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Re: The medical evidence on non-therapeutic circumcision of infants and boys-setting the record straight

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Abstract

We read with interest a review by Deacon and Muir ('D&M') that concluded so-called 'non-therapeutic' male circumcision (NTMC) of infants and children provides insufficient benefits and that risks were too high for it to be recommended in the UK [1]. Instead, they suggest delay until the boy is old enough to make his own decision. However, in contrast to the UK, policy statements by the American Academy of Pediatrics (AAP) [2] and Centers for Disease Control and Prevention (CDC) [3], finding benefits of NTMC exceed risks, are evidence-based. Flaws in D&M's arguments include reliance on small, weak, out-of-date or inappropriate studies contradicted by more recent high-quality evidence. Unlike systematic reviews and meta-analyses, D&M did not engage sufficiently with existing evidence. Studies cited were not rated by quality. They ignored a landmark high-quality study by CDC researchers of adverse events from 1.4 million neonatal and older age US males [4]. NTMC risk in infants was 0.4% and was 20-fold higher at age 1-9 and 10-fold higher at age ≥10. Similar values were cited in the AAP's policy statement. Thus D&M's claim of 1-5% risk may apply in non-US countries or to later circumcision. Also missing were key studies and important critiques of various publications they cited, as well as meta-analyses, and systematic reviews of benefits and risks (summarised in ref. [5]). If included, D&M's overall conclusion would have been more balanced. Instead of number-needed-to-treat (NNT) for each condition, they should have combined all such information into an overall risk-benefit analysis. An informed 'big picture' might then have emerged to better inform parents and practitioners. Several risk-benefit analyses have been published over the past decade, including ours in 'Mayo Clinic Proceedings' cited by the CDC. The only one for the UK found benefits exceeded risks by 200:1, with failure to perform NTMC in infancy likely resulting in at least one adverse medical condition among over half of uncircumcised males during their lifetime [6]. Contrary to D&M's assertion, the data we used for risk-benefit analyses were not 'over-estimates,' but came from high-quality studies. Contrary to their claim that the foreskin becomes fully retractile in 99% by age sixteen, our systematic review, involving 43 studies, included one finding full retractability was 51.1% in 1834 uncircumcised adolescent boys [7] and averaged 96.6% in men, being 92.2% in British National Servicemen [8]. D&M criticise a meta-analysis of lifetime UTI risk (D&M-ref22) because it contained only one study of men. But men in that study attended a STI clinic with infection symptoms, whereas the two studies D&M suggested for inclusion lacked UTI cases. D&M ignored the meta-analysis group aged 1-16 years. Thus, D&M's NNT > 100 claim is misguided as it applies to infants only. Eisenberg et al. found number of NTMCs needed to prevent one UTI in infants was 39, decreasing to 29 when other sequelae were included [9]. In comparison, childhood vaccination prevents one outpatient visit and one hospitalisation for influenza for every 50 and 1031-3050 vaccinated children, respectively [10]. D&M argue that infant NTMC would result in more boys needing antibiotics for postoperative wound infection than would need them for a UTI. Their claim is based on a 10% estimated post-NTMC wound infection prevalence. But this value contradicted their earlier statement that the overall complication rate for infant and paediatric NTMC is 1-5%. How can the prevalence of one specific complication (infection) be higher than the overall prevalence? To resolve this, we translated the German language narrative review they cited for the 10% figure (D&M-ref125) and followed the reference trail through two further review articles to the primary source: [11]. This cited two very small n values for infections: n = 2 (4%) for boys circumcised with a Plastibell device and n = 5 (10%) for boys circumcised with scissors. Thus, the 10% figure is a maximum value in a small study, applies to an old method, and is for older boys, not infants, so is misleading. D&M also assume that all of those 10% would require