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Why not the breast buds?

Guest contributor Melanie Lindwall Schaab, RN, MS, FNP-C

January 7, 2018 Intactivists often draw comparisons between removing the foreskin and removing other organs in an attempt to demonstrate how ridiculous it is to think that prophylactically removing the foreskin of a newborn is beneficial. “If you’re going to remove the foreskin, why not the appendix? Or your daughter’s breast buds?” Although the argument is likely facetious, I decided to take it at face value and respond intelligently to their question. The organs usually brought up for comparison are the wisdom teeth, tonsils, appendix, and breast buds.

Foreskin

Anesthesia. Local anesthetic is used in newborn circumcisions. Child circumcisions typically use general anesthetic. Adult circumcisions may use either general or local, and so can be expected to cost less than child circumcisions but far more than newborn circumcisions.

Medical Indication. Circumcision is medically indicated in roughly 10% of males not circumcised at birth. However, approximately half (50%) of males will experience complications related to retaining their foreskins [Morris, Bailis, & Wiswell, 2014]. In this way, circumcision is different from all the other procedures suggested here because the foreskin may cause problems without the problems being so severe as to warrant removal. In other words, let’s say you don’t have him circumcised as a newborn. There’s a 2.2% chance he’ll end up with a UTI in the first year of life, and the average cost of treating a UTI in a male infant is $1,111 [Schoen, Colby, & Ray, 2000]. That single UTI alone costs about four times more than his newborn circumcision would have and involves more pain and medication for treatment of the problem than his newborn circumcision would have warranted. Nevertheless, getting him circumcised at that age (past the newborn stage) would cost so much that it might result in net financial loss and the complications associated with a later circumcision are much higher and may pose more danger than the complications associated with a single UTI. He may end up with more complications related to foreskin retention, or he may not. Furthermore, especially if he lives in a country where newborn circumcision is rare, getting him circumcised poses a serious risk of causing emotional problems down the road due to feeling like the “odd man out” or “abnormal” or “damaged.” Therefore, most foreskin problems are treated the less expensive route, which involves throwing drugs at the patient rather than removing the offending organ. By contrast, appendicitis, symptomatic wisdom teeth, tonsillitis, and breast cancer are all by far most often treated with removal of the offending organ. Tonsillitis is the only one that may often be treated without surgery, but nevertheless, the vast majority of tonsillitis cases are treated with surgery, unlike foreskin problems, the majority of which are not treated with circumcision. So that’s why I put both 10% (the number who need a circumcision) and 50% (the number who have foreskin-related complications).

Complication Rate. Complications occur in about 0.2-0.6% of prophylactic newborn circumcisions [Kacker et al, 2012]. Post-newborn circumcisions (infant, child, adolescent, adult) pose over 10 times higher risk with a complication rate of roughly 6% [Weiss, 2010]. Benefits of prophylactic newborn circumcision outweigh the risks at least 100 to 1 [Morris, Bailis, & Wiswell, 2014].

Age at Lowest Risk. Newborns experience the lowest incidence of complications. The complication rate is 10-20 times higher in adults as compared to newborns.

Cost. Circumcisions cost on average $291 in the U.S. [Kacker et al, 2012]. Circumcision affects not just the risk of later medically-necessary circumcision, but of a wide range of other problems in males and their female partners, including genitourinary infections, sexually-transmitted infections, cancers, and structural problems. When all of these are considered, prophylactic newborn circumcision results in significant cost savings, even if you were to take the money you would have spent on the circumcision and put it in an investment account with 3% interest. [Ganiats et al, 1991; Lawler, Bisonni, & Holtgrave, 1991; Colby et al, 2001; Gray, 2004; Schoen, Colby, & To, 2006; Morris, Castellsague, & Bailis, 2006; Kacker et al, 2012]

Conclusion. Although the total number of risks and benefits are small, the ratio strongly favors circumcision, specifically newborn circumcision, and prophylactic newborn circumcision results in significant savings on health expenses across the lifespan.

Wisdom Teeth

Anesthesia. Prophylactic removal of the wisdom teeth is typically performed under local anesthesia. Similarly, prophylactic newborn circumcision is typically performed under local anesthesia.

