News about circumcision from Australia

and around the world : 2017

 

 

 

FGM prosecution in USA risks accusations of hypocrisy and double standards

 

The prosecution of four members of the Dawoodi Bohra sect of Islam living in Michigan, USA, for performing female genital mutilation, raises ticklish questions of multiculturalism, religious freedom, the scope of individual rights, parental power over children and the concept of harm. Analysing the issues involved in this, the first prosecution under US FGM legislation, Brian Earp warns that the case risks accusations of bias against both Muslims and boys. This is because the mode of genital cutting employed by the Dawoodis is very slight, reportedly nothing more than a small nick to the genitals, causing little permanent harm. This is in contrast to the mode of cutting (i.e. circumcision) employed by both Jewish people and many other American parents on boys, which is far more extensive, risky and damaging. The inconsistency in the law - prohibiting female genital cutting while permitting and even encouraging circumcision of boys - is usually justified on the basis that FGM is always more damaging and, in contrast with circumcision, confers no health benefits.

Earp warns, however, that this would be dangerous line for the prosecution for three reasons: first because, in this case, the damage inflicted by the Dawoodi rite is far less damaging than routine circumcision of boys; secondly because the health benefits of routine circumcision of boys are contested and increasingly viewed as insufficient to outweigh the risks and harms; and thirdly because the argument is an invitation to those who support or practise FGM for cultural/religious reasons to discover health benefits - as some advocates of the operation are already doing. But, he points out, most people who oppose FGM do so because they regard it as a violation of the human rights of the child, and would still oppose it even if it did confer health benefits. If genital cutting is a violation of the human rights of girls, however, it must also be a violation of the human rights of boys: as Earp, discussing the best means to protect children from harm, concludes: “My own preference is for debate and dialogue, not bans and vilification. But whatever approach one takes, it is time to move beyond the tired (and false) dichotomies of male versus female, religion versus culture, and health benefits versus no health benefits. The focus for critics of genital cutting going forward, I contend, should be on children versus adults — that is, on bodily autonomy and informed consent.”

In Australia, two members of the same Islamic sect were convicted of FGM on two young girls in March 2016 and sentenced to gaol terms. In this case the judge found no significant physical injury had been inflicted on either child but there were “likely to be some adverse psychological effects”. Report on this site here.

Brian Earp. Does Female Genital Mutilation Have Health Benefits? The Problem with Medicalizing Morality. Quillette, 15 August 2017.  Also at Journal of Medical Ethics Blog

 

Doctors may reasonably be blamed for harm arising

from unnecessary genital surgeries

 

A well considered article in the AMA Journal of Ethics (published by American Medical Association) argues that in many cases doctors are blameworthy when harm arises from unnecessary genital surgeries that they perform. These include “normalising” surgery on intersex infants and children; circumcision of boys; and cosmetic vaginal surgery. The Abstract reads as follows: “We argue that physicians should, in certain cases, be held accountable by patients and their families for harm caused by “successful” genital surgeries performed for social and aesthetic reasons. We explore the question of physicians’ blameworthiness for three types of genital surgeries common in the United States. First, we consider surgeries performed on newborns and toddlers with atypical sex development, or intersex. Second, we discuss routine neonatal male circumcision. Finally, we consider cosmetic vaginal surgery. It is important for physicians not just to know when and why to perform genital surgery, but also to understand how their patients might react to wrongful performance of these procedures. Equally, physicians should know how to respond to their own blameworthiness in socially productive and morally restorative ways.”

Samuel Reis-Dennis, PhD, and Elizabeth Reis, PhD. Are Physicians Blameworthy for Iatrogenic Harm Resulting from Unnecessary Genital Surgeries? AMA Journal of Ethics 19 (8), August 2017: 825-833.

Non-therapeutic circumcision is a form of iatrogenic injury

In a related article in the same journal, J. Steven Svoboda, director of Attorneys for the Rights of the Child, argues that non-therapeutic circumcision is a form of iatrogenic injury (i.e. caused by doctors, from Greek work iatros, physician). The Abstract reads as follows: Non-therapeutic circumcision (NTC) of male infants and boys is a common but misunderstood form of iatrogenic injury that causes harm by removing functional tissue that has known erogenous, protective, and immunological properties, regardless of whether the surgery generates complications. I argue that the loss of the foreskin itself should be counted, clinically and morally, as a harm in evaluating NTC; that a comparison of benefits and risks is not ethically sufficient in an analysis of a nontherapeutic procedure performed on patients unable to provide informed consent; and that circumcision violates clinicians’ imperatives to respect patients’ autonomy, to do good, to do no harm, and to be just. When due consideration is given to these values, the balance of factors suggests that NTC should be deferred until the affected person can perform his own cost-benefit analysis, applying his mature, informed preferences and values.

