REVIEW
ARTICLE
UROLOGISTS AND CIRCUMCISION OF NEWBORNS EDGAR
J. SCHOEN,
M.D.
From the Department of Pediatrics, Kaiser Permanente Medical Center, Oakland, California
ABSTRACT-Although urologists have played a key role in performing clinical studies providing the rationale for newborn circumcision, they have not had primary responsibility for the decision to perform the procedure. Recent confirmatory evidence that newborn circumcision has significant preventive health benefits has called attention to previous urologic articles. This review summarizes the contributions of urologists to the controversy on circumcision of newborns over the past sixty years and emphasizes the importance of clinical objectivity in this field. Urologists have a unique role in the history of circumcision of newborns in the United States. Much of the initial data establishing cirumcision of newborns as a valuable preventive health measure were collected by urologists. However, although urologists diagnosed and treated diseases associated wi.th presence of the foreskin, they had no influence on the decision to perform circumcision of the newborn. For years, it had been apparent to the practicing urologist that circumcision of newborns simplified genital hygiene throughout life and prevented phimosis, paraphimosis, and balanoposthitis. Classic urologic studies almost sixty years ago showed that circumcision of newborns prevented penile cancer in later life, but the authors of these studies were disappointed by their lack of influence on those physicians (generally obstetricians, pediatricians, or family practitioners) who perform circumcision of newborns. Wolbarst in 1932l and Dean in 19352 presented convincing data that cancer of the penis could be prevented by circumcision of newborns. Wolbarst’ collected a series of 1,103 cases of penile cancer from hospitals in the United States and found that none had occurred in men circumcised in infancy. Because Jews comprised 3 percent of the population, he expected 33 cases in Jewish men, yet there were none. Three years later, Dean2 found that none of the 120 men with cancer of the penis in New
UROLOGY
I AUGUST1992
i VOLUME40.NUMBER2
York City’s Memorial Hospital were Jewish, although Jews comprised one third of the patients with other forms of cancer in the hospital. Both these authors recognized the importance of circumcision of newborns in preventing penile cancer and urged that the procedure become routine for newborn males in the U.S. Wolbarst noted “with gratification” that non- Jewish parents were beginning to have their newborn sons circumcised, but Dean, foreseeing interspecialty difficulties, expressed dissatisfaction that urologists were not responsible for circumcision of newborns and encouraged obstetricians to perform the procedure routinely. The majority of the medical profession, as well as the general population, became convinced of the health benefits of circumcision of newborns, and from the 1940s onward, most U.S. males (85% to 90 % in the 1950s through the 1970s) were circumcised as newborns. Data confirming the cancer-preventive effect of newborn circumcision continued to be published from urologic centers around the U.S. From 1932 through 1986, more than 1,600 cases of cancer of the penis were reported in six major series; not one of these men with cancer had circumcision as a newborn. l-6 Similarly, of about 50,000 men with cancer of the penis in the U.S. during this period (750 to 1,000 cases yearly) only 10 men were circumcised as newborns.’ It seemed inconceivable to urologists that in spite of this definitive documentation, in
99
the early 197Os, recommendations against newborn circumcision were coming from pediatric and obstetric organizations, those groups who were the “gatekeepers” and performers of the procedure. 8,QDagher, Seizer, and Lapides in 1973 reported 156 cases of cancer of the penis, all in uncircumcised men, and reflected the frustration of urologists in stating that “despite overwhelming evidence from urological surgeons that neoplasm of the penis is a lethal disease that can be prevented by removal of the foreskin, some physicians continue to argue against routine circumcision in a highly emotional and aggressive fashion.” In 1986, Persky and deKernio# expressed similar sentiments. The opposing attitudes of different medical specialties toward circumcision of newborns may be due to the fact that the procedure is a preventive health measure. The untoward effects are seen immediately or shortly after the procedure, whereas the protective action against disease is seen during the course of a lifetime, mainly in adulthood. Thus, neonatologists seeing only the pain and complications of newborn circumcision tend to be anticircumcision, whereas urologists are generally in favor of the procedure because they see its benefits throughout life, not only in penile cancer prevention, but in promotion of genital hygiene and protection against phimosis and balanoposthitis as well. These interdisciplinary jurisdictional differences were best illustrated when the neonatologist directing one of the largest newborn nurseries in the country banned newborn circumcision from this nursery, regardless of parental wishes. lo Similarly, the development of pediatric urology as a subspecialty has resulted in a dichotomy within urology because, like neonatologists, pediatric urologists, by training and practice, are most likely to see complications of newborn circumcision and least likely to see the protective effects later in life.“-13 A new dimension in the circumcision controversy was introduced largely by the work of Wiswell et al. 14,15A neonatologist originally opposed to circumcision, Wiswell followed up a report suggesting that urinary tract infections (UTIs) were more common in uncircumcised male infants. The Wiswell et aZ.15 study included more than 200,000 male infants from U.S. Army hospitals. To Wiswell’s surprise, data indicated that circumcision of newborns protected against UTIs in males during the first year of life, a finding confirmed in later outpatient and prospective studies.16,” As they did