antibiotics. In fact, most such infections are superficial and resolve with local treatment. A study of 5521 NTMCs noted infection in 23 (0.4%) [12]. Of these, only 4 (17%) required antibiotics, the rest resolving with topical antiseptics. In contrast, antibiotics are advised for all UTIs in infants, even if the UTI is merely suspected. Based on a NNT of 100 for infant UTI prevention by NTMC and the estimate of 0.4% for infections [12], instead of the much lower 0.0834% in the large US study [4] (where only 2.2% of those, i.e., 0.0018%, were likely NTMC-related), one can calculate n = 10 UTIs prevented from 1000 circumcisions, and n = 4 wound infections. If the figure of 17% of wound infections requiring antibiotics is representative, then 0.7 of those 4 wound infections would need antibiotic treatment, as opposed to all ten UTIs. Infant NTMC therefore results in a substantial net reduction in antibiotic use even when erring in D&M's favour, and
REVIEW ARTICLE OPEN
Re: The medical evidence on non-therapeutic circumcision of
infants and boyssetting the record straight
Brian J. Morris
1
, Stephen Moreton
2
, John N. Krieger
3
, Jeffrey D. Klausner
4
and Guy Cox
5
© The Author(s) 2022
IJIR: Your Sexual Medicine Journal; https://doi.org/10.1038/s41443-022-00579-z
We read with interest a review by Deacon and Muir (D&M) that
concluded so-called non-therapeuticmale circumcision (NTMC)
of infants and children provides insufcient benets and that risks
were too high for it to be recommended in the UK [1]. Instead,
they suggest delay until the boy is old enough to make his own
decision. However, in contrast to the UK, policy statements by the
American Academy of Pediatrics (AAP) [2] and Centers for Disease
Control and Prevention (CDC) [3], nding benets of NTMC exceed
risks, are evidence-based.
Flaws in D&Ms arguments include reliance on small, weak, out-
of-date or inappropriate studies contradicted by more recent high-
quality evidence. Unlike systematic reviews and meta-analyses,
D&M did not engage sufciently with existing evidence. Studies
cited were not rated by quality.
They ignored a landmark high-quality study by CDC researchers
of adverse events from 1.4 million neonatal and older age US
males [4]. NTMC risk in infants was 0.4% and was 20-fold higher at
age 19 and 10-fold higher at age 10. Similar values were cited in
the AAPs policy statement. Thus D&Ms claim of 15% risk may
apply in non-US countries or to later circumcision.
Also missing were key studies and important critiques of various
publications they cited, as well as meta-analyses, and systematic
reviews of benets and risks (summarised in ref. [5]). If included,
D&Ms overall conclusion would have been more balanced. Instead
of number-needed-to-treat (NNT) for each condition, they should
have combined all such information into an overall risk-benet
analysis. An informed big picturemight then have emerged to
better inform parents and practitioners. Several risk-benet analyses
have been published over the past decade, including ours in
Mayo Clinic Proceedingscited by the CDC. The only one for the UK
found benets exceeded risks by 200:1, with failure to perform
NTMC in infancy likely resulting in at least one adverse medical
condition among over half of uncircumcised males during
their lifetime [6]. Contrary to D&Ms assertion, the data we used
for risk-benet analyses were not over-estimates,but came from
high-quality studies.
Contrary to their claim that the foreskin becomes fully retractile
in 99% by age sixteen, our systematic review, involving 43 studies,
included one nding full retractability was 51.1% in 1834
uncircumcised adolescent boys [7] and averaged 96.6% in men,
being 92.2% in British National Servicemen [8].
D&M criticise a meta-analysis of lifetime UTI risk (D&M-ref22)
because it contained only one study of men. But men in that study
attended a STI clinic with infection symptoms, whereas the two
studies D&M suggested for inclusion lacked UTI cases. D&M ignored
the meta-analysis group aged 116 years. Thus, D&Ms NNT > 100
claim is misguided as itapplies to infants only.Eisenberg et al. found
number of NTMCs needed to prevent one UTI in infants was 39,
decreasing to 29 when other sequelae were included [9]. In
comparison, childhood vaccination prevents one outpatient visit
and one hospitalisation for inuenza for every 50 and 10313050
vaccinated children, respectively [10].
