the child is old enough to grant consent,265 circumcisions would rarely be performed in this country, as is the case in most other nations.

      One author has noted that parents may authorize overtreatment of a child, even though it provides no medical benefits to the child and may actually cause him harm, because it makes the parents feel better that they are purchasing some “care” for their child. The author opines that this is a form of child abuse-causing harm to a child in order to gratify parents-and, perhaps stating the obvious, contends that “the infant’s interests should absolutely supercede those of his or her parents.”266

      E. Non-medical reasons including social concerns and religion cannot justify parental permission for circumcision

      Many parents choose circumcision for their sons not because they mistakenly believe it is medically beneficial, but rather for non-medical reasons. Most common is a concern that their son may have social difficulties if his genitals do not look exactly like those of his father and those of the majority of his peers.267 This claimed social benefit for the child is both unsupported and insufficient to justify a non-consensual surgical intervention. It is unsupported because there is no evidence that intact boys undergo any greater social difficulties as a result of the difference between their genitals and those of their fathers or peers. If there were any such risk, any competent person could easily deal with this by explaining to their son that his genitals are natural and those of his father and some of his peers were surgically altered when they were babies. These “social concerns” are not sufficient enough to violate the physical integrity of a non-consenting person.

      A small percentage of North American parents choose circumcision for religious reasons, and our society is uncomfortable in criticizing or countermanding parents who act for their children on the basis of deeply held convictions. As discussed supra in Part I.D., it is a mistake, however, for physicians to believe that parents have a right to make their religious beliefs controlling on the question of whether a child is to undergo a non-medically indicated surgical procedure. No court has ever held that parents have a first amendment right to have unnecessary medical procedures performed on their children. To give that power gratuitously to certain parents because they have particular religious beliefs would be to violate one of their children’s constitutional and moral rights-the right to equal protection. If the state and the medical profession protect some children against medically inappropriate practices, they must protect all children against all medically inappropriate practices unless they can demonstrate that denying that protection to some children would be better for those children (who themselves have no religious beliefs).268 As the Supreme Court has stated, parents are free to make martyrs of themselves, but they are not free to make martyrs of their children.269 In other words, parents are not free to force their children to undergo unnecessary and harmful surgery, however well intentioned they might be. A United Kingdom family court has recently endorsed the principle that at least where two parents of two different religions disagreed on whether to circumcise, and where a local authority exercising parental responsibility under a care order, a circumcision could not be ordered. The court noted that mainstream medical opinion in the United Kingdom requires both paternal and material consent to a circumcision.270

F. Informed Consent

      Finally, even of non-medically indicated surgery is such as circumcision were legally and ethically permissible to perform on children, parental authorization for such surgery would still have to comport with the requirements of informed consent. As previously discussed, there are three basic requirements to informed consent: 1) disclosure of all relevant and material information; 2) verifying and fostering the capacity of the decision-maker; and 3) ensuring that the decision is voluntary.

          1. Disclosure

      Physicians are always under a legal and ethical duty to fully disclose to the decision-maker all available information regarding a proposed procedure. Because the duty requires all available information and not just the information a given physician happens to have acquired to be disclosed, physicians are under a duty to acquire all available information to as surgery that they perform. Physicians who perform circumcisions, therefore, have a legal and ethical duty to their infant patients to obtain and provide to the patients’ parents all available medical information regarding circumcision. This includes all pertinent available information about the nature of the foreskin, the pain that infants incur when it is removed, the risk of complications from the surgery, and any possible medical benefits and costs that may result from having it removed. A medical practitioner who fails to completely disclose the potential physical costs (and, presumably, other disadvantages is negligent.271

          a. Nature and purpose of the foreskin

      Recent articles in leading medical journals have documented the foreskin’s complex structure.272 Although the foreskin has been described as “the fold of skin covering the glans,”273 it is actually a complex, junctional tissue similar to the eyelids or the lips. It is designed to protect the glans of the penis, an internal structure, from trauma and infection.274 It also contains the highest concentration of fine-touch neuroreceptors in the penis. Only lips and fingertips have comparable neuroreceptors densities. By contrast, the glans is a neurologically dumb organ.275 Due to the foreskin’s rich abundance in neuroreceptors and its exquisite specialization as a producer of sexual pleasure, it may, in fact, be the most sensitive part of the infant male’s body.276

      Parents also need to be aware that the anatomically complete penis' involuting structure allows for erection without tightening of the skin over the penile shaft. During coitus the complete skin system of the penis, including the foreskin, allows for non-traumatic intromission and penile movement within the vaginal vault without chafing.277 Physicians owe a duty to male patients to inform their parents of the functionality and sensitivity that their sons will lose for a lifetime if a circumcision is carried out.

          b. Pain

      Physicians have an obligation to be forthright with parents about the pain that infants endure when their foreskin is removed surgically. Evidence suggests that physicians rarely do so, and that this omission is clearly unethical. Mary physicians may neglect to discuss the pain with parents because they fear it will be disturbing for the parents. But it should be disturbing and physicians owe a duty to the infant patient to make his parents aware of this disquieting aspect of circumcision. Physicians have a further obligation to make parents aware that adequate and safe anesthesia is not available during the neonatal period. They owe no duty to parents to make them feel better about granting permission for an unnecessary surgery.

          c. Risk of Complications

      Because healthy, richly innervated, erogenous tissue is removed with every circumcision, the complication rate of circumcision-if “complication” means harmful effect is 100% because it denies the patient the use and function of this specialized tissue. As mentioned above, the risk of additional immediate complication is between 2% and 10%.278 The danger of a later complication, such as meatal stenosis, represents an additional 5% to 10% likelihood of a harmful complication.279 Many of the potential immediate and later complications can be quite severe. Physicians are clearly obligated to make parents aware of these complication rates and the nature of the harms that might befall their son.

          d. No Significant Medical Benefits

      No significant medical benefit clearly has been demonstrated to result from routine neonatal circumcision, ash physicians have a duty to inform parents of that fact. As discussed below, studies purporting to demonstrate prophylactic health benefits have fatal flaws in their design and/or focus on maladies that are extremely rare - much rarer than the complications that result from circumcision itself.280 At best, these studies demonstrate the truism that amputation of healthy tissue can have marginally reduce the rate of maladies afflicting the organ from which it was taken simply because less tissue is available to contract a condition. Naturally, routine prophylactic amputation in children has never been entertained as an ethically or scientifically viable medical procedure. When the proposed benefits and real costs are aggregated, as in a cost-utility analysis, the proposed benefits are insufficient to counter the real costs.281 A physician who states that neonatal circumcision helps those illnesses without stating that any potential benefits are far outweighed by the real harm perpetrated violates his or her duty to provide accurate, complete information.

          e. Are physicians adequately disclosing this information?

      Evidence of actual practice reveals that physicians who perform circumcisions themselves know next to nothing about the part of the body that they are removing. A 1975 survey revealed that 47% of physicians believed that a non-retractable foreskin in a newborn was an indication for circumcision, when it is perfectly normal and healthy for a newborn’s foreskin to be non-retractable and for the foreskin to become retractable only as a boy approaches adolescence.282 There is little evidence that physician knowledge has improved since then.283

      The misinformation promulgated regarding the painlessness of circumcision is unconscionable. Parents who cringe when their baby’s heel is pricked for a blood sample are led to believe that their son feels little or no pain when a large part of his penis is cut off. This may be because parents typically believe that anesthesia is used even when it is not, or that if a local anesthesia is in fact used, the anesthesia is highly effective when it is not.

      With respect to the risk of complications and the supposed medical benefits associated with circumcision, studies reveal that physicians underreport the risks and exaggerate the supposed benefits. A 1987 study found that physicians routinely inform parents about only a small minority of the medical complications associated with elective circumcisions.284 The common practice is to mention only pain, infection and bleeding as complications of newborn circumcision.285 This is far below the standard level of disclosure for other surgeries, whether medically indicated or cosmetic. The physician should disclose each of the many potential complications mentioned above, addressing the risks of serious bodily harm and even death, the probability of “success,” and the alternatives to circumcision, ad any risks associated with these alternatives. A study has shown, however, that physicians do not do this.286 When selecting which medical complications to mention to parents, physicians tend to use a subjective assessment of the frequency and seriousness of complications. The study revealed that the physicians’ probability of estimates were inaccurately low and their assessments of the seriousness of potential complications were consistently lower than those expressed by mothers of newborn sons.287

      There are many reasons why physicians provide inadequate information. Many who discuss the surgery with the mother postpartum assume that the arguments for and against circumcision have already been discussed with a health care provider. Those who meet the parents well in advance of the birth may simply feel too busy to properly discuss the pros and cons with the parents, and may not have equipped themselves with the literature necessary to adequately present the facts to the parents. Compliance with the medical profession’s ethical requirement for obtaining true informed consent is a time-consuming, laborious process. Doubtless, wherever they can, many physicians will cut corners on such a task, especially where as with circumcision, they may believe than some parents would prefer not to learn the full truth regarding potential complications.288 The current perception that circumcision is “just a little snip” and the cultural prejudice that a child’s physical integrity is less important than an adult’s physical integrity makes it easier to justify bypassing a full disclosure.

      In addition, physicians may simply feel uncomfortable full discussing with parents the risks of circumcision.. Furthermore, many parents choose circumcision for non-medical reasons. Likewise, many physicians see circumcision as a cultural, not a medical, practice. Physicians may believe that discussing the possible complications with parents is more likely to upset the parents than to influence the parent’s decision. Parental hostility following complete disclosure is not uncommon.289 The easiest path, in terms of the physician’s own comfort, is to provide sparse information because the parents will decide who will provide medical care for their child, and sometimes the fear of losing patients may override the duty to do what is in the best interest of the child.

      Edward Etchells et al. suggest that physicians base the content of their discussions with the parents on the perceived motives of each set of parents:

If the parents’ decision is based on strong cultural beliefs and practices, a detailed impersonal account of all known risks and benefits would probably not be relevant or helpful. However, if the decision is based on personal experiences (e.g., the father was circumcised), a detailed discussion of the risks and benefits would be helpful in helping the parents to come to a decision.290

      This approach is simply untenable. Obvious practical and ethical difficulties are created by an approach that requires physicians to determine parental motives and to provide widely diverging types and levels of information depending on this determination. More fundamentally, the authors fail to explain how parental motives alters the risk, the benefits, the treatment options, or the physician’s duty to the patient, i.e. the child, to give full disclosure. Tellingly, physicians’ positions regarding circumcision are inconsistent with their positions on therapeutic privilege291 and substitute consent for adult incompetent patients.292 This suggests a failure to accord proper respect to the interests and rights of children who are the patients and an improper focus on the interests and desires of the parents. The extent of information that parents actually want or feel comfortable receiving is legally and ethically irrelevant to the physician’s duty of disclosure.

