THE QUESTION OF PENILE CANCER
The supposed correlation between circumcision, especially when performed in infancy or early childhood, and lack of subsequent penile cancer, has been one of the biggest medical arguments in favor of the operation. Is circumcision during infancy justified as a preventive measure against this disease? Are the pain and trauma of circumcision, the risk of immediate complications, and the lifelong deprivation of one’s foreskin outweighed by a high possibility of eventual cancer of the penis? Is amputation of the foreskin an effective means of insurance against this disease? If so, is it the only effective means of preventing this disease?
One of the earliest studies of penile cancer took place in 1907. Barney observed 100 cases of epithelioma (skin‑cell based cancer) of the penis. These were observed over 33 years of practice. He noted that the disease is rare, equaling about 2.8 cases yearly at Massachusetts General Hospital where he conducted his research, and constituting around 1% of all cancers. He mentions that no Jews were included in his study.1
During the 1920s and ’30s medical authorities gave considerable attention to penile cancer and attempted to link it to lack of circumcision. Because the disease is rare among Jews and Moslems, and because both of these groups practice circumcision, authorities concluded that cutting off the foreskin was an effective means of preventing penile cancer.
In 1932 Wolbarst conducted a study based on a nationwide (U.S.) questionnaire, medical literature, and personal correspondence. From this he made the following observations:
1. Cancer of the penis does not occur in Jews circumcised in infancy.* It has occurred in an uncircumcised Jew.
2. Penile cancer does occur in Muhammedans (Moslems), who practice ritual circumcision between the 4th and 9th year, but not in infancy. A few cases have been recorded.
3. Penile cancer occurs almost exclusively in the uncircumcised, who also suffer from phimosis, and occasionally in men circumcised in adult life.
4. There is no racial immunity** against penile cancer in Jews or Muhammedans. The one common factor which induces immunity is circumcision in early life.
5. Penile cancer constitutes at least 2‑3 % of all cancer in men.
6. The annual mortality from penile cancer in the U.S. is about 225, all or at least most of which can be prevented by circumcision in early life.2
These findings are still being cited today as the basis for the alleged medical arguments in favor of neonatal circumcision. However, today there is growing evidence that his observations are only partially true. The wisdom of a surgical approach as a means of preventing a rare disease is highly questionable. The facts about cancer of the penis must be carefully scrutinized.
What is Cancer of the Penis? How Does it Develop? What are its Causes and Related Factors?
According to Bruhl:
“Carcinoma of the penis occurs rarely, and among our patients it takes with a frequency of 0.6%, last place among the malignant disease of the male urogenital tract after carcinoma of the kidney, prostate, bladder, and testicles. It originates mostly in the inner part of the prepuce of the penis or the inner part of the glans, and sparing the corpus spongiosum penis urethrae, spreads within the corpus cavernosum [the body of the penis]. In our department, from 1928‑1974, 124 penile cancers were observed. In 69 of these the histologic diagnosis could be reviewed. In 95.7% a squamous cell carcinoma had been found.”3
The condition is almost invariably associated with phimosis ‑ the condition in which the foreskin cannot be easily retracted over the glans for washing. This fact is repeatedly stated by nearly all authors who have studied the disease.
According to Barney:
“In many cases the patient said he was never able to retract his foreskin.”4
“In penile cancers the prepuce is almost always tight or long and may be adherent to the underlying glans. There is retention of smegma, a peculiarly odiferous sebum, with continuous irritation. This continual irritation of the smegmatic debris results in redness, itching, a foul discharge, edema of the prepuce, and ulceration.”5
However, in a few cases, previous circumcision appears to have been the cause or provided the originating site for the penile cancer.
“…six cases who had previous circumcision, and who said that the wound had either never healed or that the cancer had first begun in its edges. This surely is a form of trauma and in these cases it was apparently the beginning of the trouble.”6
Cancer of the penis is nearly always a slow growing cancer which is easily curable, especially if detected in its earlier stages. However, many writers have observed that patients with this disease often delay treatment until it has reached advanced stages.
Colon, who researched the subject in 1952, comments:
“Carcinoma of the penis is a lesion of the skin, definitely a skin carcinoma. Its very early lesions are not often seen because being relatively painless at first, the patient usually seeks medical advice at an unbelievably late stage of the disease.“7
Cancer of the penis is frequently associated with sexually transmitted disease. In Graham’s study 32% had either syphilis or gonorrhea.8 The question arises as to whether STD is a causal factor in the development of penile cancer, or whether both diseases are associated with other factors.