D&M argue that infant NTMC would result in more boys needing
antibiotics for postoperative wound infection than would need
them for a UTI. Their claim is based on a 10% estimated post-NTMC
wound infection prevalence. But this value contradicted their earlier
statement that the overall complication rate for infant and
paediatric NTMC is 15%. How can the prevalence of one specic
complication (infection) be higher than the overall prevalence?
To resolve this, we translated the German language narrative
review they cited for the 10% gure (D&M-ref125) and followed the
reference trail through two further review articles to the primary
source: [11]. This cited two very small nvalues for infections: n=2
(4%) for boys circumcised with a Plastibell device and n=5 (10%)
for boys circumcised with scissors. Thus, the 10% gure is a
maximum value in a small study, appliesto an oldmethod, and is for
older boys, not infants, so is misleading. D&M also assume that all of
those 10% would require antibiotics. In fact, most such infections
are supercial and resolve with local treatment. A study of 5521
NTMCs noted infection in 23 (0.4%) [12]. Of these, only 4 (17%)
required antibiotics, the rest resolving with topical antiseptics.
In contrast, antibiotics are advised for all UTIs in infants, even if
the UTI is merely suspected. Based on a NNT of 100 for infant UTI
prevention by NTMC and the estimate of 0.4% for infections [12],
instead of the much lower 0.0834% in the large US study [4]
(where only 2.2% of those, i.e., 0.0018%, were likely NTMC-related),
one can calculate n=10 UTIs prevented from 1000 circumcisions,
and n=4 wound infections. If the gure of 17% of wound
infections requiring antibiotics is representative, then 0.7 of those
4 wound infections would need antibiotic treatment, as opposed
to all ten UTIs. Infant NTMC therefore results in a substantial net
reduction in antibiotic use even when erring in D&Ms favour, and
Received: 29 January 2022 Revised: 22 April 2022 Accepted: 28 April 2022
1
School of Medical Sciences, University of Sydney, Sydney, NSW 2006, Australia.
2
CircFacts, 33 Marina Avenue, Warrington WA5 1HY, UK.
3
Department of Urology, University of
Washington School of Medicine, Seattle, WA 98194, USA.
4
Department of Medicine, Population and Public Health Sciences, Keck School of Medicine of the University of Southern
California, Los Angeles, CA 90033, USA.
5
Australian Centre for Microscopy and Microanalysis, University of Sydney, Sydney, NSW 2006, Australia.
email: brian.morris@sydney.edu.au
www.nature.com/ijir
IJIR: Your Sexual Medicine Journal
1234567890();,:
without considering later UTIs and other infections also prevented
by infant NTMC. When coupled with the increasing problem of
antibiotic resistance, particularly in relation to infant UTIs, NTMC in
infancy represents a signicant benet.
For STIs, D&M fail to explain how in socioeconomically
advantaged countries most HIV infections occur from receptive
anal intercourse in men-who-have-sex-with-men (MSM). In insertive
MSM, risk is substantially lower in those circumcised. D&M suggest
that some men forego condom use after circumcision, but ignore a
2021 meta-analysis by Gao showing no such decline in condom use.
While current HIV treatments extend lifespan, D&M did not
acknowledge patientslifelong elevated risk of HIV-associated
comorbidities. D&M refer to studies by Van Howe, but not the
numerous critiques of his methods and awed statistics [5].
Castellsagué et al.s critique was titled: HPV and circumcision: A
biased, inaccurate and misleading meta-analysis.
Their review of penile cancer was misleading. In all studies,
penile cancer prevalence was much lower in circumcised men.
NNT for uncircumcised males was 900 for Denmark and 600 for
the US [13]. Based on average UK male life expectancy of ~79
years, 33.15 million male population, and ~700 cases/annum
(Cancer Research UK), one can calculate a NNT of ~600 for the UK
if penile cancer were unique to uncircumcised males, and ~1000 if
only three-times higher. Circumcised men are also at lower risk of
prostate cancer. Increasing circumcision prevalence in the UK from
the current ~20% to ~90% should result in fewer cases.
