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REVIEW ARTICLE OPEN
Re: The medical evidence on non-therapeutic circumcision of
infants and boys—setting 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-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 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 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 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% figure 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 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
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 significant benefit.
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 patients’lifelong elevated risk of HIV-associated
comorbidities. D&M refer to studies by Van Howe, but not the
numerous critiques of his methods and flawed 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&M’s reference 85, found risk of meatal stenosis
was 0.656% [14]. Most diagnoses are actually a ventral ‘meatal
web’and are asymptomatic, so clinically nonsignificant.
Because adverse event risks are 10–20-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 first week of life.’D&M’s reference 83 disputed those
figures and other data finding <2% experience excessive pain.
D&M miscommunicate a survey of parents’perceptions during
the 6 weeks following their newborn sons’circumcision (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 finding similar or
better function in circumcised men, D&M cite seriously flawed
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 CDC’s 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
benefits 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 first 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 4–8%).
•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.
•Benefits start immediately after healing is complete. •Benefits 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:e756–85.
3. Centers for Disease Control and Prevention. Background, methods, and synthesis
of scientific 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.
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adverse events associated with male circumcision in US medical settings, 2001 to
2010. JAMA Pediatr. 2014;168:625–34.
5. Morris BJ, Moreton S, Krieger JN. Critical evaluation of arguments opposing male
circumcision: a systematic review. J Evid Based Med. 2019;12:26 3–90.
6. Morris BJ, Krieger JN. Non-therapeutic male circumcision. Paediatr Child
Health. 2020;30:102–7. https://www.paediatricsandchildhealthjournal.co.uk/
action/doSearch?text1=Morris+BJ%2C+Krieger+JN.+Non-therapeutic+male
+circumcision.&field1=AllField.
7. Yang C, Liu X, Wei GH. Foreskin development in 10421 Chinese boys aged 0-18
years. World J Pediatr. 2009;5:312–5.
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.
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influenza: number needed to vaccinate to prevent 1 hospitalization or outpatient
visit. Pediatrics. 2007;120:467–72.
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;68:593–5.
12. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison
of the Gomco clamp and the Plastibell device. Pediatrics. 1976;58:824–7.
13. Kochen M, McCurdy S. Circumcision and the risk of cancer of the penis. A life-table
analysis. Am J Dis Child. 1980;134:484–6.
14. Morris BJ, Krieger JN. Does circumcision increase meatal stenosis risk?–A
systematic review and meta-analysis. Urology 2017;110:16–26.
15. United Nations Human Rights Office of the High Commissioner for Human Rights,
Convention on the Rights of the Child. 44/25 20 November 1989. http://www.
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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-profit,
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 financial, religious, or othe r
affiliations that might influence the topic of male circumcision.
ADDITIONAL INFORMATION
Correspondence and requests for materials should be addressed to Brian J. Morris.
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© The Author(s) 2022
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