Graham also comments that sometimes doctors misdiagnose the condition:
“In the medical lifetime of any general practitioner few such cases are seen. The physician is not cancer conscious and generally mistakes the condition for a venereal disease. Thus valuable time is lost.”9
Cancer of the penis is a disease that is commonly associated with extremely poor personal hygiene.
Wolbarst, one of the leading proponents of routine infant circumcision as a cancer preventive, states:
“…There is a direct relationship between the lack of hygienic care of the male genitals and the occurrence of penile cancer, and that it is most common among peoples in whom ignorance and poverty combine to maintain hygiene at its lowest standard.”2
While cancer of the penis has been virtually non‑existent among Jews, it is also true that neither “ignorance” nor “poverty” have been typical characteristics of Jewish people. Jews are a remarkably intelligent people, commonly achieving financial success, attaining higher education, and are well represented among the professional classes. These people almost always have a high standard of living and are consequently clean in their personal habits regardless of circumcision.
Cancer of the penis is rare, but not non‑existent in individuals circumcised in infancy or early childhood. There are a few documented cases of penile cancers which have developed in individuals circumcised in infancy.10, 11, 12
According to one recent study:
“Thirty‑six biopsy specimens taken from 11 men ranging from age 21 to 36, each of whom had multiple reddish to violaceous papules, some distinctly verrucoid or velvety on either or both the shaft and glans of the penis … histologically … all specimens submitted showed indubitable changes of squamous cell carcinoma in situ. Ten of the 11 men had been circumcised in infancy. In none of the cases was there evidence of squamous cell carcinoma extending into the dermis. All were treated and resolved by either chemicals which were applied topically, or by surgical excision.”13 [Apparently this condition is not a typical penile cancer.]
Most victims of penile cancer are elderly men. According to one study:
“…The average age of our patients was 65; the youngest patient was 38 years old.”14
A curious finding is that while penile cancer is extremely rare among males circumcised in infancy or early childhood, somehow circumcision during later childhood or adulthood confers less “immunity.” For example, penile cancer is extremely rare among Jews circumcised in infancy, but occasionally does occur among Moslems who practice circumcision during childhood. The reason for this is not known.
Kennaway cites Dean’s speculations:
“It may be that when an infant is circumcised and the glans is no longer protected by the prepuce, a denser, thicker epidermis develops, which is resistant to the formation of cancer by chronic irritation. When circumcision is performed in later years the glans may have lost its ability to produce a resistant covering, and although there is no longer irritation from retained secretions, the glans remains relatively sensitive to the contacts of everyday life.”15
Another possibility is that Moslems, as well as some medical practitioners tend to not do as “complete” of a circumcision as do the Jews. They do not cut off as much skin and often do not force the remaining skin away from the glans in the manner of the Jewish “Periah.” Perhaps for a few individuals the remaining foreskin does become phimosed to the glans, collect smegma and develop infection. This can be a problem among people who believe that genital hygiene is unnecessary because circumcision is practiced. A poorly cared for penis that is partially circumcised may also predispose the individual to penile cancer in a small number of cases.
In other cases, previous circumcision has been the direct cause of penile cancer — the cancer developing at the site of the poorly healing circumcision scar. This would only develop as a result of an adult circumcision, since cancer of the penis does not occur in infants or children.
Laboratory Experiments That Have Tested the Alleged Carcinogenic Properties of Smegma
Smegma is simply dead epithelial (skin) cells, which if allowed to accumulate provides a medium for the growth of bacteria. It collects on the genitals of both males and females, and for most people is washed away by simple, regular bathing. Circumcised males do develop smegma, although to a lesser extent than their intact counterparts. If a male is not circumcised smegma may collect underneath the foreskin in a manner similar to wax developing in one’s ears. Like earwax, smegma has a natural tendency to dissipate as fast as it is produced. If this does not happen, retracting the foreskin and cleaning out the smegma is a very simple matter. For a few intact males who have never been taught that the foreskin should be retracted and cleaned, or who are extremely negligent in their personal cleanliness habits, smegma build‑up beneath the foreskin can be a troublesome problem. (Needless to say, neglect and poor habits of personal hygiene bring about problems with all parts of the body!)