D&M misconstrue a multinational study by Castellsagué et al. of
HPV and cervical cancer (D&M-ref68) which included not just male
partners of high-risk, but also those of intermediate risk. Contrary
to D&M, RCT data exist. While HPV vaccination has lowered HPV
prevalence in the UK, only 64.9% of year 9 females completed the
2-dose course in year 2019/2020, quadrivalent and nonavalent
HPV vaccines cover 2 low-risk types, and 2 and 7, not all 14,
oncogenic HPV types, and lifelong effectiveness is not assured.
Our recent meta-analysis of all 27 studies (1.5 million males),
that included D&Ms reference 85, found risk of meatal stenosis
was 0.656% [14]. Most diagnoses are actually a ventral meatal
weband are asymptomatic, so clinically nonsignicant.
Because adverse event risks are 1020-fold higher for circumcision
of non-neonatal males [4], and circumcision reduces risk of infections
and other conditions over the lifetime, NTMC is cost-saving.
For pain, effective local anaesthetic methods are mandated.
The CDC stated, painless circumcision [by Gomco clamp] is
possible in almost all [93.3%] newborns if it is performed
during the rst week of life.D&Ms reference 83 disputed those
gures and other data nding <2% experience excessive pain.
D&M miscommunicate a survey of parentsperceptions during
the 6 weeks following their newborn sonscircumcision (D&M-
ref103). Pain scores were not increased for up to 6 weeks,and
the study stated, no long-term adverse effects were noted
in the 6 weeks of follow-up.D&M claim that NTMC pain has
long-term effects but cite as support pain during neonatal
intensive care management, heel sticks and cardiac surgery.
Contradicting speculation that NTMC pain causes central
nervous system changes affecting empathy, a 2020 study by
Miani found no such association.
Sexual function was addressed, but rather than a balanced
overview of the considerable physiological and epidemiological
evidence, as well as RCTs and meta-analyses nding similar or
better function in circumcised men, D&M cite seriously awed
studies (D&M-refs114&123); see [5] for critiques. In addition, D&M
cite an online post by Van Howe (D&M-ref113) of his peer-review
of the CDCs draft policy. This failed to sway the CDC.
Table 1summarises the advantages of infant NTMC as compared
to later age circumcision. Our extensive systematic review of the
contrasting evidence found that high-quality data supports NTMC
[5]. NTMC is, moreover, legal and ethical. Jacobs 2013 interpreted
Article 24(3) of the United Nations Convention on the Rights of the
Child [15] as favouring NTMC, since not circumcising boys has been
deemed as prejudicial to their health. The AAP and CDC found
benets of NTMC exceeded risks, and, noting cultural sensitivities,
recommended parental choice, education, insurance coverage, and
provider training.
DATA AVAILABILITY
For data referred to in this Comment article please email the rst author.
REFERENCES
1. Deacon M, Muir G. What is the medical evidence on non-therapeutic child
circumcision? Int J Impot Res. 2022. Online ahead of print.
Table 1. Issues to consider for timing of male circumcision: neonatal vs. later.
Neonatal circumcision Circumcision of older boys and men
Simple. More complex.
Quick (takes several minutes). Half an hour or more to perform.
Cost is lower. Much more expensive (often unaffordable).
Low risk (adverse events 0.4%). Moderate risk (adverse events 48%).
Bleeding (uncommon) is minimal and easily stopped. Bleeding more common, requiring cautery or other interventions.
Sutures not needed. Sutures or tissue glue needed.
Convenient for patient. Inconvenient (time off school or work).
Local anaesthesia for age <2 months. General anaesthesia for age >2 months to age 9 years.
Local anaesthesia for men, although general anaesthesia often preferred by
surgeon.