J. Steven Svoboda. Nontherapeutic Circumcision of Minors as an Ethically Problematic Form of Iatrogenic Injury. AMA Journal of Ethics 19 (8), August 2017: 815-824.

Circumcision “least effective” method of HIV prevention among MSM

 

A study of United States men who have sex with men (MSM) found that of several methods of reducing the risk of HIV acquisition, circumcision was the least effective. The 1-year risk of becoming infected with HIV was found to be 8.8% with no prevention strategies; 6.9% with circumcision; 5.5% if taking only the active role; 2.7% with consistent condom use; and with PrEP (pre-exposure prophylaxis) a risk of 5.1% (average adherence), 2.5% (high adherence) and 0.7% very high adherence. The 10-year risk of HIV acquisition was 60.3% with no prevention strategies; 51.1% with circumcision; 43.1% if taking only the active role; 24% with consistent condom use; and with PrEP a risk of 40.5% (average adherence), 22.2% (high adherence) and 7.2% (very high adherence). In other words, the study showed that circumcision provided no significant protection against HIV transmission, and scored extremely poorly in comparison with condom use alone. The only strategy more effective than consistent condom use was regular medication with PrEP medications: as the abstract of the paper concludes, “Very high adherence to PrEP alone or with other strategies appears to be the most powerful tool for HIV prevention”. That being the case, it is time to consign circumcision as an HIV prevention tactic to the dustbin of medical mistakes where it belongs.

Shrestha RK, Sansom SL, Purcell DW. Assessing HIV acquisition risks among men who have sex with
men in the United States of America
. Rev Panam Salud Publica. 2016; 40(6):474–8.

In memory of Laurence Cox

 

Circumcision Information Australia would like gratefully to acknowledge a generous gift from the estate of the late Laurence Cox. Dr Cox was a much-loved university teacher in Newcastle where he undertook investigations into the harm of circumcision and established support groups for men who felt they had been injured. In the course of this work he organised a survey of circumcision harm, the results of which were published in an academic paper in 2009, co-authored with Dr Robert Darby** — a study that has been extensviely cited in the ongoing debate. On his death Dr Cox left a generous donation to Circumcision Information Australia in his will in order to assist us to continue our efforts to promote awareness of the harm of circumcision and defend the right of all children (both girls and boys) to bodily integrity. Circumcision Information Australia extends its condolences to Laurence’s family, especially his two sons Stephen and David and their children, and thanks them for their assistance and support in relation to this bequest.

** Objections of a sentimental character: The subjective dimension of foreskin loss. In: Chantal Zabus (ed.), Fearful Symmetries: Essays and Testimonies around Excision and Circumcision (Amsterdam and New York: Rodopi, 2009). Full text available here.

Doctor who circumcised boy without mother’s consent sued for assault,

but “should be prosecuted”

 

A doctor accused of circumcising a boy without his mother's consent should be prosecuted, a leading human rights lawyer has said. The three-month-old boy was circumcised for religious reasons [i.e. his father’s family were Muslim] while staying with his paternal grandparents in 2013. A police investigation was dropped but Saimo Chahal QC wants Nottinghamshire Police to take action against the doctor, Balvinder Mehat. The boy’s mother believes circumcision amounts to MGM, or “male genital mutilation”, and is inhumane. “I am deeply hurt by what has happened to my son and the suffering I have been forced to witness,” she said. “No amount of money in the world could make right what's been done, and my only hope is to raise awareness of MGM and reveal the true suffering this procedure really inflicts on tiny babies. “My life will never be the same again and I dread my son growing up and learning what happened to him.” She has written to police stating that they have misapplied the law and must review the decision not to prosecute.