      The misleading presentation medical personnel typically give to parents may also result from a failure to seek out available information. Three years after the release of the 1975 AAP Task Force on Circumcision report, which stated that “[t]here is no absolute medical indication for routine circumcision of the newborn,”293 only 49% of Chicago area, pediatricians, obstetricians and family practitioners were aware of the AAP’s position.294 At that time, 41% recommended routine infant circumcision despite the AAP report, while only 15% recommended the infant forgo the practice.295 The frequency of routine circumcision in Chicago area hospitals (70% to 90% remained unchanged in the three years following the AAP’s statement.296 Another study in 1975 analyzed a random group of 92 primary care physicians and 103 parents of male infants.297 Despite the content of the 1975 AAP report, 65% of the physicians conveyed a positive attitude about routine neonatal circumcision to their patients.298 Although pediatricians were more likely to have a neutral attitude, both family and general practitioners were more likely to favor routine neonatal circumcision.299

      A particular physician’s attitude toward circumcision may derive more from the results of personal experience and cultural background than from careful study of the medical literature. A physician’s gender and circumcision status, for example appear to affect whether he or she promotes or discourages circumcision. One study found that 100% of the health care providers surveyed who encouraged circumcision were male, while 81% of those discouraging the practice were female.300 Another survey found that circumcised physicians were more likely to favor circumcision than those not circumcised.301 Physicians asked to summarize their opinions regarding circumcision offered a wide variety of opinions, ranging from “personally I appreciated the cosmetic effect” to “barbaric ritual perpetuated for irrational reasons.”302

      The Code of Ethics of the Canadian Medical Association instructs physicians to “inform [their] patient[s] when [their] personal morality would influence the recommendation or practice of any medical procedure the patient needs or wants’ and to indicate when their opinion is contrary to the generally held position of the profession.303 This is undoubtedly sound practice. It suggests that a physician who belongs to a religion that requires male circumcision should disclose this during any discussion with a patient or parent concerning circumcision. Likewise, a physician who recommends neonatal circumcision has an obligation to state, depending on what country he is practicing in, that his national medical organization does not recommend neonatal circumcision. As with any ineffective, outdated treatment, physicians have a sound basis for refusing to perform neonatal circumcision.304

      Physicians’ failure to adequately inform themselves about circumcision and to pass on all acquired relevant information is reflected in the level of parental knowledge about circumcision when parents give permission for the surgery. A 1979 study surveyed two hundred mothers to determine their attitudes toward and knowledge of neonatal circumcision.305 Of those that were either doctors or other health care providers, 95% circumcised their sons. Although the mothers offered a wide variety of reasons for granting permission, few of these reasons had any medical validity (let alone sufficient weight to actually make their decision rational). Eighty-seven percent of mothers considered circumcision to be without risk or complications, and 80% of mothers stated that no physician ever explained the risks to them.306 A 1996 study revealed that 35% of mothers who gave permission for circumcision of their sons believed that neonatal circumcision had no risks involved.307 Twenty-five percent of the women in this study believed that they had not been given enough information.308

      Finally, the physician is obligated to disclose all personal interests unrelated to the patient’s health that he or she may have when obtaining consent to medical treatment.309 The Supreme Count of California held that a cause of action for lack of informed consent exists where a physician fails to disclose, prior to obtaining the patient’s consent to remove his spleen, that the physician has made arrangements to use portions of the spleen for economically beneficial medical research purposes.310

      In the circumcision context, there arises a particular egregious, if relatively rare, application of this principle that his drawn significant media attention in recent years - the harvesting of foreskins from living babies and the subsequent use of the foreskins for profit by the medical industry.311 Clearly such use of foreskins taken from living donors should be prohibited even with parental permission, because it is not related in any way to the circumcision itself and the affected infant cannot possibly consent to this use of his formerly, healthy functional tissue.312 In fact, two American Medical Association (AMA) policy statements appear to explicitly bar such a practice. AMA Policy E-2.08 on “Commercial Use of Human Tissue,” requires informed consent from patients for the use of organs or tissues in clinical research, mandates disclosure of potential commercial applications prior to realizing a profit on products developed from biological materials, prohibits the use of human tissue and its products for commercial purposes without the prior consent of the patient providing the original cellular material, and demands that diagnostic and therapeutic alternatives offered to patients conform to standards of good medical practice and be free of influence in any way be the commercial potential of a patient’s tissue.313 AMA policy E-2.167 on “The Use of Minors as Organ or Tissue Donors” requires that all such use have parental approval, that a “clear benefit” to the minor exist, that the minor be the only available source of the tissue, and that minors be allowed to serve as sources of tissue only for close family members.314 Medical applications of foreskins harvested from live donors are also forbidden under international law pursuant to the European Convention on Human Rights and Biomedicine.315 Even if such use of circumcised foreskins were ethical, physicians would certainly have an obligation to disclose that potential conflict of interests to parents.

          2. Capacity

      Medical personnel have a duty to the newborn child to ensure that parental surrogates have the capacity to make a rational, reflective decision about circumcision. They should fully disclose all relevant information about the procedure well in advance of the birth, and then evaluate whether the parents understood the information. If the parents do not appear to understand, the physician should attempt to convey the information in another way that is clearer to the parents. Some researchers have contended that parents are less rational in medical decisions concerning their children than they are in medical decisions concerning themselves.316 Medical personnel may therefore have a heightened duty when dealing with parental surrogates to ensure the surrogate is capable of making a rational decision on behalf of the infant patient.

      Several studies have looked into different media for presenting information to parents about circumcision and what effect each would have on the likelihood of parents giving permission. A survey of obstetric clinic patients in a large urban hospital showed that oral communication of the risks involved would significantly reduce the rate of circumcision (72% in the study group versus 94.4% in the control group). The authors concluded that mothers in the population they studied requested circumcision for their sons because of inadequate medical information or strong social motives.317 Another study showed that videotape counseling modestly reduced parental permission for circumcision when compared with standard oral counseling (70.5% versus 75.9%, OR=0.76, 95%, CI=0.61-0.94). Prior to the study, the circumcision rate at that medical center was 90.4%.318

      Parents may actually be resistant to receiving information about circumcision, and that would diminish their capacity to understand what is presented. One study of oral provision of information to mothers about risks had to be suspended when many mothers became upset and expressed their unwillingness to have the physician who provided the information care for their children in the future.319 The obstetrical nurses were also belligerent to the physician who provided the mother’s with oral information because the physician was upsetting their patients.321 Parents are often irritated by any discussion of circumcision because their minds are already made up.320 Told that circumcision carries the risk of penile amputation, serious life-threatening infection, and death, parents find that their self-esteem challenged by this information because they do not want to unnecessarily place their children at risk while at the same time often being unwilling to rethink a decision they have already made. In short, they do not want to be confused or unsettled by the facts. As noted previously, the physician’s obligation is to the child, not to the parent, and that obligation includes a duty to overcome parental resistance, and ensure that parents receive, understand, and take into account all of the facts.322 Otherwise, their permission for circumcision of the infant cannot be effective.

          3. Voluntariness

      The voluntariness requirement demands that physicians provide information regarding circumcision to parents in an unbiased fashion well in advance of the birth and that physicians do not themselves propose the procedure to parents. To ensure that any parents who are predisposed to request circumcision receive full information in advance of birth, the physician might tell parents that he or she will assume, unless the parents indicate otherwise, that the baby is not to be circumcised. If the subject first arises at birth, or if the parents do not receive the relevant information about the procedure until the time of birth, the physician should refuse to perform the procedure until such time as the parents have been able to review the information fully and demonstrate to the physician that they understand the information. One group of physicians has suggested simply waiting twelve hours after birth before asking parents about circumcision, in order to provide an opportunity to discuss the procedure’s advantages and disadvantages with the parents.323 However, given the tremendous psychological and physical impact of becoming a parent, this waiting period is inadequate to allow the parent sufficient opportunity to allow the parent sufficient opportunity to absorb and analyze information regarding the circumcision procedure before making a decision. Some writers have questioned whether, given the perinatal emotional upheaval, parental permission can ever be truly free and informed in the neonatal context.324 Indeed, one author (Svoboda) has accumulated a significant number of consent forms for neonatal circumcision, not a single one of which adequately discloses all significant risks to the procedure in a manner parallel to the disclosures which are commonly made for other surgeries.325

      Unfortunately, current practice appears inconsistent with the voluntariness requirement as well. It is customary in the United States to ask a woman during one of the initial prenatal visits whether she desires circumcision for her baby if it is a boy.326 As noted above, offering a medically unnecessary surgery such as circumcision is unethical.327 It is also a subtle form of coercion; offering circumcision can easily be interpreted as a recommendation.328 Mothers are left with the impression that “it must be the thing to do, or our doctor would not have told us about it.”329

      Even more troubling is the common occurrence of parents being presented with the circumcision question for the first time when a mother is in labor at a hospital. Surgeon George Kaplan notes that “all too often the consent to circumcise is included in a sheaf of papers that the mother signs hurriedly on her way to the delivery room. No discussion has been held regarding the merits of the procedure or of the inherent risks.”330 Kaplan characterizes this practice as “inexcusable.”331 Raising the circumcision issue for the first time upon the mother’s arrival at the hospital to give birth amounts to manipulation and coercion. Because the physician and the hospital benefit financially from the parent’s decision, such a practice raises grave concerns about unethical profiteering.

      Effective consent to elective, cosmetic surgery cannot arise unless and until the patient himself is capable of giving it. Infant males are clearly incapable of providing voluntary consent (and in fact uniformly howl in protest of the procedure), and without medical necessity or urgency, there is no justification for looking to a surrogate to give permission. Unlike cases involving medical necessity for treatment of a child, in the circumcision context there is simply no predicate for departing from the general rule that the patient himself must give voluntary consent to any incursion on his physical integrity by medical professionals. The AAP Committee on Bioethics sensibly recommends delaying, elective, cosmetic surgery until a child is old enough to give consent., and this would apply to circumcision.332 As previously noted, the Australian Association of Paediatric Surgeons has taken this position specifically with respect to circumcision,333 as have scholars who have considered the issue.334 Because, as discussed above, no sufficient conditions exist for not deferring the procedure, ethically and legally it must be deferred, given the harm caused by the procedure and the probability that as an adult the patient will most likely not desire it.