Medical Indication. Experts estimate that as many as 80% of people whose wisdom teeth are not prophylactically removed will have complications later, most requiring removal; nevertheless, many are now calling for prophylactic wisdom tooth extraction to be ended [Rabin, 2011]. In this way, it’s similar to the foreskin because at least half of males whose foreskins are not prophylactically removed will have complications later, a sizeable minority of which require removal; and in spite of this, many are now calling for newborn circumcision to be ended.

However, unlike circumcision, the exact statistics of wisdom tooth removal—specifically, how frequently it’s medically indicated—are scarce, and the actual number is probably far lower, around 25%, with one study estimating it to be medically necessary in only 12% of cases [Rabin, 2011]. In this case, it’s again similar to the foreskin, removal of which is medically necessary in about 10% of males.

However, it’s also dissimilar to the foreskin because wisdom teeth that cause no problems are not removed while wisdom teeth that cause any symptoms whatsoever are removed [Rabin, 2011] — in other words, the total complication rate from wisdom teeth retention is as low as 12%. However, the foreskin is most often not removed if it causes minor problems and only removed if it causes serious problems. Since serious problems may occur in about 10% and minor problems in about 50%, complications of foreskin retention are likely far higher than complications of wisdom teeth retention.

Impacted wisdom teeth can be asymptomatic initially, but later result in long-term damage [Brauer et al., 2013]. In this way, it’s similar to the foreskin, which may not have any symptoms initially but ultimately result in a condition requiring circumcision or more radical surgeries as treatment, such as lichen sclerosis or penile cancer.

Complication Rate. One area where there is a glaring difference between wisdom teeth removal and circumcision is in the risks of the surgery. While the overall complication rate from newborn circumcisions hangs around 0.2-0.6% and the serious complication rate is about 0.01%, the overall complication rate from wisdom teeth extraction is 2.6-30.9% and the serious complication rate is roughly 1% [Brauer et al, 2013]. This means the overall complication rate of wisdom tooth extraction is roughly 42 times higher and the serious complication rate is 100 times higher than with circumcision.

Age at Lowest Risk. Another significant difference between wisdom teeth extraction and circumcision is that it is not necessarily better when performed at a younger age. Circumcision of older children and adults poses more than a 10 times higher complication incidence as compared to circumcision of newborns. In contrast, wisdom teeth removal can only be performed in older children at the youngest because they don’t exist in young children or infants.

Cost. The cost of prophylactically removing all four wisdom teeth ranges $1,000 to $3,000 depending on region and how complicated the procedure is [CostHelper, 2015]. This is almost 10 times higher than the cost of newborn circumcision. Because wisdom tooth problems are exclusively treated with surgical removal, a financial cost-benefit analysis is a simple matter of comparing the cost to remove all people’s wisdom teeth versus the savings from removing wisdom teeth in people who would have needed it anyway. If 25% of people require wisdom tooth removal and it costs $2,000 per person, prophylactically removing all wisdom teeth would pose a net cost of $500 per person. In contrast, newborn circumcision results in significant cost savings.

Conclusion. Thus, because the benefits of prophylactic wisdom tooth extraction are probably low in comparison to the benefits of prophylactic newborn circumcision, and the risks of wisdom tooth extraction are so great in comparison to the risks of circumcision, there is a far narrower risk-benefit ratio. In fact, when looking simply at the complication rates of prophylactic removal versus tooth retention, the risks may outweigh the benefits, but there is little solid data on this. In stark contrast, the benefits of circumcision outweigh the risks at least 100 to 1 based on literally dozens of studies on the topic. Furthermore, prophylactic wisdom tooth removal would result in significant financial loss, while newborn circumcision results in significant cost savings.

Tonsils/Adenoids

Anesthesia. Tonsils are removed under general anesthesia. This is the opposite of newborn circumcision.

Medical Indication. The reasons for tonsillectomies have shifted from predominately due to infection in the 1970s to predominately due to upper airway obstruction in the 2000s [Erickson et al, 2009]. This is due in part to changes in treatment, where physicians prefer to administer antibiotics repeatedly rather than remove the offending organ (in part because the recurrent tonsillitis may resolve over time), to improved ability to diagnose airway obstruction causing obstructive sleep apnea (OSA), and to greater understanding of the health, behavioral, and academic risks of OSA [American Academy of Otolaryngology—Head and Neck Surgery, N.d.; Erickson et al, 2009]. Back in 1938 in the U.K., it was thought that 4-6% of children would require tonsillectomy in contrast to a total tonsillectomy incidence of roughly 32% [Glover, 1938]. A recent study of several areas in Italy found that an average of 678 tonsil/adenoid surgeries were performed on children aged 2-9 with an average of 14,726 children aged 2-9 in the population [Fedeli et al, 2008]. This comes out to an incidence of about 4.6%, which agrees with the 1938 British expected incidence of medically-necessary tonsillectomies. This is roughly half of the medically-necessary circumcision rate.