Nearly all victims of penile cancer have tight foreskins and extremely poor habits of personal cleanliness. It is not certain what predisposes the penis to cancer in such cases, but the hypothesis has been presented that smegma is somehow a cancer causing agent. A few laboratory experiments with animals have attempted to answer the question.
In 1947 Plaut and Kohn‑Speyer applied horse smegma (collected from dead animals in rendering plants) to mice. In 190 mice the smegma was placed in an artificially created skin tunnel. 122 mice received subcutaneous injections of smegma. 88 mice had it applied to the skin surface. 150 control mice were treated with cerumen (ear wax). After 500 days 47% of those treated with smegma were alive as compared with 30% of the controls. After 600 days 26% and 6% had survived respectively. After 700 days the survival rate was 12% and 11/2 %. (Author’s note: Apparently this experiment proves that earwax is more lethal than smegma!)
No tumors grew out of any of the control mice. 7 tumors grew out of the 400 smegma‑treated mice. These included 4 papillary warts, 2 hornifying squamous‑cell carcinomas, 1 undifferentiated skin carcinoma, and 1 spindle‑cell sarcoma.
The authors conclude:
“There is nothing to indicate the possible nature of the supposed carcinogenic factor in smegma.”16
Reddy and Baruah conducted a similar experiment with mice, but involving fewer subjects, in 1961:
Fresh human smegma was injected in mice. There were 29 males and 16 females. 10 of each were used for controls. Nearly 50% of the animals died during the first year, some of infection of the genital tract probably caused by irritation from application of smegma and bacteria.
No macroscopic (visible to the naked eye) changes were observed in the male test animals. Microscopic examinations failed to show neoplastic changes.
No macroscopic growths were observed among the females. Microscopic examinations showed varying degrees of irritation, and hyperplasia (an excessive amount of normal cells).
“Definite proof of the carcinogenic potentialities of smegma in its fresh state or in its altered form due to bacterial decomposition is lacking.”17
Socioeconomic Factors Related to the Incidence of Penile Cancer
Many authorities have noted that nearly all victims of penile cancer come from lower socioeconomic groups for whom health care and information about disease symptoms are less available than for the middle class.18
For a myriad of unfortunate reasons a large proportion of black people have been relegated to the lower classes.
In 1944 Schrek noted a significantly high percentage of African American*** patients with penile cancer. He observed 120 cases of cancer of the penis (out of 11,790 patients at that hospital) and found 27.5% of these men were African American, compared to 8.45% African American people among the control group.19
In 1946 Schrek and Lenowitz conducted a study. Out of a group of 139 men with carcinoma of the penis, 28.1 % were African American, compared to 7% of the control group. They hypothesized that the higher incidence of this disease among African American males was related to: (a) lower incidence of circumcision, (b) greater incidence of venereal disease, or (c) racial susceptibility.
The authors found that the African American people observed in their study had a higher incidence of early circumcisions than did the men of other races. This was explained as a result of interns and residents in hospitals, particularly in the South, practicing circumcision on African American infants. Apparently the parents were poor, on welfare and/or in clinic‑like settings, and parental consent for circumcision was not obtained.
The authors concluded that lack of circumcision is not the factor which is responsible for the high incidence of carcinoma of the penis among African American men.
African American men had approximately twice the incidence of syphilis as white men (17.5% and 7.6%) and twice the incidence of gonorrhea (42.1% and 22.0%). Half of the African American men and three‑fourths of men of other races were free of STD.
Schrek and Lenowitz concluded:
“…White and [African American] men who do not develop venereal disease are equally susceptible to carcinoma of the penis. There is then no evidence of any unusual susceptibility of [African Americans] to carcinoma of the penis or of any immunity of white men to this lesion…. It has been shown that patients with carcinoma of the penis have a very high incidence of venereal disease. Evidently there is a correlation between the tumor and the infection…. The findings suggest that environmental, not racial, factors determine the incidence of carcinoma of the penis.”19
Worldwide Distribution of Penile Cancer
It is true that cancer of the penis is rare among males who have been circumcised. However, it is also true that disease is equally rare in many parts of the world where males keep their foreskins.