      With all compelling reasons to delay circumcision, it is necessary to examine why circumcision is performed at such a young age. For many years, two rationales supported the practice of circumcising right after birth. First, it was once thought that the newborn could not feel pain.335 Although this has been proven false,336 and the opposite - that newborns actually feel greater pain from the same trauma than do adults - has been proven true, some physicians still blindly adhere to the old myth.337 Second, it was once regarded as less costly to perform circumcision right after birth because general anesthesia is not used.338 That rationale might have some force if the first rationale, that babies feel less pain were true, but it is hard to imagine any medical professional seriously espousing this rationale today, when the babies-feel-no-pain myth has been disproved. One would expect that medical professionals would not use ineffective anesthesia on older children and adults simply because it would be cheaper, and that no parents would knowingly agree to subject their infant to excruciating pain when that could easily be avoided, simply to save money.

      But old habits die hard in the medical profession. In the case of children, rationality runs up against an additional obstacle - a pervasive unconscious view of children as less than full persons and of childhood as simply a time to be gotten through, a prelude to adulthood, rather than a period of life having independent worth, which should be as happy a time as society can make it. Medical personnel possessing this attitude may decide that pain in infancy is less cause for concern than pain in later life; adult pain is serious, but infant pain will be gotten over. So it may well be a lack of respect for newborns as persons and a lack of concern for their experience rather than any genuine medical rationale that compel physicians to perform circumcision in the neonatal period.339


      134. See Re J (Child’s Religious Upbringing and Circumcision), [1999] 2 F.L.R. 678 (Fam. Div.), affirmed, [2000] 1 F.L.R. 571 (C.A.). The Family Division is also available at <http://www.butterworths,co.uk/academic/fortin/cases/Re_J.htm> (last visited Nov. 17, 2000).
      135. London v. Glassner, California Court of Appeal, 1st District, No. A032040 (unpublished, petition for review denied); see also R. Morris, The First Circumcision Case, THE TRUTH SEEKER 47 (July/August, 1989).
      136. London v. Glassner, supra note 135. Adam London brought the case via his mother, who acted as guardian ad litem. The consent form signed by the mother stated that neonatal circumcision had no medical purpose. The issue before the court was whether a parent could grant permission for a surgical procedure that had no medical purpose.
      
137. See Fishbeck v. North Dakota, 115 F.3d 580, 580-81 (8th Cir. 1997). The plaintiffs attempted to challenge a North Dakota law (N.D. Cent. Code § 12,1-36-01 (1997)) prohibiting female genital mutilation on the grounds that the law was unconstitutional for lack of equal protection of males.
      138. C. Shoemaker, Baby M. Lawyer Joins Case on Circumcision, [Bridgewater, New Jersey] Courier News, Nov. 4, 2000, at D1.
      
139. See S. Pac. Terminal Co, v. Interstate Commerce Comm’n, 219 U.S. 498, 515 (1911); see also, e.g., Roe v. Wade, 410 U.S. 113, 125 (1973).
      140. Edgar J. Schoen, Wiswell TE, Moses S., New Policy on Circumcision - Cause for Concern, 105 PEDIATRICS 620, 620-23 (2000).
      
141. See Editor, Circumscisus, 49 MED. REC. 430, 430 (186).
      
142. See FREDERICK HODGES, A Short History of the Institutionalization of Involuntary Sexual Mutilation in the United States, in SEXUAL MUTILATIONS: A HUMAN TRAGEDY 17-40 (G.C. Denniston & M.F. Milos eds. 1997).
      
143. See American Academy of Pediatrics, Report of the Task Force on Circumcision, 84 PEDIATRICS 388, 388, 390 (1989).
      144. See Yosef A. Kaweblum et al., Circumcision Using the Mogen Clamp, 23 CLINICAL PEDIATRICS 679. 681-682 (1984); see also R.S. Van Howe, Variability in Penile Appearance and Penile Findings: A Prospective Study, 80 BRIT. J. UROLOGY 776 (1997).
      145. See K.R. Shankar & A.M.K. Rickwood, The Incidence of Phimosis in Boys, 83 BJU INTL (Suppl. 1) 101, 101 (1999); see also A.M.K. Rickwood et al., Phimosis in Boys, 52 BRIT. J. UROLOGY 147 (1980).
      146. See D.M. Fergusson et al., Neonatal Circumcision and Penile Problems: An 8-year Longitudinal Study, 81 PEDIATRICS 537, 537-39 (1988); See also Lynn W. Herzog & Susana R. Alvarez, The Frequency of Foreskin Problems in Uncircumcised Children, 140 AM. J. DISEASES CHILD. 254, 254-55 (1986); Van Howe, supra note 144, at 777-78.
      147. See Van Howe, supra, note 144, at 778.
      
148. Teresa To et al., Cohort Study on Circumcision of Newborn Boys and Subsequent Risk of Urinary-Tract Infection, 352 LANCET 1813, 1813-1815 (1998); J.C. Craig, J.F. Knight, P. Sureshkumar, E.Mantz, L.P. Roy, Effect of Circumcision upon Incidence of Urinary Tract Infection in Preschool Boys, 128 J. PEDIATRICS 363, 363-67 (1990).
      149.Jan Winberg et al., Epidemiology of Symptomatic Urinary Tract Infections in Childhood. 252 ACTA PAEDIATRICA SCANDINAVICA SUPPL. 1, 8 (1974); T Bergstrom, Sex Differences in Childhood Urinary Tract Infection, 47 ARCHIVES OF DISEASE IN CHILDREN 227 (1972); S.R. Saxena, D.C. Bassett, Sex-related incidence in Proteus Infection of the Urinary Tract in Childhood, 50 ARCHIVES OF DISEASE IN CHILDREN 899 (1975); R.J. Hallett et al., Urinary Tract Infection in Boys: A Three-year Prospective Study, 2 LANCET 1107 (1976); Linda Pead & Rosalind Maskell, Study of Urinary Tract Infection in Children in One Health District, 309 BRITISH MEDICAL JOURNAL 631, 632 (1994); T Bergstrom et al., Symptomatic Urinary Tract Infection in Boys in the First Year of Life with Special Reference to Scar Formation, 1 INFECTION 192 (1973).
      150. See To et al., supra note 148, at 1813, 1815 (1998).
      
151. See Thomas E. Wiswell et al., Declining Frequency of Circumcision: Implications for Changes in the Absolute Incidence and Male to Female Sex Ratio of Urinary Tract Infections in Early Infancy, 79 PEDIATRICS 338, 341 (1987).
      152. See Jan Winberg et al., The Prepuce: A Mistake of Nature?, 1 LANCET 598, 599 (1989).
      153. Alfred Pisacane et al., Breastfeeding and Urinary Tract Infection, 336 LANCET 50, 50 (1990); Alfredo Pisacane et al. Breast-Feeding and Urinary Tract Infection, 120 J. PEDIATRICS 87, 87, 89 (1992); Giovanni V. Coppa et al., Preliminary Study of Breastfeeding and Bacterial Adhesion to Uroepithelial Cells, 335 LANCET 569, 570 (1990); Staffan Mårild et al., Breastfeeding and Urinary Tract Infection 336 LANCET 942, 942 (1990); Staffan Mårild et al., Medical Histories of Children with Acute Pyelonephritis Compared with Controls, 8 PEDIATRIC INFECTIOUS DISEASE J. 511, 515 (1989).
      154. See D.C.L. Savage et al., Covert Bacteruria of Childhood. A clinical and Epidemiological Study, 48 ARCHIVES DISEASE CHILDHOOD 8, 14 (1973).
      
155. See generally Marguerite J. Patrick, Influence of Maternal Renal Infection on the Fetus and Infant, 42 ARCHIVES DISEASE CHILDHOOD 208 (1967).
      
156. See generally Mustapha Maherzi et al., Urinary Tract Infection in High-Risk Newborn Infants, 62 PEDIATRICS 521 (1978); Abdulkareem I. Airede, Urinary Tract Infections in African Neonates, 25 J. Infection 55 (1992); A. Eliakim et al., Urinary-Tract Infection in Premature Infants: the Role of Imaging Studies and Prophylactic Therapy, 17 J. PERINATOLOGY 305 (1997); Chester M. Edelmann Jr. et al., The Prevalance of Bacteruria in Full-Term and Premature Newborn Infants, 82 J. PEDIATRICS 125 (1973).
      
157. See Mårild, Medical Histories, supra note 153, at 511-15.
      
158. See Peter Malleson, Prepuce Care, 77 PEDIATRICS 265, 265 (1986); See also Kenneth L. Harkavy, The Circumcision Debate, 79 PEDIATRICS 649, 649 (1987); Stan J. Watson, Care of the Uncircumcised Penis, 80 PEDIATRICS 765, 765 (1987); Nicolas Cunningham, Circumcision and Urinary Tract Infections, 77 PEDIATRICS 267, 267, (1986).
      