with penile cancer, urologists provided important objective information on male infant UTIs, particularly in explaining the pathophysiology. Roberts et aZ.lsJe in this country and urologic investigators in Sweden20s21demonstrated that uropathic bacteria, particularly P-fimbriated Escherichia coli, preferentially bind to the mucosal surface of the foreskin and then ascend the urinary tract. In 1986 Roberts22 voiced support for circumcision of newborns. Perhaps the most outspoken proponent of circumcision of newborns is a California urologist, Aaron Fink. Although located in the heartland of anticircumcision organizations and attacked by lay groups, columnists, and media figures, Fink persisted in citing and documenting the advantages of circumcision. Largely through his efforts, the California Medical Association in 1988 adopted a resolution recommending newborn circumcision as a beneficial public health procedure. 23 In 1987 Fink2’ theorized that mini-abrasions on the delicate mucosal surface of the foreskin predispose toward acquisition of the acquired immunodeficiency syndrome (AIDS) virus, an opinion subsequently supported by evidence from sexually transmitted disease clinics in the U.S. and Africa.25-27 Urologists have continued to have a major role in the circumcision controversy. They have provided objective data and valuable clinical observations in a field where there have been many undocumented opinions. General urologists as a group have favored circumcision, a policy often not followed by pediatric urologists.11-13In addition to this intraspecialty controversy, some outspoken anticircumcisionists have been falsely identified as urologists. In 1983, an opinionated and misleading article opposing circumcision of newborns appeared. lo It was widely assumed that Wallerstein,lo the author, was a urologist; he was identified as such in The New York Times.28 In actuality, he was not a physician at all but a retired businessman and communication expert associated with the anticircumcision cause.2e In 1990 the author of an anticircumcision editorial was referred to as a urologist 30;he is a pediatrician and a medical advisor to one of the largest lay anticircumcision groups. In 1987, the American Academy of Pediatrics (AAP), largely in response to the evidence linking infant UT1 to the uncircumcised state, formed a Task Force to review evidence for and against circumcision of newborns and to make recommendations. This interdisciplinary group
100
UROLOGY
I AUGUST1992
/ VOLUME40.NUMBER2
of six members, of which I was chairman, was aided by two urologists, Frank Hinman, Jr., of the University of California, San Francisco, who was a Task Force member, and David Mininberg of Cornell University, New York, who was a liaison from the Urology Section of the AAP The broad knowledge, experience, and judgment of these urologists added an important dimension to our report, particularly in providing incidence data and precise definitions . The Task Force report published in 198g31 documented the medical advantages of circumcision of newborns (some material had appeared in the urologic literature more than fifty years earlie+) as well as its disadvantages and risks. Although the report stopped short of recommending circumcision of newborns as a routine procedure, evidence published since its completion confirming the value of newborn circumcision in preventing UTIs in male infantql**” as well as data from Africa indicating that heterosexual transmission of the AIDS virus is less likely in circumcised men,2e*27suggest that the advantages of routine circumcision of the newborn outweigh the risk.~.~~,~~ Urologists are still not directly involved in performing circumcision of newborns in the U.S., but the data they have produced in the past half century have been pivotal in the evolution of evidence favoring routine circumcision of newborns. In my opinion, the U.S. public owes its gratitude to the work and dedication of such urologic clinicians and investigators as Wolbarst and Dean in the 193Os, Dagher in the 197Os, and Persky, Roberts, and Fink in the 1980s. Although largely ignored or discredited in the past, their efforts now seem vindicated. 280 W. MacArthurBoulevard Oakland,California94611-5693 References 1. Wolbarst AL: Circumcision and penile cancer, Lancet 1: 150 (1932). 2. Dean AL Jr: Epithelioma of the penis, J Uro133: 252 (1935). 3. Lenowitx H, and Graham AP: Carcinoma of the penis, J Ural 56: 458 (1946). 4. Hardner GD, et al: Carcinoma of the penis: analysis of therapy in 100 consecutive cases, J Urol 168: 428 (1972). 5. Dagher R, Selxer ML, and Lapides J: Carcinoma of the penis and the anti-circumcision crusade, J Urol 110:79 (1973). 6. Per&y L, and deKernion J: Carcinoma of the penis, CA 36: 258 (1986).