Healing is fast (<2 weeks). Healing takes 6 weeks or more.
Cosmetic outcome usually good. If stitches used stitch marks may be seen.
No prior anxiety. Fear of undergoing an operation.
Does not disrupt feeding or other day-to-day activities. Abstinence from sexual intercourse for the 6-week healing period.
No embarrassment. May be embarrassed.
Benets start immediately after healing is complete. Benets delayed. Meantime may suffer from medical problems that he would
have been protected against if circumcised earlier.
Avoids costs for treatment of later medical conditions that
circumcision protects against.
Cost of treatment of these, including both direct and indirect costs.
B.J. Morris et al.
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IJIR: Your Sexual Medicine Journal
2. American Academy of Pediatrics Task Force on Circumcision. Male circumcision.
Pediatrics. 2012;130:e75685.
3. Centers for Disease Control and Prevention. Background, methods, and synthesis
of scientic information used to inform Information for Providers to Share with
Male Patients and Parents Regarding Male Circumcision and the Prevention of
HIV Infection, Sexually Transmitted Infections, and other Health Outcomes. 2018.
https://stacks.cdc.gov/view/cdc/58457.
4. El Bcheraoui C, Zhang X, Cooper CS, Rose CE, Kilmarx PH, Chen RT. Rates of
adverse events associated with male circumcision in US medical settings, 2001 to
2010. JAMA Pediatr. 2014;168:62534.
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circumcision: a systematic review. J Evid Based Med. 2019;12:26 390.
6. Morris BJ, Krieger JN. Non-therapeutic male circumcision. Paediatr Child
Health. 2020;30:1027. https://www.paediatricsandchildhealthjournal.co.uk/
action/doSearch?text1=Morris+BJ%2C+Krieger+JN.+Non-therapeutic+male
+circumcision.&eld1=AllField.
7. Yang C, Liu X, Wei GH. Foreskin development in 10421 Chinese boys aged 0-18
years. World J Pediatr. 2009;5:3125.
8. Osmond TE. Is routine circumcision advisable? J R Army Med Corp. 1953;99:254.
9. Eisenberg ML, Galusha D, Kennedy WA, Cullen MR. The relationship between
neonatal circumcision, urinary tract infection, and health. World J Mens Health.
2018;36:17682.
10. Lewis EN, Grifn MR, Szilagyi PG, Zhu Y, Edwards KM, Poehling KA. Childhood
inuenza: number needed to vaccinate to prevent 1 hospitalization or outpatient
visit. Pediatrics. 2007;120:46772.
11. Fraser IA, Allen MJ, Bagshaw PF, Johnstone M. A randomized trial to assess
childhood circumcision with the Plastibell device compared to a conventional
dissection technique. Br J Surg. 1981;68:5935.
12. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison
of the Gomco clamp and the Plastibell device. Pediatrics. 1976;58:8247.
13. Kochen M, McCurdy S. Circumcision and the risk of cancer of the penis. A life-table
analysis. Am J Dis Child. 1980;134:4846.
14. Morris BJ, Krieger JN. Does circumcision increase meatal stenosis risk?A
systematic review and meta-analysis. Urology 2017;110:1626.
15. United Nations Human Rights Ofce of the High Commissioner for Human Rights,
Convention on the Rights of the Child. 44/25 20 November 1989. http://www.
ohchr.org/en/professionalinterest/pages/crc.aspx.
AUTHOR CONTRIBUTIONS
Concept and structure: BJM. Drafting of the paper: BJM. Critical revisions and
redrafting: SM, JDK, and GC. Supervision: BJM.
FUNDING
Open Access funding enabled and organized by CAUL and its Member Institutions.
COMPETING INTERESTS
BJM is a member of the Circumcision Academy of Australia, a not-for-prot,
government registered, incorporated medical society that provides evidence-based
information on male circumcision to parents, practitioners and others, as well as
contact details of doctors who perform the procedure (website: https://www.
circumcisionaustralia.org). SM is an editor of, and contributor to, http://www.circfacts .
org, a website that provides evidence-based information on male circumcision. JNK is
co-inventor of a circumcision device patented by University of Washington. He has
not received any income from this. The authors have no nancial, religious, or othe r
afliations that might inuence the topic of male circumcision.