159. See Mårild, Medical Histories, supra note 153, at 511-15.
      
160. See id.
      
161. See Asgar Askari & A. Barry Belman, Vesicoureteral Reflux in Black Girls, 127 J. UROLOGY 747 (1982); see also Steven J. Skoog & A. Barry Belman, Primary Vesicoureteral Reflux in the Black Child, 87 PEDIATRICS 538 (1991); Kathy N. Shaw et al., Prevalence of Urinary Tract Infection in Febrile Young Children in the Emergency Department [Abstract E16], 101 no.2 PEDIATRICS 390 (1998), also available at <http://www.pediatrics.org/cgi/content/full/102/2/e16> (last visited Nov. 12, 2000); Calvin M. Kunin, The Natural History of Recurrent Bacteruria in Schoolgirls, 282 NEW ENG. J. MED. 1443, 1444 (1970); Calvin M. Kunin, Epidemiology and Natural History of Urinary Tract Infection in School Age Children, 18 PEDIATRIC CLINICS N. AM. 509 (1971).
      162. See generally Theresa A. Schlager et al., Explanation for False Positive Urine Cultures Obtained by Bag Technique, 149 ARCHIVES PEDIATRICS & ADOLESCENT MED. 170 (1995); P.M. Fleiss, Explanation for False Positive Urine Cultures Obtained by Bag Technique, 149 ARCHIVES PEDIATRICS & ADOLESCENT MED. 1041; (1995); W.L. Robson & A.K. Leung, Explanation for False Positive Urine Cultures Obtained by Bag Technique, 149 ARCHIVES PEDIATRICS & ADOLESCENT MED. 1042 (1995); Jacob Amir et al., The Reliability of Midstream Urine Culture from Circumcised Male Infants, 147 AM J. DISEASES CHILD. 969 (1993); Theresa A. Slager et al., Bacterial Contamination Rate of Urine Collected in a Urine Bag from Healthy Non-Toilet-Trained Male Infants, 116 J. PEDIATRICS 738 (1990).; Xavier Saez-Llorens et al., Bacterial Contamination Rates for Non-Clean-Catch and Clean-Catch Midstream Urine Collections in Boys, 109 J. PEDIATRICS 659 (1986); Jacob A. Lohr et al., Bacterial Contamination Rates for Non-Clean-Catch and Clean-Catch Midstream Urine Collections in Boys, 109 J. PEDIATRICS 659 (1986); W. A. Bonadio, Urine Culturing Techniques in Febrile Children, 3 PEDIATRIC EMERGENCY CARE 75 (1987); J. D. Nelson & P.C. Peters, Suprapubic Aspiration of Urine in Premature and Term Infants, 36 PEDIATRICS 132 (1965); G.D. Abbot, Neonatal Bacteriuria - The Value of Bladder Puncture in Resolving Problems of Interpretation Arising from Voided Urine Specimens, 14 AUSTL. PEDIATRIC J. 83 (1978); John M. McCarthy & Charles V. Pryles, Clean Voided and Catheter Neonatal Urine Specimens. Bacteriology in the Male and Female Neonate. 106 AM. J. DISEASES CHILD. 473 (1963); John J. Boehm & James L. Haynes, Bacteriology of ‘Midstream Catch’ Urines: Studies in Newborn Infants, 111 AM. J. DIS. CHILD 366 (1966); C.G.H. Newman et al., Pyuria in Infancy, and the Role of Suprapubic Aspiration of Urine in the Diagnosis of Infections of the Urinary Tract, 2 BRIT. MED. J. 277 (1967); Ofelia T. Monzon et al., A comparison of Bacterial Counts of the Urine Obtained by Needle Aspiration of the Bladder, Catheterization and Midstream-Voided Methods, 259 NEW ENG. J. MED. 764 (1958); Paul Valenstein & Frederick Meier, Urine Culture Contamination: A College of Am. Pathologists and Q-probes Study of Contaminated Urine Cultures in 906 Institutions, 122 ARCHIVES PATHOLOGY & LABORATORY MED. 123 (1988); J. Pylkkänen et al., Diagnostic Value of Symptoms and Clean-Voided Urine Specimens in Childhood Urinary Tract Infection, 68 ACTA PAEDIATRICA SCANDINAVICA 341 (1979).
      
163. See Alejandro Hoberman & Ellen R. Wald, Urinary Tract Infections in Young Febrile Children, 16 PEDIATRIC INFECTIOUS DISEASE J. 11 (1997); see also S. Hansson et al., Low Bacterial Counts in Infants with Urinary Tract Infection, 132 J. PEDIATRICS 180 (1998).
      
164. See Elizabeth R. Mueller et al., The Incidence of Genitourinary Abnormalities in Circumcised and Uncircumcised Boys Presenting with an Initial Urinary Tract Infection by 6 Months of Age [Abstract 121], 100 PEDIATRICS 580, 580 (1997).
      165. James A. Roberts, Neonatal Circumcision: An End to the Controversy? 89 SOUTHERN MED. J. 167 (1996); James A. Roberts, Is Routine Circumcision Indicated in the Newborn? An Affirmative View, 31 J. FAM. PRACT. 185 186-88 (1990); Thomas E. Wiswell, Circumcision Circumspection, 336 NEW ENG. J. MED. 1244, 1244-45 (1997); Thomas E. Wiswell, Circumcision - An Update, 22 CURRENT PROBLEMS IN PEDIATRICS 424, 424-25, (1992); Thomas E. Wiswell, Routine Neonatal Circumcision: A Reappraisal, 41 AMERICAN FAMILY PHYSICIAN 859, 860 (1990); Thomas E. Wiswell, Do You Favor …Routine Neonatal Circumcision? Yes, 84 POSTGRADUATE MED. 98, 98-99 (1988); Edgar J. Schoen, The Status of Circumcision of Newborns, 322 NEW ENG. J. MED. 1308, 1309 (1990); Edgar J. Schoen, Benefits of Newborn Circumcision: Is Europe Ignoring Medical Evidence? 77 ARCHIVES OF DISEASES IN CHILDHOOD 258 (1997); Edgar J. Schoen et al., New Policy on Circumcision - Cause for Concern, 105 PEDIATRICS 620 (2000).
      166. See Roberts, supra note 165, at 168-70 (1996); Schoen, supra note 165, at 258, Thomas E. Wiswell, Do You Favor …Routine Neonatal Circumcision? Yes, 84 POSTGRADUATE MED. 98, 98-99 (1988); Thomas E. Wiswell & Dietrich W. Geschke, Risks from Circumcision During the First Month of Life Compared with Those for Uncircumcised Boys, 83 PEDIATRICS 1011, 1011, 1013 (1989); Thomas E. Wiswell, Routine Neonatal Circumcision: A Reappraisal, 41 AM. FAM. PHYSICIAN 859, 859-60 (199); Thomas E. Wiswell, Circumcision Circumspection, 336 NEW ENG. J. MED. 1244, 1244-45 (1997); Thomas E. Wiswell, Circumcision Questions [Letters to the Editor-Reply], 93 PEDIATRICS 1021, 1022 (1994).
      
167. Many of the European countries, though the records kept as part of their national health insurance, keep national registries of disease incidence. No such registries are maintained in the United States.
      
168. See generally Ingemar Helin & Jan Winberg, Chronic Renal Failure in Swedish Children, 69 ACTA PAEDIATRICA SCANDINAVICA 607 (1980); E. Esbjörner et al., Children with Chronic Renal Failure in Sweden 1978-1985, 4 PEDIATRIC NEPHROLOGY 249 (1990).
      
169. See Helin, supra note 168, at 610.
      
170. See Esjörner, supra note 168, at 249.
      
171. See William F. Gee & Julian S. Ansell, Neonatal Circumcision: A Ten-year Overview: With Comparison of the Gomco Clamp and Plastibell Device, 58 PEDIATRICS 824, 827 (1976).
      
172. See Hiroyuki Kayaba et al., Analysis of Shape and Retractability of the Prepuce in 603 Japanese Boys, 156 J. UROLOGY 1813 (1996).
      173. See C.S. Muir & Janine Nectoux, Epidemiology of Cancer of the Testis and Penis. National Cancer Institute Monograph 53: Second Symposium on Epidemiology and Cancer Registries in the Pacific Basin 145-64 (1979).
      
174. See T. Iverson et al., Squamous Cell Carcinoma of the Penis and of Cervix, Vulva, and Vagina in Spouses: Is There Any Relationship? An Epidemiological Study from Norway, 1960-1992, 76 BRIT. J. CANCER 658, 658 (1997).
      
175. See A. G. Maiche, Epidemiologal Aspects of Cancer of the Penis in Finland, 1 EUR. J. CANCER PREVENTION 153 (1992).
      
176. See M. Frisch et al., Falling Incidence of Penis Cancer in an Uncircumcised Population (Denmark 1943-90), 311 BRIT. MED. J. 1471 (1995).
      177. See P.A. Wingo et al., Cancer Statistics, 1995, 45 CAL. CANCER J. FOR CLINICIANS 8-30 (1995).
      
178. See id.
      
179. See S.L. Parker et al., Cancer Statistics, 1995, 47 CAL. CANCER J. FOR CLINICIANS 5-27 (1997).
      
180. See further discussion supra Part II.C.
      181. See further discussion supra Part II.C.
      182. See Gee, supra note 171, at 824-27.
      
183. See Svoboda, supra note 32 at 201-15 (routine male circumcision violates numerous human rights under a variety of international treaties including the Convention on Civil and Political Rights and the Convention on the Rights of the Child); Denniston, supra note 61.
      
184. See R.S. Van Howe, Does Circumcision Influence Sexually Transmitted Diseases? A Literature Review, 83 (Suppl. 1) BJU INT’L. 52, 52-62 (1999).
      185. See id.
      
186. See De Vincinzi & T. Mertens, Male Circumcision: A Role in HIV Prevention?, 8 AIDS 153 (1994); R.S. Van Howe, Circumcision and HIV Infection: Meta-Analysis and Review of the Medical Literature, 10 INTL J. STD & AIDS 8 (1999).
      187. See Van Howe, supra note 186, at 8-16.
      
188. See id.
      
189. See Nigel O’Farrell & Matthias Egger, Circumcision in Men and the Prevention of HIV Infection: A “Meta-Analysis” Revisited, 11 INTL J. STD & AIDS 137, 141 (2000); R. Hayes & H.A. Weiss, Meta-Analysis on the Relationship between Male Circumcision and HIV Infection (paper presented at the Thirteenth Meeting of the International Society for Sexually Transmitted Diseases Research, Denver, Colorado, July 13, 1999).
      
190. See O”Farrell & Egger, supra note 189; Hayes & Weiss, supra note 189.
      
191. See Steven Moses et al., Analysis of the Scientific Literature on Male Circumcision and the Risk for HIV Infection, 10 INT’L J. STD & AIDS 626 (1999).
      
192. See Maria Quigley et al., Sexual Behaviour Patterns and Other Risk Factors for HIV Infection in Rural Tanzania: A Case Control Study, 11 AIDS 237 (1997).
      
193. See Robert Kelly et al., Age of Male Circumcision and Risk of Prevalent HIV Infection in Rural Uganda, 13 AIDS 399, 399 (1999).
      
194. See Jeff Seed et al., Male Circumcision, Sexually Transmitted Disease, and Risk of HIV, 8 J. OF ACQUIRED IMMUNE DEFICIENCY SYNDROME & HUMAN RETROVIROLOGY 83 (1995); see also Edward O. Laumann et al., Circumcision in the United States, Prevalence, Prophylactic Effects, and Sexual Practice, 277 JAMA 1052 (1997); Mark Urassa et al., Male Circumcision and Susceptibility to HIV infection among men in Tanzania, 11 AIDS 73 (1997); Van Howe, supra note 144, at 52-62.
      
195. See Gee, supra note 171, at 827.
      
196. See Carlos A. Moreno & Janet P. Realini, Infant Circumcision in an outpatient setting, 85 TEX. MED. 37. 37 (1989).
      
197. See James M. Sutherland et al., Hemorrhagic Disease of the Newborn: Breast Feeding as a Necessary Factor in the Pathogenesis, 113 AM. J. DISEASES IN CHILD. 524 (1967).
      