Complication Rate. A recent meta-analysis found that the overall complication rate in children is about 19% [De Luca Canto et al, 2015]. Complications of tonsillectomies in children (19%) is thus roughly 48 times the complication rate of newborn circumcision (0.4%).

Age of Lowest Risk. Moderate to severe complications are much higher in adults (20%) than in children (2-4%) [Seshamani et al, 2014]; thus, the complication rate is roughly 5-10 times higher in adults than in children. In this way, it’s similar to circumcision, where the complication rate is roughly 10-20 times higher in adults than in newborns. However, there’s no apparent benefit to prophylactically removing tonsils in newborns as opposed to older children, as surgery under general anesthetic in newborns is riskier than the same in older children. In this way, it’s different from circumcision, because circumcision of newborns is safer than circumcision of older infants, children, adolescents, or adults.

Cost. The cost of a tonsillectomy ranges $4,000-$7,000 without insurance, averaging $5,500, and it costs about $500 less for children than for adults. An adenoidectomy costs $5,000-8,200, averaging $6,000. A combination tonsillectomy and adenoidectomy costs $10,000-14,000, averaging $11,500 [CostEvaluation, N.d.]. If we consider the approximately 5% of people who will require a tonsillectomy versus the $5,500 it costs per surgery, prophylactically removing 100% of tonsils would constitute a net loss of $275 per person. This net loss might actually be slightly lower because some tonsillitis cases are treated with antibiotics instead of tonsillectomy and the cost of antibiotic treatment (office visit fee, purchase of prescription, sometimes multiple follow-up visits, etc., and tonsillitis has a habit of recurring, meaning that this charge may be doubled or tripled) may be slightly less than the cost of the surgery.

Conclusion. Tonsillectomy is similar to circumcision in that it’s less risky when performed younger, but dissimilar in that it’s riskier in newborns than in children. However, tonsillectomies are required about half as often as circumcision is required, poses 48 times the complication rate as newborn circumcisions, and prophylactic tonsillectomies would pose a net financial loss compared to a net gain with prophylactic newborn circumcision.

Appendix

Anesthesia. Appendectomies are almost exclusively performed under general anesthesia, which automatically poses much higher risk than the local anesthesia used in circumcisions.

Medical Indication. Lifetime risk of appendectomy is about 12% in males. The incidence is stated to be double in females [BMJ Publishing Group, N.d.], but half of suspected acute appendicitis in females turns out to be something else (e.g., ovarian cyst, ectopic pregnancy, etc.) [Minutolo, 2014]. In this way, it is similar to the foreskin, where about 10% of males will require its removal for medical reasons. However, acute appendicitis is almost exclusively treated with surgery [Craig, N.d.a; Craig, N.d.b], whereas foreskin complications are typically treated without surgery. Thus, while the acute appendicitis rate closely mirrors the appendectomy rate (~12%), the circumcision rate (~10%) is only a fraction of the overall foreskin complication rate (~50%). In other words, the foreskin is far more likely to cause problems than is the appendix, but is just as likely to require removal.

Complication Rate. The complication rate from appendectomies ranges 3% for laparoscopic surgeries to 13% for open surgeries in adults [Minutolo et al, 2014]; thus, open surgery has approximately 4 times higher risk. In children, the risks are significantly higher, at 13% for laparoscopic surgeries to 23% for open surgeries [Paya et al., 2000]; thus, in children, open surgery poses only about double the risk of laparoscopic surgery, but significantly greater risk than the same surgeries in adults. Laparoscopic surgeries occasionally are impossible and must be converted to open surgeries (1.4% in one study of adults [Minutolo et al, 2014] and 4.3% in a study of children [Paya et al, 2000]), so the plan to lower the risk as much as possible by choosing the least risky operation is usually feasible but not entirely predictable [Minutolo et al, 2014]. In contrast, newborn circumcision complications range 0.2-0.6% and adult circumcisions have approximately 10-20 times higher risk. The complication rate from pediatric appendectomies is 33-58 times higher than the complication rate from circumcision. Furthermore, less than 0.01% of newborn circumcisions will require additional surgical correction, which is roughly 150 times lower than the incidence of laparoscopic appendectomies having to be converted to open appendectomies.