ADDITIONAL INFORMATION
Correspondence and requests for materials should be addressed to Brian J. Morris.
Reprints and permission information is available at http://www.nature.com/
reprints
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© The Author(s) 2022
B.J. Morris et al.
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IJIR: Your Sexual Medicine Journal
... Systematic reviews found women, including those from non-circumcising cultures, overwhelmingly prefer a circumcised penis for sexual activity [154,155]. Across countries, cultures and sexual preference, a majority of men too regard being circumcised as esthetically pleasing and more sexually desirable to women [129][130][131][132][133][134][135]. While esthetics is clearcut, sexual pleasure may be purely physical, or could be influenced by psychological factors. ...
... London urologists Matthew Deacon and Gordon Muir recently published a review [155] examining pros and cons of infant NTMC. Although not addressing the BMA's statement directly, being UK-based, their review is relevant to the BMA's guidance, so it would be remiss not to mention it here. ...
... Although not addressing the BMA's statement directly, being UK-based, their review is relevant to the BMA's guidance, so it would be remiss not to mention it here. Several of the present authors examined it and found it was selective with the literature, misleading and contradictory [155]. ...
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The British Medical Association (BMA) guidance on non-therapeutic circumcision (NTMC) of male children is limited to ethical, legal and religious issues. Here we evaluate criticisms of the BMA’s guidance by Lempert et al . While their arguments promoting autonomy and consent might be superficially appealing, their claim of high procedural risks and negligible benefits seem one-sided and contrast with high quality evidence of low risk and lifelong benefits. Extensive literature reviews by the American Academy of Pediatrics and the United States Centers for Disease Control and Prevention in developing evidence-based policies, as well as risk-benefit analyses, have found that the medical benefits of infant NTMC greatly exceed the risks, and there is no reduction in sexual function and pleasure. The BMA’s failure to consider the medical benefits of early childhood NTMC may partly explain why this prophylactic intervention is discouraged in the United Kingdom. The consequence is higher prevalence of preventable infections, adverse medical conditions, suffering and net costs to the UK’s National Health Service for treatment of these. Many of the issues and contradictions in the BMA guidance identified by Lempert et al stem from the BMA’s guidance not being sufficiently evidence-based. Indeed, that document called for a review by others of the medical issues surrounding NTMC. While societal factors apply, ultimately, NTMC can only be justified rationally on scientific, evidence-based grounds. Parents are entitled to an accurate presentation of the medical evidence so that they can make an informed decision. Their decision either for or against NTMC should then be respected.
... We read with interest the response by Morris et al. [1] to our recently published review, and thank them for their comment. Despite our efforts to provide a reasoned and balanced assessment of current evidence [2], they continue to rely heavily on self-cited and previously discredited studies, and repeatedly make inaccurate assessments of the quality of available evidence, based on entrenched and partisan opinion. ...
... Finally, Morris et al. produce a table which attempts to compare the merits of neonatal circumcision with circumcision of 'older boys and men' [1]. The inclusion of older boys in this comparison fails to reflect one of the key conclusions of our review, and also omits the very reasonable option of not getting circumcised whatsoever. ...
... Such a justification rests on the assumption that these potential future health benefits will in some way "outweigh" the harms of the procedure, whether intrinsic (e.g., pain, damage to or loss of sensitive, prima facie valuable genital tissue [84][85][86] ), or accidental (e.g., possible surgical complications, negative psychosexual sequalae) [87][88][89][90] . Whether this is a reasonable assumption, at least for penile circumcision, is debated by several authors in this issue [91][92][93][94][95] , while an analogous debate on the potential benefits and harms of intersex surgeries can be found in Part 1. ...