Rates of penile cancer in various countries throughout the world have been reported as follows:
Number of Cases of Penile Cancer per 100,000 Males:
|United States||0.8 to 1.2||Italy & Bulgaria (1969)||0.5|
|Canada (1971)||0.7||Poland (1970)||0.7|
|Norway (1959-1961)||1.0||Hungary (1971)||0.7|
|Finland (1970)||0.8||Israel (1960-1963)||0.1|
|(1967)||0.5||Puerto Rico (1950s & 1960s)||4.5|
|(1966 & 1963)||0.4||Columbia (1962-1964)||2.3|
|Iceland (1955-1963)||1.0||Nigeria (1960-65)||0.2|
|Netherlands (1969)||0.8||South Africa||4.6|
Statistics were reported differently for the following countries:
Percentage of Incidence of Penile Cancer Out of All Cancers in Males:
Brazil ……………………………. 4.5%
Percentage of Incidence of Penile Cancer Out of All Cancers:
Paraguay & Venezuela ………. 3%
Ceylon …………………………. 13.7%
China (1919)…………………. 22%
Percentage of Incidence of Penile Cancer Out of All Neoplasms (Abnormal Growths) in Males:
India …………………………..2.8% to 22 %
It is most important to note that the rates of penile cancer, while low in Israel which has an exclusively circumcised male population, and low in the U.S. with a largely circumcised male population, are equally low in Canada and all of the European countries listed which have a standard of living similar to ours. Circumcision is practiced only sporadically in Canada and rarely among non‑Jews in all European countries. The rates of penile cancer are somewhat higher in “underdeveloped” countries which have hotter climates and significantly lower standards of living‑although the disease is still relatively rare.
As the standards of living in underdeveloped countries improve the rates of penile cancer will diminish. (Note that in China the rate of penile cancer after 1919 diminished to almost half that country’s previous rate even though Chinese men are not circumcised.) Therefore, if we wish to help poorer countries, we should do so by improving their living conditions and teaching them better hygienic practices rather than by bringing our clamps and scalpels to cut off the foreskins of their infants. For many countries, such as China and India, are culturally resistant to adopting circumcision. Cutting off the foreskin is a foreign and repugnant concept to many people throughout the world, just as female circumcision is to us. It is ironic that a country such as ours, where virtually all homes have bathrooms and modern plumbing, has adopted circumcision as a supposed “cleanliness” measure, while other countries in which many people lack such “luxuries” are loathe to amputate foreskins.
Persky notes that circumcision is not the only, or the most significant variable in the rates of penile cancer. He comments:
“Great variation in incidence among noncircumcising tribes in Uganda suggest social and hygienic factors. The Lugbara, who do not circumcise but have high standards of cleanliness, have lower rates than the nearby Nyoro…. High rates in East Africa have been attributed to poor hygienic practices.”20, 21
According to Shabad, the rates of penile cancer in the U.S.S.R., (now Russia) a population that does not commonly practice male circumcision, is approximately the same as that of the United States, Canada, and other European countries.
“In the U.S.S.R., the incidence of penile cancer has varied in recent years from 0.5% to 1% of dangerous disease in male subjects. The morbidity of penile cancer in the Russian Soviet Federative Socialistic Republic in 1960 was 0.3 per 100,000.”12
From the available statistics it can be concluded that cancer of the penis is an extremely rare disease. Personal hygiene is an important variable in the development of penile cancer. An intact penis is not a significant factor in the development of the disease in countries with modern standards of living and adequate personal hygiene.
Methods of Treatment of Cancer of the Penis
Why has the medical profession been so eager to amputate foreskins in the hopes of preventing a disease which is quite rare and is equally preventable with adequate washing? The answer apparently is that the cure for more advanced cases of penile cancer is particularly horrible. The prognosis for cancer of the penis is relatively favorable. The cure rate is high. A smaller percentage of patients die of penile cancer than from many other types of cancer. However, the cure for the more advanced cases of penile cancer is amputation of the penis ‑ a “fate worse than death” in the minds of most men. This fact has been avoided by all of the other opponents of routine circumcision ‑ but it must be dealt with squarely. For doctors’ perception of human health tends to become distorted because they see so much illness and this is the reason that the medical profession has been unusually concerned with this rare disease.
The less advanced cases of penile cancer are remedied by simpler measures.
According to Bruhl:
“A small lesion, confined to the prepuce, is mostly managed by circumcision alone. Local radiation is added to circumcision when the lesion is in the glans and biopsy shows it to be limited to the superficial surface of the epithelium.”3
“Carcinoma of the penis may be treated … radiologically. If the tumor is superficial and no larger than 2.5 cm. in diameter, it is treated with X‑rays. Sterility is inevitable.23
(Fortunately most men who contract penile cancer are past the age of desiring to father children.)