Age at Lowest Risk. As discussed above, appendectomies are riskier in children than in adults. Thus, it would be more dangerous as a prophylactic measure performed in infancy than as a prophylactic or treatment measure performed in adolescence or adulthood. The typical age of appendectomies is early teens to late 40s [BMJ Publishing Group, N.d.]. In the hypothetical situation of prophylactically removing appendixes, it would be far safer and more beneficial to wait at least until adolescence; however, with circumcision, it is far safer and more beneficial to perform it in the newborn period.

Cost. Appendectomies cost anywhere from $1,500 to $180,000 in the U.S., averaging about $33,000 [Castillo, 2014]. This contrasts with about $291 for newborn circumcision. Again, acute appendicitis is almost exclusively treated with appendectomy, so we can very accurately estimate the cost of acute appendicitis by simply going with the cost of appendectomies. If 12% of males require appendectomy, and it costs $33,000 on average, prophylactic removal in all males would equal a net cost of $3,960 per patient. In contrast, circumcision saves money.

Conclusion. Appendectomies are required about as frequently as circumcision is required; however, the complication rate from foreskin retention is about 5 times higher than the complication rate from appendix retention. The risks of appendectomies are about 33-58 times higher than the risks of newborn circumcision, and the proportion of appendectomies that require further surgical correction is about 150 times higher than the proportion of newborn circumcisions that require further surgical correction. There is no benefit to performing appendectomies in a younger age (in fact, it would be riskier in a younger patient), and the cost of prophylactic appendectomies would be exorbitant. This contrasts to the benefits of circumcision outweighing the risks at least 100 to 1; greater benefits for circumcision performed at a younger age; and cost savings from circumcision.

Breast Buds

When I did the research on these comparisons, I discovered that the breast buds comparison is the absolute most ridiculous argument I’ve ever read. That’s why I saved it for last.

Anesthesia. Mastectomies are performed under general anesthesia.

Medical Indication. The incidence of medically-indicated mastectomy among women in the U.S. is approximately 0.058% [Susan G. Komen, N.d.], compared to a medically-indicated circumcision rate of about 10%. Thus, your son is about 170 times more likely to require circumcision than your daughter is to require a mastectomy.

Prophylactic mastectomy hugely reduces (by about 90%) the risk of breast cancer but does not eliminate it, and removing both breasts when only one has cancer reduces the risk of cancer recurrence by about 95% [Tuttle et al, 2010]. One study of women considered high risk for breast cancer found that those undergoing prophylactic mastectomy had a 0% incidence of breast cancer and those refusing prophylactic mastectomy had a 7% incidence of breast cancer [Domchek, 2010]. Thus, your son is roughly at equal risk of requiring a circumcision later if he isn’t circumcised as a newborn as a high-breast-cancer-risk woman is of developing breast cancer if she doesn’t have a prophylactic mastectomy. Furthermore, breast cancers very rarely appear in women younger than their 40s and are almost completely preventable by prophylactic mastectomy at that age, whereas many of the benefits of circumcision are gone if the procedure is performed at an older age than the newborn period. So it would be more accurate to compare newborn circumcision to prophylactic mastectomies in middle-aged high-risk women.

A rather disgusting but accurate joke I’ve heard is that we feed babies with our breasts, but we don’t feed babies with men’s foreskins. In all seriousness, though, current evidence shows no certain or even likely (only hypothetical) serious detriments to health from the loss of the other organs discussed here, but loss of the breasts can cause serious detriments to both the health of the woman (mastectomy increases the risk of certain cancers, for example) and the health of her baby due to her inability to breastfeed.

Complication Rate. The complication rate from breast cancer surgeries ranges 25% (mastectomy alone) to 56% (mastectomy plus reconstruction) in patients under 65 years of age (median 40.5%); the rate is as high as 69% in patients over 65 [Azvolinsky, 2015]. This compares to an overall complication rate of 0.2-0.6% in newborn circumcisions (median 0.4%). An important note is that intactivists will specifically state “breast buds,” implying that they’re talking only about removing the nipples. However, breast cancers occur not only in the nipples but also (far more commonly) in the surrounding breast tissue and lymph nodes, all of which must be removed, so it cannot be argued that it would be a simpler, less involved surgery in a baby as compared to an adult. Thus, the median mastectomy complication rate is about 101 times higher than the median newborn circumcision complication rate.