The mother is being assisted by Tim Alford from the anti-circumcision group Men Do Complain, who said the boy has already experienced discomfort because of being circumcised. “He has had a couple of visits to the doctors, one to the NHS emergency centre, with inflammation around the wound,” he said. “Since the hot weather he has had another flare-up, probably due to abrasion against his undergarments. “His glans, which normally in a four-year-old would be fully protected by the prepuce at all times, looks very red and sore, and the remnants of the prepuce is inflamed, and weirdly stacked-up behind the glans. At the moment [his mother] is applying a prescription moisturising lotion, and ensuring he has soft underwear. It’s all quite distressing really. Poor lad.”

Further details at Men Do Complain

There was a parallel case in Bundaberg, Australia, where a Turkish father had two boys circumcised without the mother’s (let alone the boys’) consent, and in contravention of an order from the Family Court. Full details on this site.

The law and ethics of male circumcision: BMA guidelines

Guidelines on circumcision issued by the British Medical Association are critical of non-therapeutic circumcision and state clearly that consent from both parents is necessary.

Source: “Doctor acted illegally by circumcising boy”. BBC News, 2 June 2017.

 

Circumcised men at twice the risk for cancer-causing Human Papilloma Virus

 

A study presented at the annual meeting of the American Urological Association has found that circumcised men are twice as likely to harbour human papilloma virus (HPV), certain strains of which cause genital warts and various genital cancers in both males and females. Previous studies on this question have been inconclusive: earlier research showing that uncircumcised men had a higher incidence of HPV have been discredited by others showing that there is little difference. This is the first study to show that circumcision may actually increase the risk of HPV infection and thus of the cancers that it causes. A key finding of the study is that HPV is quite commonly found throughout the population and that most strains are not harmful. An even more important point to note is that there are now effective vaccines against these strains, available for both boys and girls and providing long-term protection.

The full text of the report follows.

The study presented by Daugherty and colleagues at the American Urological Association meeting in Boston utilized data collected from the NHANES. They queried the database for data regarding all men aged 18 to 59 years who had received penile swabs from 2013 to 2014. They also collected information regarding other STDs, HPV vaccination and circumcision status. Of 1,520 men for whom there was complete information regarding HPV infection and circumcision status, they found that 45.2% had HPV infection from any strain. Of note, they found that only 2.9% of the men were infected with strains HPV 6 and 11, and 5.8% were infected with HPV 16 and 18. Reflecting previous NHANES data, 45.2% of participants had some strain of genital HPV. In all, 2.9% were infected with one of the two low-risk strains, while 5.8% had one of the high-risk strains.

Most participants (77.8%) were circumcised. The higher risk for high-risk HPV was evident (OR = 2; P = .03), but there was no significant increase in risk for low-risk HPV in circumcised men (OR = 1.05; P = 0.9). Despite the risk for circumcised men, only 7.8% of all participants — and 13.4% of those aged 18 to 29 years — received HPV vaccinations. “This again brings up the importance of talking about vaccination,” Daugherty said. “Some of the HPV strains don’t necessarily cause major disease ... but at the same time, there are certain types of strains that you can prevent, and the big thing is people are unaware that the vaccine is available, and that this is something you can prevent.”

Although results have varied, earlier studies have generally shown that uncircumcised men are more likely to be infected with HPV than circumcised men. In a 2008 study published in The Journal of Infectious Diseases, researchers found that uncircumcised men were significantly more likely than those who were circumcised to be infected with a potentially cancer-causing HPV strain (adjusted OR = 2.51) and to be infected with several HPV strains (aOR = 3.56).

Previous NHANES data, meanwhile, have shown cause for alarm in all populations. Nearly half of 1,868 men had some kind of genital HPV strain. Another NHANES dataset showed that 25.1% of men and 20.4% of women in the U.S. have at least one high-risk genital HPV strain. “Part of the issue is that HPV is much more prevalent than most people think or assume,” Daugherty said. “The concern is that most of them will not actually develop any sort of lesions from it, but at the same time, they could turn out to be infectious and infect others.” – by Joe Green

Circumcised men at twice the risk for cancer-causing HPV, study shows. Healio Infectious Diseases News, 22 May 2017.