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The risk-benefit profile of neonatal circumcision is not clear. Most studies have focused on urinary tract infections but other health sequelae have not been evaluated. While evidence supports benefits of circumcision, a lack of randomized trials has been cited as a weakness. National guidelines provide mixed recommendations regarding neonatal circumcision. We review the weight of evidence and utilize current statistical methodology on observational data to examine the risks and benefits of neonatal circumcision.
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Importance: Approximately 1.4 million male circumcisions (MCs) are performed annually in US medical settings. However, population-based estimates of MC-associated adverse events (AEs) are lacking. Objectives: To estimate the incidence rate of MC-associated AEs and to assess whether AE rates differed by age at circumcision. Design: We selected 41 possible MC AEs based on a literature review and on medical billing codes. We estimated a likely risk window for the incidence calculation for each MC AE based on pathogenesis. We used 2001 to 2010 data from SDI Health, a large administrative claims data set, to conduct a retrospective cohort study. Setting and participants: SDI Health provided administrative claims data from inpatient and outpatient US medical settings. Main outcomes and measures: For each AE, we calculated the incidence per million MCs. We compared the incidence risk ratio and the incidence rate difference for circumcised vs uncircumcised newborn males and for males circumcised at younger than 1 year, age 1 to 9 years, or 10 years or older. An AE was considered probably related to MC if the incidence risk ratio significantly exceeded 1 at P < .05 or occurred only in circumcised males. Results: Records were available for 1,400,920 circumcised males, 93.3% as newborns. Of 41 possible MC AEs, 16 (39.0%) were probable. The incidence of total MC AEs was slightly less than 0.5%. Rates of potentially serious MC AEs ranged from 0.76 (95% CI, 0.10-5.43) per million MCs for stricture of male genital organs to 703.23 (95% CI, 659.22-750.18) per million MCs for repair of incomplete circumcision. Compared with boys circumcised at younger than 1 year, the incidences of probable AEs were approximately 20-fold and 10-fold greater for males circumcised at age 1 to 9 years and at 10 years or older, respectively. Conclusions and relevance: Male circumcision had a low incidence of AEs overall, especially if the procedure was performed during the first year of life, but rose 10-fold to 20-fold when performed after infancy.
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Few studies on foreskin development and the practice of circumcision have been done in Chinese boys. This study aimed to determine the natural development process of foreskin in children. A total of 10 421 boys aged 0 to 18 years were studied. The condition of foreskin was classified into type I (phimosis), type II (partial phimosis), type III (adhesion of prepuce), type IV (normal), and type V (circumcised). Other abnormalities of the genitalia were also determined. The incidence of a completely retractile foreskin increased from 0% at birth to 42.26% in adolescence; however, the phimosis rate decreased with age from 99.7% to 6.81%. Other abnormalities included web penis, concealed penis, cryptorchidism, hydrocele, micropenis, inguinal hernia, and hypospadias. Incomplete separation of foreskin is common in children. Since it is a natural phenomenon to approach the adult condition until puberty, circumcision should be performed with cautions in children.
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Non-therapeutic circumcision refers to the surgical removal of part or all of the foreskin, in healthy males, where there is no medical condition requiring surgery. The arguments for and against this practice in children have been debated for many years, with conflicting and conflicted evidence presented on both sides. Here, we explore the evidence behind the claimed benefits and risks from a medical and health-related perspective. We examine the number of circumcisions which would be required to achieve each purported benefit, and set that against the reported rates of short- and long-term complications. We conclude that non-therapeutic circumcision performed on otherwise healthy infants or children has little or no high-quality medical evidence to support its overall benefit. Moreover, it is associated with rare but avoidable harm and even occasional deaths. From the perspective of the individual boy, there is no medical justification for performing a circumcision prior to an age that he can assess the known risks and potential benefits, and choose to give or withhold informed consent himself. We feel that the evidence presented in this review is essential information for all parents and practitioners considering non-therapeutic circumcisions on otherwise healthy infants and children.