198. See Thomas E. Wiswell et al., Circumcision in Children Beyond the Neonatal Period, 92 PEDIATRICS 791, 791 (1993), see also S. Walfish et al., Circumcision of New Immigrants, 126 HAREFUAH 119 (1994); Venkata R. Jayanthi et al., Postneonatal Circumcision with Local Anesthesia: A Cost-Effective Alternative, 161 J. UROLOGY 1301, 1301 (1999).
      199. See Abdall S. Awidi, Delivery of Children with Glanzman Thrombasthenia and Subsequent Blood Transfusion Requirements: A Follow-up of 39 Patients, 40 AM. J. HEMATOLOGY 1, 1 (1992); see generally G. Steinau et al., Tageschirurgische (TCH) Eingriffe In Kindealter an Einer Chirugischen Klinik, 118 ZENTRALBLATT FÜR CHIRUGIE 25 (1993); R.W. Watts and P.A Stokes, Secondary Arterial Hemorrhage following Circumcision: An Unusual Case of Antepartum Haemorrhage, 26 AUSTL. & N.Z. J. OBSTETRICS & GYNECOLOGY 312 (1986); John Denton et al., Circumcision Complication: Reaction to Treatment of Local Hemorrhage with Topical Epinephrine in High Concentration, 17 CLINICAL PEDIATRICS 285, 285, (1978); J. S. Poll & J.E. Prinsen, Niet-geplande opname na dagverpleging bij kinderen, 134 NEDERLANDS TIJDSCHRIFT VOOR GENEESKUNDE 1089 (1990); Wolfgang Cyran, Aus der praxis einer Gutachterstelle: Schwere Nachbluting nach einer Phimosenoperation, 88 ZEITSCHRIFT FÜR ÄRZTLICHE FORTBILDUNG 703 (1994); Gee, supra note 171, at 824-27; T.M Tsang & P.K Tam, Complications of Circumcision, 81 BRIT J. SURGERY 473, 473 (1994); Willson, Cesarean Section for Threatened Eclampsia and Death of the Child following Circumcision, 68 J. OBSTETRICS 351 (1913).
      
200. See J. Stranko et al., Impetigo in Newborn Infants Associated with a Plastic Bell Clamp Circumcision, 5 PEDIATRIC INFECTIOUS DISEASE 597, 597-98 (1986); see also A.B. Zafar, R.C. Butler, D. J. Reese, L.A. Gaydos and P.A. Mennonna, Use of 0.3% Triclosan (Bacti Stat) to Eradicate an Outbreak of methacillin Resistant Staphylococcus Aureus in a Neonatal Nursery, 23 AM J. INFECTION CONTROL 200, 200 (1995); John D. Nelson et al., A Prolonged Nursery Epidemic Associated with a Newly Recognized Type of Group A Streptococcus, 89 J. PEDIATRICS 792, 792 (1976); Thomas E. Wiswell et al., Staphyloccoccus Aureus Colonization after Neonatal Circumcision in Relation to Device Used, 119 J. PEDIATRICS 302, 302 (1991).
      
201. See Barry V. Kirkpatrick & Donald V. Eitzman, Neonatal Septicemia after Circumcision, 13 CLINICAL PEDIATRICS 767, 767 (1974); see also David Braun, Neonatal Bacteremia and Circumcision, 85 PEDIATRICS 135, (1990); R Southby & Myers, A Case Against Circumcision, 2 MED J. AUSTL. 393, 393 (1965); T.G. Cleary & S. Kohl, Overwhelming Infection with Group B Beta-Hemolytic Streptococcus Associated with Circumcision, 64 PEDIATRICS 301, 301 (1979).
      202. See Samuel Menahem, Complications Arising from Ritual Circumcision Pathegenesis and Possible Prevention, 17 ISR. J. MED. SCI. 45, 45 (1981); see also J.M. Scurlock & P.J. Pemberton, Neonatal Meningitis and Circumcision, 1 MED. J. AUSTL 332 (1977).
      203. See D.F. Du Toit and W.T. Villet, Gangrene of the Penis after Circumcision: A Report of Three Cases, 55 S. AFR. MED J. 521, 521 (1979); see also Sidney J. Sussman et al., Founier’s Syndrome. Report of Three Cases and Review of the Literature, 132 AM. J. DISEASES IN CHILD. 1189, 1189 (1978); I. Evbuomwan & A.S. Aliu, Acute Gangrene of the Scrotum in a One Month Old Child, 36 TROPICAL & GEOGRAPHICAL MED. 299, 299 (1984); Adetunji A. Adeyokunnu, Fournier’s Syndrome in Infants; A Review of Cases from Ibadan, Nigeria, 22 CLINICAL PEDIATRICS 101, 101 (1983); Willam G. Hamm & Frank F. Kanthak, Gangrene of the Penis following Circumcision with High Frequency Current, 42 S. MED. J. 657, 657 (1949); P. Thorek and P. Egel, Reconstruction of the Penis with Split-Thickness Skin Graft: A case of Gangrene following circumcision for Acute Balanitis, 4 PLASTIC & RECONSTRUCTIVE SURGERY 469 (1949); S. Ahmed et al., Penile Reconstruction following Post-Circumcision Penile Gangrene, 9 PEDIATRIC SURGERY INT’L 295, 295 (1994); S. Kurel, Iatrogenic Penile Gangrene: 10-Year Follow-Up, 95 PLASTIC & RECONSTRUCTIVE SURGERY 210, 210 (1995); Edward W. Pinkham Jr & Andrew W. Stevenson Dr., Unusual Reaction to Local Anesthesia: Gangrene of the Prepuce, 9 U.S. ARMED FORCES MED. J. 120, 120 (1958); David P. Bliss et al., Necrotizing Fasciitis after Plastibell Circumcision, 131 J. PEDIATRICS 459, 459 (1997).
      204. See Endia K. Anday & Joyce Kobori, Staphylococcal Scalded Skin Syndrome: A Complication of Circumcision, 21 CLINICAL PEDIATRICS 420, 420 (1982); David Annunziato & Louis M. Goldblum, Staphylococcal Scalded Skin Syndrome. A Complication of Circumcision, 132 AM. J. DISEASES OF CHILD. 1187, 1187 (1978).
      205. See Binita R. Shah et al., Clinical Picture, 4 ARCHIVES FAM. MED. 670, 671 (1995).
      
206. See K. Uwyyed et al. Scrotal Abscess with Bacteremia Caused by Salmonella Group D after Ritual Circumcision, 9 PEDIATRICS INFECTIOUS DISEASE J. 65, 65 (1990); see also Gabriel Dinari et al., Umbilical Arteritis and Phlebitis with Scrotal Abscess and Peritonitis, 6 PEDIATRICS SURGERY 176, 176 (1971).
      
207. See J.C. Craig et al., Acute Obstructive uropathy - A Rare Complication of Circumcision, 153 EUR. J. PEDIATRICS 369 (1994); see generally J.D. Eason et al., Male Ritual Circumcision Resulting in Acute Renal Failure, 309 BRIT. MED. J. 660 (1994); M.G. Ochsner, Acute Urinary Retention: Causes and Treatment, 71 POSTGRADUATE MED. 221 (1982); W. Berman, Letter: Urinary Retention Due to Ritual Circumcision, 56 PEDIATRICS 621 (1975); M. Frand. et al., Complication of Ritual Circumcision in Israel, 54 PEDIATRICS 521 (1974).
      208 See D. J. Smith et al., An Uncommon Complication of Circumcision, 73 BRIT. J. UROLOGY 459 (1994).
      
209. See H. Stefan. Reconstruction of the Penis after Necrosis Due to Circumcision Burn, 4 EUR. J. PEDIATRICS SURGERY 40 (1994), see also J.B. Rosefsky, Glans Necrosis as a Complication of Circumcision, 39 PEDIATRICS 774 (1967); J.R. Woodside, Necrotizing Fasciitus after Neonatal Circumcision, 134 AM. J. DISEASES IN CHILD. 301 (1980); N. Sterenberg et al., Necrosis of the Glans Penis Following Neonatal Surgery, 68 PLASTIC & RECONSTRUCTIVE SURGERY 237 (1981); J.R. Woodside, How to Lessen Risk of Wound Infection after Circumcision, 48 MODERN MED. 93 (1980).
      