UROLOGY
I
AUGUST 1992
I
VOLUME 40, NUMBER 2
7. Rogus BJ: Squamous cell carcinoma in a young circumcised man, J Urol 138: 861 (1987). 8. Thompson HC, King LR, Knox E, and Korones SB: Report of the Ad Hoc Task Force on Circumcision, Pediatrics 56: 610 (1975). 9. Guidelines for Perinatal Care: Evanston, Illinois: American Academy of Pediatrics; Washington, DC, American College of Obstetricians and Gynecologists, 1983. 10. Wallerstein E: Circumcision: the uniquely American medical enigma, Urol Clin North Am 12: 123 (1985). 11. Duckett JW: The neonatal circumcision debate, in King LR (Ed): Urologic Surgery in Neonates and Young Infants, Philadelohia. WB Saunders. 1988. DD 291-299. i2. Kaplan GW: Newborn &urn&ion: controversy revisited, Dialogues Pediatr Urol 11: l-8 (1988). 13. Gearhart JP: Says little medical evidence to justify routine circumcision, Pediatr News 24: 38 (1990). 14. Wiswell TE. Smith FR. and Bass IW: Decreased incidence of urinary tract infections in circumcised male infants, Pediatrics 75: 901 (1985). 15. Wiswell TE, et al: Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infection in early infancy, Pediatrics 79: 338 (1987). 16. ‘Nlus K, and Kallenius G: Epidemiological aspects of Pfimbriated Escberichia coli. IV Extraintestinal E. coli infections before the age of one year and their relation to fecal colonization with P-fimbriated E. coli, Acta Paediatr Stand 76: 463 (1987). 17. Herxog LW: Urinary tract infections and circumcision: a case-control study, Am J Dis Child 143: 348 (1989). 18. Roberts JA, et al: Experimental pyelonephritis in the monkey: VII. Ascending pyelonephritis in the absence of vesicoureteral reflux, J Urol 133: 1068 (1985). 19. Roberts JA, et al: Receptors for, pyelonephritogenic Escherichia coli in primates, J Urol 131: 163 (1984). 20. de Man P, et al: Bacterial attachment as a predictor of renal abnormalities in boys with urinary tract infection, J Pediatr 115: 915 (1989). 21. Svanberg Eden C, et al: Adhesion to normal human uroepithelial cells of Escherichia coli from children with various forms of urinary tract infection, J Pediatr 93: 398 (1978). 22. Roberts JA: Does circumcision prevent urinary tract infection, J Urol 135: 991 (1986). 23. Fink AJ: Newborn circumcision as a public health measure, California Medical Association Res. 305-88, adopted March 8, 1988, House of Delegates. 24. Fink AJ: Circumcision and heterosexual transmission of HIV infection to men (Letter), N Engl J Med 316: 1545 (1987). 25. Quinn TC, et al: Human immunodeficiency virus infection among patients attending clinics for sexually transmitted diseases, N Engl J Med 318: 197 (1988). 26. Simonsen JN, et al: Human immunodeficiency virus infection among men with sexually transmitted diseases: experience from a center in Africa, N Engl J Med 319: 274 (1988). 27. Cameron DW, et al: Female to male transmission of human immunodeficiency virus type I: risk factors for seroconversion in men, Lancet 2: 403 (1989). 28. Konner M: Symbolic wound, New York Times Magazine, 1988, May 8, pp 58-59. 29. WaIlerstein E: Circumcision: An American Health Fallacv.II New York, Springer, 1980. 30. Siwek J: Circumcision: the debate continues (Editorial), Am Fam Physician 41: 817 (1990). 31. Schoen EJ, et al: Report of the 1987-1988 task force on circumcision, Pediatrics 84: 388 (1989). 32. Wiswell TE: Routine neonatal circumcision: a reappraisal, Am Fam Physician 41: 859 (1990). 33. Schoen EJ: The status of circumcision of newborns, N Engl J Med 332: 1308 (1996). I
101
ARTICLE
UROLOGISTS AND CIRCUMCISION OF NEWBORNS EDGAR
J. SCHOEN,
M.D.