Article
Recent guidance on nontherapeutic male circumcision (NTMC) from the UK focuses on ethical and legal issues, addressing in particular religious NTMC. The guidance is generally negative, especially regarding NTMC of minors. This contrasts to guidance provided in other countries where a wider range of literature has been reviewed. There is strong medical data showing that NTMC protects against urinary tract and sexually transmitted infections, dermatological problems, and genital cancers. A risk-benefit analysis of infant NTMC for the UK shows that benefits exceed risks by 200 to one, and that more than half of uncircumcised males may experience a foreskin-related adverse medical condition over their lifetime. Infancy presents a window of opportunity for NTMC, because the procedure is simpler, adverse event risk is low, convenience, quicker healing, good cosmetic outcome, lower costs, and provides immediate and lifelong benefits. This article reviews the evidence for possible benefit and offers a global perspective on NTMC which may be helpful in considering the merits and demerits of NTMC by families. Keywords: dermatology; foreskin; infection; inflammation; neoplasms; policy
Article
Context: Meatal stenosis (MS) as a potential complication of male circumcision and controversy regarding the magnitude of risk. Objectives: To conduct a systematic review and meta-analyses to assess (1) MS diagnosis after circumcision, (2) the potential association of MS with circumcision, and (3) a potential method of prevention. Data sources: PubMed, Google Scholar, Cochrane Library and bibliographies of original studies were searched using the keywords circumcision and stenosis or stricture. Study selection: Studies containing original data on MS following circumcision at any age. Data extraction: Two reviewers independently verified study design and extracted data. Results: Thirty eligible studies were retrieved. A random effects meta-analysis of 27 studies (350 MS cases amongst 1,498,536 males) found that the risk of MS in circumcised males was 0.656% (95% confidence interval 0.435-0.911). Meta-analysis of 3 observational studies that compared MS prevalence in circumcised and uncircumcised males found non-significantly higher prevalence in circumcised males (odds ratio 3.20; 95% confidence interval 0.73-13.9). Meta-analysis of 3 randomized controlled trials investigating the effect of petroleum jelly application to the glans after circumcision found that this intervention was associated with MS risk reduction (relative risk 0.024; 95% confidence interval 0.0048-0.12). Conclusions: MS risk after circumcision is low (< 1%). Weak evidence suggests that MS risk might be higher in circumcised boys and young adult males. Risk is reduced by petroleum jelly application. Further research of MS arising from lichen sclerosus in older uncircumcised males is needed.
Article
Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP’s 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association’s template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners’ competency in discussing circumcision’s benefits and risks with parents. The Task Force made the following recommendations:Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure.Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.Elective circumcision should be performed only if the infant’s condition is stable and healthy.Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management.Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision.If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns.Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing;Teach the procedure and analgesic techniques during postgraduate training programs;Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents;Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises.The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report.
Article
• The low incidence of penile cancer in the United States is frequently cited as a reason for not justifying the risk of neonatal circumcision as a prophylactic measure. Although uncircumcised men are uniquely at risk for this malignant neoplasm, previous approaches have used annual incidence data collected without regard to circumcision status, thus tending to underestimate the true risk to this susceptible group. In addition, the concept of lifetime risk has not been addressed. Using data from the Third National Cancer Survey and previously published circumcision prevalence figures in a life-table analysis, we estimated the lifetime risk for cancer of the penis in uncircumcised males. The predicted risk is 166 per 105, or one in 600; the estimated median age of occurrence is 67 years. These data deserve to be considered with other morbidity factors in the context of the neonatal circumcision debate. (Am J Dis Child 134:484-486, 1980)
Article
The records of 5,882 live male births were reviewed to ascertain the incidence and nature of complications following neonatal circumcision. Approximately one half of the patients were circumcised with the Gomco and half with the Plastibell. The incidence of complications was 0.2%; most frequent were hemmorrhage, infection, and trauma, there were no deaths; and no transfusions were given.