Circumcision, sexual function and penis sensitivity: Bossio et al criticised

 

A study by Bossio et al published in the Journal of Urology in June 2016 was widely misreported as showing that circumcision made no difference to the sensitivity of the penis. Even leaving aside the vagueness of this measure (do they mean sensitivity to pain or to pleasure? what about other measures of sexual functionality and satisfaction?) the reports seriously misrepresented the findings of the study, which actually showed that men with foreskins had a lower threshold of sensitivity and circumcised men a higher threshold – in other words, that men with foreskins were more sensitive to touch, and circumcised men less sensitive. As the authors admit in their reply to criticisms of their article published in a later issue of the journal, “the foreskin was observed to be most sensitive to fine touch pressure thresholds.” Of course, there are other issues to be taken into account, some of which are raised in the letters criticising the paper, but there is not the slightest basis for media and other reports that circumcision “makes no difference” to sexual experience.

Letters in reply to the Bossio et al paper printed in December 2016 issue of the journal are reproduced on this site.

Australian circumcision incidence continues to fall

 

Figures from Medicare show that circumcision incidence in Australia continues to decline and is now at the lowest rate since records were kept. Between Financial Year 2009/10 and 2015/16 the number of circumcisions of boys under 6 months of age fell from 20,246 to 14,880 – a decline of about 30%. The fall was particularly dramatic in New South Wales (down from 8750 to 5923) and Queensland (down from 5611 to 3145). There were small falls in South Australia, the Northern Territory and the Australian Capital Territory, and slight rises in Victoria and Western Australia – where, however, the figures remain well below NSW and Qld (2943 and 1361 cases respectively). See Table 1 for details. These figures are based on claims under Medicare item 30653, circumcision of a male under 6 months of age, and may not include all circumcision operations performed in Australia – those carried out as part of a childbirth “package”, for example, or by community operators, such as Mohels servicing the Jewish community. On the other hand, it is not likely that parents who arrange circumcisions with GPs and so-called specialist clinics would fail to claim the rebate, so it is likely that the figures give a reasonable approximation of the true picture. Even if they understate the incidence, the declining trend is obvious.

Full details at statistics page

 

Circumcision, sexual experience and harm: Implications for law and ethics

 

The harm of circumcision is highly subjective, extends more broadly than mere surgical complications and can be as much psychological as physical. These points are only part of the argument of a detailed and comprehensive discussion of the harms of non-therapeutic circumcision of male minors, and the question of whether it should be regarded as ethically and legally permissible. The paper was published as a contribution to a forum on recent events in Germany, where an appeals court determined that medically unnecessary circumcision of a minor was unlawful because it violated his right to physical integrity and self-determination. In response to am angry reaction by Jewish and Muslim organisations the decision was subsequently overturned by special legislation in the German parliament, but the issue remains unsettled and debate continues. The controversy has highlighted the striking contrast in attitudes and policy between female genital cutting (FGM), on the one hand, and male genital cutting (circumcision) on the other. At the very moment when the Bundestag was enshrining the legality of circumcision of boys (up to the age of 6 months) it was increasing the penalties for any form of female genital cutting, no matter how mild or symbolic, and irrespective of age. As Shahvisi has argued, this sort of inconsistency not only discriminates against males and treats them as second class citizens, but infantilises and restricts the autonomy of adult women who may wish to modify their own genitals in accordance with the traditions of their culture or for aesthetic or other personal reasons. As the authors comment, this situation is inconsistent with the trend towards gender equality and creates an ethical and legal anomaly that is likely to be the focus of controversy for many years to come.

The abstract of the paper follows. It is one of several responses to a detailed discussion of the German court decision and subsequent controversy by Steven Munzer.

Surgically modifying the genitals of children - female, male, and intersex - has drawn increased scrutiny in recent years. In Western societies, it is illegal to modify the healthy genitals of female children in any way or to any extent in the absence of a strict medical indication. By contrast, modifying the healthy genitals of male children and intersex children is currently permitted. In this journal in 2015, Stephen R. Munzer discussed a controversial German court case from 2012 (and its aftermath) that called into question the legal status of non-therapeutic male circumcision (NTC), particularly as it is carried out in infancy or early childhood. Whether NTC is legal before an age of consent depends partly upon abstract principles relating to the best interpretation of the relevant laws, and partly upon empirical and conceptual questions concerning the degree to which, and ways in which, such circumcision can reasonably be understood as a harm. In this article, we explore some of these latter questions in light of Professor Munzer’s analysis, paying special attention to the subjective, personal, and individually and culturally variable dimensions of judgments about benefit versus harm. We also highlight some of the inconsistencies in the current legal treatment of male versus female forms of non-therapeutic childhood genital alteration, and suggest that problematically gendered assumptions about the sexual body may play a role in bringing about and sustaining such inconsistencies.