Age of Lowest Risk. The risks are lower if the woman is younger when the procedure is performed—namely, if she is middle aged versus if she is elderly, but this is true for all surgeries. All surgeries are riskier in the elderly than in young adults and middle-aged adults, in the same way that most surgeries are riskier in children than in adults, with circumcision being a notable exception. It can be presumed that the risks of prophylactic mastectomy would be greater in children because of the greater risks associated with general anesthesia in children as compared to adults, and the greater difficulty visualizing all of the tissue that must be removed.

Cost. A mastectomy plus reconstruction costs roughly $89,000. Thus, comparing the likelihood that it would have been medically necessary to the cost of the procedure, we have an estimated cost of $5,162 per patient if all girls received prophylactic mastectomies at birth.

Conclusion. This is the most ridiculous of all the comparisons I’ve heard. Your son is 170 times more likely to require circumcision than your daughter is to require a mastectomy; the median complication rate of mastectomies is 101 times higher than the median newborn circumcision complication rate; there is greater risk in children, in stark contrast to circumcision; and it is far from cost effective, unlike circumcision. Removing the breasts prophylactically has also been demonstrated to cause a variety of health problems in the woman and potentially in her children, in contrast to circumcision, which has almost exclusively been demonstrated to prevent health problems in both the male and his female partner(s).

Conclusion

The foreskin is entirely unique in comparison to other organs we might consider prophylactically removing. It is far more likely to cause problems, its removal involves a far lower complication rate, it is the only organ that is safest to remove in newborns, and it is the only organ where prophylactic removal would result in cost savings. Newborn circumcision, the prophylactic removal of the foreskin, simply cannot be logically compared to the prophylactic removal of any other organ.

The simple fact is that circumcision poses benefits that greatly exceed the risks, but both benefits and risks are small in overall number. For instance, uncut boys have about 10 times more UTIs than do cut boys, but only about 2% of cut boys will have a UTI in the first year of life. Nevertheless, given that the benefits outweigh the risks 100 to 1 and that circumcision results in huge cost savings and being uncut is 3 times more likely to be regretted than being circumcised [YouGov, 2015], many parents very logically choose circumcision.

References

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Azvolinsky, A. (2015). “Mastectomy plus reconstruction has highest complication rate.” Cancer Network. http://www.cancernetwork.com/sabcs-2015/mastectomy-plus-reconstruction-has-highest-complication-rate

BMJ Publishing Group (N.d.). “Acute appendicitis.” Last updated: 01 Sep 2015. http://bestpractice.bmj.com/best-practice/monograph/290/basics/epidemiology.html

Brauer, H.U., Green, R.A., & Pynn, B.R. (2013). “Complications during and after surgical removal of third molars.” Oral Health. http://www.oralhealthgroup.com/features/complications-during-and-after-surgical-removal-of-third-molars/

Castillo, M. (2014). “Cost of an appendectomy? Reddit user posts $55,000 bill.” CBS News. http://www.cbsnews.com/news/cost-of-an-appendectomy-reddit-user-posts-55000-bill/

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De Luca Canto, G., Pachêco-Pereira, C., Aydinoz, S., Bhattacharjee, R., Tan, H.L., Kheirandish-Gozal, L., …Gozal, D. (2015). “Adenotonsillectomy complications: A meta-analysis.” Pediatrics, 136(4):702-718. doi: 10.1542/peds.2015-1283.