210. See P.S. Bergeson et al., The Inconspicuous Penis, 92 PEDIATRICS 794 (1993); See generally J.A. van-der-zee et al., Een Ernstige Complicatie Ten Gevolge Van Rituelle Circumcisie Van Een ‘Begraven’ Penis, 32 NEDERLANDS TUDSCHRIFT VOOR GENEESKUNDE 1604 (1991); J. Radhakrishnan & H.M. Reyes, Penoplasty for Buried Penis Secondary to “Radical” Circumcision, 19 J. PEDIATRICS SURGERY 629 (1984); M. Kon, A Rare Complication Following Circumcision: The Concealed Penis, 130 J. UROLOGY 573 (1983); R.D. Talarico and J.E. Jasaitis, Concealed Penis: A Complication of Neonatal Circumcision, 110 J. UROLOGY 732 (1973); W.C. Trier & G.W. Drach, Concealed Penis. Another Complication of Circumcision, 125 AM. J. DISEASES IN CHILD. 276 (1973); G.J. Alter et al., Buried Penis as a Contraindication for Circumcision, 178 J.AM. COLL. SURGERY 487 (1994); C.E. Horton et al., Hidden Penis Release: Adjunctive Suprapubic Lipectomy, 19 ANNALS PLASTIC SURGERY 131 (1987); P.K. Donahoe & M.A. Keating, Preputial Unfurling to Correct the Buried Penis, 21 J. PEDIATRICS SURG. 1055 (1986); D.H. Stewart, The Toad in the Hole Circumcision - A Surgical Bugbear, 191 BOSTON MED. & SURGERY J. 1216 (1924); S.R. Shapiro, Surgical Treatment of the Buried Penis, 30 UROLOGY 554 (1987); M. Maizels et al., Surgical Correction of the Buried Penis: Description of a Classification System and a Technique to Correct the Disorder, 136 J. UROLOGY 268 (1986).
      211. See B.S. Strimling, Partial Amputation of Glans Penis during Mogen Clamp Circumcision, 97 PEDIATRICS 906 (1996); see generally J. Sherman et al., Clamp Circumcision: Successful Glanular Reconstruction and Survival following Amputation, 156 J. UROLOGY 842 (1996); A.F. Yilmaz et al., Rare Complication of Circumcision: Penile Amputation and Reattachment, 23 EUR. UROLOGY 423 (1993); D.A. Gilbert et al., Phallic Construction in Prepubertal and Adolescent Boys, 149 J. UROLOGY 423 (1993); Menahem, supra note 202, at 45-48; S.B. Levitt et al., Iatrogenic Microphallus Secondary to Circumcision, 8 UROLOGY 472-74 (1976); G. Audry et al., Amputation of Penis after Circumcision - Penoplasty Using Expandable Prosthesis, 4 EUR. J. PEDIATRICS SURGERY 44 (1994); J.P. Gearhart & J.A. Rock, Total Ablation of the Penis after Circumcision with Electocautery: A Method of Management and Long-Term Followup, 142 J. UROLOGY 799-801 (1989); A. Azmy et al., Successful Reconstruction following Circumcision with Diathermy, 57 BRIT. J. UROLOGY 587 (1985); K.A. Hanash, Plastic Reconstruction of Partially Amputated Penis at Circumcision, 18 UROLOGY 291 (1981); A. Y. Izzidien, Successful Replantation of a Traumatically Amputated Penis in a Neonate, 16 J. PEDIATRICS SURGERY 202 (1981); J. Money, Ablatio Penis: Normal Male Infant Sex-Reassigned as a Girl, 4 ARCHIVES OF SEXUAL BEHAVIOR 65-71 (1975); G.R. Gluckman et al., Newborn Penile Glans Amputation during Circumcision and Successful Reattachment, 153 J. UROLOGY 778 (1995); J.B. Brimhall, Amputation of Penis following a Unique Method of Preventing Hemorrhage after Circumcision, 4 ST. PAUL MED. J. 490 (1902); E. Neulander et al., Amputation of Distal Penile Glans During Neonatal Ritual Circumcision - A Rare Complication, 77 BRIT. J. UROLOGY 924 (1996); A Hanukoglu et al., Serious Complications of Routine Ritual Circumcision in a Neonate: Hydroureteronephrosis, Amputation of Glans Penis, and Hyponatraemia, 154 EUR. J. PEDIATRICS 314 (1995); B.L. Lerner, Amputation of Glans Penis as a Complication of Circumcision, 46 MED. RECORDS & ANNALS 229 (1952).
      212. See generally M. Cetinkaya et al., Two Serious Complications of Circumcision. Case Report, 27 SCANDINAVIAN J. UROLOGY & NEPHROLOGY 121 (1993).
      
213. See J. Orozco-Sanchez & R. Neri-Vela, Denudacion total del pene por circumcision. Descripcion de una technical de plastia del pene para su correccion, 48 BOL. MED. HOSP. INFANT MEX. 565, 565-69 (1991); see generally J.R. Sotolongo Jr. et al., Penile Denudation Injuries after Circumcision, 133 J. UROLOGY (1985) P. Smey, re: Penile Denudation Injuries after Circumcision, 134 J. UROLOGY 1220 (1985); C.L. Wilson & M.C. Wilson, Plastic Repair of the Denuded Penis, 52 S. MED. J. 288-90 (1959); J. Van Duyn & W.S. Warr, Excessive Penile Skin Loss from Circumcision, 51 J. MED. ASSN GA. 394 (1962); J.B. Brown, Restoration of the Entire Skin of the Penis, 65 SURGERY, GYNECOLOGY & OBSTETRICS 362 (137); J.B. Brown & M.P. Fryer, Surgical Reconstruction of the Penis, 17 G. P. 104, 104-07 (1958); W.W. Ezell et al., Mechanical Traumatic Injury to the Genitalia in Children, 102 J. UROLOGY 788-92 (1969).
      214. See J. Horwitz et al., Abdominal Distension following Ritual Circumcision, 57 PEDIATRICS 579 (1976).
      
215. See M.R. Auerbach & J.W. Scanlon, Recurrence of Pneumothorax as a Possible Complication of Elective Circumcision, 132 AM. J. OBSTRETICS & GYNECOLOGY 583 (1978).
      
216. See E.R. Owens & J.L. Kitson, Plastibell Circumcision, 44 BRIT. J. CLINICAL PRAC. 661 (1990; see also N.S Dattes & N.R Zinner, Complication from Plastibell Circumcision Ring, 9 UROLOGY 57 (1977); R.E. Johnsonbaugh, Complication of a Circumcision Performed with a Plastic Disposable Circumcision Device: Long-Term Followup, 133 AM. J. DISEASES IN CHILD 438 (1979); T. Malo & R.J. Bonforte, Hazards of Plastic Bell Circumcisions, 33 OBSTETRICS & GYNECOLOGY 869 (1969); G. Jonas, Retention of a Plastibell Circumcision Ring: Report of a Case, 24 OBSTRETRICS & GYNECOLOGY 835 (1984); M.M. Rubenstein & W.M. Bason, Complication of Circumcision Done with a Plastic Bell Clamp, 116 AM. J. DISEASES IN CHILD. 381 (1968).
      
217. See generally J.T Lackey et al. Subglanular Urethral Fistula from Infant Circumcision, 62 J. IND. STATE MED. ASS’N 1305 (1969); J.T. Lackey et al., Urethral Fistula Following Circumcision, 206 JAMA 2318 (1968); R.D. Limaye & R.A. Hancock, Penile Urethral Fistula as a Complication of Circumcision, 72 J. PEDIATRICS 105 (1968); A. Benchekroun et al., Fistules urethrales après circoncision: a propos de 15 cas, 3 MAROC MED. 715-18 (1981); J.T. Lau & G.B. Ong. Subglandular Urethral Fistula Following Circumcision: Repair by the Advancement Method, 126 J. Urology 702 (1981); I.W. Shirake, Congenital Megalourethra with Urethrocutaneous Fistula following Circumcision: A Case Report, 109 J. UROLOGY 723 (1973); S.Y. Tennenbaum & L.S. Palmer, Congenital Urethrocutaneous Fistulas, 43 UROLOGY 98-99 (1994); A.H. Colodny, Congenital Urethrocutaeous Fistulas, 44 UROLOGY 149 (1994); S. Johnson, Persistant Urethral Fistula following Circumcision: Report of a Case, 49 U.S. NAVAL MED. BULL. 120-22 (1949).
      218. See A.R. Mackenzie, Meatal Ulceration following Neonatal Circumcision, 28 OBSTETRICS & GYNECOLOGY 221 (1966); see also H.F Meyer, Meatal Ulcer in the Circumcised Infant, 99 MED. TIMES 77 (1971).
      
219. See generally L.D. Jee & A.J. Millar, Ruptured Bladder following Circumcision Using the Plastibell Device, 65 BRIT. J. UROLOGY 216 (1990).
      
220. See generally K.P. Connelly et al., Gastric Rupture Associated with Prolonged Crying in a Newborn Undergoing Circumcision, 31 CLINICAL PEDIATRICS 560 (1992).
      221. See generally A. Mor et al., Tachycardia and Heart Failure after Ritual Circumcision, 62 ARCHIVES DISEASE CHILDHOOD 80 (1987)
      
222. See generally M.L. Ruff et al., Myocardial Injury following Immediate Postnatal Circumcision, 144 AM. J. OBSTETRICS & GYNECOLOGY 850 (1982).
      
223. See generally C.K. Pearlman, Caution Adivsed on Electrocautery Circumcisions, 19 UROLOGY 453 (1982); C.K. Pearlman, Reconstruction following Iatrogenic Burn of the Penis, 11 J. PEDIATRICS SURGERY 121 (1976).
      
224. See J.E. Curtis, Circumcision Complicated by pulmonary Embolism, 132 NURSING MIRROR MIDWIVES J. 28, 28-30 (1971).
      
225. See generally John F. Redman et al., Postcircumcision Phimosis and Its Management, 14 CLINICAL PEDIATRICS 407 (1975); Kaweblum, supra note 144; Hawa Patel, The Problem of Routine Circumcision, 95 CAN. MED. ASSN J. 576 (1966); C. Terry Russell & Janet Chaseling, Topical Anaesthesia in Neonatal Circumcision: A Study of 208 Consecutive Cases, 25 AUSTL. FAM. PHYSICIAN 530-534, suppl. 1 (1966); Van Howe, supra note 144, at 776.
      226. See R. Arnon et al., Unilateral Leg Cyanosis: An Unusual Complication of Circumcision, 151 EUR. J. PEDIATRICS 716, 716 (1992).
      
227. See generally C.D Berry Jr. & R.R. Cross, Jr. Urethral Meatal Caliber in Circumcised and Uncircumced Males, 92 AM. J. DISEASES CHILD. 621 (1956); A Steg & G. Allouch, Senose du Meat et Circoncision, 85 J. UROLOGY & NEPHROLOGY 727 (1979); J.D. Frank et al., Urethral Strictures in Childhood, 62 BRIT. J. UROLOGY 590 (1988); C. Viville & J. Welzer, Les Retrcecissements Iatrogenes de l’Urethra (R.I.U.) Masculin. A Propos De 50. Obsrevations, 87 J. Urology 413 (1981); John Graves, Pinpoint Meatus: Iatrogenic? 41 PEDIATRICS 1013 (1968); Meyer, supra note 176; D.M. Griffiths et al., A Prospective Survey of the Indications and Morbidity of Circumcision in Children. 11 EUR. UROLOGY 184 (1985); M.C. Daley, Circumcision, 214 JAMA 2195 (1970); Douglas Gairdner, The Fate of the Foreskin: A Study of Circumcision, BRIT. MED. J. 1433-37 (1949); Patel, supra note 225, at 576; Alexandra Stenram et al., Circumcision for Phimosis: A Follow-Up Study, 20 SCANDINAVIAN J. UROLOGY & NEPHROLOGY (1986); A. Stenram et al., Circumcision for Phimosis: Indications and Results, 75 ACTA PAEDIATRICA SCANDINAVICA 321 (1986); R. Persad et al., Clinical Presentation and Pathophysiology of Meatal Stenosis following Circumcision, 75 BRIT J. UROLOGY 91 (1995); A. Ralph Thompson, Stricture of the External Urinary Meatus, 1 LANCET 1373-77 (1935; J. Brenneman, The Ulcerated Meatus in the Circumcised Child, 21 AM. J. DISEASES IN CHILD. 38-47 (1921); Paul Freud, The Ulcerated Urethral Meatus in Male Children, 31 J. PEDIATRICS 131-42 (1947); W.M. Mastin, Infantile Circumcision a Cause of Contraction of the External Urethral Meatus, 4 ANNALS ANATOMY & SURGERY 123 (1981); Van Howe, supra note 144, at 776.
      228. See generally A.G. Toguri et al., Penile Tourniquet Syndrome Caused by Hair, 72 S. MED . J. 627 (1979); F.S. Haddad, Penile Strangulation by Human Hair. Report of Three Cases and Review of the Literature, 37 UROLOGY INTL 375-88 (1982); Allan J. Pantuck et al., Hair Strangulation Injury of the Penis, 13 PEDIATRIC EMER . CARE 423 (1997); M. Aboulola et al., Plaies de l’urètre par cheveu étrangleur, 21 CHIRUGIE PÉDIATRIQUE 283 (1980); A.Y. Bashir & M. El-Barbary, Hair Coil Strangulation of the Penis, 25 ROYAL COLL. SURGERY 47-51 (1980).
      