Earp, B. D., & Darby, R. Circumcision, sexual experience, and harm. University of Pennsylvania Journal of International Law, 37(2) 2017, online symposium.

The paper is also available to download from Brian Earp’s Academia page

Long-term harm from circumcision shown by large-scale survey

 

Circumcision has a an adverse impact on male health and causes significant harm, not merely in the short term or when surgical complications occur, but over the long term of a male’s life and as an inevitable result of the surgery. This is the finding of an article in the International Journal of Human Rights, based on a survey of over 1000 men, and which argues that the harm of circumcision is great enough to warrant further detailed investigation and to place a big question mark over the continuation of this practice. The abstract of the paper follows:

Amid growing bioethical and human rights concerns over non-therapeutic infant male circumcision, calls have been made to investigate long-term impacts on the men these infants eventually become. The present inquiry attempts to identify factors contributing to concerns of men claiming dissatisfaction with or ascribing harm from neonatal circumcision. This large sample size survey involved an online questionnaire with opportunities to upload photographic evidence. Respondents revealed wide-ranging unhealthy outcomes attributed to newborn circumcision. Survey results establish the existence of a considerable subset of circumcised men adversely affected by their circumcisions that warrants further controlled study. Empirical investigations alone, however, may be insufficient to definitively identify long-term effects of infant circumcision. As with non-therapeutic genital modifications of non-consenting female and intersex minors, responses are highly individualistic and cannot be predicted at the time they are imposed on children. Findings highlight important health and human rights implications resulting from infringements on the bodily integrity and future autonomy rights of boys, which may aid health care and human rights professionals in understanding this emerging vanguard of men who report suffering from circumcision. We recommend further research avenues, offer solutions to assist affected men, and suggest responses to reduce the future incidence of this problem.

Tim Hammond & Adrienne Carmack. Long-term adverse outcomes from neonatal circumcision reported in a survey of 1,008 men: an overview of health and human rights implications. International Journal of Human Rights, on-line first, 21 February 2017.

This is a highly significant study that confirms much previous evidence and tightens the screws on the diminishing band of circumcision advocates and practitioners. Over the last century or so, defenders of circumcision have repeatedly stated that if circumcision was shown to be harmful, they would stop doing it. Some authorities even went to far as to propose that if circumcision was harmful the state should step in to protect boys by regulating or even prohibiting the procedure. In 1896, for example, the German Jewish doctor Abraham Glassberg published a defence of circumcision in which he argued not only that it was necessary among Jews for cultural reasons, but that it was equally desirable – even to the point of legal compulsion – among non-Jews, for reasons of health. Glassberg’s only concession was that if circumcision were shown to be harmful there would be a public interest in legal regulation and restriction of the practice.** He did not set out any criteria or benchmarks for this proof, however, and so confident was he that no such proof would ever be found that he did not realise he was leaving a hostage to fortune whose moment of truth has now arrived: Glassberg’s chickens have come home to roost, circumcision has been proven to be harmful. It is now up to the defenders of circumcision to admit that their own case for stopping the practice has been made and to give it up as Glassberg promised.

Leonard Glick, Marked in your Flesh: Circumcision from Ancient Judea to Modern America (New York: Oxford University Press, 2005), p. 134-6.

Shock, horror: Foreskin health risk doubles in 2 years

 

A couple of years ago Brian Morris drew a certain amount of attention to himself with the claim that the benefits of circumcision outweighed the risks by 100 to 1. At the time child health authorities ridiculed the claim as scientifically baseless, exaggerated, implausible, frankly preposterous and just crazy. His additional suggestion that circumcision was just like vaccination and should be compulsory was described as the dumbest idea ever. Undeterred by these harsh words, our fearless anti-foreskin warrior has now published a further article in which he claims that the benefits of circumcision outweigh the risks by 200 to 1, and that 50 per cent of all uncircumcised men will experience medical problems as a direct result of their regrettable genital anatomy.