Young reports on the “Radical Operation for Cancer of the Penis.” However devastating, it is reassuring to learn that total amputation and emasculation are not necessary. The scrotum, testicles, and a stump of the penis remain. The author describes this:
“…We have had no recurrence at the penile stump and no evidence of extension to the scrotum or contents to show that the most radical operation of total emasculation is not necessary nor is the more radical removal of the entire penis necessary…. The patients upon whom [this] radical operation for cancer of the penis has been carried out are not incapacitated in any way. Their wounds have healed within a reasonable time and they are able to void with a well directed stream. Satisfactory intercourse has been reported … and firm erections of the remaining portions of the penis. Patients appear satisfied with the result.”24
During the 1920s and ’30s when many doctors came out strongly in favor of infant circumcision as a prophylaxis against penile cancer, radical amputation of the penis was more commonly done as a cure for this disease than it is today. Today more sophisticated types of X‑ray treatments have enabled cases of penile cancer to be cured by radiation that in years past would have been treated by amputation.
“An infant runs a considerably greater risk of experiencing a serious complication of circumcision than he does of ever contracting penile cancer. It must also be remembered that the infant is at the beginning of his life, while the penile cancer victim has already lived most of his life.”
According to Bruhl:
“When the tumor involves both the prepuce and the glans and also extends into the shaft of the penis for a short distance, partial amputation is recommended. But it should be noted that today possibilities of applying supervoltage rays in this stage of carcinoma of the penis apparently show at least the same results as surgery, thus avoiding mutilation.”14
In addition, today more sophisticated methods of restorative plastic surgery have been developed which can reconstruct a functional phallus and restore sexual function when the penis has been lost either from accidents or by an operation.
Bruhl discusses this:
“With the nerves intact in the stump and with testicles present, both sensory and hormonal factors remain and titillation of the remnant cavernous bodies can result in a sexual impetus to the extent of … ejaculation. The patient is not necessarily sterile although the modus apparandi [sic] for the transmission of sperm through the pendulous urethra is missing.
“The repair of this deficiency by plastic reconstruction of the amputated penis can be satisfactorily accomplished. The new organ can assume the normal physiological functions not only of urination but also can afford connubial gratification to both participants during coitus….
“Restoration [is] accomplished by utilizing tube skin grafts into which rib cartilage was implanted.”
There are additional considerations. The man with cancer of the penis is almost always elderly. If he is having sexual relations it is almost invariably with a wife to whom he has been married for many years. She is certainly going to be understanding and accepting of his healing and limitations as well as thankful to have him alive. He is not in the same position as a younger man who is out to impress new girlfriends.
Also, in the complications chapter many documented cases of serious damage to and amputation of the penis resulting from circumcision were covered. An infant runs a considerably greater risk of experiencing a serious complication of circumcision than he does of ever contracting penile cancer. If an infant is circumcised he faces a risk of approximately one in 500‑1,000 of suffering from a serious complication of circumcision. Penile cancer occurs at a rate of approximately 1 in 100,000 per year in most “developed” countries, and 1 in 20,000 to 30,000 per year in most “underdeveloped” countries – thus constituting a much smaller individual risk. Since only a few victims of penile cancer ever undergo partial penile amputation, and even fewer die of the disease, the individual risk of disfiguration or death is even smaller.
When weighing the possibility of serious complications of circumcision against the risk of penile cancer, we must also remember that the infant is at the beginning of his life, while the penile cancer victim has already lived most of his life. Therefore, serious damage to the penis resulting from infant circumcision is ultimately more devastating than serious damage to the penis as a cure for penile cancer in an elderly person.
Apparently a “sacrificial” psychology has been in effect for the rationale of infant circumcision as a prophylaxis against penile cancer. Most men would prefer to go through life without their foreskins and choose the same for their sons if this were the only insurance against a strong possibility of losing one’s entire penis to cancer. However, the facts all indicate beyond any doubt that penile cancer is extremely rare, penile amputation is even rarer, total amputation is not necessary, and circumcision is not the only prevention.