From the Department of Pediatrics, Kaiser Permanente Medical Center, Oakland, California
ABSTRACT-Although urologists have played a key role in performing clinical studies providing the rationale for newborn circumcision, they have not had primary responsibility for the decision to perform the procedure. Recent confirmatory evidence that newborn circumcision has significant preventive health benefits has called attention to previous urologic articles. This review summarizes the contributions of urologists to the controversy on circumcision of newborns over the past sixty years and emphasizes the importance of clinical objectivity in this field. Urologists have a unique role in the history of circumcision of newborns in the United States. Much of the initial data establishing cirumcision of newborns as a valuable preventive health measure were collected by urologists. However, although urologists diagnosed and treated diseases associated wi.th presence of the foreskin, they had no influence on the decision to perform circumcision of the newborn. For years, it had been apparent to the practicing urologist that circumcision of newborns simplified genital hygiene throughout life and prevented phimosis, paraphimosis, and balanoposthitis. Classic urologic studies almost sixty years ago showed that circumcision of newborns prevented penile cancer in later life, but the authors of these studies were disappointed by their lack of influence on those physicians (generally obstetricians, pediatricians, or family practitioners) who perform circumcision of newborns. Wolbarst in 1932l and Dean in 19352 presented convincing data that cancer of the penis could be prevented by circumcision of newborns. Wolbarst’ collected a series of 1,103 cases of penile cancer from hospitals in the United States and found that none had occurred in men circumcised in infancy. Because Jews comprised 3 percent of the population, he expected 33 cases in Jewish men, yet there were none. Three years later, Dean2 found that none of the 120 men with cancer of the penis in New
UROLOGY
I AUGUST1992
i VOLUME40.NUMBER2
York City’s Memorial Hospital were Jewish, although Jews comprised one third of the patients with other forms of cancer in the hospital. Both these authors recognized the importance of circumcision of newborns in preventing penile cancer and urged that the procedure become routine for newborn males in the U.S. Wolbarst noted “with gratification” that non- Jewish parents were beginning to have their newborn sons circumcised, but Dean, foreseeing interspecialty difficulties, expressed dissatisfaction that urologists were not responsible for circumcision of newborns and encouraged obstetricians to perform the procedure routinely. The majority of the medical profession, as well as the general population, became convinced of the health benefits of circumcision of newborns, and from the 1940s onward, most U.S. males (85% to 90 % in the 1950s through the 1970s) were circumcised as newborns. Data confirming the cancer-preventive effect of newborn circumcision continued to be published from urologic centers around the U.S. From 1932 through 1986, more than 1,600 cases of cancer of the penis were reported in six major series; not one of these men with cancer had circumcision as a newborn. l-6 Similarly, of about 50,000 men with cancer of the penis in the U.S. during this period (750 to 1,000 cases yearly) only 10 men were circumcised as newborns.’ It seemed inconceivable to urologists that in spite of this definitive documentation, in
99
the early 197Os, recommendations against newborn circumcision were coming from pediatric and obstetric organizations, those groups who were the “gatekeepers” and performers of the procedure. 8,QDagher, Seizer, and Lapides in 1973 reported 156 cases of cancer of the penis, all in uncircumcised men, and reflected the frustration of urologists in stating that “despite overwhelming evidence from urological surgeons that neoplasm of the penis is a lethal disease that can be prevented by removal of the foreskin, some physicians continue to argue against routine circumcision in a highly emotional and aggressive fashion.” In 1986, Persky and deKernio# expressed similar sentiments. The opposing attitudes of different medical specialties toward circumcision of newborns may be due to the fact that the procedure is a preventive health measure. The untoward effects are seen immediately or shortly after the procedure, whereas the protective action against disease is seen during the course of a lifetime, mainly in adulthood. Thus, neonatologists seeing only the pain and complications of newborn circumcision tend to be anticircumcision, whereas urologists are generally in favor of the procedure because they see its benefits throughout life, not only in penile cancer prevention, but in promotion of genital hygiene and protection against phimosis and balanoposthitis as well. These interdisciplinary jurisdictional differences were best illustrated when the neonatologist directing one of the largest newborn nurseries in the country banned newborn circumcision from this nursery, regardless of parental wishes. lo Similarly, the development of pediatric urology as a subspecialty has resulted in a dichotomy within urology because, like neonatologists, pediatric urologists, by training and practice, are most likely to see complications of newborn circumcision and least likely to see the protective effects later in life.“-13 A new dimension in the circumcision controversy was introduced largely by the work of Wiswell et al. 14,15A neonatologist originally opposed to circumcision, Wiswell followed up a report suggesting that urinary tract infections (UTIs) were more common in uncircumcised male infants. The Wiswell et aZ.15 study included more than 200,000 male infants from U.S. Army hospitals. To Wiswell’s surprise, data indicated that circumcision of newborns protected against UTIs in males during the first year of life, a finding confirmed in later outpatient and prospective studies.16,” As they did