This means that the danger to health posed by the foreskin has doubled in only 2 years, and should imply that boys and men all over the world (but especially in Europe, Britain and Australia) should be swarming into hospital emergency departments with crippling foreskin-related diseases. If the risk continues to soar at this rate, it will not be long before uncircumcised men are dropping like flies in the street. The fact that none of this is happening, however, does lend a certain air of unreality to Professor Morris’s alarmism, and perhaps explains the fact that, while his earlier (2014) claim met with ridicule and refutation, his latest anathema against the foreskin has left health authorities dumbfounded and speechless with amazement.

The 100 to 1 claim was made in a respectable journal as an aside to an article that was really a speculation on the possible effects of the American Academy of Pediatrics 2012 circumcision policy on United States circumcision incidence. It is noteworthy that Professor Morris’s 200 to 1 claim appears in the very obscure Chinese-based World Journal of Clinical Pediatrics. Despite its grandiose title, this is a recently established, low-ranking organ that was included in Beale’s list of predatory open access publishers. It had, in fact, already been the target of a speeding ticket from Retraction Watch for dodgy publication practices – in this case, failure to ensure objective peer review. Still, one can’t blame Morris for that: if you are going to make claims as outlandish as those made by him and his coterie at the Circumcision Academy of Australia it is not surprising that you have to scrape the bottom of the barrel.

Essay: Professor Brian Morris: Relentless anti-foreskin activist

 

Previous reports

“Just crazy”: Child health expert unimpressed by Prof Morris’s latest attack on foreskin

Scientists ridicule latest claims from pro-circumcision professor

Law should treat circumcision and FGM consistently

 

Current laws against female genital mutilation are both sexist and racist. This is the contention of a powerful article by Arianne Shahvisi, who argues that the law is racist insofar as it infantilises adult women from non-Western cultures by denying them the right to seek genital modification if they desire it, and also sexist because it ignores boys and gives them no protection against circumcision, whether they want it or not. As she writes in the international journal Clinical Ethics, despite its good intentions, the law in most Western countries is “marred with sexism and racism, since the legislation devalues the consent capacities of racialised adult women, whilst the lack of legislation around male circumcision amounts to a failure to protect the bodies of male children.” The author goes onto discuss the parallels between male and female genital cutting and to argue that there is no valid reason for regarding them as radically different: “Both are performed on the healthy, protective, erogenous tissue of children who cannot consent. Neither has any proven health benefit, while both have some associated risk, and carry implications for later sexual potential.”

Shahvisi argues that the total ban on female genital cutting, even for competent adults, and the open slather of circumcision of male infants and boys, are inconsistent with the basic principles of medical ethics as formulated by Beauchamp and Childress – autonomy, non-malevolence, benevolence and justice: “Respect for autonomy rules that patients who have capacity must have their autonomy respected provided they have been adequately informed of risks; beneficence demands that patient safety and wellbeing be prioritised, in full consideration of long-term risks and outcomes; non-maleficence urges that clinicians minimise harm, whether short-term or long-term; considerations of justice require that benefits, risks and costs are distributed equitably, and that medically equivalent patients are treated in equivalent ways.” She goes on to suggest that “a clinician considering the four principles of medical ethics would undoubtedly maintain the view that no child may have non-therapeutic modifications made to her/his body, especially those that are irreversible (i.e. involving tissue damage/removal).

In conclusion the author proposes that the existing laws against female genital mutilation “be extended to include all forms of nontherapeutic genital surgery for all children. A ‘genital mutilation act’, dovetailing with broader child protection legislation, could apply to the bodies of all those below the age of consent, including: FGM, male circumcision, and even non-therapeutic intersex genital surgeries.”

Arianne Shahvisi. Why UK doctors should be troubled by female genital mutilation legislation. Clinical Ethics, online first, 15 December 2016.

Note: Shahvisi is referring to the law in Britain, but Australian laws against FGM (part of the Crimes Act in each State) similarly make it illegal to perform genital modification surgery on adult women even if she consents, unless deemed medically necessary. This qualification had the unintended effect of allowing Graeme Reeves, “the butcher of Bega”, to escape conviction at his first trial for excising a woman’s clitoris and labia. (See full account here.)

For a discussion of the law against FGM in Australia, see Christine Mason, Exorcising Excision: Medico-Legal Issues Arising From Male and Female Genital Surgery in Australia.

See also: British judge finds male circumcision to constitute “significant harm”.

 

[ Back to Top ]