The choice of prevention of penile cancer is either to cut the foreskin off, or wash it. Many, many authors have made this point. Even Wolbarst, one of the first advocates of infant circumcision as a cancer preventive, clearly states:
“The common denominator … appears to be poor sex hygiene. The incidence of carcinoma of the penis could be reduced either by early circumcision or by good hygiene” [emphasis mine].25
The Ad Hoc Task Force of the American Academy of Pediatrics on Circumcision concluded the following:
“There is evidence that carcinoma of the penis can be prevented by neonatal circumcision. There is also evidence that optimal hygiene confers as much, or nearly as much, protection. Although circumcision is an effective method of preventing penile carcinoma, a great deal of unnecessary surgery, with attendant complications, would have to be done if circumcision were to be used as prophylaxis against this disease. Promulgation of the principles of adequate penile hygiene is an alternative prophylactic measure.”26
Many authors have emphasized that it is not merely the foreskin, but phimosis and poor hygiene that is the significant factor in the etiology of penile cancer. Preston emphasizes this fact by stating that “if a man has a foreskin which he can retract and which he keeps clean, the risk of cancer of the penis is removed.”27
(In the chapter on “The Intact Penis” the condition of phimosis, and its remedies, is thoroughly discussed. A tight foreskin is normal for an infant or young boy, and should be left alone. For an older person, phimosis can usually be remedied by very simple measures.)
In emphasizing the rarity of the disease and the inefficiency of routine surgery as prevention, Morgan quotes Marshall’s statement that:
” ‘If a surgeon would perform one circumcision every ten minutes, eight hours a day, and five days a week, he would seem able to prevent one penile cancer by working steadily for between 6 and 29 years. Since a significant number of penile cancers are curable, still more time and labor might be required to prevent a fatality from this disease.’ “28
“It is an incontestable fact … that there are more deaths each year from circumcision than from cancer of the penis.”29
Ritter, a strong opponent of neonatal circumcision, points out that there is no other part of the body that we routinely cut off simply because it has the potential of becoming cancerous. He states that penile cancer is so rare that many physicians never see a case of it in their entire practice, or may see only a few cases during their entire professional lives. Many other parts of the body are considerably more cancer‑prone than the foreskin and many other things that we encounter in life are significantly more carcinogenic. According to Ritter:
“If one wishes to practice an amputative type of preventive medicine, one could find many more rewarding structures to cut off rather than the foreskin.
“The ear. Cancer of the skin of the top of the ear is common. We could hear without the protruding aural appendage.
“The female breast…. Removing the minute breasts of all female infants in the immediate postnatal period would ultimately save tens of thousands of lives each year…. [A] new flat chest contour could … be accepted as the norm, just as the multitude of surgically pruned penises are now accepted as normal.
“The testis. Cancer of the prostate, and benign prostatic hypertrophy … could be greatly reduced in incidence or possibly eliminated, if every male had his testes removed at about the age of 35 or 40.
“The cervix. Cancer of the cervix is common … therefore we could amputate all cervixes of women past childbearing age.
“Cigarettes. The scientific evidence tying the inhalation of the carcinogens in cigarette smoke to cancer of the lung is substantial. It would be interesting to compile statistics on how many of the routine circumcision advocates have amputated themselves from smoking cigarettes. Cancer of the lung is very common in both men and women.”30
The two choices of prevention of penile cancer -‑ cutting the foreskin off versus washing it — represent two different approaches to health care: the traditional, surgical approach versus the wholistic approach. Unfortunately the established medical profession has tended to prefer the surgical approach. Many doctors have preferred to routinely cut foreskins off of infants rather than teach new parents and later the individuals to wash this area.
Both politics and economics are strongly involved in this issue. For too often many choices in human health care have not centered on what is most beneficial for the individual. Instead they have centered on who is in control and who is getting paid. A doctor is the person in control when he performs a circumcision. He cannot control whether or not that person is going to wash himself. Similarly, doctors get paid for doing circumcisions, but they do not get paid for telling people to wash.
- Barney, J. Dellinger, M.D. “Epithelioma of the Penis. An Analysis of One Hundred Cases” Annals of Surgery, Vol. 46, 1907, p. 890.
- Wolbarst, Abr. L., M.D. “Circumcision and Penile Cancer” The Lancet, Jan. 16, 1932, p. 150.
- Bruhl, P. “Problems of Therapeutic Surgery in Penis Carcinoma” Recent Results, Cancer Research, Vol. 60, 1977, p. 120‑126.
- Barney, p. 894.
- Lenowitz, Herman, and Graham, Albert P. “Carcinoma of the Penis” Journal of Urology, Vol. 56, 1946, p. 462.
- Barney, p. 896.