229. See generally Louis W. Sauer, Fatal Staphylococcus Bronchopneumonia following Ritual Circumcision, 46 AM . J. OBSTETRICS & GYNECOLOGY 583 (1943) Willson, supra note 199, at 351.
      
230. See K.J.S. Anand & P.R. Hickey, Pain and Its Effects in the Human Neonate and Fetus, 317 N. ENG . J. MED . 1321, 1321-29 (1987).
      231. See P. Drake & L. French, Analgesia during Circumcision, 45 J. FAM. PRAC. 100 (1997); Janice Lander et al., Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision: A Randomized Controlled Trial, 278 JAMA 2157-62 (1997).
      232. See Robert N. Emde et al., Stress and Neonatal Sleep, 33 PSYCHOSOMATIC MED. 491, 491-97 (1971).
      233. See Richard E. Marshall et al., Circumcision II. Effects Upon Mother-Infant Interaction, 7 EARLY HUMAN DEV. 367, 367-74 (1982).
      234. See Tom Garry, Circumcision: a Survey of Fees and Practices, OBG MANAGEMENT 34, 36 (Oct 1994); see also Catherine Kelly et al., Pediatric Residency Training in the Normal Newborn Nursery: A National Survey, 151 ARCHIVES PEDIATRICS & ADOLESCENT MED. 511, 511-14 (1997).
      235. See Robert S. Van Howe, Anesthesia for Neonatal Circumcision: Who Benefits? 12 J. PRENATAL &amp: PERINATAL PSYCHOLOGY & HEALTH 3, 3-4, 6, 9-10, 13 (1997); see also Robert S. Van Howe, Anaesthesia for Circumcision: A Review of the Literature, MALE AND FEMALE CIRCUMCISION: MEDICAL, LEGAL, AND ETHICAL CONSIDERATIONS IN PEDIATRIC PRACTICE 67, 67, 80, 81-82, 88 (George C. Denniston, Frederick M. Hodges & Marilyn F. Milos, eds. 1999); Cynthia R. Howard et al., Acetominophen Analgesia in Neonatal Circumcision: The Effect on Pain, 93 PEDIATRICS 641, 641,645 (1994); Howard J. Stang et al., Local Anesthesia for Neonatal Circumcision. Effects on Distress and Cortisol Response, 259 JAMA 1507, 1507, 1509-1510, 1511 (1988); Teresa D. Puthoff et al., Use of EMLA Prior to Circumcision, 30 ANNALS PHARMACOTHERAPY 1327, 1328, 1329 (1996); Anna Taddio et al., Efficacy and Safety of Lidocaine-prilocaine Cream for Pain during Circumcision, 336 NEW ENG. J. MED. 1197, 1197, 1200-01 (1997); Paul S. Williamson & Nolan D. Evans, Neonatal Cortisol Response to Circumcision with Anesthesia, 25 CLINICAL PEDIATRICS 412, 412, 414 (1986).
      236. See Lander, supra note 231, at 2157, 2159.
      
237. See M. Fitzgerald, The Birth of Pain, MRC News 20-23 (Summer 1998).
      238. See Suzanne Dixon et al., Behavioral Aspects of Circumcision with and without Anesthesia, 5 J. DEVELOPMENTAL & BEHAVIORAL PEDIATRICS 246, 249 (1984); see also Anna Taddio et al., Effect of Circumcision on Pain Responses during Vaccination in Boys, 345 LANCET 291, 292 (1995); Anna Taddio et al., Effect of Neonatal Circumcision on Pain Response during Subsequent Routine Vaccination, 349 LANCET 599, 599, 602 (1997).
      239. See J.D. Frank, Circumcision, Meatotomy and Meatoplasty, in PEDIATRIC SURGERY 738, 745 (L. Spitz & A.G. Coran eds. 5th ed. 1995).
      
240. See Christopher J. Cold & Kenneth A. McGrath, Anatomy and Histology of the Penile and Clitoral Prepuce in Primates: Evolutionary Perspective of Specialised Sensory Tissue of the External Genitalia, in MALE AND FEMALE CIRCUMCISION: MEDICAL, LEGAL, AND ETHICAL CONSIDERATIONS IN PEDIATRIC PRACTICE 19, 19-20 (George C. Denniston, Frederick M. Hodges & Marilyn F. Milos eds. 1999); J.R. Taylor et al., The Prepuce: Specialised Mucosa and Its Loss to Circumcision, 77 BRIT. J. UROLOGY 291, 291 (1996).
      241. See P.M. Fleiss, The Case Against Circumcision, MOTHERINGS ¶ 23 (Dec. 22, 1997).
      242. See Ronald S. Immerman & Wade C. Mackey, A Biocultural Analysis of Circumcision, 44 SOC. BIOLOGY 265, 265-67, 273 (1997).
      243. See P.M. Fleiss et al., Immunological Functions of the Human Prepuce, 74 SEXUALLY TRANSMITTED INFECTIONS 364, 364 (1998); see generally Gregory L. Smith et al., Circumcision as a Risk Factor for Urethritis in Racial Groups, 77 AM. J. PUB. HEALTH 452, 452, 454 (1987); Paul M.N. Werker et al., The Prepuce Free Flap: Dissection Feasibility Study and Clinical Application of a Super-Thin Flap, 102 PLASTIC & RECONSTRUCTIVE SURGERY 1075 (1998).
      244. See Geoffrey Jefferson, The Peripenis Muscle: Some Observations on the Anatomy of Phimosis, 23 SURGERY, GYNECOLOGY & OBSTETRICS 177, 178 (August 1916).
      245. See generally John Money & Jackie Davison, Adult Penile Circumcision: Its Erotosexual and Cosmetic Sequelae, 19 J. SEX RESEARCH 289 (1983).
      246. See C.J. Cold and J.R. Taylor, The Prepuce, 83 (Suppl 1) BJU INTL 34, 40 (1999).
      247. See Fleiss, supra note 243, at 364.
      
248, See generally J. Fred Leditsche, Australian Association of Paediatric Surgeons, Guidelines for Circumcision 1 (April 1996).
      249. See generally Australian Medical Association, Circumcision Deterred, 6 AUSTL. MED. 5 (1997).
      250. See Queensland Law Reform Commission, Research Paper: Circumcision of Male Infants (Brisbane, Australia: QLRC, 1993), available at <http://www.cirp.org/library/legal/QLRC> (lasted visited Nov. 12, 2000).
      251. See NATIONAL HEALTH AND RESEARCH COUNCIL, Report of the Ninety-Fifth Session 13 (June 1983).
      
252. See A Ritual Operation, 2 BRIT. MED. J. 1458, 1459 (1949); The Case Against Neonatal Circumcision, 1 BRIT. MED. J. 1163, 1163 (1979).
      253. See Fetus and Newborn Committee, Canadian Paediatric Society, Neonatal Circumcision Revisited, 154 CAN. MED. ASSN J. 760, 769 (1996).
      254. See generally American Academy of Paediatrics, Section on Urology, Timing of Elective Surgery on the Genitalia of Male Children with Particular Reference to the Risk, Benefits, and Psychological Effects of Surgery and Anesthesia, 97 PEDIATRICS 590 (1996).
      255. See Hugh C. Thompson et al., Report of the Ad Hoc Task Force on Circumcision, 56 PEDIATRICS 610, 611 (1975).
      256. See American Academy of Pediatrics, Task Force on Circumcision, Circumcision Policy Statement, 103 PEDIATRICS 686, 691 (1999).
      257. See id.
      
258. See American Academy of Family Physicians, Fact Sheet for Physicians Regarding Neonatal Circumcision, 52 AM. FAMILY PHYSICIAN 523, 525 (1995).
      
259. See Am. Academy of Pediatrics Task Force on Circumcision, supra note 256, at 523; Thompson, supra note 255, at 610; Fetus and Newborn Committee, supra note 253, at 769; J. Fred Leditsche, supra note 248; Australian Medical Association, supra note 249, at 5, British Medical Association, supra note 252, at 1163.
      
260. To make the case that neonatal circumcision is necessary, one need to demonstrate that it is either indispensable, inevitable, mandatory, unavoidable, or essential for good health. No one has attempted to make the case that all males with foreskins are in poor health. In his pamphlet “Neonatal Circumcision IS Necessary” surgeon Gerald N. Weiss gives a string of arguments lauding the advantages of neonatal circumcision, but never makes the case that circumcision is either indispensable or essential for good health.
      
261. See Queensland Law Reform Commission, supra note 250, In re Jane, 85 A.L.R. 409, 435 1988) (discussing the relevance of its finding by speculating that a contrary conclusion could lead to a wide range of wrongs occurring including female circumcision: “The consequences of a finding that the court’s consent is unnecessary are far reaching both for parents and for children. For example, such a principle might be used to justify parental consent to the surgical removal of a girl’s clitoris for religious or quasi cultural reasons, or the sterilization of a perfectly healthy girl for misguided, albeit sincere, reasons. Other possibilities might include parental consent to the donation of healthy organs such as a kidney from one sibling to another.”)
      
262. See Theodore G. Ganiats et al., Routine Neonatal Circumcision: A Cost-Utility Analysis, 11 MED. DECISION MAKING 282, 282-93 (1991); see also R.S. Van Howe, Neonatal Circumcision: a Cost-utility Analysis [Abstract 98086], October 25-28, 1998 (poster presentation at the 20th Annual Meeting of the Society for Medical Decision-Making, Cambridge, MA.).
      263. See Frank H. Lawler et al., Circumcision: A Decision Analysis of its Medical Value, 23 FAM. MED. 587, 590 (1991).
      264. See, EDWARD WALLERSTEIN, CIRCUMCISION: AN AMERICAN HEALTH FALLACY 131 (1980).
      