with penile cancer, urologists provided important objective information on male infant UTIs, particularly in explaining the pathophysiology. Roberts et aZ.lsJe in this country and urologic investigators in Sweden20s21demonstrated that uropathic bacteria, particularly P-fimbriated Escherichia coli, preferentially bind to the mucosal surface of the foreskin and then ascend the urinary tract. In 1986 Roberts22 voiced support for circumcision of newborns. Perhaps the most outspoken proponent of circumcision of newborns is a California urologist, Aaron Fink. Although located in the heartland of anticircumcision organizations and attacked by lay groups, columnists, and media figures, Fink persisted in citing and documenting the advantages of circumcision. Largely through his efforts, the California Medical Association in 1988 adopted a resolution recommending newborn circumcision as a beneficial public health procedure. 23 In 1987 Fink2’ theorized that mini-abrasions on the delicate mucosal surface of the foreskin predispose toward acquisition of the acquired immunodeficiency syndrome (AIDS) virus, an opinion subsequently supported by evidence from sexually transmitted disease clinics in the U.S. and Africa.25-27 Urologists have continued to have a major role in the circumcision controversy. They have provided objective data and valuable clinical observations in a field where there have been many undocumented opinions. General urologists as a group have favored circumcision, a policy often not followed by pediatric urologists.11-13In addition to this intraspecialty controversy, some outspoken anticircumcisionists have been falsely identified as urologists. In 1983, an opinionated and misleading article opposing circumcision of newborns appeared. lo It was widely assumed that Wallerstein,lo the author, was a urologist; he was identified as such in The New York Times.28 In actuality, he was not a physician at all but a retired businessman and communication expert associated with the anticircumcision cause.2e In 1990 the author of an anticircumcision editorial was referred to as a urologist 30;he is a pediatrician and a medical advisor to one of the largest lay anticircumcision groups. In 1987, the American Academy of Pediatrics (AAP), largely in response to the evidence linking infant UT1 to the uncircumcised state, formed a Task Force to review evidence for and against circumcision of newborns and to make recommendations. This interdisciplinary group
100
UROLOGY
I AUGUST1992
/ VOLUME40.NUMBER2
of six members, of which I was chairman, was aided by two urologists, Frank Hinman, Jr., of the University of California, San Francisco, who was a Task Force member, and David Mininberg of Cornell University, New York, who was a liaison from the Urology Section of the AAP The broad knowledge, experience, and judgment of these urologists added an important dimension to our report, particularly in providing incidence data and precise definitions . The Task Force report published in 198g31 documented the medical advantages of circumcision of newborns (some material had appeared in the urologic literature more than fifty years earlie+) as well as its disadvantages and risks. Although the report stopped short of recommending circumcision of newborns as a routine procedure, evidence published since its completion confirming the value of newborn circumcision in preventing UTIs in male infantql**” as well as data from Africa indicating that heterosexual transmission of the AIDS virus is less likely in circumcised men,2e*27suggest that the advantages of routine circumcision of the newborn outweigh the risk.~.~~,~~ Urologists are still not directly involved in performing circumcision of newborns in the U.S., but the data they have produced in the past half century have been pivotal in the evolution of evidence favoring routine circumcision of newborns. In my opinion, the U.S. public owes its gratitude to the work and dedication of such urologic clinicians and investigators as Wolbarst and Dean in the 193Os, Dagher in the 197Os, and Persky, Roberts, and Fink in the 1980s. Although largely ignored or discredited in the past, their efforts now seem vindicated. 280 W. MacArthurBoulevard Oakland,California94611-5693 References 1. Wolbarst AL: Circumcision and penile cancer, Lancet 1: 150 (1932). 2. Dean AL Jr: Epithelioma of the penis, J Uro133: 252 (1935). 3. Lenowitx H, and Graham AP: Carcinoma of the penis, J Ural 56: 458 (1946). 4. Hardner GD, et al: Carcinoma of the penis: analysis of therapy in 100 consecutive cases, J Urol 168: 428 (1972). 5. Dagher R, Selxer ML, and Lapides J: Carcinoma of the penis and the anti-circumcision crusade, J Urol 110:79 (1973). 6. Per&y L, and deKernion J: Carcinoma of the penis, CA 36: 258 (1986).