- Colon, Julio E. “Carcinoma of the Penis” The Journal of Urology, Vol. 67, No. 5, May 1952, p. 702‑708.
- Lenowitz & Graham, p. 464.
- Ibid., p. 482.
- Marshall, Victor F., M.D. “More on Circumcision” Medical Tribune, Vol. 83, July 12, 1965, p. 11.
- Sorrells, Morris L., M.D. “Still More Criticism” Pediatrics, Vol. 56, No. 2, August 1975, p. 339.
- Leiter, Elliot, M.D.; & Lefkovits, Albert, M.D. “Circumcision and Penile Carcinoma” New York State Journal of Medicine, Vol. 75, No. 9, p. 1520‑1522.
- Wade, Thomas R., M.D.; Kopf, Alfred W., M.D.; and Ackerman, A. Bernard, M.D. “Bowenoid Papulosis of the Penis” Cancer, Vol. 42, No. 4, Oct. 1978, p. 1890‑1903.
- Bruhl, p. 121.
- Kennaway, E.L. “Cancer of the Penis and Circumcision in Relation to the Incubation Period of Cancer” British Journal of Cancer, Vol. 1, No. 4, Dec. 1947, p. 312.
- Plaut, Alfred, and Kohn‑Speyer, Alice C. “The Carcinogenic Action of Smegma” Science, Vol. 105, 1947, p. 391.
- Reddy, D. Govinda, M.D. and Baruah, I.K.S.M., M.B., B.S. “Carcinogenic Action of Human Smegma” Archives of Pathology, Vol. 75, April 1963, p. 414‑420.
- Paige, Karen Ericksen “The Ritual of Circumcision” Human Nature, May 1978, p. 44.
- Schrek, Robert, M.D. and Lenowitz, Herman, M.D. “Etiologic Factors in Carcinoma of the Penis” Cancer Research, Nov. 12, 1946, p. 185‑186.
- Persky, L. “Epidemiology of Cancer of the Penis” Recent Results of Cancer Research, (Berlin) 1977, p. 97‑99, 101, 102.
- Ibid., p. 104.
- Shabad, A.L. “Some Aspects of Etiology and Prevention of Penile Cancer” The Journal of Urology, Vol. 92, No. 6, Dec. 1964, p. 697.
- Bleich, Alan R., M.D. “Prophylaxis of Penile Carcinoma” J.A.M.A., Vol. 143, No. 12, July 22,1950, p. 1057.
- Young, Hugh H. “A Radical Operation for the Cure of Cancer of the Penis” The Journal of Urology, Vol. 26, No. 2, Aug. 1931, p. 285‑316.
- Wolbarst, p. 187.
- Thompson, Hugh C., M.D.; King, Lowell R., M.D.; Knox, Eric, M.D.; and Korones, Sheldon B., M.D. “Report of the Ad Hoc Task Force on Circumcision” Pediatrics, Vol. 56, No. 4, Oct. 1975, p. 610.
- Preston, Capt. E. Noel, M.C., USAF “Whither the Foreskin? A Consideration of Routine Neonatal Circumcision” Journal of the American Medical Association, Vol. 213, No. 11, Sept. 14, 1970, p. 1856.
- Morgan, William Keith C., M.D. “Reply to Dr. Greenblatt” American Journal of Diseases of Children, Vol. 3, April 1966, p. 448‑449.
- Gellis, Sydney S., M.D. “Circumcision” American Journal of Diseases in Childhood, Vol. 132, Dec. 1978, p. 1168.
- Ritter, Thomas J., M.D. Personal Research and Conclusions on Circumcision and Cancer of the Penis (unpublished)
*A small number of Jews who were circumcised in infancy and later developed cancer of the penis have been reported since Wolbarts’s study was made.
**There is some speculation today that genetic immunity may indeed be responsible for Jews’ relative immunity to certain diseases, including penile cancer.
***Several articles such as this one, written several decades ago, use the outdated terms “Negroes” or “colored people.” I have chosen to use the more modern term “African American.”
http://www.cdc.gov/hiv/pdf/prevention_research_malecircumcision.pdf (CDC report)
https://www.dropbox.com/s/zz23nzayyrmih0t/ACScirc.jpg (Cancer society – non recommendation)
https://www.facebook.com/photo.php?fbid=10203239541024120&set=p.10203239541024120&type=1&theater (America Cancer Society’s official statement)