265. See Committee on Bioethics, supra note 131, at 314.
      
266. See Dale L. Moore, Challenging Parental Decisions to Overtreat Children, 5 HEALTH MATRIX 311, 320 (1995).
      
267. See Mark. S. Brown & Cheryl A. Brown, Circumcision Decision: Prominence of Social Concerns, 80 PEDIATRICS 215, 216, 217 (1987); see generally John E. Lovell & James Cox, Maternal Attitudes Toward Circumcision, 9 J. FAM. PRAC. 811 (1979). It should be noted that the circumcision rate is already below 50% in a number of states such as California ad a number of American ethnic cultures and demographic groups. People of Latino descent, for example, rarely circumcise their male children even if born in the United States. See Herzog, supra note 146, at 254; see generally Dimitri A. Christakis et al., A Trade-off Analysis of Routine Newborn Circumcision, 105 PEDIATRICS 246 (2000).
      268. See supra Part III.B.
      269. See generally Dwyer, supra note 3, at 1365-1465.
      
270. See Re J. (Child’s Religious Upbringing and Circumcision). [1999] 2 F.L.R 678 (Fam. Div.), affirmed, [2000] 1 F.L.R. 571 (C.A.) The Family Division decision is also available at <http://www.butterworths.co.uk/academic/fortin/cases/Re_J.htm> (last visited Nov. 17, 2000).
      271. See Prince v. Massachussetts, 321 U.S. 158, 167, 170 (1943).
      272. See generally In re A.C. A.2d 1235 (D.C. Ct. App. 1988; see also Etchells et al., supra note 16, at 178; David Richards, Male Circumcision: Medical or Ritual?, 3 J. L. & MED. 371, 374 (1996).
      273. See generally Taylor, supra note 240, at 291; Cold, supra note 246, at 34.
      
274. See American Academy of Pediatrics, supra note 143, at 388.
      
275. See Fleiss et al., supra note 243, at 364.
      
276. See generally Taylor, supra note 240, at 291; Zdenek Halata & Bryce L. Munger, The Neuroanatomical Basis for the Protopathic Sensibility of the Human Glans Penis, 371 BRAIN RES. 205-30 (1986); M. Von Frey, Beitraege zur Physiologie des Schemerzisinns. Zweite Mitt, 46 AKAD WISS LEIPZIG MATH NATURWISS KL BER 283-96 (1984).
      277. See Cold, supra note 246, at 41.
      
278. See K. O’Hara & J. O’Hara, The Effect of Male Circumcision on the Sexual Enjoyment of the Female Partner, 83 (Suppl 1) BJU INTL 79-84 (1999).
      279. See N. Williams & L. Kapilla, Complications of Circumcision, 80 BRIT. J. SURGERY 1231 (1993).
      280. See Patel, supra note 225, at 576; Griffiths, supra note 227, at 184; Persad, supra note 277, at 91.
      
281. See discussion Part IV.A and IV.B.
      282. See Ganiats, supra note 262, at 282; Task Force on Circumcision, supra note 256, at 686.
      
283 See generally Martin T. Stein et al., Routine Neonatal Circumcision: The Gap Between Contemporary Policy and Practice, 15 J. FAM. PRAC. 47 (1982).
      
284. See generally Christopher R. Fletcher, Circumcision in American in 1998: Attitudes, Beliefs, and Charges of Am. Physicians, in MALE AND FEMALE CIRCUMCISION: LEGAL AND ETHICAL CONSIDERATIONS IN PEDIATRIC PRACTICE, 259 (George C. Denniston, Frederick M. Hodges & Marilyn F. Milos eds. 1999).
      
285. See Jay J. Christensen-Szalanski et al., Circumcision and Informed Consent. Is More Information Always Better? 25 MED. CARE 856, 856-67 (1987).
      
286. See Fletcher, supra note 284, at 259.
      
287. See Christensen-Szalansk, supra note 85, at 856.
      
288. See id.
      
289. See id. at 864.
      
290. See id.
      
291. See Edward Etchells et al., Consent for Circumcision, 156 CAN. MED. ASSN J. 17, 18 (1997).
      
292. See Etchells, supra note 32, at 389.
      
293. See Lazar, supra note 76, at 1437.
      
294. See Thompson, supra note 255, at 611.
      
295. See Daksha A. Patel et al., Factors Affecting the Practice of Circumcision, 136 AM. J. DISEASES CHILD. 634 (1982).
      296. Id.
      
297. Id.
      
298. See Stein, supra note 283, at 47.
      
299. See id.
      
300. See id.
      
301. See Ciesielski-Carlucci et al., supra note 5, at 231.
      
302. See Stein et al. supra note 283, at 48, 49 (odds ratio = 9.46, 95% confidence interval = 1.70 - 52.71).
      
303. See Ciesielski-Carlucci et al., supra note 5, at 231.
      
304. See Canadian Medical Association, supra note 38, at 1176A-B.
      
305. See Weijer, supra note 95, at 817.
      
306. See Lovell & Cox, supra note 267, at 812.
      
307. See id.
      
308. See Ciesielski-Carlucci, supra note 5, at 235.
      
309. See id.
      
310. See Moore v. Regents of Univ. of Cal., 793 P.2d 479, 483 (Cal. 1990).
      
311. See Id. at 483.
      
312. See Karen Wright, Ready-to-wear Flesh, DISCOVER, Nov. 1999, at 46, 46; David J. Mooney & Antonios G. Mikos, Growing New Organs, SCI. AM., April 1999, at 60, 60 (describing work constructing Apligraf skin product using living human foreskin cells); Roger A. Pederson, Embryonic Stem Cells for Medicine, SCI. AM., April 1999, at 68-69, 71 (detailing Advanced Tissue Sciences’ creation of skin construct Dermagraft from discarded foreskins taken from newborn babies); Skin Paved the Way for Tissue Engineering, USA TODAY, Aug. 12, 1997, available at <http://ithaca.rice.edu/kz/USAToday/skinarticle.htm> (last visited Sept. 4, 2000); B Manson, Forget Pork Bellies, Now It’s Foreskins, SAN DIEGO READER, May 4, 1995 at 255; M.E. Meuders-Klein, The Right Over One’s Own Body: Its Scope and Limits in Comparitive Law, 6 B.C. INT’L & COMP. L. REV. 29, 48 (1983) (“any act which tends to demean even a consenting person is radically illicit and a fortiori if the act is, in addition, immoral and profit-oriented”).
      
313. See AMA Policy, E-2.08 Commercial Use of Human Tissue, available at <http://www.ama-assn.org/apps/pf_online> (last visited Sept. 4, 2000).
      314. See AMA Policy, E-2.167 The Use of Minors as Organ and Tissue Donors, available at <http://www.ama-assn.org/apps/pf_online> (last visited Sept. 4, 2000).
      315. See Council of Europe, European Treaty Series, No. 164, Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (April 4, 1997). available at <http://www.coe.fr/eng/legaltxt/164e.htm> (last visited Sept. 4, 2000. Article 19 generally prohibits non-therapeutic removal of organs or tissue from a living person for transplantation purpsose. Article 20 bars organ or tissue removal from a person without the capacity to consent, with certain limited exceptions not applicable here. Article 21 prohibits using the human body and its parts to give rise to financial gain. Article 22 provides that when in the course of an intervention any human body part is removed, it may be stored and used for a purpose other than that for which it was removed only if this is done in conformity with appropriate information and consent procedures.
      316. Alderson, supra note 18, at 106.
      
317. See Cynthia S. Rand et al., The Effect of an Educational Intervention on the Rate of Neonatal Circumcision, 62 OBSTETRICS & GYNECOLOGY 64, 64 (1983).
      
318. See Robert W. Enzenauer et al., Decreased Circumcision Rate with Videotaped Counseling, 79 S. MED. J. 717, 718 (1986).
      319. See Christensen-Szalanski, supra note 285, at 856-67.
      
320. Id.
      
321. See E.B. Feehan, Letter to the Editor, 60 PEDIATRICS 566 (1977).
      
322. See Committee on Bioethics, supra note 131, at 314-16.
      
323. See generally A.G.M. Campbell et al., Circumcision: A Balanced Report Based on Facts, Not Conjecture, 5 PATIENT CARE 56 (1971).
      
324. See generally S. Mason, Obtaining Informed Consent for Neonatal Randomized Controlled Trials - An “Elaborate Ritual” 76 ARCHIVES DISEASE CHILDHOOD F143 (1997).
      325. Sample consent forms on file at the journal’s office.
      
326. See R.S. Van Howe, Why Does Neonatal Circumcision Persist in the United States?, in SEXUAL MUTILATIONS: A HUMAN TRAGEDY 111 (G.C. Denniston & M.F. Milos eds. 1997).
      
327. See AMA, supra note 37, at 105; Canadian Medical Association, supra note 38, at 1176A
      
328. See Van Howe, supra note 326, at 105; Canadian Medical Association, supra note 38, at 1176A.
      
329. See generally D. Hovsepian, The Pros & Cons of Routine Circumcision, 75 CAL. MED. 360 (1951).
      
330. See generally G.W. Kaplan, Circumcision - An Overview, 7 CURRENT PROBLEMS PEDIATRICS 1 (1977).
      
331. See id.
      
332. See Committee on Bioethics, supra note 131, at 315-17.
      
333. See Leditsche, supra note 248, at 1.
      
334. See Alderson,, supra note 18, at 32.
      
335. M. Fitzgerald & N. Mcintosh, Pain and Analgesia in the Newborn, 64 ARCHIVES OF DISEASES IN CHILDHOOD 441 (1989); see generally Nancy Wellington & Michael J. Rieder, Attitudes and Practices Regarding Analgesia for Newborn Circumcision, 92 PEDIATRICS 541 (1993) (finding that 12% of physicians did not believe that newborns could feel pain and 35% believed that newborns could not remember pain); William L. Toffler et al., Dorsal Penile Nerve Block during Newborn Circumcision: Underutilization of a Proven Technique? 3 J. OF THE AMERICAN BOARD OF FAMILY PRACTICE 171 (1990) (concluding that 29% of physicians did not believe the pain response to circumcision was significant).
      336. See Anand & Hickey, supra note 230, at 1326.
      
337. See generally G.N. Weiss & E.B. Weiss, A Perspective on Controversies over Neonatal Circumcision, 33 CLINICAL PEDIATRICS 726 (1994).
      
338. See Jayanthis, supra note 198, at 793.
      
339. See Alderson, supra note 18, at 30.

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