UROLOGY
I
AUGUST 1992
I
VOLUME 40, NUMBER 2
7. Rogus BJ: Squamous cell carcinoma in a young circumcised man, J Urol 138: 861 (1987). 8. Thompson HC, King LR, Knox E, and Korones SB: Report of the Ad Hoc Task Force on Circumcision, Pediatrics 56: 610 (1975). 9. Guidelines for Perinatal Care: Evanston, Illinois: American Academy of Pediatrics; Washington, DC, American College of Obstetricians and Gynecologists, 1983. 10. Wallerstein E: Circumcision: the uniquely American medical enigma, Urol Clin North Am 12: 123 (1985). 11. Duckett JW: The neonatal circumcision debate, in King LR (Ed): Urologic Surgery in Neonates and Young Infants, Philadelohia. WB Saunders. 1988. DD 291-299. i2. Kaplan GW: Newborn &urn&ion: controversy revisited, Dialogues Pediatr Urol 11: l-8 (1988). 13. Gearhart JP: Says little medical evidence to justify routine circumcision, Pediatr News 24: 38 (1990). 14. Wiswell TE. Smith FR. and Bass IW: Decreased incidence of urinary tract infections in circumcised male infants, Pediatrics 75: 901 (1985). 15. Wiswell TE, et al: Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infection in early infancy, Pediatrics 79: 338 (1987). 16. ‘Nlus K, and Kallenius G: Epidemiological aspects of Pfimbriated Escberichia coli. IV Extraintestinal E. coli infections before the age of one year and their relation to fecal colonization with P-fimbriated E. coli, Acta Paediatr Stand 76: 463 (1987). 17. Herxog LW: Urinary tract infections and circumcision: a case-control study, Am J Dis Child 143: 348 (1989). 18. Roberts JA, et al: Experimental pyelonephritis in the monkey: VII. Ascending pyelonephritis in the absence of vesicoureteral reflux, J Urol 133: 1068 (1985). 19. Roberts JA, et al: Receptors for, pyelonephritogenic Escherichia coli in primates, J Urol 131: 163 (1984). 20. de Man P, et al: Bacterial attachment as a predictor of renal abnormalities in boys with urinary tract infection, J Pediatr 115: 915 (1989). 21. Svanberg Eden C, et al: Adhesion to normal human uroepithelial cells of Escherichia coli from children with various forms of urinary tract infection, J Pediatr 93: 398 (1978). 22. Roberts JA: Does circumcision prevent urinary tract infection, J Urol 135: 991 (1986). 23. Fink AJ: Newborn circumcision as a public health measure, California Medical Association Res. 305-88, adopted March 8, 1988, House of Delegates. 24. Fink AJ: Circumcision and heterosexual transmission of HIV infection to men (Letter), N Engl J Med 316: 1545 (1987). 25. Quinn TC, et al: Human immunodeficiency virus infection among patients attending clinics for sexually transmitted diseases, N Engl J Med 318: 197 (1988). 26. Simonsen JN, et al: Human immunodeficiency virus infection among men with sexually transmitted diseases: experience from a center in Africa, N Engl J Med 319: 274 (1988). 27. Cameron DW, et al: Female to male transmission of human immunodeficiency virus type I: risk factors for seroconversion in men, Lancet 2: 403 (1989). 28. Konner M: Symbolic wound, New York Times Magazine, 1988, May 8, pp 58-59. 29. WaIlerstein E: Circumcision: An American Health Fallacv.II New York, Springer, 1980. 30. Siwek J: Circumcision: the debate continues (Editorial), Am Fam Physician 41: 817 (1990). 31. Schoen EJ, et al: Report of the 1987-1988 task force on circumcision, Pediatrics 84: 388 (1989). 32. Wiswell TE: Routine neonatal circumcision: a reappraisal, Am Fam Physician 41: 859 (1990). 33. Schoen EJ: The status of circumcision of newborns, N Engl J Med 332: 1308 (1996). I
101