Domchek, S.M., Friebel, T.M., Singer, C.F., Evans, D.G., Lynch, H.T., Isaacs, C., …Rebbeck, T.R. (2010). “Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality.” Journal of the American Medical Association, 304(9):967-975. doi: 10.1001/jama.2010.1237. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2948529/

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Fedeli, U., Marchesan, M., Avossa, F., Zambon, F., Andretta, M., Baussano, I., & Spolaore, P. (2009). “Variability of adenoidectomy/tonsillectomy rates among children of the Veneto Region, Italy.” BMC Health Services Research, 9:25. doi: 10.1186/1472-6963-9-25. http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-9-25

Ganiats, T.G., Humphrey, J.B.C., Taras, H.L., & Kaplan, R.M. (1991). “Routine neonatal circumcision: A cost-utility analysis.” Medical Decision Making, 11:282-293. http://www.ncbi.nlm.nih.gov/pubmed/1766331

Glover, J.A. (1938). “The incidence of tonsillectomy in school children.” Proceedings of the Royal Society of Medicine:1219-1236. Reprint in International Journal of Epidemiology, 37(1):9-19. doi: 10.1093/ije/dym258. http://ije.oxfordjournals.org/content/37/1/9.extract

Gray, D.T. (2004). “Neonatal circumcision: cost-effective preventive measure or ‘the unkindest cut of all’?” Medical Decision Making, 24:688-692. http://www.ncbi.nlm.nih.gov/pubmed/15534350

Kacker, S., Frick, K.D., Gaydos, C.A., & Tobian, A.A.R. (2012). “Costs and effectiveness of neonatal male circumcision.” Archives of Pediatric and Adolescent medicine, 166(10):910-918. doi: 10.1001/archpediatrics.2012.1440. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3640353/

Lawler, F.H., Bisonni, R.S., & Holtgrave, D.R. (1991). “Circumcision: A cost decision analysis of its medical value.” Family Medicine, 23:587-593. http://www.ncbi.nlm.nih.gov/pubmed/1794670

Minutolo, V., Licciardello, A., Di Stefano, B., Arena, M., Arena, G., & Antonacci, V. (2014). “Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years experience in a district hospital.” BMC Surgery, 14:14. doi: 10.1186/1471-2482-14-14. http://bmcsurg.biomedcentral.com/articles/10.1186/1471-2482-14-14

Morris, B.J., Bailis, S.A., & Wiswell, T.E. (2014). “Circumcision rates in the United States: Rising or falling? What effect might the new affirmative pediatric policy statement have?” Mayo Clinic Proceedings, 89(5):677-686. doi: 10.1016/j.mayocp.2014.01.001. http://www.mayoclinicproceedings.org/article/S0025-6196(14)00036-6/fulltext

Morris, B.J., Castellsague, X., & Bailis, S.A. (2006). “Re: Cost analysis of neonatal circumcision in a large health maintenance organization.” Journal of Urology, 176:2315-2316. http://www.ncbi.nlm.nih.gov/pubmed/17070332

Paya, K., Fakhari, M., Rauhofer, U., Felberbauer, F.X., Rebhandi, W., & Horcher, E. (2000). “Open versus laparoscopic appendectomy in children: A comparison of complications.” Journal of the Society of Laparoendoscopic Surgeons, 4(2):121-124. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015389/

Rabin, R.C. (2011). “Wisdom of having that tooth removed.” The New York Times. http://www.nytimes.com/2011/09/06/health/06consumer.html?_r=0

Schoen, E.J., Colby, C.J., & Ray, G.T. (2000). “Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life.” Pediatrics, 105(4 Pt 1):789-793. http://www.ncbi.nlm.nih.gov/pubmed/10742321

Schoen, E.J., Colby, C.J., & To, T.T. (2006). “Cost analysis of neonatal circumcision in a large health maintenance organization.” The Journal of Urology, 175:1111-1115. http://www.ncbi.nlm.nih.gov/pubmed/16469634

Seshamani, M., Vogtmann, E., Gatwood, J., Gibson, T.B., & Scanlon, D. (2014). “Prevalence of complications from adult tonsillectomy and impact on health care expenditures.” Otolaryngology—Head and Neck Surgery, 150(4):574-581. doi: 10.1177/0194599813519972.

Susan G. Komen Foundation (N.d.). “Table 54: Regional differences in rates of mastectomy in the U.S.” Last updated 04 Feb 2015. http://ww5.komen.org/BreastCancer/Table54Geographicvariationinratesofmastectomy.html

Tuttle, T.M., Abbott, A., Arrington, A., & Rueth, N. (2010). “The increasing use of prophylactic mastectomy in the prevention of breast cancer.” Current Oncology Reports, 12(1):16-21. doi: 10.1007/s11912-009-0070-y.

Weiss, H.A. (2010). “Complications of circumcision in male neonates, infants and children in a systematic review.” BMC Urology, 10:2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2835667/

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